HJNO Jan/Feb 2025

MIDWIVES 36 JAN / FEB 2025 I  HEALTHCARE JOURNAL OF NEW ORLEANS   and performing cesarean sections. Mid- wifery has long been the norm in the coun- try, across all demographics, as evidenced by Princess Kate’s perinatal care provided by midwives for all of her pregnancies and births. Princess Kate followed the tradi- tion of utilizing midwives for her care that dates back to Queen Elizabeth II, who utilized midwives for her births of Prince Charles, Princess Anne, Prince Andrew, and Prince Edward. Per capita, Australia and Sweden rank among those countries with the highest saturation of midwives. BARRIERS IN THE U.S. TO MIDWIFERY PRACTICE One huge barrier to midwifery practice in the U.S. is the lack of insurance payor coverage for the services midwives pro- vide. In addition, insurance payors may cover midwifery care but to a lower level of coverage compared to the same servic- es rendered by physicians — even though the services offered by both are exactly the same. Another barrier to midwifery practice is a lack of full practice authority in all states. Full practice authority (FPA) allows advance practice registered nurses (APRNs) — including certified nurse-mid- wives, nurse practitioners, and certified registered nurse anesthetists — to practice to the fullest extent of their education and scope. Currently, there are 30 states with full practice authority forAPRNs, and Lou- isiana is not among them. 10 FPA, as defined by the American Association of Nurse Practitioners (AANP), is as follows: “[FPA is] the collection of state practice and li- censure laws that allow for nurse practitio- ners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments—including prescribe medications—under the exclusive licensure authority of the state board of nursing.” 11 The lackof FPArestrictsAPRNs such that it creates a need for a written collaborative practice agreement with a physician, which can be cost prohibitive for APRNs, as there A National Academies of Sciences, En- gineering, and Medicine report compared perinatal and midwifery outcomes from four countries with economic status simi- lar to the U.S. that have significant numbers of midwife-attended births — Australia, Canada, the Netherlands, and the United Kingdom. Five parallels were noted across the four countries with lower rates of ma- ternal mortality, low birthweight, and new- born and infant death than the U.S., which serve to explain sthe excellent outcomes associated with midwifery care within systems where midwives are the primary obstetric providers. The five common fac- tors included: 1) healthcare that is both affordable and accessible, 2) a maternity labor force emphasizing both interprofes- sional collaboration and midwifery care, 3) maternal autonomy and respectful care, 4) utilization of evidence-based guidelines on the site of birth, and 5) national data collec- tions systems. 4 Moreover, this reinforced the findings of the 2014 The Lancet series on midwifery, which recommended that midwifery be available for all childbearing women and infants with focus on preven- tion, strengthening women’s capabilities, supporting normal processes, and pro- viding access to specialty care as needed through interdisciplinary collaboration.4 The World Health Organization has long supported and advocated for the expansion of midwifery worldwide. Their statement on the issue includes: • “When midwives are educated to international standards, and mid- wifery includes the provision of family planning, it could avert more than 80% of all maternal deaths, still- births and neonatal deaths. Achieving this impact also requires that mid- wives are licensed, regulated, fully integrated into health systems and working in interprofessional teams. • Beyond preventing maternal and newborn deaths, quality midwife- ry care improves over 50 other health-related outcomes, includ- ing in sexual and reproductive health, immunization, breastfeed- ing, tobacco cessation in pregnan- cy, malaria, TB, HIV and obesity in pregnancy, early childhood develop- ment and postpartum depression. • Midwives are uniquely able to pro- vide essential services to women and newborns in even the most dif- ficult humanitarian, fragile and con- flict-affected settings. This means that midwives will make a signifi- cant contribution to delivering on the commitments made in the As- tana Declaration on Primary Health Care and the Global Action Plan on Healthy Lives and Well-Being. • Educating midwives to international standards is a cost-effective invest- ment as it saves resources by reducing costly and unnecessary interventions. • Yet there is a startling lack of invest- ment in quality midwifery education, despite the evidence of impact. Now is the time to take collective action.” 7 A recent analysis reported that a well- integrated midwifery workforce could provide 80% of essential maternal care around the world, potentially preventing 41% of maternal deaths, 39% of neonatal deaths, and 26% of stillbirths. 8 Yet therein lies a fundamental problem: midwifery is currently not well integrated into the American healthcare landscape. Unlike other high-income countries like the Unit- ed Kingdom (U.K.), Sweden, the Nether- lands, and Australia, where midwives are fully integrated as part of the healthcare landscape, attending the majority of births, theU.S. is not consistent across states in the inclusion of midwives in healthcare sys- tems. By contrast, in the Netherlands, 87% of women initiate prenatal care with their community midwife. 9 In the U.K., approxi- mately two-thirds of the labors and births are attended by midwives, with OB-GYNs attending only the most high-risk cases