Study ties states’ birth outcomes to workforce support

Brie Thumm, a certified nurse-midwife for 25 years, says the current healthcare environment in the United States is a recipe for burnout for many midwives.

“Low reimbursement for services rendered, policies that limit midwives’ compensation for the same work doctors provide, restrictive rules for births outside of hospitals, and loss of autonomy,” she said. “Why continue this uphill battle?”

Currently, more than 36% of U.S. counties lack a single obstetrician or midwife. This shortage leaves over 5 million women with limited maternity-care access.

Increased access to midwifery care is a federally recognized strategy to improve U.S. maternal health outcomes.

In a first-ever effort to compare levels of support for the maternal and child health workforce in the United States by state, researchers found key policies, such as scope-of-practice expansion for midwives and adequate Medicaid reimbursement for doulas, may lead to improved childbirth outcomes and greater workforce availability.

The researchers developed a data dashboard of 28 policy indicators across four domains: midwifery workforce, doula workforce, labor policy and economic policy. Higher scores represent more supportive policies. 

The findings were published March 11 in the journal Health Affairs Scholar.

“There’s been a lot of focus on improving maternal and child health outcomes, but the workforce — a critical part of making that happen — doesn’t often get a lot of attention,” said lead author Paula Kett, research assistant professor of family medicine at the University of Washington School of Medicine. She is the deputy director of UW’s Center for Health Workforce Studies.

Low wages drive many midwives and doulas away from maternal care, Kett said.

“Lack of stable sources of income and being asked to provide what amounts to uncompensated care leads to burnout and high attrition,” she said. “Compensation communicates the level of value society places on your skills, and when that compensation is less than the cost of living, it speaks volumes.”

Kett said the index provides states with actionable information about where to focus to improve policies to support their local maternal and child health workforce in their state.  

While a broad range of occupations, including OB-GYNs and family physicians, comprise the maternal and child health workforce, the researchers focused on midwives and doulas. They did this because of states’ varied regulatory environments, doulas' and midwives' association with better birth outcomes, and an identified need to increase access to these workforce groups.

The average maternal and child health worker index score was 50, with scores ranging from 23 (Wyoming) to 92 (California). Four states scored above 75 (California, Washington, Oregon and Colorado), all of which had supportive labor policies but varied in how supportive their policies were for the midwifery and doula workforces. Three states scored below 25: Mississippi, Idaho and Wyoming. The lower scores mainly reflected the lack of Medicaid reimbursement for doula care and fewer supportive labor policies.

Higher scores on the midwifery workforce index were correlated with greater certified nurse midwife supply, fewer maternity care deserts (areas lacking obstetrical services) and lower caesarean delivery rates.

The researchers said more studies are needed to examine ongoing barriers to better workforce support in low-scoring states such as Mississippi and Wyoming. Their research aligns with other data that show nearly two-thirds of hospitals in Mississippi lack obstetric care. Wyoming was among the states with the highest loss of rural obstetric services between 2010 and 2022.

“Improving birth outcomes in the United States requires a maternal and child health workforce that is adequately supported and compensated,” Kett said. “We hope these findings can inform planning and policy efforts to help these workforce groups thrive.”

The study was supported by a grant (U81HP32114-08-01) from the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

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