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Working to Increase the Number of Midwives—Especially “Melanated” Midwives—Across All Communities in the U.S.

Shortages of maternity care have reached critical levels in the U.S., yet midwives only attend around 10% of births. And only 8% of midwives in practice in the U.S. are midwives of color.
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Nichole Wardlaw was a physical education teacher working towards a master’s degree when she was pregnant with her first child. Still, when told she had developed preeclampsia, she says she had no idea what was going on.

“My doctor came in saying, ‘I understand you're giving my nurses a hard time.' I said, ‘no one is answering my questions about why I’m here.’ At the time they used the term toxemia, and he said, ‘you have toxemia, and it basically means if you don't cooperate, you and your baby can die.’ Immediately, I was reduced to tears because I'm like, oh my gosh I need to listen, I need to behave, I need to cooperate.”

Wardlaw recalls being told to stop working because she had to rest. “That didn't translate to me as bed rest. I was still going to the market, doing all those things, just not working. What he meant was bed-bathroom-back to bed. Well, no one told me that before.”

Then, at 34 weeks, she was getting a blood pressure check and the next thing she knew she was being induced. “I was like, why do they have me in Labor & Delivery when I'm not in labor? I knew 34 weeks was too early for my baby to come, I didn't realize that I was as sick as I was. How much better would it have been if someone had told me my blood pressure was too high and they needed to watch me. No one explained anything to me.”

That’s when Wardlaw decided she wanted to help others through the pregnancy and childbirth process and began taking the medical school prerequisites for a career in obstetrics and gynecology (OB-GYN). She didn’t know about midwifery as a profession until a conversation with her family medicine doctor led to an introduction to a local midwife, who let Wardlaw shadow her, and advised her to go back to school and become a Certified Nurse-Midwife.

“I wanted to be the person who can sit down and say, hey what's going on today? How are you eating, how are you sleeping, look at everything holistically. To say, your iron is low, but you're vegan, let’s look at some options to get your iron up. That's what she brought to the table and that's what I loved about it.”

Wardlaw has been working as a Certified Nurse-Midwife since 2005, and in 2020 opened her own community-based advanced midwifery clinic in Chesapeake, Virginia.

Integrating midwives into the health system to help close the gap in maternal care and save lives

Black mothers in the U.S. die at three to four times the rate of white mothers. In a national study of five medical complications, including preeclampsia, that are common causes of maternal death, Black women were two to three times more likely to die than white women who had the same condition. These disparities persist even among women with higher education. College educated women of color are five times more likely to die from childbirth related issues than white women with less than a high school diploma. The disproportionate toll on Black women is the main reason why the maternal mortality rate in the U.S. is so much higher than that of other industrialized countries. And, according to the CDC, three in five pregnancy-related deaths were preventable.

Many women—especially Black, Indigenous, and people of color (BIPOC) women—do not find the health system to be a safe and affirming experience, says Wardlaw. “When they complain of a pain or when something didn’t feel right, many times it's just dismissed. When a provider in the medical system says, oh you'll be fine, don't worry about it, the clients don't know, they're going to defer to the professional. And then, it becomes a situation when it's almost too late.”

It's proven that culturally congruent care increases better health outcomes, she adds. “Imagine you walk in and see a person that looks like you. There are just some things they're going to understand better in terms of culture.”

The cornerstone of the midwifery model of care, Wardlaw explains, is listening to clients and allowing them to have informed decision making in their care. “It's a partnership, not a dictatorship. You don't come to my office and I just tell you what's going to happen to you. I don't talk at you. We have a conversation, especially where there's a problem or an issue. When explanations make sense, clients feel educated, empowered and affirmed, then most of the time they will follow through.”

A landmark study in 2018 offers clear evidence that empowering midwives could significantly boost maternal and infant health. Wardlaw points out that states where midwives were integrated into the health system not only had better health maternal and neonatal outcomes, but racial disparities were removed as well.

“Across the board, the outcomes for Black and white women—regardless of socio-economic status and education—were essentially the same,” notes Wardlaw. “And then, when you look at the states where midwives have so many barriers into practice or they're not allowed to practice to the full scope of their training, those states have the worst outcomes. So, why not permeate midwifery throughout the United States? For me, that’s the hill that I'm dying on. We need to increase our workforce, so more people have exposure to midwifery care.”

Building synergies to tackle a complex problem

While 13.4% of the U.S. population is African American, only 8% of midwives in practice are midwives of color—and that includes all people of color, Wardlaw points out. “We need to increase the numbers to match our population.” That is the focus of Wardlaw’s work with the American College of Nurse Midwives (ACNM), the professional organization for Certified Nurse-Midwives and Certified Midwives. She is on ACNM’s anti-racism and midwifery education taskforce, working to support the recruitment, retention and graduation of BIPOC midwifery students.

As part of its Our Race to Health Equity initiative, Johnson & Johnson has partnered with ACNM on a two-year project to increase equity in access to midwifery education and care by identifying and addressing barriers and implementing solutions to tackle this complex issue. The project includes a comprehensive midwifery education landscape analysis and development of a strategic plan to increase the number of midwives of color by building partnerships with minority serving institutions such as historically black colleges and universities (HBCU) and tribal colleges.

“There are four medical education programs housed at HBCUs. I would love to see midwifery education programs housed in those medical schools, then I feel like we would be on our way,” says Wardlaw. “If we build it, they will come.”

Midwifery is more than just baby catching

In the U.S. midwives only attend around 10% of births, and the extent to which they can legally participate in patient care varies widely from one state to the next. Many of the states where midwives face barriers also have large Black populations.

“We were able to get legislation passed in Virginia, where Certified Nurse-Midwives now have full scope of practice,” says Wardlaw. “I took advantage of that and opened my clinic and work alongside a great community of community midwives. But just across the border in North Carolina, certified professional midwives are illegal. In the south where the numbers are the worst, if they removed the restrictions, more mothers and babies would have access to maternal health services.”

Shortages of maternity care have reached critical levels in the U.S. Nearly half of U.S. counties don’t have a single practicing OB-GYN. The shortage hits rural women hardest, but the shortage is a nationwide problem with cities like Detroit, St. Louis, Dallas and Miami, also facing severe shortfalls.

Wardlaw came into midwifery because she wanted to be a presence for moms and babies and try to support people through the pregnancy and childbirth process, but Certified Nurse-Midwives like her are primary care providers for women throughout their lifespan. Their scope of practice encompasses everything from preconception consultations, labor and delivery, and post-natal care to child and adolescent health and development.

“It’s personal, you become very ingrained in people's lives,” says Wardlaw. “Being a midwife is the toughest job you'll ever love. Sometimes there is no glory in this job, sometimes it's a battle and not supported. But I can't imagine myself being anywhere else because the work that we do is just so important. Everybody deserves a midwife.”