Can Midwives Reduce Severe Maternal Morbitity?
Published FEBRUARY 15, 2025
Helena Grant, president of New York Midwives, embodies the old midwifery adage, “impatient people will not make good midwives.”
As Grant recalls, she was working as a midwife on hospital duty. A homebirth midwife brought in her patient who had been in labor for 48 hours. The midwife sensed something was wrong.
Grant and her physician counterpart determined that the mother’s bladder was too full, stopping the baby from descending down the pelvic canal. After emptying the bladder, the physician recommended Pitocin, a medication to induce labor, but Grant said no, to let the patient’s body relax. “Have a little healing period.”
They agreed.
Five hours later, “the woman had a beautiful birth,” said Grant. By taking a natural approach, “we prevented what would have been a likely hemorrhage.”
Midwives Needed
Midwives are getting a second look today. The most recent data shows that for every pregnancy-related death in New York City, another 146 women face life threatening complications during the birthing process. They are the “near misses,” where a mother almost dies because of problems having to do with a loss of blood or infection.
Some local officials believe that integrating more midwives—with their emphasis on respectful care and reduced C-section rates for low-risk women1—into maternity centers may be a solution to addressing what clinicians call severe maternal morbidity (SMM).
A recent World Health Organization (WHO) study concludes that midwives working with professional autonomy in an integrated healthcare system can effectively reduce maternal mortality and morbidity.
Midwives—not doctors—should be the main care providers of women and newborns from pre-pregnancy on through the postnatal period. To prevent SMM, midwives work closely with their physician colleagues as part of an interdisciplinary team in order to provide the best possible care.
Grant said that in other industrialized nations, the same midwives who practice in the hospitals are the same ones who practice in the homes and the birth centers, rotating every so often. With everybody on the same page, clinicians know who is in labor outside of the hospital and who may potentially come in.
In an emergency, a home midwife may call into the hospital and say “Oh, my God. I just took two blood pressures. And Mrs. Jone’s blood pressure is now elevated. I’m coming in,” Grant said. The hospital is ready, and there soon unfolds a time-tested synergy where the physician handles the medical part of the delivery and the midwife has control over the labor and birth part.
“That is why midwifery works in these other systems because it is so integrated into the healthcare system,” she said.
NYC Underachieves
Compared to the rest of the nation, however, New York City lags behind in both midwifery care and maternal health outcomes. State records show that midwives only attended 7.23% of total births in New York City in 2021, compared to 11% nationwide, a number compiled by the federal government.
In contrast, the city’s SMM rate exceeds the national average. In 2018, the most recent year comparable data was available, CDC data shows that the average SMM rate for the United States was 76.7 per 10,000 in-hospital deliveries. In New York City that figure was 324 per 10,000 deliveries, state records reveal.
A recent Canadian study indicates that women surviving SMM are more likely to develop cardiovascular disease and chronic pain while having an increased risk of mental health hospitalizations for up to 13 years after delivery. A second study concludes that the hospital costs of SMM are 2.5 to 4 times higher than for an uncomplicated delivery.
To date Mayor Eric Adams has done little to integrate more midwifery care into the current healthcare system, which studies show can reduce SMM. Instead, the Adams administration has focused on home visiting programs to promote healthy pregnancies and providing increased access to doula care.
Something Positive
Nonetheless, New York City’s poor midwifery integration statistics masks some of the city’s recent successes. Roseanne Seminara, Director of Midwifery at New York Presbyterian Brooklyn Methodist, started a midwifery practice with two other midwives in 1992 called Park Slope Midwives.
Methodist Hospital, the nearby hospital, did not want them in Park Slope. “It was competition,” said Seminara, “and so the first year we had thirty deliveries.”
Fast forward to 2018 and the two entities merged together, in part because of steep malpractice insurance premiums and in part to build up the business. Seminara said that today Park Slope Midwives has over 1,000 deliveries a year, making it the largest midwifery practice in New York City.
Seminara said there is a “team approach” and that the midwives are no longer resented by hospital staff. “We have a monthly meeting with pediatricians…physicians and everybody presents their high risk patients so that everybody knows who is coming up,” she said.
Our midwives do not perform cesareans, said Seminara, obstetricians do. “We want to be there at their head getting the baby skin-to-skin, taking pictures for them, being supportive of them and the partner.”
She attributes their excellent outcomes “to listening to the patients they care for and establishing a trusting relationship.”
Vaginal Births
Under WHO guidelines, a midwife practicing in her scope of practice supports a natural, physiological process of childbirth and uses interventions only when medically necessary. Research finds that spontaneous vaginal births without interventions, the type of birth midwives help bring about, have lower rates of SMM when compared to cesarean births or vaginal births using interventions.
Two common medical interventions during vaginal birth include labor induction with medication and the artificial rupture of membranes (breaking the water). Both interventions are used to start or accelerate labor.
“What leads to a lot of interventions is induction of labor,” said Seminara. “We just don’t induce people because they are tired of being pregnant. We induce for medical reasons.
Once a person is in labor though, she said, “we try to get the patient up. We try to get her ambulating, in the shower, on the birthing ball.”
Nicole Aljoe, a midwife at the Brooklyn Birthing Center, the only freestanding birthing center in New York City, said for long labors, that “as long as the baby’s heart rate is going well, and there is no fever, and the mother is doing well and the baby is doing well, we stay as long as possible.”
Aljoe also said that teaching expectant mothers the stages of labor beforehand and how to prepare their body for birth helps women to better understand the labor process. “You are going to know that something is wrong with you before I do. So if I teach you things to look for,” said Aljoe, “I am starting a conversation that you are reaching out to me to let me know something.”
C-sections
In New York City, cesarean deliveries accounted for the most cases of SMM. The most recent data put out by the city shows that two-thirds of SMM occurred in individuals who had cesarean deliveries.
The city’s cesarean rate was 33.18 percent in 2021, according to state records, higher than WHO’s recommended rate of 10-15 percent.
A bill passed in the State Assembly last year to curb medically unnecessary C-sections asks that healthcare providers provide patients with a written explanation on why a cesarean is medically necessary and inform them of the risks associated with the procedure.
Those risks include heavy blood loss that can result in a hysterectomy or blood transfusion, uterine rupture, and organ injuries, including bladder damage.
Assemblymember Amy Paulin, who sponsored the bill, said the Assembly has passed the bill for at least six years, but it gets held up in the Senate. Paulin said she was unsure exactly why that was.
Aljoe said that one of the major reasons for cesarean births today is the increasing rates of obesity. When a woman has obesity, the baby gets too big and this puts her at an increased risk of gestational diabetes.
The most important way, Aljoe said, for an out-of-hospital midwife to avoid SMM is through screening. “Are you a good candidate for-out of-hospital birth? Because if you have a medical issue on baseline,” she said, “that puts you at a higher risk.”
The Brooklyn Birthing Center website says it “is designed for healthy people having an uncomplicated pregnancy and anticipating a normal birth.” The birthing center only works with low risk pregnancies and says that “conditions such as high blood pressure or uncontrolled gestational diabetes would make a hospital birth necessary.”
WHO believes that midwives can decide for themselves which patients are at low risk for a midwife delivery and which are not, saying that midwives working within their scope of practice have the necessary competencies to assess risks in women and newborns in order to make informed decisions.
“As long as you are deemed low risk, and everything that has been going on in your pregnancy that has been good, usually the body takes care of itself,” Aljoe said. “Your body was made to birth. We have been doing it for over 5,000 years.”
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