“A Good Birth, A Safe Birth”: The Role of Maternal Health Providers in Constructing Birth Safety in the United States

Abstract

The United States has a maternal health crisis. The maternal mortality rate for 2020 was 23.8 deaths per 100,000 live births, the worst of any other high-income country, and stark racial disparities persist as Black pregnant women are three times more likely to die than their white counterparts nationally. Federal and state governments have turned to the maternal health workforce to make birth “more safe,” but have mainly focused on non-clinical providers like doulas. Midwives and OB/GYNs are two clinical providers with historical connections to Black maternal health outcomes and the construction of US birth safety. However, there is limited research on the relationship between identity and providers in defining birth safety. This thesis centers on these two providers to understand if policy targeting the maternal health workforce is sufficient to address the US maternal health crisis and combat racial disparities.

Specifically, this thesis evaluates how OB/GYNs and midwives assess risk, define the conditions of a safe birth, and view their role in shaping maternal health policy. Since maternal health is mainly regulated at the state level, I conducted 36 semi-structured interviews with OB/GYNs and midwives in three states: New Jersey, North Carolina, and Washington. These states were selected based on their maternal mortality rates, racial disparities, and midwife legislative environment to broadly encompass the current US maternal health landscape. I also apply authoritative knowledge and intersectional risk theory as a theoretical framework to determine who defines the conditions for a safe birth and the implications of how they do so with policy.

I found similarities and fundamental differences between the midwifery and obstetrical models of care that shape perceptions of birth safety. Both providers agreed that clinical risk factors mainly fell under the obstetrical purview—conversely, provider views of social risk factors varied by practice environment. In terms of defining the conditions of a safe birth, midwives’ definitions were very similar even when accounting for differences in philosophy of care for nurse-midwives and direct-entry midwives, while OB/GYNs had more variation depending on state context. When it comes to who decides what a safe birth is, midwives view their jobs as inherently “political,” which can make advocacy seem like an obligation as other stakeholders try to “control” their practice. OB/GYNs view their roles in shaping public policy as something positive, yet as a component of their work they can choose to do if time permits.

I conclude that the distinct models of maternal health care in the US create tension between what it means to have a “safe birth” and a “good birth.” However, when we value all birthing people, a good birth is a safe birth.