California Clinic Elevates Role of Midwives in Maternal Care

Millie offers midwife-led care to patients with low-risk or moderate-risk pregnancies.

Millie, a maternal care clinic based in Berkeley, Calif., features a midwife-led care model with doulas also providing support to patients.

A report published earlier this month by The Commonwealth Fund provides insights into the U.S. maternal mortality crisis. The report found that the United States has a higher maternal mortality rate than 13 other high-income countries. The report shows that the United States and Canada have the lowest supply of midwives and obstetrician-gynecologists among the high-income countries, and OB/GYNs outnumber midwives in the United States, Canada, and Korea.

Millie's model of care features collaboration and innovation, says Amy Kane, MD, medical director at the maternal care clinic.

"The model involves midwifery care with the support of a trained doula," she says. "Our doulas play the role of a support person in collaboration with the team. Our doulas provide prenatal and postpartum support, but they are not present at a birth."

Millie works in collaboration with physicians whenever patients have conditions that make them high risk, Kane says.

"We do not provide direct physician care, but we have strong relationships with the maternal-fetal medicine groups in the community, private OB/GYN groups in the community, and hospitalists who provide OB/GYN care," she says. "So, our midwives always have the support that they need, and our patients always have the support they need. If a patient develops a high-risk pregnancy, our midwives can hand them off directly to a physician for their care."

For most pregnancies, the most important Millie team member is the midwife, Kane says.

"The patient has a midwife who sees the patient throughout their pregnancy and the postpartum period," she says. "Most patients have the same midwife for all of their visits, but patients also get the opportunity to see other midwives on the team. Midwife visits are both in-person and virtual."

Tech support is one of the innovative elements of Millie's care model.

"One of the special things about Millie is the educational resources on our app," Kane says. "Even when you have longer prenatal visits like we do, there is never enough time to teach patients as much as they need to know. So, providing educational resources is critical. It is hard to get the right information—the Internet is vast, and it is hard for patients to find reliable sources of information."

Millie has an effective care model because the clinic is setting up a situation where patients are cared for by clinical professionals who are appropriate for the level of care that the patients need, says Mark Simon, MD, MMM, CMO at Ob Hospitalist Group.

"They have midwives involved to deliver care for low-risk patients and medium-risk patients," he says. "They can make an OB/GYN available for high-risk patients and any surgical interventions. They have the doulas engaged from a support perspective, which makes a lot of sense."

The Commonwealth Fund report indicates the importance of midwives in maternal care, Simon says.

"An interesting finding of the report is that the United States is one of the countries that has the lowest supply of midwives," he says. "If you look at how we have obstetrical care providers in this country, we are heavily physician focused. A country like Norway, which has one of the lowest maternal mortality rates, has essentially the same number of obstetricians per live births as the United States, but they have 15 more midwives per 1,000 births."

Midwives should play a larger role in U.S. maternal care, Simon says.

"I am a physician, and physicians provide great care in obstetrics, but physicians are not the be all and end all in maternity care," he says. "Clearly, the numbers indicate that we need more clinicians such as midwives providing maternity care in this country to help address maternal mortality and morbidity. Midwives are part of the solution, and they should be adopted more frequently than they are today. Hopefully, we are moving in that direction."

A higher reliance on midwives in maternal care would help address a shortage of obstetricians in the United States, Simon says.

"We just do not have enough physicians practicing obstetrics in this country," he says. "It takes a long time to train physicians, and relying on obstetricians alone is not the most effective way to deal with our maternal mortality and morbidity crisis. A better model is to have physicians working in concert with midwives."

Generating results

Data indicates Millie's model of care is driving good clinical outcomes.

• The C-section rate among Millie's low-risk, first-time mothers is 21.7% compared to the national rate of 26.3%

• Millie's patients have a low preterm birth occurrence rate at 3.01% compared to the national rate of 10.49%
   
• Millie's patients experience a low birthweight rate at 3.66% compared to the national rate of 8.52%

Compared to OB/GYN-led clinics, Millie has a lower cost of care, according to Anu Sharma, MS, Millie CEO and founder.

"Clinical studies and the experience of peer nations has shown that midwifery-led care leads to fewer C-sections and other interventions for low-to-moderate risk pregnancies," she says. "Midwifery-led care is also less expensive than OB-led care in terms of staffing costs."

Millie excels at early detection and management of risk, which lowers costs, Sharma says.

"In addition to C-sections, other drivers of cost are related to poor management of care and late detection of risks," she says. "These result in readmissions, preterm births, NICU stays, and unnecessary emergency room usage."