Where Did My Midwife Go?

Ariel Bernstein, MPH, CPM is a midwife in the US having practiced in 4 different states before she received her Masters in Public Health in global health from Harvard University. She is passio¹nate about expanding the role of midwives worldwide and firmly believes that midwives should be at the center of all maternal health systems and that they have the power (given the right tools) to end excess maternal mortality globally.

Underpaid, under-appreciated, understaffed, and burnt out.  Midwives are walking away at time when the world needs them most.  

According to leading global health institutions, worldwide there is an estimated shortage of nearly 1,000,000 midwives. While many organizations are working to figure out how to increase that number, and train more midwives, increasingly in the west midwives are leaving the profession.ⁱ In a recent posting on a Facebook group for midwives that has thousands of members, somebody proposed the question, “In your opinion, why do you think midwives and other birth care workers are walking away from midwifery.” There were over 300 answers within 24 hours and the number one cited reason in the comments was burnout. Midwives discussed repeatedly that they simply couldn’t make it work year after year. Low wages, the endless stress of being on call, lack of childcare support for a heavily female dominated profession, moral injury, political instability and the impact of laws on female reproductive healthcare, were the most common issues raised as the reason for midwifery burnout.  Midwives reported that being a midwife “destroyed their health” and many talked about how it even affected their personal relationships, with many comments citing high divorce rates and the impact of their career on trying to raise a family. In a profession that is mostly female, the issue of work-life balance when it comes to raising a family has a lasting impact on workforce retention and career longevity.  How can women be expected to support the childbearing cycle of others if their profession doesn’t support their own family planning goals?

Many midwives also talked about the crushing level of responsibility that they carried, and how the weight of the liability of their job can be crushing (morally, emotionally, and psychologically).  Midwives reported not being able to take adequate time off to rest or recover, particularly after difficult outcomes, especially for certified professional midwives and those in private practice. Many people talked about secondary trauma, from witnessing difficult births or going through traumatic experiences with their patients. They discussed not being able to recover from such events or getting enough support to process things that they witnessed including obstetric violence. Many midwives talked about how they work in a broken system, or rather, a system is not broken but is not designed to support better outcomes for providers or patients.

Midwives expressed that they had gone through years of training that often left them starting their career as a provider already burnt out with little support due to a training process that many also feel is inherently abusive. Another consistent comment reflected low salaries; highlighting how midwives view their pay in relation to the amount of time spent on call, the intensity of the work, and the level of responsibility that they shoulder. Many midwives reported that they simply were not able to make a living despite working long hours.  The cost of care delivery is especially burdensome for those who are in private practice and those caring for vulnerable populations. This was especially true for midwives who worked in a community setting and have erratic call schedules that might leave them being on call 24/7 for weeks if not months on end.

The mental health aspect of burnout cannot be ignored.  While birth is often the most transformative and joyous event in someone’s life, it can also be traumatizing for providers who witness, experience, and hold space for families who experience miscarriages, stillbirths, and infant loss as well as other negative outcomes.   For some midwives, the mental toll of never having time off, or never knowing when they might be called to work, and never truly being able to relax or shut their phones off exacerbate their own mental health. Someone described it as “Swimming upstream your whole life, fighting the current.”

Additionally, “moral injury” – the trauma of being required to do things within the context of a medical system that they felt was against their own moral values, was cited as an overlooked mental health factor.  Adequate rest, time off, and compensation for a physically, emotionally, and psychological taxing profession must be addressed.

Comments shared repeatedly how difficult it is to work in both the community setting and the hospital setting with little respect from the medical system.  One midwife stated, “Midwifery is emotionally physically and intellectually exhausting, it asks us to sacrifice everything for others.”  Midwifery requires a deep level of empathy, and therefore attracts people to the profession who are deeply empathetic, it is the role of the midwife to care deeply for others, but it often means that there is no one left to care deeply for her. It is impossible to give of yourself for years without having a work-life balance, or enough time and resources to take care of oneself. One of the most common words repeated was “sacrifice”. Midwives felt that by and large midwifery was a career of sacrifice. Sacrificing oneself, one’s time, even one’s family to take care of others. It is impossible to continue to sacrifice yourself forever.

The health impact of midwifery is also significant.   One midwife shared, “Our body breaks down due to physical mental and emotional abuse, lack of self-care and boundaries.” There were also comments about how expectations from patients have changed over time, with many midwives feeling that patients increasingly have unrealistic expectations about the role of their provider in their birth outcome. Community based midwives talked about how when the need to transfer occurs there is a fear increasingly of the blame being placed on them instead of an acceptance of a change of plans being necessary to provide safe care. A fear of prosecution and litigation was also mentioned dozens of times with difficult to navigate political issues affecting reproductive health especially in the US.

If the world needs more midwives, then we must take care of our workforce! We cannot, as a global community, continue to demand that midwives provide so much with so little resources and support. No matter where midwives practice the themes remain the same: they just do not have enough support to keep going. Midwives deserve to be compensated; they deserve to be paid well for their highly skilled profession. They deserve respect and autonomy in practice. Especially in the US, they deserve to be integrated into the larger medical system and respected for filling a critical role in providing excellent maternity care in a country that is increasingly failing to serve with the needs of mothers.  A critical look at how to retain existing midwives in the workforce globally is necessary. We cannot simply create a system that trains people just to chew them up and spit them out.