Bioethics Forum Essay

Midwives Are Essential for Improving Mississippi’s Maternal and Infant Health

The Mississippi State Department of Health recently declared infant mortality a public health emergency. The state’s infant mortality rate — deaths within the first year of life — is not only the highest in the nation, it is also rising. Mississippi is an important case study for understanding how limited access to midwifery care represents both a reproductive ethics and reproductive justice issue that warrants urgent attention and discourse.

With 9.7 infant deaths per 1,000 live births, Mississippi’s 2024 infant mortality rate is at its highest in more than 10 years. There is a gaping disparity in outcomes: The mortality rate of Black infants is 1.57 times higher than the state average and more than double the rate of white, non-Hispanic babies (2.62) and Hispanic babies (2.41). In one year, Mississippi saw a 24% increase in Black infant mortality. An important marker of the overall health of a society, the rising infant mortality rate in Mississippi signals a broader national health crisis.

Actionable solutions are needed now. While the Mississippi health department’s press release offered several recommendations to improve infant health outcomes, it omitted any explicit mention of expanding access to midwifery care, a proven strategy for improving maternal and infant health. The World Health Organization identifies midwifery as key to reducing global maternal mortality rates and neonatal deaths, deaths within the first 28 days of life. This is an importantpoint to highlight because children less than 28 days old are “driving much of the increase” in Mississippi’s infant mortality rate. Yet, Mississippi has some of the most restrictive midwifery laws in the country. Midwives attend just 1.9% of births in the state, one of the lowest percentages in the country.

To reduce infant deaths, the Mississippi health department suggests “expanding community health worker programs to connect mothers and babies with care and resources where they live” and “eliminating OB [obstetrics] deserts.” Midwives are uniquely positioned to implement these recommendations. They have the expertise to support births at home, in freestanding birth centers, and in the hospital and are well-equipped to address many reproductive health needs. Fifty-one percent of Mississippi counties are maternity care deserts, “areas without access to birthing facilities or maternity care providers.” With many hospitals  closing their labor and delivery units especially in rural areas, the need for midwifery care is increasing and should be prioritized as a central component of the state’s health efforts.

Particularly in the segregated South, Black midwifery has had a long and storied history. Black midwives provided essential reproductive health care and were deeply respected as trusted healthcare experts in the communities they served. While midwifery is one of the world’s oldest vocations, its near decimation as a profession in the United States is rooted in racial injustice, particularly anti-Black racism deeply embedded in the healthcare system. Quality midwifery care improves health outcomes for all women and people who give birth by providing access to the full spectrum of reproductive health care in a safe and supportive space.

The health crisis in Mississippi highlights how limited access to care is a reproductive justice concern. The ties between infant health and maternal health are obvious and are important to acknowledge because Mississippi simultaneously confronts one of the nation’s highest maternal mortality rates and the highest infant mortality rate. Yet, nearly six weeks after its infant mortality emergency declaration, the Mississippi health department laid off employees working in the Office of Preventive Health and Health Equity. 

The dismantling of reproductive health infrastructure nationally undermines efforts to advance maternal and infant health outcomes. Notably, the U.S. Department of Health and Human Services Secretary significantly downsized the Centers for Disease Control and Prevention’s Division of Reproductive Health. Consequently, the federal Pregnancy Risk Assessment Monitoring System (PRAMS), the CDC’s premier pregnancy surveillance system, was suspended. To reduce mortality and support thriving communities, we must prioritize high-quality care across the pregnancy continuum by strengthening access to community health resources, including mental and social support services. Midwives have long advanced the health of individuals, families, and communities. Their contributions are especially relevant in today’s efforts and ongoing challenges to improving maternal and reproductive equity.

Healthy People 2030 aims to significantly reduce infant mortality rates by addressing the underlying social determinants of health, including access to quality healthcare, education on safe sleep practices, and the promotion of breastfeeding. With their preventive care approaches across a patient’s reproductive life span, midwives are equipped with the skills and training to support national maternal and infant health goals and to proactively meet communities’ holistic needs long before a public health crisis unfolds.

Kelley Akhiemokhali, MA, is a clinical research associate in the Center for Medical Ethics and Health Policy at Baylor College of Medicine.

Faith E. Fletcher, PhD, MA, is an associate professor in the Center for Medical Ethics and Health Policy at Baylor College of Medicine. She is also a Hastings Center Fellow and a Greenwall Bioethics Faculty Scholar. @FaithEFletcher

Any opinions, conclusions, and recommendations expressed in this article are those of the author and do not represent the views of Baylor College of Medicine.