Climate leadership is failing, though not for want of ideas. Still, the loudest suggestions, like shifting to renewable energy and eating more sustainably, can overshadow another climate solution that experts and lived experience suggest can help: birth workers, such as midwives and doulas. Investment in these workers, in turn, advances another human right under threat: reproductive justice.
Surviving climate change will come down to mitigation and adaptation. While mitigation has more to do with avoiding and reducing emissions, adaption refers to choosing behaviors that can protect communities holistically—like providing safe and reliable reproductive care. Because gender equality in climate action can’t be achieved without the safeguarding of sexual and reproductive health rights, the United Nations views strengthening health systems as another way of combating climate change. According to the United Nations, strengthening health systems is one way to combat climate change because because sexual and reproductive health rights are “essential for gender equality in climate action.” Meanwhile, a core principle of reproductive justice is the right to raise children in safe and sustainable communities. This is why many view reproductive justice and environmental justice as one and the same.
Because midwives sit at the intersection of these issues and already provide care to people experiencing environmental harm, enhanced access to midwives is a step toward protecting women and children from the climate crisis. Countries like the United States, where ob-gyns and not midwives are at the center of maternal health, are in turn “not taking advantage of a tool that could mitigate some of the effects of climate change,” says Sally Pairman, chief executive of the International Confederation of Midwives.
When it comes to maternal mortality, the benefits of midwives specifically are already clear. Midwives can deliver 87 percent of all essential sexual, reproductive, maternal, and newborn health services. This includes providing prenatal care and managing labor and delivery. Their work, which dates back to 40,000 BC, has a low environmental impact compared to obstetric-led care in hospitals. The field is viewed as “low-tech, high-touch,” says midwife Lorna Davies, co-author of the book Sustainability, Midwifery, and Birth. Its low-carbon footprint is, in part, linked to reduced travel and fewer medical interventions and supplies. Despite technological advances like medications to control bleeding and infection control, many fundamental duties remain the same as they ever were.
Furthermore, midwives emphasize culturally sensitive care, patient engagement, and health education during personalized, lengthy visits—in contrast to an appointment with an ob-gyn, which typically lasts 16 minutes or less. The first 10 minutes of midwife appointments are spent examining the patient and fetus’ health. The rest of the time goes toward addressing holistic needs, like answering questions about nutrition or providing guidance on access to mental health services. As a result, the World Health Organization views midwives as an evidence-based approach to reducing maternal mortality, stillbirths, and preterm births.
And crucially, midwives integrated into their communities can positively influence patient decisionmaking because their model of care facilitates a trusting relationship. They are trained to nimbly manage pregnancies with a minimum of supplies, which is why they are dispatched during crises like blizzards and hurricanes and asked to aid hospitals burdened with climate-related disasters. All this makes them uniquely positioned to talk to their patients about coping with climate change and advocate for their needs.
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The International Confederation of Midwives first adopted a position on climate in 2014, arguing that midwives must influence “social change in relation to sustainability” and that midwifery education should incorporate the health implications of climate change. Women, pregnant people, children, and the developing fetus are more likely to suffer from the effects of disasters and the environmental pollutants that further climate change. For example, pregnant people are more vulnerable to excess heat exposure than healthy, non-pregnant people; studies link higher temperatures to preterm birth, low birth weight, and stillbirth. Other research shows a connection between heat stress and a number of threats to maternal health, like preeclampsia, a sudden increase in blood pressure and the leading cause of maternal death in the US.
“We now have to educate on the impacts of the climate, like wildfires, as well as other environmental exposures,” says Tanya Khemet Taiwo, an assistant professor in the Department of Midwifery at Bastyr University. Taiwo is also a certified professional midwife, one of the three professional designations for midwives in the US. The profession has always focused “on health education and risk assessment because our visits allow enough time to understand the context of a patient’s life,” Taiwo says. Courses modules on caring for patients in crisis settings are common, and professional organizations like the American College of Nurse-Midwives offer further training and workshops. Midwives, and midwives-in-training, are taught fundamentals like what supplies are especially handy during a disaster, how to deliver psychological first aid, and how to guide new mothers in breastfeeding while managing displacement.
Many frontline birth workers already know how to assist birth during floods, fires, and earthquakes. They are acutely aware of how social and literal environments influence their patients and help their patients overcome climate threats by teaching them how to respond to dangers like heat and poor air quality. For example, some midwives in wildfire-affected Oregon advise their patients on the ways smoke can enter indoor spaces. In some instances, these providers also supply necessities during crisis; in the aftermath of Hurricane Laura, the Birthmark Doula Collective launched a 24-hour emergency parent-infant hotline and dispersed ready-to-feed formula.
These workers have the potential to do even more if they’re incorporated into state and hospital disaster plans. Overcoming climate change also means living through it, and people continue to have babies during emergencies.
Yet Skye Wheeler, a senior researcher in the women’s rights division of Human Rights Watch, has found that birth workers are often not integrated into hospital responses until the crisis has already hit: When Wheeler interviewed a midwife in California, the midwife recalled a moment when wildfires shut down her local hospitals. A doctor called her and said, “Can you help us deliver these babies?”
In a way, Covid gave a preview of how collaboration between ob-gyns and midwives could look in other disaster settings. During the pandemic, midwifery-led birth centers and home births saw an increased number of pregnant patients who asked to switch their care from burdened hospitals, according to Dr. Trish Voss of the American College of Nurse-Midwives. This was especially true in rural America where there was already a shortage of health professionals. Midwives served patients whose hospitals suspended or cut their obstetric services because of workforce shortages, financial challenges, and too many patients. Some viewed this pivot as the inciting event that could lead to expanded access to midwives. But despite that interest, some birth centers which experienced a boom during the start of the pandemic are now closing, unable to stay open because of costs.
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What’s keeping midwives from making a larger dent in the fight against climate change? To start with, there are not enough of them. The United Nations reports that there’s a shortage of around 900,000 midwives worldwide. This shortage extends to the US, which has worse maternal mortality rates compared to other high-income countries where midwives have a central role in care.
In the US especially, multiple insurance-related hurdles stand between patients wanting to work with a midwife or doula and getting to do so. “What’s worrisome from an equity standpoint is that Black, Indigenous, and Latinx people often live in states where there are more barriers to access the midwife,” says Saraswathi Vedam, the lead investigator at the Birth Place Lab and professor of midwifery at the University of British Columbia. Vedam’s research demonstrates that integrating midwives into the American health care system positively influences equity and health outcomes.
There’s a throughline between these barriers to midwife access and the racist campaign to undermine midwifery in favor of the medicalization of childbirth and the rise of white male obstetricians and gynecologists. In the early 1900s, these doctors targeted midwives, who were often Black, by criminalizing and discrediting their work. One prominent early obstetrician, Joseph DeLee, called midwives a “relic of barbarism.” This history underlies why many Americans at worst, think of midwifery as unsafe or don’t think about it at all. “I’ve been a midwife for 37 years, and it’s still amazing to me how little the average person knows about professional midwifery and what it can offer,” says Vedam.
Connecting patients to the birth workers who can provide climate-focused care—to the people who will ask their patients whether they have air conditioning, whether they have a plan if their home floods, and whether they know how to apply for an electricity stipend—requires dismantling the stigmas that underlie and hinder structural barriers.
Supporting the workforce itself is also key: Wheeler and her colleagues at the National Birth Equity Collaborative are currently asking midwives, doulas, and other maternal care workers about what they already do to address climate impacts and what more they would like to do. The idea is that these results can help develop collaborative training between birth workers and other professionals, like epidemiologists and climate scientists. She views the work as solidarity building, observing that “the climate crisis is teaching us we need to be intersectional in how we approach health.” This type of collaboration has happened before, though through piecemeal efforts. For example, in 2018, researchers hosted a training on heat exposure and maternal health in the community room of an El Paso, Texas, birth center. After the pilot project, the attending doulas and midwives reported that they spoke more often with their clients about heat risks.
But there is room to grow. Davies also thinks there’s a need to make “sustainability literacy a core component in every midwifery curriculum”—a codification that goes beyond midwifery’s deep-rooted connection to sustainability. Her point, and her work on the subject, have already influenced midwifery in her country, New Zealand. Alison Eddy, chief executive of the New Zealand College of Midwives, says Davies’ midwifery and sustainability research was a catalyst for the profession, inspiring them to seriously consider how to serve as a climate solution.
There is a responsibility to “educate and lead midwives to become climate change champions in their work, to think and act critically in how they use resources in their practice, and to consider their role in advocacy to hold governments, hospitals, and politicians to account,” says Eddy. She’s put this belief into practice: The College has advocated for the recognition of the special needs of pregnant people and infants in New Zealand’s Climate Change Response (Zero Carbon) Amendment Bill.
In the US, there is some movement toward investing in midwives because of their connection to improved health outcomes: In June, the Biden administration released a “blueprint” for addressing the maternal health crisis that included a promise to work with states to expand access to doulas and midwives. With women particularly vulnerable to the effects of climate change, there needs to be a similar effort that reflects their connection to climate-related care.
So much talk about the climate crisis concerns what we need to give up. But midwife-expanded care is a rare example of something we can gain.