Two Years of Transformation: Imagining a Stronger Midwifery System in Massachusetts

Two years later, the work of turning legislation into lived experience continues. For the Community Birth and Doula Integration (CBDI) team, this anniversary is an opportunity not only to recognize progress, but to imagine what comes next.

That radical imagination took us to Lisbon, Portugal when members of the CBDI team traveled to Lisbon for the 34th International Confederation of Midwives (ICM) Triennial Congress.

Held every three years, the Congress brings together midwives, educators, researchers, policymakers, professional associations, and community partners from around the world to share knowledge, establish standards, strengthen relationships, and imagine new possibilities for care. The 2026 Congress brought more than 3,000 participants together under the theme “One Million More Midwives.” (ICM 2026)

The theme reflects an urgent global reality. The latest evidence estimates a shortage of nearly one million midwives worldwide. ICM reports that increasing the global midwifery workforce could prevent 67% of maternal deaths, 64% of newborn deaths, and 65% of stillbirths—potentially saving up to 4.3 million lives annually by 2035. (International Confederation of Midwives)

The message is simple: we need more midwives.

But we also need to ask a harder question: What kind of system will allow midwives to thrive once we have them?

The United States spends more on maternal and infant health than any other high-income country, yet our outcomes remain some of the worst among high-resourced nations. Maternal and infant morbidity and mortality are unacceptably high, preventable deaths remain common, and racial inequities persist.

At the same time, the people providing care are struggling.

Midwives, nurses, physicians, doulas, and other maternity care professionals are experiencing profound stress and burnout. People who have invested years of education, training, and professional development are leaving the field—or considering leaving—because the conditions of the work environment are unsustainable.

Burnout prevention, therefore, cannot be an employee wellness initiative added onto a broken system.

It is a health-system design issue.

We cannot recruit a million more midwives into systems that exhaust the people already doing the work.

If we want a strong maternity workforce, we must build and sustain environments where people can have long, safe, and satisfying careers. That means designing care systems around relationships, appropriate autonomy, manageable workloads, psychological safety, respect, meaningful collaboration, and time to rest and recover.

This is not separate from quality and safety. It is part of quality and safety.

At ICM 2026, we learned about innovative approaches to education, clinical care, workforce development, and community-based models. We listened to conversations about eliminating obstetric violence and recognizing Indigenous midwifery knowledge and practice for the contributions they make to contemporary maternity care.

We talked with academic partners about how to collaborate instead of competing. Learning about how they measure and describe effective innovations that can be replicated in communities around the world.

We asked nurses and midwives how they are feeling about their work—and what would make that work less traumatic.

And, we rested.

We shared meals and conversation together. We immersed ourselves in the Portuguese culture. Those things are not distractions from the work.

They are part of the work.

True to the core of midwifery, a short list of essential ingredients for perinatal health system re-design grew during our time in Lisbon:

Radical imagination.
Trust. Respect. Connection.
Collaboration over competition.

Indigenous intelligence.
Rest.
Joy.
Community.

The Community Birth and Doula Integration Initiative is transformation in action. We are working toward culture change—not simply adding another service to the existing health care system.

On August 24, 2024, Massachusetts enshrined an important foundation for that transformation. Chapter 186 of the new general laws established numerous regulatory and statutory changes. These included a new Maternal Health Access and Birthing Patient Safety Task Force, co-chaired by the Massachusetts Health Policy Commission and Department of Public Health, to examine maternal health access, investment, and patient safety across the Commonwealth. (Massachusetts Health Policy Commission); creation of a Board of Registration in Midwifery to license certified professional midwives, revisions to facility regulations governing freestanding birth centers, and expanded platforms to review perinatal morbidity and mortality on an ongoing basis.

But legislation and regulation are only the beginning.

The deeper work is building the relationships, infrastructure, and culture that make integrated care possible.

That means creating meaningful connections between community midwives, doulas, hospitals, EMS, public health agencies, payers, educators, and families. It means developing reliable transfer-of-care processes. It means helping hospital teams understand what happens in home birth and birth center settings—and helping community providers understand hospital systems.

Most importantly, it means recognizing that these professionals are not working toward different outcomes.

We have the same goal: healthy parents, healthy babies, and respectful experiences of care.

We may have different settings, different tools, and different approaches. Integration allows us to learn from those differences rather than allowing them to become barriers.

When hospital-based professionals spend time learning about community birth, they can begin to imagine what might be possible in their own settings: more continuity, more trust in physiologic birth, more watchful waiting when appropriate, deeper listening, and greater confidence in the capacity of the body to birth.

When community providers engage with hospitals, they can build stronger relationships before an emergency occurs. A transfer can become a coordinated transition rather than a rupture in care.

And when we create systems that respect both approaches, everyone learns.

That is the promise of integration.

It also offers an opportunity to address burnout differently. A system built around trust, respect, connection, and shared responsibility can reduce the isolation that contributes to exhaustion. A system that values clinical expertise and embodied wisdom can give professionals more agency. A system that makes space for rest, reflection, creativity, and joy can help people remain in the work.

We cannot prevent every difficult birth.

We can design systems that make difficult work more sustainable.

Two years after the passage of Massachusetts’ landmark midwifery legislation, we have much to celebrate—and much more to build.

Our task is not simply to increase the number of midwives and have more births in birth centers and at home.

It is to create an ecosystem in which midwives can practice at the top of their education and training, collaborate across settings, and build careers that are safe and satisfying.

It is to create a maternity care system where families can receive respectful, trauma-informed care from professionals who know one another, trust one another, and know how to work together.

And it is to build a system where the future does not demand people work until burnout occurs to provide excellent care.

The future we are imagining looks different.

For maternity care professionals, it looks like a well-supported system that makes room for collaboration, autonomy, innovation, rest, relationship, and joy.

For pregnant people and their babies, it looks like safe, supported labor and birth—with the people they love nearby and a skilled, caring team ready to respond when needed—whether birth happens at home, in a birth center, or in a hospital.

Two years ago, Massachusetts changed the law.

Now we can change the culture.

And maybe that is the most important lesson we brought home from Lisbon: transformation begins when we allow ourselves to imagine something better—and then build it together.