While disparate outcomes for Black women and people and other systematically excluded groups are persistent and well documented, research on models of care that are more likely to lead to healthier and more desirable outcomes remains limited [38]. Our findings demonstrate clear evidence for how midwifery care as practiced outside of institutional settings offers childbearing people a greater likelihood of experiencing respect, autonomy, and satisfying engagement during one’s childbearing journey.

In our analysis, compared to people receiving care from a physician in a hospital, participants with midwifery care in community settings had more than five times the odds of reporting high levels of decision-making autonomy and were five times more likely to report that their provider showed them high levels of respect. Participants also reported fourteen times the odds of having enough time in prenatal visits with community midwives than when cared for by physicians. Participants receiving midwifery care in hospital settings were almost two times more likely to report having enough time during their prenatal visits. These results are consistent with previous studies demonstrating that independent models of midwifery-led care in homes and freestanding birth centers, which can encompass cultural and emotional aspects of care, and have sufficient time to provide relationship-based care, enhance the quality of care experiences and may contribute to a sense of personal safety [39, 40].

While maternity care in the U.S. is predominantly provided by obstetricians, growing discourse calls for the comprehensive values-based care offered by the midwifery care model as practiced across birth settings (home, freestanding birth center, and hospitals) [41]. The integration of midwifery care across settings would improve care quality and improve maternal health outcomes in the U.S. [1, 42]. Midwifery care and birth center care (overwhelmingly provided by midwives) are consistently identified as key strategies needed to enhance perinatal health outcomes [39, 43,44,45]. Yet, compared to countries that demonstrate healthier and safer outcomes, the organization of maternity care in the US provides limited access to choice in birth settings [including hospitals, freestanding birth centers (FBC), and homes] and limited integration of midwifery across maternity care services [22, 42, 46].

By measuring experiences of care stratified by both provider and setting, our study demonstrates the importance of the care setting in shaping patient outcomes and experiences. Partcipants cared for by midwives in community settings reported better care experiences than those cared for by physicians in the hospital, however, these benefits did not remain consistent for those cared for by midwives working in hospital settings. While participants cared for by midwives in hospitals reported more autonomy and more time spent in prenatal care compared to physicians, there were no differences in the levels of respectful care or mistreatment reported. This suggests that the setting where midwifery care is delivered has a significant impact on the capacity to operationalize key tenants of the midwifery model [47].

Research conducted by Vedam et al. [22] and Yang et al. [23] demonstrated the potential for midwifery care to improve population level health outcomes if buttressed by structural policies that support autonomous midwifery practice, such as licensing, full scope of practice, access to midwifery care, fair insurance reimbursement and enhanced regulations. In states where midwives practiced with greater autonomy, Yang et al. [23] demonstrated lower odds of cesarean delivery, preterm birth, and low birth weight, compared with states with more limited midwifery autonomy. Vedam et al. [22] also provided strong evidence that in states where the regulatory environment for midwifery practice facilitated autonomous, full scope of practice, there were far better outcomes for women and childbearing people—including higher rates of spontaneous vaginal delivery, vaginal birth after cesarean (VBAC), and breastfeeding, and significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death. Both studies suggest that midwives practicing to the fullest expanse of their scope is critical to achieving optimum clinical outcomes. Subsequent investigations demonstrate the effect of midwifery care integration on experiential outcomes. Our findings support that there is a potent influence of the context for midwifery practice and enabling practice environments in institutional settings on experiential outcomes [27,28,29, 48].

Given the hierarchical structure and organization of maternity care in the US—as an obstetrician-led, hospital-centric, technocratic space, more robust methods are needed to also differentiate the impact of the models and settings of care, a deliberate move away from analysis by provider type alone. Our findings suggest that midwives providing their care outside of institutions—in homes and freestanding birth centers—are better able to support core principles of person-centered care rooted in a human rights approach which centers respect, relationship, and autonomy in decision-making. However, when the midwifery care model is within an institution such as a hospital, the constraints and culture of that environment are challenged to support the core values of midwifery [12, 49]. Global inclusion of person-centered care, which is organized to support a person’s autonomy, provide a respectful approach, and support for informed and culturally relevant decision-making is scarce in institutional settings [26, 50]. Our analysis of intragroup differences among midwives (community and hospital) demonstrates that the implementation of the midwifery care model is deeply influenced by the setting itself.

Our findings add to evidence showing the model itself seems to be strongly influenced by the setting in which care is given—with community settings (home and freestanding birth centers) offering greater likelihood of support and the hospital settings being limited by the constraints of a medical approach to care which deprioritizes experiential outcomes [51]. As presently enacted, hospital maternity settings do not provide an enabling environment for full realization of the midwifery model of care. An enabling environment is defined as the social system within which people function [52]. All the rules, laws, policies, power relations and social norms that govern engagement in these spaces are considered impactful to the overall functionality and culture of a system [53]. This confirms global understanding that the culture and organization of the care environment itself serves as a limiting or enabling factor in ensuring high quality care [48, 49]. Singular focus on provider behaviors fails to address the complex and intersecting factors that determine the quality of experiential care.

Challenges in operationalizing the midwifery model of care in hospitals are often due to the dominant physician-based practice model, which is pathology-focused and technocratically driven [54, 55]. The tendency for practitioners in hospitals to rely heavily on interventions creates a challenge to practice autonomy for both the service user and the midwife [12, 49, 56]. The confines of the practice policies, approaches to risk stratification and interprofessional dynamics are all factors that limit the midwifery model from flourishing in hospital and institutional settings [48, 57]. As Newnham and Kirkham argue “large institutions that prioritize a midwife–institution relationship over a midwife–woman relationship are in themselves unethical and inimical to the midwifery philosophy of care.” [58, p. 2147]. Our findings suggest that while ‘how’ care happens matters, ‘where’ that care happens is equally important.

Deep systemic and organizational changes are necessary to support the integration of midwifery across the range maternity care services. Two strategic directions and impact investments could enhance perinatal care services: (1) integration of a human rights-based framework across all care delivery settings and (2) restructuring hospital-based care to allow for more optimal midwifery care integration to build facility policies to enable the midwifery care model to thrive.

Maternal health care often happens without explicit commitment to a human rights-based approach to care. A limited framing of professional ethics as solely dependent on interpersonal interactions and biases, fails to consider the structural and institutional factors that also threaten human rights and dictate the social nature of human interactions [59, 60]. Our findings indicate a clear need to improve experiences of care in hospital settings and shift institutional approaches to better align with person-centered models of care. A pragmatic example of how healthcare praxis can incorporate rights-based principles is offered in the ‘Black Birthing Bill of Rights’ [61]. The resource visually outlines core principles of autonomy and respect in birth. It is also intended to provide guidance to hospitals, health care providers, government health agencies and others to “change/improve their ethic, policies, and delivery approach to serving Black women and persons throughout the birthing process” [61]. This is a clear and direct example of orienting healthcare practice and relationships to uphold the core principles of human dignity, autonomy and self-determination.

Given the prevalence of midwives working within the hospital setting—their philosophical approach to care can be difficult to actualize as institutional values are focused on profitability and risk profiling designed to locate pathology. These values ultimately drivs divestment from supporting physiologic labor and birth and the psychosocial components of care [49, 57]. Maternity care in the US is a medical model of care led by physicians which predominantly operates through a hierarchical approach over a collaborative approach [62]. For a person-centered care model to flourish in all birth settings, a horizontal approach that promotes active collaboration built on principles of professional regard, mutual respect, and trust in the expertise offered by each provider type is essential [63]. For example, care bundles with simulations solely focused on clinical management without consideration of person-centeredness and interprofessional collaboration perpetuate the gap in our ability to measure and address the psychosocial dynamics that impact outcomes. To address the comprehensive needs of women and childbearing people, healthcare quality improvement initiatives must incorporate affective and social dimensions of care as system level drivers of care—not only relegated to the responsibility of individual providers but embraced to orient the organization and implementation of care. Research continues to show that respect, autonomy and informed decision making are highly valued by perinatal care service users—both locally and globally [25, 64] and are key to ensuring anti-oppression, culturally respectful care becomes the new standard of care [25, 65]. Increased integration of midwifery care into all care pathways—at home, in freestanding birth centers and in hospitals, may ensure greater ability to offer high quality and culturally safe experiences of care to all childbearing people.

The sampling strategy for this study was not designed to be representative, limiting the generalizability of the findings. Participants of color were oversampled to explore factors associated with wide disparities in U.S. birth outcomes by race/ethnicity and the systematic exclusion of racialized populations from research. This survey also intended address the lack of data on experiences of childbearing care outside hospital settings. In previous studies, analyses stratified by both birth setting and provider were limited due to small sample sizes. Our sampling strategy allowed for rigorous comparisons by birth setting and provider type.

A large proportion of our sample reported living in New York state. However, the strength of findings even after controlling for variation in sociodemographic characteristics, and pregnancy risk factors suggest that differences in experiences of care based on setting are unlikely to be limited to a particular state or demographic but may represent a large-scale, systemic problem.

It is also possible that multiple participants gave birth in the same hospitals (especially for births in New York) and we were unable to control for clustering of births within hospitals. Hence, our analysis does not account for the well-documented variations in the quality of care between hospitals [66]. Additionally, we note that our analysis did not assess the potential mitigating effects of continuity of provider across the arc of prenatal care to labor and birth care on the care experience.