Consulting a midwife when not pregnant: what happened in France after the 2009 reform?

BACKGROUND: While access to gynecologists in France has become very difficult for most women, demography of midwives is dynamic (+ 10.5% between 2013 and 2018), especially in ambulatory positions. In the same time, in 2009, a healthcare reform in France extended the skills of midwives. While they have been historically associated to care for pregnancy and childbirth, midwifes have been authorized from then to intervene for the gynecological follow-up of non-pregnant women. This paper explores how this reform affects the probability of women to consult a midwife when not pregnant, and the heterogeneity of this effect according to women's characteristics. DATA AND METHODS: Using longitudinal administrative data on the healthcare consumption of French women, we reconstruct pregnancy periods and control for a rather large number of individual characteristics (age, health status, outpatient care expenses, rate of extra fees born, region, index of a taxonomy of the French living areas, etc.). We use a generalized estimating equations (GEE) probit regression model to study the change in the probability of non-pregnant women aged 15 to 55 to consult a midwife between 2007 and 2017. RESULTS: We find that the probability of consulting a midwife for reasons other than pregnancy increases after the 2009 reform, particularly since 2012, and increasingly so. This increase is particularly important for women having a recent pregnancy, suggesting that midwives are their own “sales representatives”. The increase is also especially high in rural areas and deprived periurban areas. It can be related to the very poor healthcare supply in these two types of areas that are both characterized by a low supply of care, particularly for healthcare specialists. KEY MESSAGES: • The 2009 reform broadening the scope of midwives’ skills is illustrated in practice through an increase in the use of midwives outside pregnancy by all women and this concerns all types of territories. • the increase appears rather slow, given the significant rationing of gynecological care in many areas due to financial barriers and lack of professionals.