[dropcap]M[/dropcap]aternity care in rural America is disappearing fast. Between 2004 and 2014, 9 percent of rural counties lost hospital obstetric services. Now, more than half of our nation’s rural counties lack such services. Despite 15 percent of the nation’s population living in rural areas, only 6.4 percent of OB/GYNs work there.

Maternal and infant mortality—both tied to lack of adequate prenatal, delivery, and postpartum care—are shockingly high in the U.S., and the rates are highest in rural areas. Despite the increased risk of complications, the number of planned C-sections is often higher in rural areas because many women fear they might not make it to the hospital in time for the birth if they go into labor naturally.

Most shocking are the racial disparities in pregnancy and birth outcomes, as maternal and infant mortality are two to four times higher among black women compared to white women. Predominately black rural counties are more likely to lack or lose obstetrical care.
When a patient calls a hospital in labor, “you have ER doctors rolling the dice: do we get her on the ambulance or not? Will she make it to the hospital?” said Dr. John Waits, a family physician and obstetrician in rural Bibb County, Alabama.

In west and southwest Alabama, Waits says travel time for maternity care can be upwards of two hours. “Now, times that by a factor of 15 to 40 prenatal visits. And if you develop diabetes or hypertension—which are epidemics in rural areas—now you need two visits a week,” said Waits. “Twenty percent of our county are no-car families. Much of the rest are one-car families. Prenatal care suffers horrendously.”

Of Alabama’s 54 rural counties, 45 had hospitals offering obstetrical services in 1980; today only 16 do. It has the fewest maternity-care providers per capita and one of the highest infant mortality rates in the nation. Here, the infant mortality rate actually increased in 2016. The rates of infant and maternal mortality are about three times higher for black women than they are for white women.

Waits says what’s really dangerous about these rural maternity-care deserts is how much institutional knowledge evaporates when a labor and delivery unit is shuttered.

“In a hospital with a labor and delivery unit, ER doctors are accustomed to seeing pregnant women come through the doors; they are comfortable with dealing with them,” Waits said. “When a labor and delivery unit closes, the doctors leave, the nurses leave. Then it’s up to the ambulance personnel to take care of women and children. Without a labor and delivery unit, they aren’t going to the hospital except in crisis. You lose the institutional memory of how to care for that population.”

“Women aren’t choosing a midwife because of money—Medicaid will pick up their hospital tab—they’re trying to limit interventions and have a good, natural birth.”

So what’s the solution to this growing crisis?

Enter midwives, who for low-risk patients, can deliver lower-cost maternity care with just as good or better outcomes and consistently higher satisfaction rates. A recent study found no increased risks for midwife-attended rural births when compared with non-rural ones.

In countries with similarly unavailable hospital-based maternity care, midwives are seen as a life-saving solution. In the U.S., a decades-long campaign sewing skepticism about the safety of midwifery means nearly 90 percent of births are attended by physicians.

“Midwives have been shut out,” says Jennie Joseph, a British-trained midwife whose pioneering model for “easy access prenatal clinics” has improved birth outcomes in Florida. “We should be able to provide prenatal care at the very least, if not delivery.”

Joseph says if patients receive prenatal care with a midwife—care they wouldn’t have otherwise gotten because of cost, lack of an obstetrician, or distance/transportation issues—“that in and of itself will save lives. Midwifery could really make a difference in rural areas.”

In the first report of its kind, a panel of maternity care experts mapped the integration of midwives into regional U.S. health systems. They found higher levels of midwife integration were associated with better health outcomes: significantly higher rates of spontaneous vaginal delivery, vaginal birth after cesarean (VBAC), and breastfeeding, as well as much lower rates of obstetric intervention, cesarean, preterm birth, low birth weight, and infant death.

Unfortunately, the data also showed even in the state with the highest rate of midwife integration—Washington, which scored 61 out of a possible 100 points—there is still a long way to go. The problem? For starters, the term “midwife” has no standard definition. Multiple types of midwives exist in here: Certified Nurse Midwives (CNMs), Certified Midwives (CMs), Certified Professional Midwife (CPMs), and licensed midwives (LMs).
CNMs and CMs have masters degrees in midwifery and are certified through the American Midwifery Certification Board. CNMs are registered nurses and are licensed to practice in all 50 states, while CMs are only licensed in four states. Nationally, nurse midwives attend 8.3 percent of births. The vast majority of births occur in hospitals; only 3 percent of CNM/CM-attended births occur in birthing centers, another 3 percent in homes. Many states require these midwives to practice under an obstetrician.

CPMs and LMs, on the other hand, are largely viewed as outside the medical establishment. They are often referred to as lay midwives, they attend births in birthing centers or homes. They may have only have a high school diploma, but should have completed training and an apprenticeship with a certified midwife. While LMs must only meet the state licensure requirements, CPMs are certified through North American Registry of Midwives (NARM). To achieve certification, midwives must observe 10 births, deliver 20 babies under supervision, and conduct 40 postpartum exams, 20 newborn exams and 75 prenatal exams.

While NARM certification is the standard for lay midwives in the U.S., not everyone believes it requires enough training. In a 2015 statement, the American College of Obstetricians and Gynecologists (ACOG) instead endorsed the International Confederation of Midwives (ICM) education and training standards. While all CNMs and CMs meet these standards, as many as two-thirds of lay midwives don’t. ACOG asserts universal implementation of ICM standards would help ensure safe, high-quality care.

Laws governing lay midwifery vary widely by state. Thirty-three states recognize lay midwives via licensure, but there are big variations in what’s required for licensure and what midwives are allowed to do. These differences mean some states enjoy cooperation among physicians and midwives, while in others, hostility reigns. Interprofessional cooperation is connected to better health outcomes.

“Especially in rural areas, I definitely think they could help fill gaps in care,” says Karen Brock, who’s spent her life as a midwife in rural Cullman County, Alabama, just like her grandmother before her. “Travel time is less of a concern since midwives often travel to families.” She estimates she’s delivered around 1,500 babies since 1983.

With a score of 18 out of 100, Alabama ranked next-to-last in midwifery integration. (North Carolina was last with a 17.) In 2017, Alabama became the most recent state to offer lay midwives licensure. The practice had been illegal there since 1976. In states without licensure regulations, professional midwives risk prosecution. Practicing medicine without a license is often punishable as a felony and carries steep fines. Previously, many Alabama midwives traveled to Tennessee to tend to their patients or attempted to practice under the radar.

“I’ve had women travel three hours to me to get the kind of care they wanted,” Brock said. Over the past 14 years, she says she’s taken an average of 50 moms a year across state lines to receive midwifery care in Tennessee where she is licensed. Brock says most Alabama midwives quit practicing when it became illegal; others left the state to set up their practice where it was legal.

Historically, midwives delivered most babies in America. Even by 1900, midwives still attended half of births. Since most midwives were black women or immigrants, the stigmatization of midwifery throughout the 20th century made a particular impact on women of color. In the 1920s, there were over 42,000 midwives practicing in the U.S. Most were black women serving black communities. By the mid-’30s, 60 percent of births to black women in the south were still midwife-attended; 90 percent of white women birthed under physicians. Segregated healthcare meant black women often received lower-quality care than their white peers, so they were likely better off with a midwife.

The push to discredit and restrict the practice of midwifery was purportedly about safety, but the data didn’t bear that out. In truth, the smear campaign was actually a case of sexism, xenophobia, and racism. Midwives were labeled as witches or witch doctors; ignorant, superstitious, and dirty. This hit rural southern states hardest. Alabama began requiring midwives to attend state-run training, no matter how long they had been practicing. When the state outlawed practicing midwifery over age 65, all 150 black “granny midwives” were suddenly unable to earn a living.

Unfortunately, the recent resurgence in midwives has largely been among wealthy white women. And structural racism continues to impact healthcare quality for black Americans.
Joseph says the question we need to be asking is: “Why isn’t every woman getting the same quality of care?” In 1998, she founded the nonprofit Commonsense Childbirth with the hope of improving maternity care for people of color.

“They typically blame the women, to educate them—‘these women are so bad, they’re so naughty; these women should eat better’—but you can’t do that when it’s across the socioeconomic strata,” Joseph said. “For women of color, it’s not just about income, education, insurance; it’s not that they are not trying hard enough. Racism, classism, discrimination is built into the healthcare system. We have to face it, otherwise I don’t think we can fix it.”

According to the midwife integration assessment, states where more black babies are born had significantly lower access to midwives. The researchers concluded that more midwives would lead to “long-term health benefits for black mothers.”

So now that midwifery is legal again in Alabama, patients will soon have more options when it comes to maternity care, right? Maybe. Brock says because of all the restrictions in the new state licensure bill, “a non-established midwife is going to have a very hard time; they’re going to go to Tennessee where it’s easier to practice.”

The largest burden is having to carry medical malpractice insurance. Florida and Indiana are the only other states that require lay midwives to carry malpractice insurance. Premiums can range from $5,000 to upwards of $30,000 a year. In addition, the Alabama bill stipulates lay midwives are not allowed to care for twins, breech, or VBACs. “These restrictions aren’t evidence-based,” Brock insists. “We’re having to compromise a lot to get licensure.”

Until recently, Alabama was also one of the roughly half-dozen states where nurse midwives are required to work under a physician’s supervision. When nurse midwives are granted independence from doctors, they tend to practice in rural settings.

In Alabama, nurse midwives attend two percent of births, but their use is growing. Brock says after a health department survey showed Alabama was the worst state to be a nurse midwife, it “made hospitals realize that women wanted this kind of care, so they began hiring more.” In 2016, one Birmingham clinic hired its first nurse midwife in 20 years. “One was just hired here in Cullman,” Brock said.

Waits believes midwives can be “a great physician extender, but in the face of full institutional closure, they’re not gonna move the needle” on these gaps in rural maternity care.

“Midwives can be a part of the team, but they shouldn’t be put in a position where there’s no local capacity to deal with prematurity, emergency operative obstetrics,” Waits said. “They’re good at helping in specific contexts, but have a very limited usefulness. Licensed professional midwives, if they were in out community, they would be fine for term, uncomplicated deliveries and prenatal care. Dangerous home births are not the problem here. Many patients need a C-section, need a NICU.”

So what other options exist for filling maternity care gaps? Well, there are programs offering financial incentives to work in rural areas, and plenty of medical residencies offering rural healthcare tracks, but clearly these haven’t been enough.

It’s not that medical students aren’t interested in obstetrics or in working in rural areas, Waits says. It’s that when they’re offered job contracts at the end of their education, these positions literally don’t exist.

“Women aren’t choosing a midwife because of money—Medicaid will pick up their hospital tab—they’re trying to limit interventions and have a good, natural birth.”

“You’re not going to do it with one recruit. It’s not about encouraging more med students to go into obstetrics, it’s that they would have to want to move somewhere and grow a labor and delivery unit from the ground up,” said Waits. That’s what he did. Before 2015, Bibb County had been without a labor and delivery unit for 20 years. It was no small feat, as he and his team spent five years getting the unit ready to receive patients.

“This isn’t about people not willing or able to do this work, it’s about infrastructure. We need to look at the way we reimburse hospitals for labor and delivery care,” Waits said.
Costs are of course at the root of many hospital closures. Research shows hospital closures spiked in states that chose not to expand Medicaid. Alabama is one such state. It’s especially expensive to keep a labor and delivery unit open, due to the high cost of obstetric intervention and the low patient-to-medical professional ratios. In addition, medical malpractice premiums skyrocketed in the 1980s, especially for OB/GYNs. From 1985 to 2000, the number of hospitals offering obstetrics fell 23 percent.

“You have to deliver 50 to 100 babies a year to clear your medical malpractice premium payment,” Waits said, explaining that when he and his team surveyed all of the labor and delivery units that had closed in recent years, the premium costs were one of the top reasons for closure.

In Alabama, roughly 55 percent of patients are on Medicaid. Long waits for Medicaid approval mean pregnant women on Medicaid often don’t receive any prenatal care until well into their second trimester in Alabama.

The Affordable Care Act requires Medicaid to cover nurse midwifery services, but not all states require private insurance to cover it. In eleven states, Medicaid also covers professional midwives. Without insurance coverage, only women who can afford to pay for a midwife out-of-pocket can utilize their services.

“Women aren’t choosing a midwife because of money—Medicaid will pick up their hospital tab—they’re trying to limit interventions and have a good, natural birth,” Brock said. Many low-risk patients who might have otherwise chosen a midwife may ultimately end up costing Medicaid more money for an obstetrician and hospital birth because that’s what their insurance dictated. It’s often those Medicaid-covered OB tabs that are straining hospital budgets.

Waits says rural hospitals should invest in family doctors with OB/GYN certification because when they don’t get the volume of pregnant patients required to meet insurance premiums, a family doctor can treat plenty of other types of patients. But he cautions they will still need institutional support in the form of a team of nurses and physician assistants who know how to care for pregnant women and newborns.

Given the severity of the maternity-care crisis, rural doctors may have to start accepting midwives into their regional care networks.

“I really hope, my desire is that midwives will be in a position of some respect again, that medical professionals would look on us as a valuable profession,” Brock said. “I’d like to think it’s changing; things take longer in Alabama.”