[dropcap]I[/dropcap]n a recent United Health Foundation report, Vermont was named the third healthiest state overall in the country. Since the creation of the report in 1990, Vermont has risen 17 places. It enjoys a low percentage of uninsured people (3.8 percent) and was ranked second in women and children’s health. Vermont’s women are especially healthy. At 61 percent, they self-reported the highest rate of “high health status” in the U.S.

Babies are doing well here, too. Vermont boasts some of the lowest infant mortality and childhood poverty rates in the nation. It is consistently ranked by Wallethub as one of the best states in the U.S. to have a baby. In fact, 2017 was the second year in a row Vermont earned the number one slot. It made the top five on measures of most midwives, OB/GYNs, pediatricians, family doctors, and child care centers per capita.

One of the big hurdles to providing high-quality in rural areas is lack of health care professionals interested in working there. So how does a predominantly rural state like Vermont attract such an amazing density of health care workers?

“Vermont is a wonderful place to practice medicine. The medical community … is very collegial, so it’s an inviting place to work,” said Dr. Anna Benvenuto, medical director of specialty services in the women’s health department at the University of Vermont’s Porter Medical Center in Middlebury. “The ability to create long-term relationships with families across generations is a unique and enriching experience.”

What’s more, she says the “availability of a multitude of outdoor activities, vibrant arts scene, and ability to be socially engaged offers a wide range of opportunities outside of work. There is an ability to create a manageable work-life balance.”

So is there anything we can glean from Vermont’s maternity care-delivery model that might help other rural states? Benvenuto says there are a few things that really elevate the state’s care. First is the Northern New England Perinatal Quality Improvement Network, a collaborative of hospitals and homebirth midwives throughout Vermont and New Hampshire that creates protocols for pregnancy and delivery care, holds educational conferences for care providers three times a year, and performs case reviews.

Currently, 25 states have active perinatal quality collaboratives, with many others in the works. States with PQCs have seen significant improvements in the care of mothers and newborns. PQCs goals include reducing newborn infections, neonatal abstinence syndrome, elective early deliveries, maternal hemorrhage and hypertension, and increasing human milk use.

Next is the Vermont Child Health Improvement Program, another research and quality improvement program, which collects statistics for every Vermont hospital that provides obstetric services. They then present a summary of their report and provide an educational session for the medical staff focused on specific areas to target for improvement.

Many rural states across the country are losing maternity care options. Nine percent of rural counties lost hospital obstetric services between 2004 and 2014. When hospitals struggle financially, obstetric units tend to be first on the chopping block because they are incredibly costly. Vermont has fared better than many other rural states in this respect. All of the state’s hospitals continue to offer obstetrical services, so there are no large gaps in geographical coverage like the ones appearing in other counties across the nation.

“We are fortunate that hospitals continue to support birthing units. Women in many other rural areas are experiencing the closing of the nearest birthing unit—forcing long drives and reducing access to both routine prenatal care, delivery services and emergency management,” said Benvenuto.

This increased access means a large proportion of women don’t miss out on critical prenatal care. Data from 2015 show 84 percent of pregnant Vermont residents received prenatal care in the first trimester and only 6.6 percent of babies were born at a low birth weight. Nationally, one of the Healthy People 2020 goals is to increase the proportion of pregnant women who receive care in the first trimester from 71 percent in 2007 to 78 percent in 2020. Lack of adequate prenatal care is associated with an increased risk of low birth weight, prematurity, stillbirth and infant death.

A density of caregivers also gives patients a lot of choice, and better pre-pregnancy and intra-pregnancy health care. In most areas of Vermont, women have a choice of whether they want to see an obstetrician, midwife, or obstetric-certified family practice physician for their maternity care. Women in other states may miss out on such care because they can’t afford it or have to travel too far to receive it. Some states allow women to access Medicaid coverage at higher incomes after they become pregnant, but adequate care before and between pregnancies can also contribute to better maternity outcomes for moms and babies.

“Primary care has been cultivated for decades in Vermont. This robust network means that a higher percentage of women start pregnancy with chronic medical conditions under better management,” said Benvenuto. “Many women have also pursued pre-pregnancy consultation, so they have a better understanding about their risks going into pregnancy. Some women choose to delay childbearing until their conditions are better controlled, reducing their pregnancy-related risks.”

Vermont also has the seventh lowest caesarean section rate in the country. C-sections involve many of the same risks as any other major surgery, such as blood clots, and repeat C-sections can increase the risk of postpartum hemorrhage. To improve outcomes for birthing mothers at Benvenuto’s hospital, they focused on some of the highest-risk pregnancy conditions: hypertension/preeclampsia (dangerously high blood pressure) and postpartum hemorrhage. These are among the top contributors to maternal mortality.

“We have educated our obstetrical care staff and emergency providers using evidence-based protocols and developed at-the-bedside tools to manage these conditions,” Benvenuto said.

While it’s very tempting to want to compare birth outcomes across states, to say Alabama’s outcomes are significantly worse than Vermont’s–it’s important to remember it’s not always a case of apples-to-apples, as it were. States face different challenges, and racism in particular (in health care settings and the accumulating toxic effects of everyday discrimination) can have an incredibly detrimental, even deadly, effect on the pregnancy and birth outcomes of Black women.

“When comparing states, you have to be careful. Unless you have many years of data, it can be tricky to compare. It’s disingenuous to compare a state with an almost completely white population to one with a large African American population,” said Dr. William Callaghan, chief of the Maternal and Infant Health Branch of the Division of Reproductive Health at the Centers for Disease Control and Prevention (CDC).

Callaghan explains that the structure of segregated communities impacts how care is delivered: “Studies [have] found that outcomes of hospitals that primarily serve a black population are not the same as those that serve primarily white populations. The best levers, the best way to change those things, are people in the state realizing it’s happening. What has to happen is opinion leaders in communities driving change in how health care is delivered.”

One big way Vermont’s maternity care stands out is just how many midwife-attended births there are. Nationally, midwives attend 10 percent of births. In Vermont, however, that rate is more than double: midwives attend a whopping 23 percent of births. The University of Vermont Medical Center has the only 24/7 certified nurse-midwifery practice in the region. Additionally, 67 percent of the state’s rural hospitals employ a nurse midwife—that’s practically unheard of in the U.S.

Certified nurse midwives (CNMs) are people who’ve completed a nursing degree and midwifery training. Lay midwives, often called professional midwives or certified/licensed professional midwives must be licensed by the state in order to practice. Licensure requirements vary by state, but most include the need to have completed a certain number of hours in midwifery training or apprenticeship, and has met the standard for certification by the North American Registry of Midwives (NARM).

“67 percent of the state’s rural hospitals employ a nurse midwife—that’s practically unheard of in the U.S.”

The state requires Medicaid to cover midwifery services by nurse midwives or licensed lay midwives. In states that do not regulate lay midwives, which means they do not offer licensure—effectively rendering lay midwives as illegal practitioners of health care—Medicaid would not cover lay midwifery services. Most nurse midwives tend to oversee births at hospitals, and occasionally at birthing centers, while lay midwives tend to births largely in homes and birthing centers.

“Our practice is an integrated CNM/MD practice. We have three CNMs, three OB/GYN physicians, and a family medicine physician with additional training in obstetrics. We created a practice that elevates each clinician’s expertise,” Benvenuto said. “Our midwives provide the bulk of low-risk care, both for prenatal visits and on our delivery unit, and our physicians focus on complications of pregnancy and are always available for obstetrical emergencies.”

Vermont is one of 25 states that allow CNMs to practice independently and exert full prescriptive authority. Nineteen states require them to enter into a collaborative agreement with a licensed physician and only practice under their direct supervision; the rest of the states allow CNMs to practice independently but must enter into an agreement with a doctor for prescriptions.

Some argue supervision requirements facilitate cooperation among midwives and other health care providers, while others say it’s a paternalistic practice that stifles nurse midwives’ ability to practice freely and better meet the needs of their patients.

The Birth Place Lab recently ranked states for midwifery access and integration. Vermont was ranked thirteenth in the nation. The state has an incredibly high density of midwives, which was associated with significantly higher rates of spontaneous vaginal deliveries (as opposed to inductions), vaginal births after cesarean (VBAC), and breastfeeding, and significantly lower rates of preterm birth and low birth weight babies. Integration was based on how well these health care professionals were included in care-provider networks.

“Interprofessional teamwork is essential to the provision of high-quality maternity care,” the researchers declared. “When professionals collaborate on decision-making and when coordination of care is seamless, fewer intrapartum neonatal and maternal deaths occur during critical obstetric events. Poor communication, disagreement, and lack of clarity around provider roles are identified as primary determinants of these adverse outcomes.”

Interestingly, the bottom seven least-integrated midwifery states were all ones requiring physician supervision of nurse midwives.

In Vermont, the OB and midwife communities (both lay midwives and certified nurse midwives) typically work together very well. Some midwifery practices in the state see a nurse midwife and a professional midwife working together, which is rather unique.

“We have cultivated relationships with homebirth providers in our area so there are seamless care transitions if women require intrapartum transport to our hospital or require consultation for high-risk conditions that may develop throughout their pregnancy. Our clinicians feel that this approach to care allows us to educate and empower women throughout their pregnancies and we are able to provide support throughout their labor process,” said Benvenuto.

But like any other rural area, healthcare practitioners here face their share of challenges.

“Practicing medicine in a rural area and in a smaller hospital, there are fewer resources. Whether it is a smaller clinician staff or nursing staff, we have to always be prepared to do more with less. We are on-call more frequently than our colleagues in bigger groups, which can lead to exhaustion and burnout,” Benvenuto said. “We also don’t have a blood bank or an ICU and the closest hospital with those services is 45 minutes away, so we have to be nimble, resourceful and be willing to work independently.”

Adequate blood supplies for transfusions are essential for patients who experience hemorrhaging during childbirth. To address these varied challenges, Benvenuto says the first step is to transfer women who are likely to require high-risk care or early delivery are to the nearest tertiary care center.

Vermont has been deeply affected by the opioid abuse epidemic. There’s also a shortage of mental health providers. Families also struggle with housing and food insecurity, leading to chronic stress from multi-generational poverty, and have difficulty making it to appointments because of transportation issues: no gas money, car troubles, single-car households.

To address those challenges, Benvenuto’s medical group has created a Community Health team: a group of mental health and social workers. The team helps women find resources for basic needs like food, housing and transportation, and they also offer counseling that can be done in conjunction with their pre/post-natal visits. Benvenuto’s group has also begun providing Medication Assisted Treatment for opiate-dependent patients, which has helped reduce stigma and increased access to this much-needed treatment.

“Working to alleviate these stresses has allowed women to better focus on caring for themselves and has been shown to increase compliance with prenatal care and improve pregnancy outcomes,” Benvenuto said.

Other states should consider taking cues from Vermont’s efforts to collect data on maternal and child health outcomes and look for strategies to improve them, incorporate midwives into maternity care, and find ways to address community health challenges without increasing stigma.

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O.M. Campbell is a journalist, an essayist and a regular contributor to New York Magazine. Campbell's work focuses on the intersections of medicine, mothering, history, the environment and the arts.