When Midwifery Care Is Out of Reach

Jason E. Kaplan
Midwife Katy Rawlins and client

Home births in Oregon surged in 2020 due to the COVID-19 pandemic — but insurance coverage for midwifery care is rare.

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When Mariana Warnock started having consistent contractions in her ninth month of pregnancy, she and her husband hopped in the car. They had a three-hour drive to reach their midwife, Katy Rawlins, in Boise, Idaho.

Warnock and her family live in Halfway, Oregon, in a region that can be described as a “midwife desert.” Opting for midwifery care over a hospital birth with all three of her pregnancies meant a three-hour drive to a birthing center in Meridian, Idaho, for her first two and Rawlins’ Boise practice for her third.

“At first I was worried about being able to handle the pain,” says Warnock. Midwives, unlike OB/GYNs, do not offer epidurals. Instead they utilize birthing tubs, different positions for laboring, massage, and other forms of natural pain management. After her first, Warnock knew she could handle it. “Katy would say, ‘You can do this, you’re doing great, you’re so strong.’ Hearing those words just melts the pain away.”

In 2020 a record number of American families gave birth at home with midwives, looking to avoid overcrowded hospitals, restrictions on the presence of partners and labor support, and the risk of infection from a still-mysterious disease. Of 39,820 babies born in Oregon in 2020, 957 were born at home — a 16% increase from 2019.

But that increase in interest did not lessen the challenges of a practice that operates on the outskirts of mainstream health care. In Oregon those challenges were underscored by the announcement that Birthingway College of Midwifery, Oregon’s only school offering in-person training for direct-entry midwives, is due to close following the graduation of the 2022 cohort. Last year also saw the introduction of House Bill 2388, which would have increased access to midwifery care in Oregon by requiring providers to cover out-of-hospital births and increase payouts to midwives and birthing centers — a bill that ultimately failed.

At the time of writing this piece, I am eight months pregnant. My partner and I toured birthing centers and interviewed midwives in my second trimester, hoping to plan an out-of-hospital birth. I don’t want pain medication during labor, and I want caretakers who respect that decision and support me with alternatives, but my insurance only covers hospital births. Despite the significantly lower costs of birthing at home or at a birthing center, financially it will make more sense for us to be at a hospital.

As a middle-class white woman living in a city with many home-birth midwives, birthing centers and hospitals with midwives, I have more options and lower risks than many. In rural parts of Oregon, midwives remain difficult to find, and multiple birthing centers have shuttered in recent years, creating greater gaps in distance and quality of care for Oregon mothers, forcing people like Warnock to drive many hours to a provider like Rawlins. And Black women in the U.S. face a three to four times greater risk of maternal mortality from preventable causes than white women — a risk that multiple studies have shown midwifery care can reduce.

The increased interest in birthing at home during COVID did serve to shed some light on a model of care that prioritizes individual patients, far from the overcrowded halls of hospitals. Yet midwives and home-birth advocates are still fighting for better access to a type of care they see as not just an appealing option to some but a necessary component to adequate maternity care for all.

0722 midwife KatyMidwife Katy Rawlins and client. Photo: Jason E. Kaplan

The Home Birth / Hospital Divide

The Midwives Alliance of North America describes midwifery care as “uniquely nurturing, hands-on care before, during and after birth.” A midwife is a type of health care professional specializing in pregnancy and childbirth who develops “a trusting relationship with their clients, which results in confident, supported labor and birth.”

A Key to the Acronyms
According to the Oregon Affiliate of the American College of Nurse-Midwives, the term “midwife” can refer to several different types of providers. Certified nurse-midwives (CNMs) are advanced-practice nurses with training in both nursing and midwifery, and can practice in all birth settings but often work in clinics or hospitals. Certified professional midwives (CPMs) can be trained in a variety of ways but must pass a skills evaluation and written exam to be credentialed; licensed direct-entry midwives (LDMs) are a subset of CPMs who have received additional training and are licensed in Oregon to administer IVs and medications, order ultrasounds, and perform newborn screenings. CPMs and LDMs typically attend births at homes and in birthing centers. (A third type of midwife, the certified midwife, or CM, is similar to the CNM credential but does not require a nursing degree. CMs are recognized in a handful of states, but Oregon is not one of them.)

While OB/GYNs exclusively deliver babies in hospitals, where epidurals and Cesarean sections are common, midwives typically deliver babies at patients’ homes or in freestanding birthing centers. Midwifery care generally results in significantly lower rates of C-sections and operative vaginal deliveries. And many feel it’s a more comfortable and emotionally supportive way to give birth, which contributes to healthier outcomes.

The individualized model of care also emphasizes cultural and racial sensitivity, pairing parents with caregivers who can identify with or honor specific cultural or religious needs. In the U.S., midwifery care has deep roots in Black communities; in the first few decades of the 20th century, when the number of midwife-attended births dropped from 50% to 12.5%, Black midwives continued to attend half of Black births. In 2014 home births were slightly more popular among white families, with 11% of all white live births attended by CNMs or CMs, compared to 8% of Black live births that used midwives that year.

While the vast majority of U.S. births — more than 98% — take place in hospitals, the number of home births was already on the upswing before COVID-19 hit. In 2004, .87% of U.S. births took place outside hospitals; by 2014 that number had climbed to 1.5%, according to a 2016 analysis of birth certificate data. The raw numbers remain low, but that’s a 72% increase. A 2019 analysis by the same authors said out-of-hospital births were particularly popular in the Pacific Northwest.

Warnock was first drawn to midwifery care when, pregnant with her first daughter, friends and family members who worked at the local hospital warned her not to come there unless absolutely necessary.

For those who aren’t familiar with (or are skeptical of) the differences between midwifery care and hospital care when it comes to pregnancy, labor and birth, Warnock’s decision to travel so far may seem strange, even irresponsible.

But the U.S. also has the highest maternal death rate of developed nations — and it’s rising. A report from the Commonwealth Fund shows 17.4 maternal deaths per 100,000 live births in the U.S., while the U.K. has 6.5 and Germany has 3.2. Another difference between the U.S. and these other developed countries when it comes to pregnancy and birth? Midwives provide most prenatal care and deliveries in the U.K. and the Netherlands — countries whose primary health systems are, according to the Commonwealth Fund, among the strongest in Europe.

And between 2018 and 2020, the maternal death rate in the U.S. increased for all races, but most drastically for gestating parents who are Black or Hispanic. Both of those groups, the 2019 analysis noted, are increasingly likely to give birth outside of hospitals.

0722 midwife ShafiaMidwife and doula trainer Shafia Monroe.  Photo: Jason E. Kaplan

“Women of color are hearing these frightening maternal-mortality statistics, and we are afraid to birth with the medical model of care,” says Shafia Monroe, a midwife, doula trainer, and renowned leader in the movement to advance Black midwives and Black birth. Monroe founded the International Center for Traditional Childbearing — now the National Association to Advance Black Birth — in 1991, after moving from Boston to Portland when she was seven months pregnant and finding there were no Black midwives who could provide her care. There is still a severe shortage of Black midwives, Monroe says.

“It’s disheartening for the high statistics, when we know that 60% of the maternal mortality for Black women is preventable,” says Monroe.

In addition to providing more culturally competent care, midwives devote extensive time to getting to know their patients. Rawlins says she typically sees her patients for 13 to 17 prenatal visits, each an hour long, before a birth — at which point she may be with them for several days of laboring.

“We’re in their homes and have context for what their life is really like,” Rawlins says. “Any physician’s care would be completely different if they could step into their home.”

Postnatal care also looks drastically different with a midwife.

“Most midwives see babies at one day, at three days, at one week, two weeks and four weeks. And we’re seeing mom and baby at each of those,” says Nora Hawkins, a midwife in Wallowa County. The standard follow-up with a physician at a hospital is one appointment at six weeks postpartum.

By the time they were halfway between Halfway and Boise, Warnock wasn’t sure if she could make it. So she called her brother, who lived nearby.

“I told him to fill up the tub,” she says, adding that she told him, “I guess I’m having this baby at your house.” She called Rawlins, who closed the distance between them in record time. But then the contractions slowed and eventually stopped. They all slept that night and continued on to Boise the next morning. They waited several days for labor to pick up again and eventually decided to go back home. “I told my husband, ‘I just want to see my girls.’” Six hours after their return trip to Oregon, they were back in the car and driving to Boise again. Contractions were back, at a frequency and intensity that indicated active labor. This time Rawlins gave Warnock a list of things to have on hand, just in case the baby came quickly, while they were driving.

Rawlins says distance is always a concern. But also, “when babies come quickly, it’s usually because everything is perfect, and in those cases, we can trust the process of birth.

Warnock was about 20 minutes from Rawlins when she felt like she needed to push.

Going the Distance

“Insurance is one of the main barriers to access to care,” says Silke Akerson, a certified professional midwife and the executive director of the Oregon Midwifery Council.

Akerson was a key player in the fight to pass House Bill 2388. That meant going up against powerful insurance companies that are generally opposed to insurance mandates.

But Akerson says the issue runs deeper than the logistical challenges of obtaining insurance coverage.

“I think the greatest challenge for all maternity care providers, not just midwives,” says Akerson, “is that our government, economy and culture don’t support the health of mothers and babies — in structural ways that [exist] long before they’re in our care.”

0722 midwife NoraWallowa County midwife Nora Hawkins with a client. Photo: Jason E. Kaplan

Hawkins, like Rawlins, treats many patients who travel great distances to see her. Until recently, she was the only licensed midwife in Oregon who practices east of Bend. Many of Hawkins’s patients are covered under the Oregon Health Plan. The Affordable Care Act requires that all providers offer network participation to midwives on the same terms as doctors. But midwives across the state, including Hawkins and others in Oregon, say it’s often difficult to get OHP to cover their services. (In June the Oregon Health Authority did announce a plan to increase OHP reimbursement for care by doulas — birth companions who provide nonmedical support to families through pregnancy and birth, both in and out of hospital settings. Rawlins enthusiastically shared news of the state’s announcement on her Instagram account.)

Many midwives decline to accept OHP because of the logistical hurdles of getting paid. But Hawkins says part of why she became a midwife was to increase access to high-quality care — and with so many people in her region insured under OHP, it wouldn’t be right not to work with them.

But something like a hospital transfer or a test result that suddenly puts a patient in the category of “high risk,” according to OHP, can leave the midwife without reimbursement for prenatal care and/or a home birth that was initially approved.

Hawkins says a midwife and their team may have been caring for a woman for 24 hours of laboring. But if OHP decides that something that occurred during labor disqualifies them from coverage, “their reimbursement is less than the gas it took to get to all the appointments.”

Akerson says midwives and small birthing centers just don’t have the person-power to fight for the type of coverage that a big hospital can secure from insurance providers. “[Hospitals] and large businesses have experienced lawyers and a staff that does that negotiation,” she says. “A birth center with five employees just doesn’t have the leverage.”

One patient Hawkins saw a year and a half ago was refused coverage by her insurance provider because of an error in which the patient’s employer recorded the wrong month on her policy. Hawkins has appealed again and again, but she says the insurance company continues to refuse to pay the claim.

Fighting insurance companies takes up a huge amount of time for midwives, who are already running on a tight budget. “Midwifery is not something that’s going to make you rich,” says Hawkins. “You do it because you love the clients and you love babies and you love the justice of a better future starting with birth.”

0722 midwife HollyHolly Scholles, the founder and president of Birthingway. Photo: Jason E. Kaplan

Similar financial challenges have hit the institutions that train midwives: In December 2021, the Beaverton-based Birthingway College of Midwifery announced that after 28 years of training direct-entry midwives in Oregon, it will not be accepting a new cohort of students in 2022. According to Holly Scholles, the founder and president of Birthingway, Oregon’s increasing demands for what schools provide their students — things like voter-registration services and education on violence against women — are making it more and more difficult to cover operational costs.

Scholles also says donations dried up, particularly amid the pandemic.

“People who had larger amounts of money to give wanted to give it to hospitals and, you know, have a bigger, more splashy impact,” she says.

By 2019 Birthingway leadership was already looking for ways to transition to more online learning and reduce expenses.

“Then COVID hit,” recalls Scholles. “And we felt like we couldn’t bring in a new class of people when we weren’t sure if they could even attend births.”

The school is just one of 10 accredited by the Midwifery Education Accreditation Council.

“It is a loss to the whole country,” Scholles says.

Monroe echoes that disappointment.

“It’s a loss to Oregon,” she says, emphasizing that the financial aid and in-person support available to students at Birthingway was significant. In Monroe’s efforts to encourage more Black women to enter the profession, not having in-person education in the state will be a huge setback, both for aspiring midwives and those who seek their care.

Scholles still holds on to hope for the future of midwifery, in Oregon and elsewhere.

“​​I believe that we have some amazing younger people coming into early adulthood who will feel drawn to this work. I’m just sad that I won’t be able to work with them.”

Following all the work done to pass House Bill 2388, Akerson says the Oregon Midwifery Council is in a regrouping phase.

In deciding what’s next, they’re “looking to Black and Indigenous-led organizations that are working on the maternal health crisis and trying to learn from their lead on where we should be putting our energies.”

Midwifery care isn’t right for everyone. If someone wishes to have an epidural, which can be a perfectly safe option for managing the intense pain of childbirth, a hospital is the only appropriate setting. And in the rare event that something goes terribly wrong during delivery, immediate access to physicians and surgeons can be critical.

Pregnancy and childbirth are a joyful, painful, exhausting, conflicting journey in which the options can be confusing. But midwifery-care advocates argue that it’s the existence of options that make all the difference — that all women should have the option to give birth in the manner and setting that feels right for them.

“What midwives believe in is choice,” says Scholles. “You should be where you feel safe, where you feel comfortable, where you want to be.”

Warnock fought the urge to push for the last half hour of their drive back to Boise. She recalls thinking how you’re supposed to focus and bear down when you’re ready to deliver your baby, so she thought “up and high.”

Rawlins met Warnock and her husband at the birthing suite — arriving straight from another birth she’d attended — and got her in the tub where she could finally stop fighting contractions. “She was amazing,” recalls Rawlins, who recognized Warnock’s coping techniques and positions that worked best for her in her last two births.

“It’s really hard to be on call 24/7,” she says. “It is also wildly rewarding to see these people all along, to show up and be there.”

Warnock delivered baby Alice just 20 minutes after arriving.

“Seeing them meet and fall in love with their baby was a moment I could never forget,” says Rawlins. “It’s special every single time.”

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