The rise of midwives in rural America

Midwives who travel could give rural women a better birthing experience

Katy Rawlins is putting on her makeup as she sits at the drive-thru coffee stand. It’s only 7 a.m., but she’s already in a rush — she has 263 miles to drive today. 

As a midwife who travels, Rawlins’ clients span a wide swath of territory — stretching across the Oregon border down to southwestern Idaho. Some seek her out because they cannot afford gas or child care to make regular prenatal visits, let alone the costs of giving birth, while others prefer the control and comfort of bringing their child into the world at home. 

Rawlins became fascinated by birth in the 1980s as a child growing up in a small town in Nebraska near the home of celebrated novelist Willa Cather. When Rawlins became pregnant with her third daughter at age 23 in 2008, she knew she wanted to have the baby at home.

At the time, midwifery occupied a legal gray zone in Idaho — midwives could practice if they didn’t administer medications — so she tapped into a semi-underground network to find a midwife. She gave birth to her daughter at home with her husband and midwife by her side.

“It was the most normal thing we had ever done,” she says. 

Today, Rawlins is just one of a small number of midwives serving rural families in the West. Midwives attend roughly 12% of births in the United States, while in other Organization for Economic Cooperation and Development countries they attend somewhere between 50% and 75% of births. One study published in The Lancet Global Health found that increased midwife services could result in 280,000 fewer deaths in mothers, 2 million fewer deaths in newborns and more than 2 million fewer stillbirths per year by 2035.

Those numbers would be a huge shift for the U.S., which has the worst maternal mortality rates among developed countries (the number has almost doubled in the last 20 years, and over 60% of these deaths are preventable).

The numbers are worse for those who aren’t near urban hubs (there are 29.4 maternal deaths per 100,000 in rural areas compared to 18.2 in urban regions). Over 100 rural hospitals have closed in the U.S. since 2010, and of those that remain only about half have obstetric services as cost-cutting measures have resulted in the elimination of specialty care. Today, 2.2 million women of childbearing age live in a county that has no obstetric care providers and no birth centers. 

While some research shows that midwives could help fill in the gaps in rural health care and the presence of nurse-midwives in hospitals has become more widely accepted, home birth does have higher risks than hospital births. A study published in 2015 in The New England Journal of Medicine comparing planned out-of-hospital births with planned in-hospital birth outcomes found that the perinatal death rate was higher for the former, although “the absolute risk of death was low in both settings.”

As Jeffrey Ecker, a doctor at Massachusetts General Hospital, wrote in the Harvard Health Blog, “Sometimes emergencies happen, and having the tools, medicines and facilities to respond quickly can make a difference. But having all those things at hand means they will also be used in cases in which doing nothing would have been just fine.”

As obstetrics care becomes increasingly difficult to access — financially and geographically — and parents choose what they want their birth experience to be, midwives may provide a level of care for families living in rural America that they wouldn’t otherwise have access to at all.

The mom part of the brain
Oh, the places you’ll go ... to work

First up on Rawlins’ drive on a recent morning in July is a woman living in Ontario, Oregon, roughly 45 miles northwest of Rawlins’ home near Boise. Kaylee Gruendler, the expectant mother, is 32 weeks pregnant. The family recently moved from Boise to Oregon so they could afford a more spacious house for their three children but found that the midwifery services Gruendler could access in the city were no longer an option. So she contacted Rawlins, who has been making the drive to the one-story house ever since.

When Rawlins walks in, she gives Gruendler a hug. During the visit, she asks about any ongoing discomfort, schedules future testing, makes sure blood work has been completed and talks about the list of items Gruendler will need to get for the home birth. Then, she pulls out a handheld Doppler ultrasound, puts a little gel on the tip and listens to the baby’s heartbeat.

Once all the questions and checkups have been completed, they talk about diapers and potty training and the nurse-midwife who will also attend Gruendler’s birth to provide an extra set of hands and expertise (Rawlins likes to have at least one other licensed midwife at all the home births she attends). 

After an hour, it’s time to go. Rawlins puts her laptop and other equipment away and texts her next client in Midvale, Idaho. By 8:30 a.m., she’s back on the road. 

Midwifery is an ancient practice. The Bible makes numerous references to midwifery, as do early Greek and Roman texts. Many Indigenous cultures have their own traditional midwifery practices. Up until the early 1950s and ‘60s in the South, Black midwives served rich and poor women alike and provided care to Black women who were not admitted to hospitals due to policies barring them, says Robbie Davis-Floyd, an anthropologist at Rice University who has been studying the midwifery movement 1991.

Rather than integrating midwives into a medical system that made risky births safer, they were sidelined in part through campaigns that derided many of the immigrants and women of color who worked as midwives as uneducated and unclean. Dr. Joseph DeLee, a prominent Chicago doctor and leader in obstetrics in the early 20th century, called midwives a “relic of barbarism” in 1915 and considered them “a drag upon the progress of the science and art of obstetrics.”

State laws prohibiting the practice of lay midwives started going into effect in a falling dominoes-type fashion. In 1894, Massachusetts passed an act that equated midwifery with the unlicensed practice of obstetrics. In the 1910s, Alabama passed a law requiring midwives to pass an examination and register with the state health board, making it harder for midwives who had already been practicing for decades to continue. In 1917, California made uncertified midwifery a misdemeanor.

The decimation of the midwifery profession was essentially completed by the 1960s through a combination of changing social norms that reclassified birth as a medical procedure and state laws that sometimes prohibited midwives from using medications or required those who had long careers as midwives to jump through hoops to get certifications.

At the same time, women in rural America — where few hospitals existed — still required care. After completing her education in nurse-midwifery in England, Mary Breckinridge returned to rural Kentucky (where midwifery was never illegal) in the 1920s and pioneered Frontier Nursing Services. The women Breckinridge trained “rode on horseback, crossing rivers during floods, riding up the mountains, to attend all the childbearing women and to provide health care for all families,” Davis-Floyd says. 

But it wasn’t until the 1970s that midwifery started to make a true comeback, when the social unrest of the time collided with women’s desires to take back control of their birth experience.

In 1975, Carol Leonard, who helped found the Midwives Alliance of North America, gave birth to her only child in the Merrimack Valley, along the border of Massachusetts and New Hampshire. She recalls lying on her back with her arms and legs strapped down. And while the birth was a simple one, she says a doctor told her afterward, “Some women are meant to be breeders and some women are meant to be workers. You are definitely a breeder.”

Leonard was infuriated by the demeaning comment. She packed up her bag and her baby and immediately left. After the experience, Leonard became interested in midwifery, with hopes that she could make birth a more natural and positive experience for other expecting mothers. She studied with a country doctor in Henniker, New Hampshire, who taught her how to perform each skill necessary for safe, natural births — everything from turning breech babies to placing sutures. A local health center where she worked and studied started giving her name out to women interested in home births.

Leonard was worried about the potential threat of arrest and lobbied for legislation that passed in 1981 that allowed lay (also called “direct entry”) midwives — those who did not go through formal schooling — to obtain voluntary licenses. In 1982, Leonard helped found the Midwives Alliance of North America.

Lay midwives began to spring up in El Paso, Texas, Santa Cruz in California, and in Tennessee. All the while, midwives were organizing and advocating for laws legalizing and standardizing the practice across the nation.

Today, certified nurse-midwives are legal in all 50 states, while certified professional midwives (they do not have nursing licenses but are certified through the North American Registry of Midwives and are considered “direct-entry”) are able to legally practice in 35 states.

Now, the practice of certified midwives and certified nurse-midwives isn’t as much of a hot-button topic. But the location of where they practice and where mothers give birth is.

The safety of home versus hospital birth has been strongly debated for a century. The American Academy of Pediatrics does not recommend a home birth at all, stating, “Hospitals and accredited birth centers remain the safest settings for births in the U.S.” Similarly, the American Medical Association has taken a firm stance against home births, noting that “the safest setting for labor, delivery and the immediate post-partum period is in the hospital.”

Today, out-of-hospital births account for under 2% of all births in the U.S. That’s not a large portion, but it’s more than it was at the turn of the 21st century. Home births have increased by nearly 80% since 2004, and the COVID-19 pandemic has caused even more parents-to-be to avoid hospital-based care. However, most of the births attended by nurse-midwives and certified midwives occur in hospitals (roughly 94%). Certified midwives and physicians alike tend to agree that high-risk births should remain in the hospital under specialized care.

That’s in line with best practice, as studies show that the best birth outcomes are a result of “highly integrated” systems, where midwives and physicians work closely together.

“Midwives provide quality care, especially those that are certified and trained,” says Dr. Sean Esplin, the senior medical director for women’s health of Intermountain Healthcare, which has 23 labor and delivery units across Utah and Idaho. “The future is to create a team where you have excellent midwifery care that’s also working together with physicians that are required to provide backup services.” In the ideal situation, Esplin would like to see certified nurse-midwives delivering in hospitals, where physicians can quickly come in to deal with medical emergencies. 

Seeing expecting mothers’ need for representation and better care in the hospital setting changed Nicolle L. Gonzales’ life. While working at Indian Health Services in Santa Fe, New Mexico, Gonzales — a member of the Navajo Nation — was unhappy with the way Native women were treated as patients — how little providers seemed to know about the birth and pregnancy experience, and the lack of power women had in the hospital setting. 

But what struck her most was the difference between the hospital in Santa Fe and a hospital in an affluent community she’d previously worked in. “The women I took care of there were very authoritative, they knew what they wanted, they were bossy, and the nurses listened. They had a lot of power. And I saw them having more enjoyable birthing experiences,” Gonzales says.

So, she returned to school to study midwifery and founded the Changing Women Initiative, a nonprofit focused on serving Native women in New Mexico.

The close relationships midwives like Gonzales build with their clients and the consistent contact both prior to and after birth allows midwives to monitor problems that might arise. This could be especially crucial for underserved communities.

According to the Centers for Disease Control and Prevention, Black and Indigenous women have a pregnancy-related mortality ratio roughly three times higher than that of white women. The organization lists multiple factors from “underlying chronic conditions” to “structural racism and implicit bias.” Or, as one obstetrician-gynecologist told a writer for the Harvard Public Health magazine, “The common thread is that when Black women expressed concern about their symptoms, clinicians were more delayed and seemed to believe them less.”

“That’s the benefit of being a nurse-midwife for 10 years and working where I’ve worked,” Gonzales says. “I get to bring all my skill sets forward to try and address this problem of access.”  

When asked why she chose home birth, Divinity Rasti explains that half of her family is Mexican and the other half Black.

“I got to see two different perspectives of how my Mexican side was treated in the medical field versus how my Black side was treated in the medical field,” she says. She say her great-grandmother died during knee surgery because doctors didn’t elevate her knees. 

Then, when Rasti was pregnant with her daughter, she went in for her first doctor’s appointment. She was nervous, and when her blood pressure was taken it came back high. The nurses took it two more times, and it got higher in each reading. They told her she had to take medication, but she insisted, “No, I’m just scared. I’m terrified to be here.” 

“I just didn’t feel heard from the start of walking in, and it wasn’t anything new. I was used to my family’s experiences,” Rasti said. After that appointment, Rasti decision to employ a midwife was cemented. 

Katy Rawlins’ last appointment of the day is with Rasti, who is now 12 weeks pregnant with her second child. Rasti’s home is spacious and modern. It’s her comfort zone, and when Rawlins takes her blood pressure the reading comes back normal. 

How women choose to give birth is changing. Robbie Davis-Floyd sees that there’s been a big shift since she first began studying midwifery.

But she says more needs to be done for expectant mothers. Better relationships between midwives and physicians. Greater access to midwifery for women who might not be able to afford it or have health insurance that will cover the costs. More training and funding for Black and Indigenous midwives who want to serve their own communities. 

Mothers choose to give birth at home for many reasons: from financial (home births tend to cost between one-half to one-third less than hospital births), to fear of a medical system that consistently has worse outcomes for women of color, to cultures that do not view birth as a medical procedure. For some, home birth is simply the norm, and midwives like Rawlins and Gonzales make that choice safer. But all the mothers in this story mentioned one common theme: They wanted their birth experience to be sacred, calm and in an environment where they were surrounded by loved ones who listen to their wishes. 

Rasti recalled the moment she had her daughter at home. Her husband climbed into the birthing tub and caught the baby. Then her midwife and husband handed her daughter to her to hold for the first time. “It was this little blissful moment, just sitting in the pool with us three.”

This story appears in the September issue of Deseret MagazineLearn more about how to subscribe.