This article was produced by Stateline, an initiative of The Pew Charitable Trusts.
For the past year or so, Toni Hill, a midwife in the lowlands of northern Mississippi, has received an influx of calls from women across the state who live in areas with no hospitals and only a smattering of health care providers.
As Covid-19 rates increased, some pregnant women did not feel safe receiving care in a hospital or were unable to contact their providers. Others, who lived in the Mississippi Delta, did not have transportation for the three-plus hour trip to Jackson, the state capital. Hill quickly found herself very overwhelmed, she said.
On most days, Hill is stretched thin: conducting home and clinic visits, which can be up to three hours away, while being a mother and running a nonprofit. Hill is one of at least 30 certified midwives and nurse midwives in Mississippi, a state where 84% of the areas with shortages of primary care health professionals are in rural counties, according to a health department report published this year.
Many rural hospitals across the country are struggling to stay afloat amid the coronavirus pandemic. Facing workforce shortages, financial challenges, and more patients than beds, some have had to cut or suspend obstetric services.
Midwives, trained professionals who specialize in maternity care, are picking up the slack. In interviews with Stateline, midwives from rural areas say they’re overwhelmed and facing burnout because of an uptick in patients—even as they’re eager to help. Doulas, who assist parents during childbirth but don’t provide medical care, also are seeing an increase in demand.
Some states, recognizing a dire need for midwifery and doula support services, have passed laws to expand care, while members of Congress are considering federal investment. Rural health experts and leaders stress that policies should focus on the challenges of affordability, insurance coverage, and lack of providers in rural areas.
This year, at least eight states—Arizona, Arkansas, California, Colorado, Connecticut, Louisiana, Nevada and Rhode Island—have passed laws that aim to improve birthing outcomes. Many of the laws have expanded Medicaid and other health insurance coverage for midwifery and doula services, required health facilities to allow doulas to attend births or increased pathways for students to become licensed midwives.
The Biden administration’s proposed Build Back Better Act would provide additional funding for postpartum Medicaid coverage as well as financial and programmatic support for doulas and nursing students.
The pandemic has revealed longstanding issues of “innate systemic racial basis” within health systems that have contributed to the maternal health crisis in the United States, said Louisiana state Rep. Matthew Willard, a Democrat. Willard sponsored a bill, signed into law by Democratic Gov. John Bel Edwards this summer, that created a state doula registry committee and required that all health insurance plans with maternity benefits cover midwifery services.
Nationwide, midwives attend less than 10% of hospital births, but in rural hospitals the figure is 30%, according to a 2019 brief by the federal Centers for Medicare and Medicaid Services.
In Nevada, legislators expanded Medicaid coverage for doula services along with pandemic-related health care bills. And in Arkansas, lawmakers passed legislation granting certified nurse midwives full practice authority without an agreement with a consulting physician.
The legislation can help, but it’s going to take more rural-centric, comprehensive policies to fix health infrastructure needs in rural America that have been exacerbated by the pandemic, said Katy Kozhimannil, health researcher and director of the Rural Health Research Center at the University of Minnesota.
Those needs include recruiting and retaining a skilled workforce and finding ways to keep labor and delivery units open despite relatively few births. Many rural hospitals have taken a financial hit, Kozhimannil said, and the pandemic has caused them to reduce services.
“In some cases, the hospital obstetric unit can’t remain open or won’t because not all communities can have a hospital that provides birth services,” she said. “And in those places, it’s very important not to turn a blind eye to the consequences that we know, [such as] more pre-term babies.”
Even before the pandemic, rural areas lacked maternal health services. In 2014, after a decade of steady decline, nearly 54% of rural U.S. counties had no hospital-based obstetric services, according to a 2020 study published in the Journal of the American Medical Association. Between 2014 and 2018, researchers found, the number of rural hospitals with obstetric services declined by another 3%.
The rural counties that were more likely to lose their hospital-based obstetric care services were less populated, more remote, had fewer doctors, had “less generous” Medicaid programs and had higher proportions of Black residents compared with White residents, said Kozhimannil, who co-authored the study.
Since January 2020, at least 21 hospitals in rural areas have closed, according to data from the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill.
When hospitals close or shut down their obstetric services, the loss can lead women to deliver on their own or in ambulances on the way to a hospital, said Jennifer Cameron, a certified nurse midwife in rural Michigan.
“They go into labor. They call 911, and they get transported to the closest facility with a labor and delivery unit. For some people it may be 45 minutes away,” Cameron said. “If someone is having a heart attack, there’s no ambulance to take them.”
After the local hospital in Manistee, Michigan, where Cameron practices, stopped offering obstetric services, she conducted more out-of-hospital births at her freestanding birth center. She is usually on call every hour of the day because she has just one part-time office assistant. Prenatal visits, labor and delivery and up to six weeks of postpartum care can cost more than $4,000. Many of her patients don’t have insurance and can’t afford to pay out of pocket.
“It isn’t sustainable. Midwives burn out. There are a lot of midwives that only take cash-pay clients and if they can’t afford to pay, then they can’t get their care,” Cameron said. “I do take someone that can’t pay me a certain percentage. I do allow a couple births per month that I know I’m not going to get paid for, because it’s the right thing to do.”
Medicaid paid for a larger share of births in rural than urban areas and for people of color than White people in 2018. The program helps to alleviate rising mortality and morbidity rates and racial disparities in maternal health outcomes, according to a 2020 fact sheet by the Medicaid and CHIP Payment and Access Commission, a nonpartisan legislative agency that provides policy and data analysis to federal and state governments about Medicaid and the Children’s Health Insurance Program.
But the reimbursement Cameron gets from Medicaid isn’t enough to cover the cost of her services, she said.
Hill, the midwife in Mississippi, said even if she did receive Medicaid payments, she still wouldn’t be able to accept more patients with her small staff.
“They’d be covering maybe $1,300 for a birth. That’s less than half of what I get paid,” Hill said.
Hill said states and policymakers will need to take more action to address the economy and well-being of rural communities overall.
“We want people to come into care healthier. I’ve talked to pregnant women who don’t even have primary care physicians,” she said. “We need more midwives [in the hospitals and birth centers] in theory, but we have to look at the community health piece, too.”
Smaller hospitals have cited decreased births, financial woes and staffing issues as primary reasons for cutting back on services in the past year. Sharon Hospital in rural Connecticut is among those that this year made plans to halt labor and delivery services. Hospital officials plan to phase out the services over the next eight to 12 months pending regulatory approval.
Over the past few years, the hospital has seen an average of about 200 deliveries per year, said Dr. Mark Hirko, president of Sharon Hospital. He had hoped to see an influx of childbirths, but with an aging population, the “numbers remain essentially flat,” he said.
Instead of keeping the labor unit, the hospital will expand on other primary care services.
“Everything pointed us in the direction that we needed to refocus and redirect our efforts towards where the population is taking us,” Hirko told Stateline. Parents-to-be now will have to travel to other birthing centers and hospitals to receive care.
Other rural health systems that cut services have lost employees as a result of the federal Covid-19 vaccine mandate for health care workers, which has been temporarily blocked by federal judges in Missouri and Louisiana.
Lewis County General Hospital in Lowville, New York, stopped delivering babies after losing at least six employees over the mandate. A similar instance occurred in rural Lamar, Colorado, which forced the Prowers Medical Center to suspend services at its maternity ward.
The staffing shortage in hospitals is placing an added burden on midwives. There were more than 12,000 certified nurse midwives and about 100 certified midwives in 2019, according to the American College of Nurse-Midwives.
The demand for midwives and other maternal care providers is higher than the supply, said Erin Ryan, a certified professional midwife and secretary for the National Association of Certified Professional Midwives. The need has increased with obstetric unit closures, she added.
According to the federal Centers for Medicare and Medicaid Services, the United States is expected to have a shortage of 22,000 obstetricians and gynecologists by 2050.
The worst shortages, the agency noted, are expected in rural areas.