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The Midwives of Appalachia Get Organized

Despite the region’s rich history of reproductive care, birth options remain incredibly limited. A group of midwives in Kentucky want to change that.

Bill Frakes/Sports Illustrated/Getty

When Laura Browning was pregnant for the first time, she knew what she wanted from her birth experience. She wanted a home birth with a midwife, ideally, and if that wasn’t possible, she wanted a nurse-midwife (who are typically hospital-based) to deliver her baby. She associated obstetricians with “quick in-and-out appointments” that lacked personal care and warmth. “I wanted to know who’s going to be delivering my baby—who’s going to be catching my baby—and have a relationship with them,” recalled Browning, who is now pregnant with her fourth child.

Many women share Browning’s misgivings about the medical establishment’s attitude toward childbirth. America’s modern OB-GYN-heavy prenatal care system often treats low-risk pregnancies like “problems” to be solved by excessive (and perhaps unnecessary) hospital interventions rather than something entirely natural that women have been doing forever. Where the OB-GYN experience can err on the side of strictly clinical, midwives work to build strong relationships with their clients—not treat them like a cog in the medical machine—instilling confidence and connection instead of hastily defaulting to the simplest or most cost-effective option for the OB-GYN or hospital. 

And the birth outcomes speak for themselves. In addition to the potential for in-depth visits, more involved prenatal education, and even at-home birth, midwifery focuses on helping the birth progress naturally and empowering the laboring woman. The rate of cesarean sections under midwifery care is 30 percent less for first-time mothers and 40 percent less for second-time mothers than with OB-GYNs, and in a 2013 study, women cared for by midwives were less likely to experience both preterm birth and miscarriages before 24 weeks. 

But Browning learned that in Estill County, Kentucky—where 22 percent of the population lives below the poverty line, more than twice the national average—birthing options for women were (and still are) pretty much nonexistent. Not only was there no one to perform a homebirth, nor any local options for delivery with a nurse-midwife, but the county where she lived is designated a Maternity Care Desert by the March of Dimes, meaning that access to maternal health services is limited or completely absent. So she did what pregnant women across the mountains of Eastern Kentucky have done for decades: She drove.

“If I wanted the midwifery model of care, I was going to have to drive an hour-and-a-half from my house all the way into Lexington, Kentucky, and that’s exactly what I did,” said Browning, who not only drove back and forth for all of her prenatal appointments but also during her labor. “But it’s not unusual for women around here to drive that far.”

In Appalachia, three in ten households lack access to broadband internet and almost 9 percent of people don’t have access to a vehicle, making researching faraway care options—and executing on them—often impossible. Pregnant women and infants are some of the most vulnerable people in modern Appalachia, where the infant mortality rate is 16 percent higher than the national average, according to the Appalachian Regional Commission. In addition to rampant hospital cutbacks and closures—which have been exacerbated by Covid-19—women are experiencing life-threatening complications during childbirth at an alarming rate. In Harlan County, for example, a 2019 USA Today investigation found that almost one out of every 10 women who gave birth at the local hospital experienced a life-threatening complication—seven times the national average.

But over the past few years, a handful of dedicated Kentucky midwives and advocacy groups have been working to change the region’s perinatal and postpartum health trajectory by advocating for a wider range of safe, accessible local birthing options and support systems for pregnant women in the state’s maternal health deserts, improving birthing practices in Appalachian Kentucky, and empowering women in a way that speaks directly to the region’s lauded midwifery heritage.

Having a wider range of nearby birthing options—like midwives—is even more critical today as an increased demand for localized, high-quality maternal care has been heightened by Covid-19. Even as women like Browning are more able than ever before to access midwives, there still aren’t nearly enough of them.

“At the beginning of the pandemic, we were getting phone calls and emails in unprecedented amounts,” said Mary Kathryn DeLodder of the Kentucky Birth Coalition, a grassroots organization working to expand and improve birth options and outcomes across the state. “People were inquiring about home birth because they weren’t sure they wanted to be in a hospital. And midwives’ schedules are full for months out now because people are looking for alternatives.”

The hospital in Hyden, Kentucky, is named after pioneering nurse-midwife Mary Breckinridge, the founder of the Frontier Nursing Service, a trailblazing organization that recruited and trained nurse-midwives to provide care for families in rural Appalachia who weren’t being reached by doctors in the first half of the twentieth century. She established the area’s first hospital—the Hyden Hospital and Health Center—in 1928 and, 11 years later, the first graduate program for midwifery in the entire United States. There’s a majestic bronze statue of Breckinridge on horseback in town—but no labor and delivery unit in the hospital that today bears her name.

Despite the region’s rich midwifery history, even Frontier Nursing University—the grandchild of Frontier Nursing Service, which trains almost one-third of all nurse-midwives in the United States, primarily via distance learning—has decamped from its roots in Hyden to a more centralized, close-to-an-airport campus just outside of Lexington. Almost 100 years after Breckinridge introduced modern midwifery to the United States via Eastern Kentucky, you’d be hard-pressed to find many midwives here at all.

In the entirety of Eastern Kentucky’s counties, there are only seven certified nurse-midwives (CNMs), and other crucial resources for pregnant women—like postpartum mental health groups and board-certified lactation consultants—have been practically nonexistent. And in a region where “diseases of despair” like overdoses, suicide, and liver disease are 46 percent higher for women than in the rest of the country, these supports can sometimes make all the difference in having a successful birthing experience for both mother and child.

“When you look at Appalachia, it has some of the worst birthing outcomes in the nation,” said Renee Basham, founder of Hope’s Embrace, a nonprofit that connects pregnant Kentucky women in rural areas with birth supports, like doulas. “Many of the counties are maternity [care] deserts. In some of these places, that means there are zero hospitals, and in others, it means they have a hospital, but only two obstetricians, so there aren’t enough doctors to cover all the pregnant women in that region.”

Rural OB-GYN offices are often overworked and understaffed, creating an atmosphere where patients feel rushed. It’s no wonder that many women with low-risk pregnancies prefer midwives, who offer a more personalized form of care. And while births attended by midwives have been rising each year nationally since 1989, for decades, Kentucky’s laws have made practicing as a midwife in the state confusing and challenging, effectively protecting doctors and hospitals from competition at the expense of patients.

CNMs in Kentucky were long required to have a “collaborative agreement” with a physician to prescribe scheduled medication (like a Percocet following an unexpected C-section) for patients. The problem is that doctors often viewed midwives as competition and thus were uninterested in helping them. Certified professional midwives (CPMs)—also known as “direct-entry” midwives, who are accredited as midwives but not trained as nurses—had to have a permit in order to practice, but before 2019, the last CPM permit issued by the state was in 1975.

But thanks to the work of groups like the Kentucky Birth Coalition and Hope’s Embrace, these restrictions have been eased. Legislation was passed in 2019 that made it easier for CPMs to get licensed, and 18 women have been approved as CPMs since the state began issuing licenses this September.

What’s more, Kentucky Governor Andy Beshear suspended the “collaborative agreement” rule for CNMs earlier this year to allow for a greater range of care during the pandemic, and many are hopeful that this shift will be a permanent change, allowing CNMs to set up stand-alone practices in areas across Appalachian Kentucky, where the need is greatest. 

The next fight for midwives is changing the restrictive rules around birthing centers, a type of free-standing healthcare facility for childbirth where care is provided in a way that centers resources like birthing tubs, family-focused rooms, greater freedom of movement during labor, and far fewer medical interventions—IVs, continuous fetal monitoring—than are found in typical hospital birthing stays. Currently, Kentucky has no birthing centers because they require a “certificate of need” from the state to open. And while it seems that living in a place that’s been designated a “maternal health desert” where the lack of a labor and delivery unit in the local hospital would surely be a certificate of need unto itself, advocates are prepared for a long, uphill battle.

“The last nurse-midwife to try and open a birthing center [in 2007] submitted her ‘certificate of need’ application and it was swiftly opposed by the three hospitals nearest to her,” explained Browning. “It went through five years of legal battles. She essentially spent her life savings then gave up and left the state.”  

But for Eastern Kentucky women looking for a wider range of options—and who are tired of settling for whatever’s closest or burning through gallons of gas to get to appointments—the struggle is worth it. Browning—who now lives in London, Kentucky, and works as a doula—was able to have her third child’s birth at home with the assistance of a CPM and is planning on doing the same with her upcoming delivery. 

“We really don’t want to drive so far for the kind of care that we want,” she said. “It’s all about having more birthing options that are close and accessible. CPMs give you another option, and birthing centers would give you even more options, because we may be able to get care to some of these places that don’t have any.”