This midwife’s office in Athens was not Laura Silva’s first stop for prenatal care.
She already went to her local hospital to talk about birthing options. But, she said it didn’t feel like she had any say in her care.
“I was not heard at all,” she said. “They said, ‘Well, we're gonna do this thing and this,' and I was like, ‘I don't like any of that.’”
But at the midwife’s office, she looked comfortable. She leaned back on the couch and held out her arm for a blood pressure test. Erica Andrews, her midwife, administered it, checking up on how Silva felt six months into her pregnancy.
Silva is grateful to have the option to get the kind of care she wants, especially when that’s not the case for many in Ohio. Reduced access to maternal care has impacted more than 96,000 Ohioans in the last two years – the most of any state, according to a 2022 March of Dimes report.
As care options become more limited, some hope homebirth midwives can fill the gaps. But, in Ohio, they’re not legally recognized as providers. Rural practitioners, like Andrews, want to change that.
No licensure comes with limitations
Andrews has been practicing in southeast Ohio for more than five years. She’s one of just two certified professional midwives who serve in the 100-mile radius around Athens. Her schedule is booked.
While midwives only attend around an average of 10 percent of births nationally, in rural areas that number jumps to 30 percent.
“Midwives cover so many areas in those gaps, but yet they will not recognize us in that way,” she said.
Ohio’s maternal morbidity rate exceeds the national average. Andrews said she believes midwives could be the key to driving those numbers down. But they’re limited in the support they can provide.
“I cannot access the life-saving medicines such as Pitocin or Cytotec that would be needed, especially if I'm in a rural area and we have a really bad bleed,” she said. “I'm not legally allowed to have or distribute those medicines.”
That’s because there is no regulation of homebirth midwives. Ohio is one of 16 states that has no licensure process, putting midwifery into a gray area.
“They're not quite legal,” said Cindy Colen, a researcher with the Ohio Policy Evaluation Network, who has studied maternal care deserts. “They're not quite illegal.”
“We need a model that encompasses all different kinds of medical care providers.”Cindy Colen, researcher with Ohio Policy Evaluation Network
Communities benefit when there are more options for reproductive health care, Colen said. Obstetric specialists are necessary to have for surgical, high-risk situations. But, midwives can handle low-risk at-home births, like Silva is planning.
She said pregnant people would have better outcomes if midwives were utilized as a first line of care.
“What we have to move away from is: there's one model, and that's the model where you go to an OB-GYN for all of your care,” she said. “We need a model that encompasses all different kinds of medical care providers.”
Declining maternal care options
OB-GYNs are scarce to begin with in rural areas, said John Palmer with the Ohio Hospital Association.
He said rural hospitals don’t often have the money to recruit specialists. Many are struggling financially and that can make it harder to maintain maternity wards.
“When you're looking at the totality of what it takes to staff it, to equip it … it is pretty costly,” Palmer said. “And oftentimes, that service is looked at as kind of the first step with reducing costs.”
As of April, nine maternity wards in Ohio had closed down in the last year. And seven rural hospitals have closed their doors completely since 2014, according to the Ohio Hospital Association.
Even if you’re lucky enough to have a hospital in your community with delivery services, it might not have the type of specialized care you’re looking for.
For example, the hospital in Athens doesn’t allow women to have vaginal births if they’ve previously had a cesarean section, said Lauren Genter, Athen’s other certified professional midwife. Genter said she often hears from community members who want this care, but don’t know how to get it.
“Your options are to drive a couple hours away, or to do it outside of a hospital setting,” Genter said.
Genter said midwives are trained for that care. But – without licensure – they have to do so without easy access to lab work or ultrasounds. And, when emergencies crop up that require Genter to transfer clients to a hospital, she’s not always taken seriously.
Since midwives aren’t licensed, doctors have no obligation to take the information the midwives pass on to them, whether it's prenatal care details or identified risk factors.
“The people giving birth, the families are the people who suffer,” Genter said. “Things might not get translated that are important about their care, records might not be transferred at all.”
Genter said midwives are meant to offer patients’ more choices and more tailored care. But without formal licensing, there’s no guarantee.
