With seven kids and one on the way, Sarah Tricamo has experienced a wide range of birthing options including both home and hospital births. When it comes to delivering her eighth child Tricamo, who lives with her family in Ashtabula County, chose a home birth, as she had with four of her other children.
“My older sister had a home birth, and she said it was absolutely out of this world,” Tricamo said. “And then our third hospital birth was a really terrible experience, and we decided, ‘You know what? How much worse could we do, having a baby at home?’”
It's an option that midwives say could help more women in the wake of rural hospital maternity ward closures across the country that have left some families with no obstetric care options nearby. In recent years, several rural Northeast Ohio hospital systems have closed their maternal care centers, forcing people in Richland County to drive further and leaving those in Portage and Ashtabula counties with no maternity ward at all.
It's not just happening in Northeast Ohio. About two in five counties in Ohio do not have a hospital or birthing center within their limits leaving expecting parents to travel further for care, according to a 2022 report from the March of Dimes, a nonprofit that works to improve the health of moms and babies.
Instead of driving further, some like Tricamo are turning to midwives. Tricamo lives in Ashtabula County, which the March of Dimes refers to as an area of “low access” to maternal care.
Her decision shows when people decide where to deliver they take into account more than just health. With seven children already, having her eighth child in a hospital nearly an hour away would put extra stress on her family, Tricamo said.
“Our parents who were really front and center taking care of our kids, they're older now,” she said. “My dad passed away, so it would be just my mom. You can't just leave seven kids with one person.”
For families in rural areas, a major benefit of midwives is that many practice in the home. Tricamo’s midwife Jessica Brown travels up to an hour and a half from her home in Hudson to her clients for prenatal and postpartum visits. Other midwives have small offices where expecting parents go for the first prenatal visits, but near the end of pregnancy, many also make home visits.
“Not everything is on the GPS. There are some dirt roads you're going down and then you turn at the corner store and then you look for this mailbox and turn there,” said Julia Meyer, a midwife practicing in the Cleveland area. “I want to make sure that I know my drive before this woman is in labor.”
In order for midwives to fill the void in rural areas, lawmakers would have to make changes to recruit more midwives, educate them and make it easier for them to get paid, said Keisha Goode, of the National Association of Professional Midwives.
“That needs to happen at the federal level because it's not just increasing access to midwives, but it's different kinds of midwives with different kinds of scope and expertise, which I think is really important,” she said.
There are two types of midwives: certified nurse midwives (CNMs) and certified professional midwives (CPMs). CNMs have a degree in nursing as well as training as a midwife while CPMs train only in midwifery, said Brown.
The distinction is important for determining how midwives can be paid. While CNMs can accept Medicaid as payment in Ohio, CPMs can not.
This means paying for a CPM, like Brown or Meyer, who charge between $2,000 and $5,000 per birth, may be out of the question for women who rely on Medicaid, the state's health insurance program for the poor.
Roughly half of women who live in maternal care deserts nationwide rely on Medicaid, according to the March of Dimes.
And even private insurance may also not cover a midwife, said Meyer.
“When you're trying to seek reimbursement from an insurance company, they're going to ask for a license number from the provider in order to reimburse,” she said. “And since [CPMs] are not licensed in the state of Ohio, we don't have that license number to seek reimbursement from the insurance company.”
Midwives said capacity is also a barrier. Brown and Meyer both reported as hospital maternity wards have closed in Northeast Ohio, they have seen an increase in homebirth inquiries from potential clients.
“I can't say for certain that it's just due to the fact that these hospitals are closing,” Brown said. "But I know that that does play a pretty big role, especially when they close on pretty short notice."
However, inquiries do not always translate to clients. Midwives working in the home only serve those who have low-risk pregnancies, said Brown. And both said they can not afford to take more than her already established number of clients because she wants to make sure she is available for each birth.
“I have an average of three to four clients per month,” Meyer said. “I could have several more. However, with being a solo health care practitioner, I believe in high quality of care and once I get above five I really feel like I'm stretched too thin.”
Although midwives can provide convenient care for low-risk pregnancies, Brown said they cannot solve all the issues created by maternity ward closures — especially in case of an emergency.
In case of an emergency, transportation to a hospital may still be necessary. Limited access to hospitals with maternity wards makes these situations even more pressing, Brown said.
“It may take 45 minutes for the ambulance to get there,” she said. “Then you're looking at an additional period of time for that ambulance to then get to wherever it is that it's taking the birthing person.”
Despite these risks, Tricamo said she is excited to have her eighth baby at home with help from Brown next month. Regardless of whether someone lives in a rural area or not, Tricamo said, there is something special about delivering your baby at home.
“In homebirth, it's you and your husband and a midwife and possibly her assistant. And it's absolutely quiet, except for the sounds of your baby,” Tricamo said. “And you get to sit there for ten or 15 minutes and just absolutely rest in the fact that the worst is over and you get to look at the new human in your life.”
