As Birthing Units Close, Where Do Midwives Fit In?
As hospitals close their birthing units, independent midwives are reluctant to provide care in areas without a safety net.
By Emily Hedegard and Kate Cough/Maine Monitor
Editor’s Note: This story is the second in a series exploring maternity care in Maine.
MAINE—The vast majority of births in Maine — roughly 97 percent — occur in hospitals. But like the rest of the country, the number of home births has risen in the state in recent years, jumping 41 percent between 2018 and 2023, from 228 to 321.
Nationwide, the percentage of home births in the United States reached 1.26 percent of all births in 2020, a 22 percent increase from 2019 and the highest level since at least 1990, according to the Centers for Disease Control and Prevention.
As hospitals around the state shut their labor and delivery units and some of those that remain struggle with staffing, some pregnant patients are choosing to give birth at home with a midwife to avoid long drives, planned inductions or because they worry their wishes would not be respected in a hospital setting.
Katelin Potter-Rivera chose to drive the two hours to a birth center in Bangor for both of her pregnancies, despite living near a hospital with an obstetric unit.
Potter-Rivera began her prenatal care at her local hospital, but said she was “turned off” during an appointment in her second trimester when staff told her they might have to end her appointment early to help deliver a baby down the hall. Giving birth during the pandemic, when many hospitals were limiting who could be in the delivery room, Potter-Rivera also wanted to ensure her husband could attend her birth.
Potter-Rivera ultimately gave birth at Holly No. 7, a freestanding birth center in Bangor that saw an 82 percent increase in births between 2018 and 2023. The number of overall births there is still small — 40 in 2023 — but the center, which is staffed by professional midwives, saw the biggest percentage increase of any hospital or birthing center in the state over the past five years.
“I just knew I wanted something different than the hospital,” said Potter-Rivera. “The hospital is just so corporate; very conveyor belt — get you in and out — which serves a time and a place. But that made my husband and I think, ‘there’s probably better care [out there].’”
While experts said it is still too early to determine the health consequences of recent maternity unit closures, several women The Monitor spoke to who lived far from their nearest birthing hospital said they had been scheduled for a planned induction, in part to ensure they would make it to the hospital on time. Some said they chose to birth at home, or at a freestanding birth center staffed by professional midwives, in part to avoid a planned induction or C-section.
Maria Ikwugwalu knew when she became pregnant that she wanted to give birth with an independent midwife. But her insurance wouldn’t cover it, so she began care at a nearby hospital.
But Ikwugwalu said she was dismayed by the level of care that she received at the hospital, feeling that appointments were rushed and that staff were not as attentive as she’d hoped. Eventually she decided to pay out of pocket to cover the expenses and switched to Holly No. 7, which charges $5,800 for midwifery care and birthing at home and an additional $1,200 for birthing at the birth center in Bangor.
“Switching over to the midwifery center… the difference was like night and day,” said Ikwugwalu.
Research shows that rates of induction and C-sections are far higher in planned hospital births than with planned out-of-hospital births. In 2022, according to the Centers for Disease Control and Prevention, the C-section rate in Maine was 31.7 percent, more than double the 10 to 15 percent rate recommended by the World Health Organization. While both interventions can be necessary and life-saving, both carry their own serious risks.
“More inductions will happen because of the closing of these small hospitals,” said Chris Yentes, a certified professional midwife who has been practicing since 1992.
Home birth also carries risks. Although planned home birth is associated with much lower rates of maternal intervention — like induction and C-sections — than planned hospital birth, a 2015 New England Journal of Medicine study found that birthing at home carried roughly double the risk of neonatal death and a threefold increase of seizures and serious neurologic dysfunction.
The rates of death are still low — 2.4 fetal deaths per 1,000 patients at home versus 1.2 in the hospital — but they are elevated for those giving birth at home.
Midwifery-attended births on the rise
Hospitals are incorporating more nurse-midwives into their practices, both in Maine and around the nation. Nationwide, between 2012 and 2022, the proportion of births attended by a Certified Nurse-Midwife increased from 7.9 percent to 10.9 percent, according to a report from the American College of Nurse Midwives. Maine’s largest hospital systems, MaineHealth and Northern Light Health, offer midwifery services at several hospitals.
Both the American Academy of Pediatrics and ACOG recommend only midwives who are certified by the American Midwifery Certification Board, and recommend hospitals and accredited birth centers as the safest settings for birth.
In Maine, hospitals typically employ certified nurse-midwives, who are registered nurses with a master’s degree in nurse-midwifery. Nurse-midwives are licensed to attend births in hospital settings as well as at birth centers and at home, and can care for both low and high-risk patients.
Nurse-midwives are different from certified professional midwives (CPMs) and certified midwives (CMs) who typically care for people birthing at home or in freestanding birth centers.
Under Maine law, CPMs and CMs (sometimes referred to as “independent midwives”) are required to have completed formal midwifery training via a program accredited by the Midwifery Education Accreditation Council (or, for those certified nationally before 2020, when Maine’s licensing law went into effect, a bridge certificate) and are only allowed to care for patients with low-risk pregnancies. They cannot deliver twins or breech babies.
They can order certain tests, such as ultrasounds, and certain drugs. They can deliver babies for a person who has previously had one C-section, but only if the person meets certain criteria. If a patient becomes higher-risk during a pregnancy or birth, they are required to transfer care to a physician.
While they may provide care in a hospital setting with the permission of the hospital, none of the hospitals interviewed by The Monitor said they allowed independent midwives to actively participate in births for liability reasons.
Maine currently has 39 actively-licensed certified professional midwives and one certified midwife, according to data provided by the Board of Complementary Health Care Providers.
Midwives are different from doulas, who are not required to be licensed in Maine and do not provide medical care. Doulas provide ongoing educational, physical and emotional support to pregnant, birthing and postpartum people and their families. However, there is no national standardized training, certification or exam requirement, and standards can vary widely between training organizations.
There is a push to increase access to doula care in the state. Sen. Denise Tepler, a Democrat representing Sagadahoc County, recently introduced a bill requiring MaineCare to cover doula services, and she said another colleague has plans to introduce a similar measure.
No plans to incorporate independent midwives
Hospital executives The Monitor spoke with said they did not have plans to incorporate certified professional midwives or certified midwives into their practices, focusing instead on certified-nurse midwives and doulas.
Dr. Amy Belisle, chief child health officer and chief pediatrician for the Maine Department of Health and Human Services, said the state is looking for ways to improve the transition when a person needs to be transferred from a home or freestanding birth center to a hospital, but that incorporating independent midwives into practice “is not currently a strong focus.”
The Maine Association of Certified Professional Midwives has developed a “Perinatal Transitions Program” to standardize the handoff when patients need to be transferred to a hospital. The program includes a standardized form designed to be distributed to EMS workers and hospitals in the event of a transfer, as well as a place to provide feedback on the transfer and schedule a debrief.
Making it clear that the person is seen by a trained midwife who can provide information on their condition, rather than having an accidental birth at home, is important for dispatchers as they are directing calls, said Ariel Bernstein, an certified professional midwife who recently graduated from Harvard with a masters in public health. “We’ve done a lot of work with the Maine EMS on a state level to provide better education.”
Natalia Hall, associate vice president for Northern Light Women’s Health, said the hospital system planned to “get creative” and incorporate more nurse-midwives into its care teams, but did not have plans to work more closely with independent midwives.
Midwives around the state said they had good relationships with their local hospitals.
“Maine is a really amazing place where we have great communication and great relationships with hospital care providers,” said Morgan Miller, a certified professional midwife and member of the board of MACPM. “Overwhelmingly, midwives in Maine have existed within an incredibly collaborative system.”
Dr. Candice Dersch, interim chair of obstetrics and gynecology at MaineHealth, who has worked as an obstetrician at Maine Medical Center in Portland for 14 years, said she had good relationships with the independent midwives in the area.
“Maine Health as a whole is very committed to improving the care, the obstetrical care, and, for that matter, all gynecologic care for women and men,” said Dr. Dersch, “and understands that patients have options in where they choose to deliver and give birth, and we’re committed to trying to make that a safe option for all patients.”
The relationship between Maine’s largest healthcare system, MaineHealth, and the midwifery community was tested last year with the introduction of L.D. 1205, a bill that would have changed the group standards under which independent and certified midwives operate from being delineated by the National Association of Certified Professional Midwives to the American College of Nurse-Midwives and the American College of Obstetricians and Gynecologists, a dramatic shift.
The legislation would also have changed data collection requirements for independent midwives and have required that, instead of consulting with other providers when a question arose, they refer patients for care.
The bill, which was at first championed by hospital executives at MaineHealth, sparked outrage among midwives around the state, who saw it as a dramatic overreach. The legislation was ultimately withdrawn by its sponsor, Rep. Michele Meyer, after negotiations around an amendment broke down.
Bernstein said she got her masters degree in part to become an advocate for midwives in Maine.
“Midwives are not a voice at the table when it comes to public health policies and legislative policies,” said Bernstein. “Again and again we face this dynamic where somebody in Augusta can pass a law that changes what we can or can’t do, or how we have to do something, and often with very little regard to what that is like, what is the reality of that on the ground for us.”
Sarah Calder, director of government affairs for MaineHealth, said the organization would not be moving forward with anything similar to L.D. 1205 this session, instead focusing on children’s behavioral health, long-term care and the healthcare workforce, as well as fighting proposed cuts to MaineCare.
Midwives reluctant to offer care as labor and delivery units close
In interviews, many independent midwives said they were more reluctant to offer their at-home services as hospitals nearby closed their birthing units. A lack of trained hospital staff means that if something goes wrong during a home delivery, there is no safety net.
“That limits people’s choices further, because now, not only can they not have a hospital to birth at, but maybe they can’t birth at home in their community either, because it’s not safe for the midwives to provide care for them in that area,” said Bernstein.
Independent midwives The Monitor spoke with said they wanted to work more closely with hospitals. Bernstein said that incorporating midwives into prenatal and postpartum care could help bridge the gap in services.
“Not everybody wants to birth at home, or should birth at home, but everybody deserves really good prenatal care, and everybody should be able to access prenatal care within their community,” she said.
“Maine could investigate how to work with midwives in the community to be partners in providing prenatal care, especially in areas where people are further away from those resources.”
Several midwives also called for MaineCare coverage of midwifery so more families can afford their care.
Roughly 37 percent of births in Maine are covered by MaineCare, which does not cover out-of-hospital births with independent midwives. This means those who want to give birth at home must pay out of pocket, which can cost thousands of dollars.
A 2021 state survey by the Kaiser Family Health Foundation found that, of the 42 states that responded to the survey request, 25 cover home births under Medicaid (MaineCare is Maine’s version of Medicaid), as long as patients meet certain criteria.
“The reality is like people are going to birth outside of a hospital,” said Miller, “and [Certified Professional Midwives] are a way of keeping that safe.”
This story was originally published by The Maine Monitor, a nonprofit and nonpartisan news organization. To get regular coverage from the Monitor, sign up for a free Monitor newsletter here.
All BH Story posts are compelling and important. Not only for all of us but for the next generations. This story explicitly shows the terrible choices and terrible risks of living in a country where the health and well being of those involved in child bearing means nothing to Republican ideologues and religious zealots in power.