Midwives can help fill the rural childbirth services gap, but say they're burned out and need better reimbursement

Rural women have less access to maternity and childbirth services, a trend only made worse by the coronavirus pandemic and one that contributes to higher mother and child mortality rates in rural areas, especially among people of color. Midwives are stepping in to help fill the gap, often with government support, but many are facing the same kind of stress and burnout other health-care professionals have reported, and say they aren't being reimbursed enough, reports Aallyah Wright of Stateline.

"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," Wright reports. "Doulas, who assist parents during childbirth but don’t provide medical care, also are seeing an increase in demand."

The need is great. More than half of rural counties don't have a hospital that delivers babies. That endangers the lives of mothers and infants; rural American women and infants face significantly higher mortality rates than in other wealthy countries. Many pregnant women who don't live near a hospital with obstetrical services have transportation problems that make it difficult to get to one further away that does. And even women who can make the trip are often pressured to give birth by scheduled Caesarian section, which carries health risks, rather than chance going into labor and not being able to make it to the hospital on time.

Other barriers to access have emerged during the pandemic: many pregnant women haven't felt safe going to a hospital or haven't been able to contact their care providers, Wright reports. Those issues, along with pandemic hospital staffing shortages, have prompted many pregnant women to turn to midwives.

"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," Wright reports. "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."

But some states don't recognize midwives as qualified medical providers or limit what services they can provide. And even in the states that do, many midwives say the government isn't reimbursing them enough for Medicaid patients. "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, "Wright reports.

Such 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," Wright reports. "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."