Ten years ago, when Mary Kathryn DeLodder was pregnant with her first child, she became intrigued with midwifery care and home birthing. After searching she finally located a midwife, but it was one who only worked in a hospital setting.
“I found out that it was really challenging in Kentucky at that time to find a provider to attend a home birth,” says DeLodder, who went on to have three of her four children by home birth. “I thought that that was crazy, that you had to really work so hard to find a provider.”
Although the situation has improved for women in the commonwealth who want birthing options, obstetricians and midwives remain in short supply. In fact, half of the state’s 120 counties don’t have an OB-GYN or a place to deliver a baby. And that limited access is resulting in poor outcomes for mothers: Kentucky’s maternity mortality rate is more than double the national average, according to the U.S. Centers for Disease Control and Prevention. At 40.8 per 100,000 live births, the state’s rate is also higher than that of many industrialized nations around the world.
Now doctors, educators, activists, and mothers across the state are working to improve maternal care and provide more options for women in childbirth, including greater access to midwives.
“The more options that we have for birth in Kentucky, the better off everyone is,” says DeLodder, who is now a parent advocate with Kentucky Birth Coalition.
A Resurgence of Midwifery Care
For centuries, midwives have been a critical part of maternity care. University of Kentucky history professor Melanie Beals Goan says as late as the early 1900s, half of women gave birth at home with the help of a midwife. In Kentucky, the Frontier Nursing Service, started by Mary C. Breckinridge in 1925, trained generations of midwives who went on to serve woman in rural communities.
But the tide was about to turn against midwives. Goan says by the 1930s only about 15 percent of babies were delivered with the assistance of a midwife.
“In early 20th century there was this backlash against midwives, painting them as a threat to society,” says Goan, “and that if you have the means, you need to have a trained physician.”
As a result, birth became a procedure rather than a natural process, says Susan Stone, a certified nurse-midwife and president of Frontier Nursing University.
“It became a movement mostly by the medical profession to get rid of midwives and to bring birth into the hospital,” Stone says.
Interest in midwifery has seen a resurgence in recent years as women have sought alternatives to traditional hospital births. But the U.S. still lags many other countries in midwifery care. Stone says American midwives attend about 4 out of 1,000 births, In England, midwives attend 46 out of 1,000 births.
Today there are certified professional midwives, certified nurse-midwives, and certified midwives who provide a range of maternity and birthing services as well as primary care to women from adolescence through menopause. Midwives can attend births at a hospital as well as in birthing centers or in the home.
DeLodder says most nurse-midwives in Kentucky practice in hospital settings; only seven provide home-birthing services at the present time. But she says there are un-credentialed midwives who do attend home births.
The Kentucky Birth Coalition successfully lobbied the state legislature to pass a law in 2019 to license certified professional midwives, which DeLodder says will make it easier for families to find midwifery care. She says professionalizing midwifery also gives those practitioners access to important lab tests as well as medications for issues such as postpartum hemorrhage. It also facilitates relationships between midwives and hospitals in the event a mother requires a higher level of care.
Given the shortage of OB-GYNs and the maternity care deserts that exist in much of Kentucky, UK Healthcare obstetrician-gynecologist Dr. Coy Flowers says collaborations with midwives are essential to caring for the numbers of women who need pregnancy-related services. For example, at Dr. Flowers’ practice in Georgetown, there are two OB-GYNs who work on tougher cases and surgical procedures, and a nurse-midwife that can focus on patient birthing plans.
“In the last four to five years in Kentucky, there’s been a revolution in the relationship between OB-GYNs and midwives,” says Flowers. “It’s essential for all of us to work in a collaborative way in order for us to provide the best care possible.”
In the 2022 General Assembly session, the Kentucky Birth Coalition plans to advocate for legislation to create free-standing birthing centers in the state. DeLodder says the commonwealth has no birthing centers outside of hospitals now because current law requires the state to approve a certificate of need for such facilities. She says eliminating that requirement would make it easier to open birth centers, especially in areas that lack maternity care.
Home Births Versus Hospital Births
While home births are gaining in popularity, they are not for everyone. DeLodder says some women may not be a good candidate for a home birth, while others prefer a hospital setting and access to pain medications. But some women prefer home births as a way to avoid what they see as unnecessary medical interventions such as an early induction or delivery by Cesarean section.
“In the birthing process, if you let it happen naturally, the risks minimize themselves over time,” says Flowers. “I think too much intervention, which we’ve seen in the past, has caused more problems than it was designed to preclude.”
DeLodder say midwives will discuss with their patients whether they are a good candidate for a home birth. She says some patients start their pregnancy at low risk, but may advance to higher risk status, in which case the attending midwife will work with the woman to make the decision to move the birth to a hospital setting.
Hospital births can also present risks. Stone says limited staffing may mean that one nurse and one on-call doctor may be tending to multiple women in labor.
“Things can go wrong,” says Stone. “When you have an obstetrician who’s in and out because they have a hundred things on their plate, and you don’t have midwives in the mix, and nurses may or may not be well trained in maternity care... those kinds of things can lead to those types of errors.”
That’s what happened to Mary Karen Stumbo’s mother. After delivering Stumbo in a hospital birth, the mother developed a staph infection. Stumbo says her mother already had three sons, so she was well acquainted with the birthing process and immediately realized something was amiss after Mary Karen was born.
“Her concerns were not passed up the chain and by the time they were, it was too late,” says Stumbo.
Six days later, Stumbo’s mother died having never left her hospital bed.
Now 50 years old, Stumbo says she thinks daily about the mother she never got to know. She says the experience illustrates how women must be their own advocates in health care settings.
“When you know something’s wrong, you express it,” says Stumbo. “If you’re not taken seriously, you get louder because there’s nobody that can take care of you better than you can.”
Flowers says stories like Stumbo’s offer a critical lesson for doctors and medical students.
“If you listen close enough to the patient, they’re telling you exactly what’s wrong with them,” says Flowers. “We just have to open up our ears and our minds and follow those clues that the patient is giving us.”
The Role of Doulas in Maternal Care
Doulas provide another option for women seeking support during pregnancy and birth as well as the postpartum period. Doulas don’t deliver babies and they are not medical professionals, but they provide knowledge, experience, and companionship throughout the maternity experience.
“Doula actually comes from the Greek word that means ‘woman who serves,’” says Renee Basham, a doula and executive director of Hope’s Embrace. “It’s always been this role that women would come alongside other women and help them throughout their pregnancy, labor, and birth and even the postpartum period.”
Launched in 2016, Hope’s Embrace has a cadre of volunteer doulas who provide maternity services to lower-income women throughout Kentucky.
“We were founded out of a desire to help people know the options out there and help them find where they are in their area,” says Basham. “We have people all over the state that we can connect to, whether it be for lactation support, birth support, [or] postpartum.”
She says many women don’t realize that they have the right to accept or refuse a recommended intervention, and that they can change their doctor at any point. She says research indicates that the presence of a doula reduces the risk of medical interventions and C-sections, and increases the success rate of breast feeding.
While training and certifications are available, Basham says doulas aren’t required to be certified. In the five years that she has been a doula, Basham has attended more than 25 births. She specializes in working with women who have endured trauma or who have a hearing impairment.
“In some instances, working with lower-income women, I have been the only person in that birthing room,” says Basham. “So there’s a lot of gratefulness that I’m there to remember that experience with them and share in it.”
Efforts to Address Other Maternal Care Challenges
Limited access to care isn’t the only factor driving maternal mortality in the commonwealth. Women may face underlying health conditions that can lead to hemorrhaging during birth. If they are hypertensive, they may have a stroke. They may also have complications from diabetes. Drug addiction is also a factor.
“One of the biggest problems that we face in Kentucky would be substance abuse,” says Damara Jenkins, director of nurse midwifery at U of L Health and a member of Kentucky’s Maternal Mortality Review Committee. “Like 50 percent of our accidental deaths around the pregnancy period are directly due to overdose.”
To help combat overdose deaths among expectant and new mothers, Stone says midwives now receive training on medical-assisted treatments for women with a substance use disorder.
Racial disparities in health care also drive maternal mortality. Research indicates the death rate for Black mothers is about three times higher than the rate for white women.
“It’s not being Black that is the risk factor, but it is racism,” says Jenkins. “That is what is causing higher rates of death amongst Black women.”
Bias can impact what access to care women of color have, how they are examined, and what pain management options they receive, according to Jenkins, who is one of only three Black midwives serving in Kentucky.
Stone says the American College of Nurse Midwives has launched an initiative to increase enrollment by students of color to 25 percent. Already at Frontier Nursing University, the successor to the Frontier Nursing Service, students of color comprise 28 percent of enrollment, says Stone.
Beyond midwives for the birth process, postpartum care is also a critical issue among Black mothers.
“Postpartum is a very difficult time, and when you don’t have a village around you to give you the support that you need… it can lead to things like the maternal mortality rate,” says Kazia Bryant, who is a doula and program manager of Black Birth Justice, a Louisville non-profit that advocates for maternal health and provides support services for postpartum mothers.
“We supply you with essential needs that you may need after having a baby,” says Bryant. “We have pads we can give you, nursing bras, nursing supplies. We offer lactation support… we go over diet, things that you should eat after having a baby to promote healthy bodies.”
Bryant says Black women may not feel comfortable talking with health care providers who don’t look like them or share a similar background. Other times, they may feel like their concerns aren’t properly heard. Either way, Bryant says the result is that problems aren’t addressed as quickly or as thoroughly as they should be.
“My people can come to me and know that I can help them, I won’t judge them,” says Bryant. “I’m literally there just to help you and uplift you.”
“It’s very important to have resources, especially if you’re feeling depressed, or you’re down and out, or you’re having anxiety,” says Takesha Stokes, a client of Black Birth Justice. “It’s very special to have someone to talk to, somebody in your corner.”
While it may not be feasible for the state to have fulltime obstetrical care, delivery services, and postpartum supports in every county, advocates contend it is possible to improve the quality of maternal care that women receive – if all the various providers will collaborate and cooperate.
“If you only provide obstetrical care, you’re not going to get the best care,” says Stone. “You need midwifery care, you need the doulas… you need all of these things working together to get the best outcomes.”
“Working hand in hand with a doula, nurse-midwives, OB-GYNs together is optimal,” says UK Healthcare’s Dr. Coy Flowers.