Nandi Hill rushed to Emily Rose's home at the crack of dawn.
The car was packed with Hill's supplies: oxygen tank, hemorrhaging drugs, umbilical cord scissors, stethoscope and blood pressure cuffs, among other tools.
Hill, a licensed and certified professional midwife and founder of Wadada Midwifery Care in Albuquerque, New Mexico, was excited that, on that day in March, the time had come to help Rose bring a baby girl into the world with an at-home water birth.
"On the drive there, I become peaceful and grounded and focused on my job and what I'm there to do -- and that's to make sure everyone's normal and safe," Hill said.
At a healthy 41 weeks pregnant, Rose took deep breaths while sitting in a small pool filled with water in her living room.
She shifted to her hands and knees, moaned and grunted, and then suddenly her baby girl was born. This was Rose's second pregnancy and birth.
As part of the standard midwifery care that Hill provides, she checked on Rose weekly after the birth. Hill asked about Rose's bleeding, which is often experienced after delivery, and asked how Rose was feeling -- was she stressed or sad -- among other questions.
"In that six weeks postpartum, where we lose a lot of women in this country, I'm doing a lot of follow-up care. I'm there at 24 to 36 hours post-birth, after I had left and made sure everyone's stable. I'm there at day three. I'm there at day seven, two weeks, three weeks if need be, four weeks, and six weeks," Hill said.
Now Rose and her baby girl are doing well and thriving, but Hill said that, if she could wave a magic wand, she would wish for all women in the United States to receive that same level of postpartum care that she provided Rose's family.
"That's my magic wand, that everyone gets the access to midwifery care. That everyone has the six-week follow-up care," she said.
A growing body of research suggests that services and support from either midwives or labor assistants, also known as doulas, come with health benefits for both the mother and baby, regardless of whether the delivery occurs in a hospital, birthing center or home. But differing state laws on how certain midwives are recognized and what insurance can cover, mean many women don't have access to that type of care.
The states that integrate midwives into care
Midwives are not medical doctors and there are services they are unable to provide -- such as blood transfusions or cesarean sections. An obstetrician would step in when that type of care is needed.
There are several types of midwives, but only one has been federally recognized in the United States as a provider of support and care: the certified nurse-midwife. Nationally, nurse midwife services are listed as among the "mandatory benefits" that states are required to provide through Medicaid under federal law.
Certified nurse-midwives, who provide support from the prenatal period through the postpartum period, are registered nurses and trained to work as midwives in a variety of settings, including hospitals and birthing centers. Nurse-midwives have been practicing in the United States since the 1920s. In some states, they can even legally write prescriptions.
Other types of midwifery care, such as those provided by a certified professional midwife, are regulated by state and have different types of training. These midwives also have limitations on what they can do -- for instance they don't have the same prescriptive authority as certified nurse-midwives, they aren't licensed in all states and they aren't covered by Medicaid in all states.
New Mexico has allocated Medicaid funds to include licensed midwives to provide services in the state, Hill said, but that is not the case in Illinois, where she is originally from.
"Every state is very different and because we're not federally recognized, I can't move to Illinois and set up shop legally and do the work," she said, because her credentials are not recognized there. "It's a felony for me to practice medicine there."
Then even in states where Hill could be able to practice legally, she added that there are differences in out-of-pocket costs. In New Mexico, "if you pay out of pocket in my care, it's $2,800 to $4,000. If you go to somewhere like New York state, it can be up to $10,000, $12,000," she said.
The "big buzz" among moms-to-be in New Mexico has been that midwife services are covered by Medicaid, said Nicolle Gonzales, a certified nurse-midwife in San Ildefonso Pueblo, New Mexico and founder of the nonprofit Changing Women Initiative.
Medicaid covers birth, postpartum, all the prenatal visits for a reimbursement of about $1,500, Gonzales said.
"But with a private pay, like Blue Cross Blue Shield or United Health Care Presbyterian, a midwife practice might get maybe anywhere from $3,000 to $5,000. Five thousand at the most, which is rare," she said, and reimbursements vary based on the types of credentials a provider has.
A study published last year in the journal Plos One ranked all 50 states based on how much the three professional designations for midwives -- certified nurse-midwives, certified professional midwives and certified midwives -- are integrated into regional health systems. New Mexico ranked second among states with the most integration.
Based on data from 2014 to 2015, the five states that ranked highest for integration were:
- New Mexico
- New Jersey
- New York
The five states that ranked lowest for integration were:
- North Carolina
- South Dakota
Overall, greater integration was significantly associated with higher rates of vaginal births and breastfeeding and lower rates of obstetric interventions, preterm birth, low birth weight and neonatal death, the researchers wrote in the study.
"These findings are especially significant in the light of increased costs to any health care system associated with high cesarean and preterm birth rates, and low breastfeeding rates," the researchers wrote.
Help from labor assistants
In the United States, about 700 women die each year from pregnancy or delivery complications -- more than any other developed nation -- and black and Native American women are about three times as likely to die from such complications as white women.
The disparity increases with age, as black and Native American women older than 30 are 4 to 5 times as likely to die from complications, according to the latest data from the US Centers for Disease Control and Prevention.
To help reduce that racial gap, some maternal health and advocacy groups suggest that the personalized services from midwives or labor assistants, sometimes referred to as doulas, could be a solution.
Labor assistants differ from midwives in that while they provide support and comfort during delivery, they do not provide medical advice nor can they change the clinical recommendations of a midwife or an obstetrician. Access to professionally trained labor assistants, or doulas, also varies by state, with three states so far having targeted legislation for insurance reimbursement: Minnesota, Oregon and New York.
Earlier this year, New York launched an initiative to address mothers dying in childbirth and reduce racial disparities in maternal health. It includes a Medicaid pilot program to cover doulas.
The nonprofit March of Dimes released a position statement earlier this year indicating that it "supports increased access to doula care as one tool to help improve birth outcomes and reduce the higher rates of maternal morbidity and mortality among women of color in the United States."
The statement went on to note that March of Dimes "advocates for all payers to provide coverage for doula services" and "recognizes the importance of increased training, support and capacity development for doulas."
Mothers with support from labor assistants may be four times less likely to have a baby with low birth weight, two times less likely to experience a birth complication and significantly more likely to initiate breastfeeding after birth, according to a study published in the Journal of Perinatal Education in 2014. The study involved examining birth outcomes among 128 women who delivered without a labor assistant and 97 women who used one.
"Often times we are the gateway. We notice things before the hospital staff does, or we have recommendations that can ease the process," said Tracie Collins, CEO and founder of the National Black Doulas Association.
"There's a lot of disassociation when it comes to black women being heard," she said.
'Our bodies have never been ours'
To understand problems in the present, it can help to look to the past, Collins said.
"If you think about our history within coming to this country, our bodies have never been ours. Black women's bodies were used as experimentation," she said, referring to 19th century Alabama surgeon Dr. James Marion Sims who conducted experiments on women, usually women of color and mostly enslaved black women.
There also have been cases of medical procedures, including sterilization, performed on Native women without their consent. In 1976, the US General Accounting Office found that four of the 12 Indian Health Service regions in the United States sterilized 3,406 American Indian women without their permission between 1973 and 1976.
That same year President Gerald Ford went on to sign the Indian Health Care Improvement Act to permit Medicare and Medicaid reimbursement for services provided to American Indians and Alaska Natives in the Indian Health Service and tribal health care facilities. The bill was made permanent when President Barack Obama signed it in 2010 as part of the Affordable Care Act.
In the modern day, Collins said that providing women -- especially women of color -- better access to midwifery care and labor assistance, such as through insurance coverage, could help women to feel more empowered and heard when it comes to their maternal health.
"The weight of institutional racism within western medicine is deeply, deeply embedded and will take a lot to unravel."