UNIVERSITY OF IOWA

University of Iowa will start training more midwives as rural birthing units close

Cleo Krejci
Iowa City Press-Citizen

Nearing the end of her second trimester and wondering if something was "off," Erin Almelien scheduled an extra ultrasound. Then she went into labor. 

"We were going to just check it," Almelien said. "I guess I just didn't last that long."

Delivering via emergency C-section wasn't the plan that Almelien and her wife Tracy had outlined for the birth of their second child, a now almost 2-year-old girl named Ellis. The couple had been working with certified nurse-midwives for prenatal care and expected they would handle the events of Ellis' birth, too.

Midwives are trained to approach pregnancy as the normal, physical event that it is — at least up until more complicated medical intervention becomes necessary. It's a more natural approach to pregnancy care that is favored outside the U.S. Now, more Iowa families will likely see more options for the use of midwives after the creation of a new Master of Midwifery program at the University of Iowa in fall 2022. 

"Even when I had my complication, I went into labor, they (the midwives) came in, discussed with me what was going on. Obviously, then it was the doctor that did the C-section," said Almelien, who lives in Washington. "After, they were checking on me."

Dr. Lastascia Coleman is a certified nurse-midwife and director of the new program at UI. She said that physicians are often trained to approach things from a medical model where there's a problem, a diagnosis and a treatment.

"We (midwives) kind of just let things be unless they need to be intervened upon," she said.

In Iowa, there were 138 certified nurse-midwives in 2018 —  an 84% increase from 2008. It's a field that’s projected to keep increasing its employment opportunities significantly, according to the proposal for the UI masters program.

However, certified nurse-midwives in Iowa delivered just 11% of babies in 2018, according to data from the state. Obstetricians, gynecologists and family medicine physicians handled 75%. 

But it's been well-documented that increasing the number of midwives could help to reduce other, broader issues with maternal health care in the United States.

In Iowa, much of the problem relates to access.

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At least 34 community-level hospitals in the state have discontinued their maternity services in the past two decades, according to a 2020 report to the state Legislature. Many rural counties are lacking in delivery services or have few or no OBGYNs, leaving gaps in care.

The masters program takes that into account. The program proposal approved by the state's Board of Regents in September cites an "unmet need" for people to provide maternity care in Iowa, especially in rural parts of the state. It also points out that, from 2015 to 2018, maternal mortality rose in Iowa from 20 deaths to 39.

"We think that that type of model, where practices go to having the midwives provide this care in rural communities, and have the patients return to larger hospitals just for their births, is going to help with access and making sure people are able to attend their prenatal visits," Coleman said.

Midwifery is far more common outside the United States. In Australia, for example, there are 68 midwives and seven OBGYN's for every 1,000 live births; in the U.S., it's four midwives, 11 OBGYN's, according to data from the Commonwealth Fund. Coleman said the establishment of medicine in the U.S. replaced midwives with physicians for maternal — in part because of the discrediting of the midwifery services of Black women.

"We need more midwives in Iowa to implement some of these recommendations that have come out nationally. We know that midwifery care is associated with better outcomes for people of color," she said. 

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Iowa awarded federal dollars to address maternal health care

In 2019, the Iowa Department of Public Health received $10 million from the federal government to address disparities in maternal health care. The State Maternal Health Innovation program awarded the funds to nine states, including Iowa, in light of broader issues nationwide — such as that the country's maternal mortality rate is twice that of other developed countries.

The new masters degree at UI — a five-semester, hospital-based program — is one arm of the grant. It's partially funded by IDPH.

There are many factors behind the closure of community-level maternity services in Iowa, Coleman said. There's an aging workforce that's not replacing itself. And it's expensive for physicians to operate in smaller communities, where insurance reimbursements often aren't enough to cover the high operating costs of labor and delivery units.

"It's basically like operating an intensive care unit with the staffing ratios of nurses, having providers and anesthesiologists on call all the time, but you don't need them all the time," Coleman said. "So, especially at these smaller hospitals with lower birth volumes, you're paying people to be there, ready to go, but they don't have patient volumes to support keeping the unit."

Many patients drive to the UI clinic from more than an hour away because they don't have access to prenatal services in their own communities, she continued. But those visits are crucial for monitoring symptoms that could lead to serious complications down the line. 

While maternal deaths are rare, preventable deaths related to pregnancy still occur. In Iowa, they are also six times more likely for Black women than white women, according to a 2020 report by the state's Maternal Mortality Review Committee.

One issue tied in to accessing care? Insurance coverage, especially for lower-income populations. Medicaid caps pregnancy-related coverage at 60 days after a baby is born.

"After you have a baby, 60 days, you've barely even left the house," Coleman said. "You're not really thinking about your own health yet, you're just trying to figure out how to take care of your baby."

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For the Almeliens, midwifery meant personalization

Tracy and Erin Almelien with their two children, Anders and Ellis. The couple, who live in Washington, Iowa, used midwives for prenatal care, a trend that is expected to grow in the state as rural birthing units shut down.

The delivery services in Washington, Iowa, where the Almeliens live, had closed by the time baby Ellis was on the way. They had already decided to use the university hospital for the birth, anyway, but the closure of the community services also came with an unexpected surprise: midwives.

UI has expanded its care to some rural communities that have lost their labor and delivery units, including in Muscatine and Washington counties.

The team of midwives in Washington who handled Erin's prenatal checkups was conveniently located down the road from the middle school where she teaches art. The same midwives there now handle her yearly exams. 

Knowing the people overseeing the pregnancy was important in the decision Tracy and she made to use midwives, Erin said. It's one reason why they chose midwives for the prenatal care of their first baby, now a 4-year-old boy named Anders, whom Tracy carried. 

The couple attended a "centering class" for their first baby. They met other expectant mothers as well as spent individual time with the midwives. 

"We made a network of friends that we still talk to today, which we wouldn't have had if we had just chosen to use the regular doctors," Erin said.

Cleo Krejci covers education for the Iowa City Press-Citizen. You can reach her at ckrejci@press-citizen.com or on Twitter via @_CleoKrejci.