In the small hours of a Tuesday in January, two babies were born at The Midwife Center for Birth & Women’s Health. By 9:15 that morning, one mom had already been discharged with her newborn, and the other was eating an omelet and English muffin — the center’s signature breakfast — in a queen-sized bed.
Patients typically stay four to 12 hours at The Midwife Center [TMC], compared to one or two nights after giving birth at a hospital.
Aside from the nitrous oxide tank propped against the wall, the birth swing hanging from the ceiling and the bathtub in the center of the room, birthing suites at TMC can be mistaken for bedrooms. “The idea is a home-like feel,” said Emily McGahey, clinical director and certified nurse-midwife at TMC.
Family photos and art line the exposed brick of McGahey’s exam room, and a poster that reads “Breastfeeding: the original recipe” hangs in the lab area. At prenatal and routine gynecological appointments, clients do not get undressed unless the exam requires them to and, when needed, they are given cotton gowns rather than paper ones. It is typical for appointments to last an hour and they “never start on the exam table because that just creates an uneven power dynamic,” McGahey said.
(Left) One of the birthing rooms at The Midwife Center for Birth & Women’s Health. (Right) Midwife Jessie Holmquist carries what’s left of a homemade breakfast from the room of a birthing person after they gave birth at the center, on Tuesday, Jan. 10, 2023, in the Strip District. The homemade meal is part of the center’s approach to creating a homey and comfortable experience surrounding the birth experience. (Photos by Stephanie Strasburg/PublicSource)
In the United States, midwives attend about 8% of births. Yet in countries with far better maternal health outcomes, midwives outnumber OB-GYNs during delivery.
Midwifery care emphasizes natural birth, trauma-informed care and shared decision-making between client and provider. The field has improved maternal health outcomes, leading to a national rise in demand. But state regulations, inequitable pay and inadequate diversity remain as barriers. Midwives are working to address the obstacles in various ways, including a local program to train the next generation of midwives.
A crash course in midwifery
The first time Tori Riapos heard her baby’s heartbeat, she didn’t know what she was listening to. Prenatal appointments at her OB-GYN office often felt rushed, but this one stood out. Riapos remembers being confused when her doctor used the fetal heartbeat monitor, unsure what the device was and what it was being used for. “I looked at my husband and I was like, ‘Oh, I guess that’s her heartbeat,’ and [the doctor] didn’t say anything to me,” Riapos recalled.
That experience, coupled with others like it, and the fact that her favorite physician was leaving the practice, led Riapos to switch to TMC. There, she said, every prenatal appointment was grounded in “open and honest communication,” and she felt more in touch with her body and pregnancy. And giving birth with them? “Perfect doesn’t even describe it.”
Last year, 270 newborns — about 1.4% of the Allegheny County total — were delivered at TMC. It’s the only freestanding birth center in Western Pennsylvania, but midwives also deliver babies in homes and, more commonly, hospitals. “If you’re doing it right, it should be almost identical in every setting,” certified nurse-midwife Nancy Niemczyk said.
For low-risk pregnancies, midwives can reduce the risk of intervention, preterm birth and cesarean delivery.
Midwifery care is also often cheaper than its conventional counterparts. This is especially true at freestanding birth centers. The standard charge for a vaginal birth is over $16,000 at leading Pittsburgh hospitals, two times higher than TMC’s $8,350 rate.
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In addition to TMC and hospital births, a very small number of women in the region deliver at home. “Home birth is more work than the others,” Niemczyk observed. But she said many of the comforts of a home delivery can be incorporated into hospital births, including laboring without food restrictions and constant monitoring.
Birth photographers and doulas Jess Thomas and Kate Csallner said there can be more stimulation in hospital births than families anticipate. “You can ask for intermittent monitoring of the baby, but a lot of times it’s continuously monitoring,” Thomas said. She and Csallner have attended and compared home, hospital and TMC births.
“Hospitals are great tools when we need them,” Csallner explained, referring to the fact that hospital births are the safest option for risky pregnancies and the only option for women who receive C-sections and epidurals. But Csallner said the out-of-hospital births she’s documented are especially in touch with birth as “a natural human process.”
The region’s budding, and only, midwifery program
In 2016, the University of Pittsburgh launched its Nurse-Midwife Program. “It’s long been evident that we needed a midwifery program in Pittsburgh,” said Niemczyk, the program’s director. In February 2022, the program received full accreditation status.
Before her work at Pitt, Niemczyk was the clinical director of TMC. It had taken TMC roughly a year to hire a new midwife. Without a midwifery program in Pittsburgh, Niemczyk said, people left the city for their training and never came back. “We were trying to lure people to come in from out of state,” she said of TMC’s recruitment strategy. “That was very difficult.”
McGahey said it takes longer to onboard midwives from out of state because they need to be licensed in Pennsylvania.
While Pitt has the only midwifery program between Cleveland and Philadelphia, only a few students cycle through the program each year.
One demographic Niemczyk didn’t anticipate attracting was students in the military. Pitt’s program grants students a DNP, Doctor of Nursing Practice. “Many midwifery programs are on a master’s degree level,” Niemczyk explained, “and the military now wants all their midwives to have a doctoral degree.”
Depending on their state (or military affiliation), the degree a midwife holds can be critical to the care they provide and the pay they receive.
Regulations limit midwifery in PA
In more than a dozen states, Medicaid reimburses midwives less than physicians for the same care. This is not the case in Pennsylvania, which reimburses licensed midwives at 100% the rate it reimburses physicians. The catch is that these providers must be certified nurse-midwives, not certified midwives. The difference is a degree in nursing. “This just doesn’t make sense to me,” said Niemczyk. “In most of Europe, midwives don’t have to be nurses before becoming midwives.”
Even as certified nurse-midwives, providers may receive less equitable pay based on the structure of their care.
“In the United States, most obstetric care is billed globally,” McGahey explained. “Typically, providers get paid in one chunk for the entirety of the care.” That means that a prenatal appointment may cost the same amount whether it’s 20 minutes or 60. And while that may pull clients toward midwifery, it can push clinicians away from the field.
Another barrier to midwifery care can be collaborative agreements. Pennsylvania requires certified nurse-midwives to sign an agreement with a physician that outlines the care they can provide. The outcome largely depends on the participating physician.
This hasn’t been a problem for Niemczyk. “I have always in my career been very lucky to have collaborative agreements with physicians who were very hands-off.”
McGahey reports that TMC has had excellent collaborative and referral relationships, but finds the requirement restrictive for her colleagues who practice in rural areas, where midwifery care is needed most. Amid a national shortage of obstetrics providers in or near rural areas, McGahey views midwives as a critical part of the solution.
Midwives could also help offload demand that local abortion providers are facing, but Pennsylvania is one of 29 states that bar midwives from prescribing abortion pills.
The future of midwifery
McGahey is well-versed in the politics of midwifery through her work with the Pennsylvania affiliate of the American College of Nurse-Midwives [ACNM], where she serves as a legislative committee co-chair. If stagnation is any indicator, she has her work cut out for her.
According to Pennsylvania’s Department of State, it’s been 14 years since the last major update to state midwifery legislation, which allowed qualified nurse-midwives to prescribe.
McGahey has a growing list that she wants to be included in the next update. “We are currently working on a bill to modernize midwifery,” McGahey said of her work with the PA-ACNM. In addition to repealing regulatory barriers — like those requiring collaborative agreements and nursing degrees — McGahey wants to expand the services licensed midwives can provide.
At the top of her list is medication-assisted treatment [MAT] for opioid-use disorder. “As we look back on our maternal mortality review committee, the No. 1 cause of death in that first year postpartum is what we call accidental poisoning, which is typically drug-related overdoses,” McGahey said. “Federally, midwives are recognized as appropriate providers of MAT.” In Pennsylvania, they are not.
McGahey said this is a missed opportunity because recent mothers can be especially motivated to transition from opioids to MAT.
McGahey also sees the need for internal growth within midwifery. Historically dominated by immigrants and women of color, midwifery shrank in the early 20th century when the medical model forced the field out of health care. As midwifery resurfaces, its racial composition is now 85% white.
According to a 2019 city report, women of color have disproportionately high maternal morbidity and mortality rates. McGahey said she believes growing the number of midwives of color can help address the problem.
“We know that care delivered by concordant racial providers has better outcomes,” McGahey said. Two of TMC’s eight midwives are Black, proportionate to the clients they serve.
One way Niemczyk would want to expand care is with birth centers that operate within the hospital system. These could be a bridge between maternity wards and a freestanding birth center, and could couple with the growing workforce from Pitt’s midwifery program.
Niemczyk, who holds a Ph.D. in epidemiology, said midwifery works best when it’s integrated into health care.
“When there’s hostility and the midwives aren’t part of the system, then you have bad outcomes,” she said. But when the shared attitude between physicians and midwives is, “‘Let’s all work together,’ then you really have good outcomes.”
Sophia Levin, a student at Carnegie Mellon University, is a freelance journalist and former PublicSource intern. She can be reached at sophia@publicsource.org.
This story was fact-checked by Kalilah Stein.