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Midwife hopes new Iowa law helps meet maternal care needs
‘Licensing midwives is just one of the big steps that is necessary”
Sep. 11, 2023 7:00 am, Updated: Sep. 11, 2023 7:24 am
VINTON — Bethany Gates became interested in helping women during their pregnancy after her first home birth.
Gates gave birth to her first daughter in a hospital, but chose to give birth to her second daughter at home in early 2011. Upon seeing the difference between standard hospital care and the specialized care of home birth midwives, Gates said she felt compelled to be a source of encouragement and care to women seeking a more natural experience.
“At the time that I had my first home birth, there were very few midwives in the state,” she said. “In fact, my midwife traveled hours just to attend my home birth, and I could count on one hand at the time the number of midwives (practicing in Iowa), And so I wanted to be able to train … to offer informed consent and just more options to women who wanted that” individualized, personal care.
Gates became a certified doula in 2011. A year later, she decided she wanted to head down the path of becoming a home birth midwife, and pursued an apprenticeship with certified professional midwives in the area. She completed her midwifery apprenticeship in the spring of 2017. That March, she sat for and passed the eight-hour North American Registry of Midwives exam, receiving her certification in April 2017. She would go on to receive the certification from the U.S. MERA — which is comprised of the seven organizations responsible for midwifery education, regulation and association in the United States — in 2020.
Gates is now a certified professional midwife at Shiphrah Birth Services offering home birth services in Eastern Iowa, and is a member of the Iowa Midwives Association.
Iowa’s maternity care deserts
Thousands of Iowans are losing access to maternal care.
About 50 labor and delivery units have closed in the state in the last 15 years, said Gates. That is leading to maternal care deserts.
One-third of Iowa counties are considered “maternity care deserts” without a hospital or birth center offering obstetric care and without any obstetric providers, according to a 2022 report by the March of Dimes, a nonprofit focused on maternal and infant health.
Iowa ranks among the states with the lowest ratio of maternal care providers per capita. The lack of providers, particularly in rural areas, force expecting women to frequently take off work and drive long distances for appointments.
Iowa hospitals face mounting financial pressure, including stagnating Medicaid reimbursement rates, and rural Iowa providers often struggle to hire and retain medical staff, Gates said.
More women also are choosing more natural birthing options.
During the height of the pandemic, home births in the United States increased 22 percent in 2020 and 2021, according to the Centers for Disease Control and Prevention. And demand continues to increase, said Gates, whose practice has doubled the number of home births she has attended since the start of the pandemic because mothers were concerned about exposure and hospital restrictions.
Gates is hopeful new state legislation signed into law in June, House File 265, will lead to more providers including midwives in their care teams to help fill a growing need for maternal care, particularly in rural Iowa.
Supporters — including the bill’s floor manager, Rep. Bobby Kaufmann, R-Wilton — say midwives can play a critical role in maternity care as Iowa struggles with a provider shortage.
But major medical groups and providers in Iowa opposed the legislation, arguing it could mislead Iowans on the safety of going to a midwife instead of to a doctor or nurse, who are better equipped to handle pregnancy complications.
New law establishes licensing for midwives
The law provides licensure for certified professional midwives, who provide care in homes and free-standing birth centers. Unlike certified nurse midwives, who are already licensed by the state as nurse practitioners and practice primarily in hospital settings, CPMs are not required to have a nursing degree.
The state’s first certified nurse-midwifery program welcomed its inaugural class of nurse-midwifery students last week. The University of Iowa Hospitals and Clinics’ Nurse-Midwifery Education Program seeks to address a growing need for certified nurse-midwives to improve health care access and maternal health outcomes.
The program is part of the Iowa Maternal Health Innovation Program, a five-year effort by the Iowa Department of Health and Human Services and UI Health Care to improve access to high-quality obstetric care in the state, targeting underserved and rural populations. Nurse-midwives provide preventive and gynecologic health care, including annual wellness exams, contraceptives, family planning and menopause care.
According to UIHC, nearly 30 percent of babies born at rural hospitals in the United States are delivered by midwives.
“We need to increase the number of certified nurse-midwives in the state in order to provide access to quality care for expecting mothers,” Lastascia Coleman, clinical associate professor of obstetrics and gynecology-midwifery at the UI, said in a statement.
Gates hopes more providers will start including midwives in their care teams.
Gates praised the passage of the new law, which she said will open the doors for certified professional midwives from neighboring states to practice in Iowa.
She argued the licensing process will improve maternal health care in Iowa. She referenced a 2018 study that suggests that integrating midwives into regional health care systems could result in better newborn and maternal health outcomes.
The new licensure will be managed by the Iowa Board of Nursing, which will establish a midwifery advisory council to advise on education requirements, standards of practice, professional ethics, disciplinary actions, medications and other relevant issues.
A person practicing midwifery in Iowa will be able to obtain a license to practice beginning July 1, 2024.
The law also allows midwives to obtain and administer certain drugs, including anti-hemorrhagic medications to control postpartum bleeding, local anesthetic and antibiotics, which require a license. Licensed midwives also would be able to order labs and ultrasounds at all health care facilities in the state. Currently, only a handful of facilities will allow certified professional midwives to order those services, Gates said.
Licensed midwives would be required to provide each client with a signed consent form that describes their qualifications, a copy of their emergency plan and whether the midwife carries professional liability insurance, and the benefits and risks of home birth. It also states health care providers accepting the transfer of a client from a licensed midwife are not civilly or criminally liable for outcomes arising from actions or omissions of the midwife. Gates said that will help facilitate a smoother working relationship with hospital-based providers.
"For me, all of those things in my opinion makes birth safer for the women choosing to plan a home birth,“ she said. ”So I’m just looking forward to just having access to the basic things that allow me to provide care within that full standard of practice that is within my scope, but the state has been behind on recognizing.”
Iowa’s new law also limits the liability of a health care provider that accepts clients transferred from a licensed midwife, and requires insurance providers to extend maternity benefits to cover services provided by licensed midwives on the same terms as similar services provided by other health care providers.
Currently, Gates said most families pay out of pocket for home births.
What is a midwife?
Midwives routinely provide care for low-risk pregnancies, and may also care for women whose pregnancies are high-risk and partner with physicians who specialize in high-risk cases.
While they have extensive training in pregnancy care and can deliver babies, they are not able to provide medical and surgical care, such as a C-section. If complications arise, care is transferred to an OB-GYN.
“Most midwives … train for about three to five years before they meet all of those requirements,” Gates said. “It’s a pretty stringent set of requirements because we are practicing in an out-of-hospital setting so that training is a lot more specific than the training that you have at a hospital.”
Midwives provide prenatal, childbirth, newborn and postpartum care. That includes prenatal visits, counseling on nutrition, childbirth education, listening to the baby’s heartbeat and monitoring vital signs of the baby and mother and testing for gestational diabetes and group B strep.
“We’re doing all of that antenatal testing that happens for those women who are in a hospital-based setting as well, (and) we come to their homes when moms are in active labor,” Gates said. “We are assessing mom and baby throughout labor to make sure everything is within the scope of normal,” and facilitate delivery.
Afterward, they perform postpartum checkups to make sure the mother is recovering and that her baby and breastfeeding are going well.
Maternal mortality rate spikes in Iowa, U.S.
Iowa’s maternal mortality rate — the total number of deaths due to pregnancy, childbirth and during postpartum period per 100,000 live births — has steadily risen over the past two decades.
Maternal deaths in the United States spiked in 2021 to 32.9 maternal deaths per 100,000 live birth — a 40 percent increase from the previous year, according to data from the CDC. Iowa saw 43.4 maternal deaths per 100,000 live births in 2021.
Maternal mortality is higher in the United States compared with any other developed nations. And racial disparities persist in the United States, where maternal mortality rates for non-Hispanic Black women are three to four times higher than the rates for white women, according to a 2021 Iowa Maternal Mortality Review Committee report, which found 63 percent of pregnancy-related deaths were preventable.
“I truly believe it’s because we are underutilizing midwives” as a front line in maternity care, Gates said.
Studies have shown that among women with low-risk pregnancies, midwifery care was associated with substantially fewer preterm births and labor interventions.
“We’ve got a lot of work to do,” Gates said. “Licensing midwives is just one of the big steps that is necessary.”
Gates hopes state lawmakers next year will extend postpartum Medicaid coverage to include 12 months of postpartum care and raise Medicaid reimbursement rates keeping providers from continuing to practice in the state.
“I think if Iowa can address some of those things, that will make Iowa a more attractive state for providers to come, work in and stay in as well,” Gates said.
Comments: (319) 398-8499; tom.barton@thegazette.com
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