Midwives are essential, helpful, and cherished in rural and underserved communities, and simultaneously, face enormous challenges. In rural areas of New Mexico, and many other states, it’s not unusual to drive up to 100 miles to provide midwifery care. Often, midwives who serve multiple counties or clients in rural locations will coordinate such that they are able to see multiple families in a “travel day,” which can sometimes mean seeing 2-4 clients in a couple to a few hundred mile radius, roundtrip. Obviously, this puts additional stress on the midwife, and their vehicle, as they will have to plan accordingly for any appropriate and timely lab testing if provided in or out of the home, as well as coordinating with clients, not to mention their own families. Many will also have to consider external and environmental factors, such as weather and road conditions, cell phone, and internet service, if any.
Midwives are in high demand in these areas because of the personalized care they offer and because they are willing to travel. The emphasis on health and safety are an equal and shared responsibility between the client, often what is referred to as informed and shared decision making. Discussions are held amongst the midwife and the family to create, if not wholly plan for, alternative contingency plans for the unexpected, a fast labor and birth, for example, and agreements are made far in advance. Oftentimes, a homebirth emergent “kit” including a Doppler, or pH strips, in addition to the other homebirth supplies, may be used with instruction, and always, with close communication with the midwife.
Community birth has its own set of location based midwifery competencies for a variety of factors. One of which is, transfers will inevitably happen. Rural locations can make transfer decisions even more complicated and require a high level of critical thinking, relationship building, and both emergent and urgent care plans. Urban areas often carry the burden of providing informed decision making education to clients on which hospitals will be “friendly”, whereas rural areas often don’t have this luxury and may face the additional burden of long drive times, heightened provider disrespect from hospital staff, and obstetrical mistreatment or even violence simply because a family chose to attempt a home birth.
As we make progress toward the return of full integration of midwives in community these challenges have to be addressed. Improved and respectfully responsive medical transportation systems that have been trained in community birth transfers, statutes and reimbursement that supports telehealth, and programs like Smooth Transitions that support quality improvement and relationship building will be vital to making systemic changes. Workshops like Primary Maternity Care’s, Step Up Together Action Collaboratives that provide drills that work through transfer situations from home or birth center, actually engage EMS, and complete in the transfer hospital improve these systems, build collaboration, and improve quality care.
We are in a history making moment of perinatal care and midwifery integration in this country. If we want to actually offer the best possible client care to everyone in underserved communities throughout the nation we owe it to those giving birth and the families and friends that support them to collaborate in the creation of systems that honor people’s right to choose their provider and place of birth and embody respectful co-management and transfer of care between providers.