This spring, stories from three different sources covered a topic of urgent interest to Hoosiers.
In mid-March, NPR’s Morning Edition picked up a story from Perry County, Indiana, and WNIN about Deaconess Health System’s simulation team training emergency room staff in rural hospitals for pregnancy-related emergencies. As birth rates drop in the U.S. and hospitals focus more on profitability, labor and delivery services have been cut from rural and urban hospitals, most of which serve low-income households. The ER in Tell City, like Montgomery County, lacks staff trained to provide one of humankind’s oldest forms of healthcare: pregnancy, labor, delivery and postpartum care.
In a second story, Religion News Service reported April 8, that one of the largest Catholic health systems, Ascension Healthcare, was closing even more of its labor and delivery units so that only 49 of its 140 hospitals would provide obstetrics care. That’s lower than the average of all 674 Catholic hospitals combined. Only 299 of those offer obstetrics care. This happened even as in 2022, Catholic bishops “prayed for a favorable ruling in Dobbs v. Jackson Women’s Health Organization.” During that time, the bishops’ conference urged Catholic institutions to “be witnesses of love and life by expanding and improving the extensive network of comprehensive care including pregnancy help centers, maternity homes, and Catholic health care and social service agencies.”
On April 19, the Associated Press obtained papers through the Freedom of Information Act reporting several dozen complaints of pregnant individuals being refused care in 19 states from 2022-23. A dozen incidents occurred prior to the Dobbs decision in June 2022, and two dozen afterward showed that women in a pregnancy-related crisis were turned away from hospitals, leading to stillbirths and miscarriages without medical guidance. These incidents violate the Emergency Medical Treatment and Labor Act, which mandates that no one can be turned away from an ER. According to EMTALA, all individuals who come to an ER must be screened, stabilized, provided immediate examination and treatment and, when needed, appropriate transfer.
The AP reported that “pregnant patients have become radioactive to emergency departments’ in states with extreme abortion restrictions,” according to Sara Rosenbaum, a George Washington University health law and policy professor.
One in four women in Indiana lives in a maternal healthcare desert, according to the March of Dimes. Montgomery County has a maternal vulnerability index score of 60.2, placing it in the second most dangerous category. Some of the highest risk factors for pregnant individuals in the state include physical environments, mental health and substance use disorder, physical health, and reproductive healthcare.
The problem is complicated by too few healthcare providers and outdated laws limiting the expansion of one class of provider: midwives, particularly certified professional midwives and certified direct-entry midwives, which Indiana has chosen to license the same way. They are the only providers trained for out-of-hospital birth and perinatal care. Because midwifery approaches care holistically, and midwives often enter into a person’s home, working with the entire family, reducing interventions, and approaching pregnancy and reproductive options as a matter of health, not a pathological condition, women under midwife-assisted care tend to have better outcomes.
While midwife-assisted healthcare is the backbone in most other developed (and developing) nations, the U.S. has deviated since its earliest years, when medicine increasingly evolved into an industry, driven by business models.
“In the U.S., the standard is obstetrics, rooted in pathology,” said Haddie Katz of Tandem Community Birth Center. “We in the U.S. pathologize pregnancy and birth, whereas other countries don’t. Midwives share the knowledge that this is a normal function of the body. The body knows how to be in labor and go through the process. It needs little interference. It needs us to hold the space, and we have better outcomes when we do.”
Obstetrics is trained for complications, Katz says, Roughly 80% of the American pregnant population falls under the markers of normal and healthy pregnancies. Obstetrics is specialized for pregnancies complicated by conditions like hypertension, gestational diabetes, preeclampsia and multiple gestations (twins, etc.). Not only does midwifery offer healthcare with fewer interventions, its outcomes are not just healthy parents and babies, but better mental health.
“The number one risk associated with birth is mental health. If we don’t tell people from the get-go that they need intervention, then we set folks up for success by believing in them,” Katz said. Though midwives are also trained for pathology and the unexpected, most training teaches them “how to sit on their hands, how to recognize and defend normalcy and then when to use the specialized skills, as well as knowing when NOT to use them.”
Long before obstetrics, midwifery was the go-to, the safe, the traditional. Midwife-assisted healthcare offers the promise of easing pressure on an overloaded healthcare system. Women in communities like Montgomery County often live an hour or so away from obstetrics care, and they’re more likely to be financially strapped.
If the state eased specific restrictions and promoted the use of certified professional midwives (who were legally recognized in Indiana in 2013), data suggests that outcomes and care would improve. CPMs often provide care in homes, meet with entire households and observe the physical environment, the social determinants of health, and possible mental health factors starting with prenatal care and continuing through postpartum.
Indiana’s current laws are throttling the opportunities and options women have. The laws as written are squeezing Katz and other direct entry or certified professional midwives out of practice. Other midwives, such as certified nurse midwives, who have hospital privileges, are being laid off as hospitals prioritize the most profitable services — that is, those with the most medical intervention.
It’s not unlike the Monty Python skit from the 1983 film The Meaning of Life, when a laboring woman is told she can do nothing while OB/GYN calls for more apparatus, especially the most expensive machine in the hospital in case the administrator comes.
“Don’t worry. We’ll soon have you cured,” John Cleese’s physician character says to the patient before cheerily adding, “Goodbye.” The husband is not allowed to be present. The mother asks, “What do I do?” and is told she is not qualified, and a host of students are allowed to gape at her. After the birth, the room empties and the final doctor warns the mother she’ll feel “a total irrational feeling of depression” so there’ll be loads of happy pills for her.
Whereas Britain took the film’s message as prescient, U.S. medical systems still commodify birth and prioritize the most profitable, least legally risky procedures, triggering the closure of Labor & Delivery departments. The high alert created by post-Dobbs laws has providers afraid of legal action, but Indiana had ominous problems before 2022. Certified professional midwives and direct-entry midwives were required to have a collaborating physician who is “involved in the field of obstetrics.” If that physician practices in a group, insurance rules require that every physician in the practice share the insurance liability, even if some of them are not collaborating with midwives. As malpractice insurance for reproductive healthcare climbed and more physicians jointly practiced, midwives are having a harder time meeting the collaborating physician requirement, not to mention carrying the exponentially more expensive malpractice insurance.
The result? Fewer midwives can practice. “Entire group of midwives, explicitly and uniquely trained for out-of-hospital births, are leaving people getting sicker and not prepared for birth,” Katz said. CPMs are finding it impossible to obtain licensure and practice, just when people need to better understand their options and have agency in their own care and when it could build trust in healthcare providers. We’re regressing to the time before 2013, when women who wanted birthing options voted with their dollars, choosing home births even when it wasn’t licensed or covered by insurance. As the current system drives more midwives and pregnant people into the shadows, they’ll continue to vote for the choice that works best for them, even if it hides in the shadows.
The question is, will it ease the pressure on a system? Women who are turned away from hospitals face dangerous outcomes. Women choosing trained midwives have to go underground. The future puts women in a double bind when most people prefer to operate in the light of safety and openness. But if the system doesn’t allow them to make the right decisions for their healthcare, they still make decisions that they believe are right for themselves, their families, and their loved ones. Legislators should be on notice.
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The League of Women Voters column on the week of April 19 omitted Dan Guard’s timely contribution to Vote411.org with his information. Though we strive to fact-check, this error occurred and Guard’s hard work to contribute should be recognized. That said, we encourage voters to visit Vote411.org for updates and we thank all candidates who help voters make the best decision possible by answering the questions.
The League of Women Voters, a non-partisan, multi-issue organization encourages informed and active participation in government, works to increase public understanding of major policy issues and influences public policy through education and advocacy. All men and women are invited to join the LWV where hands-on work to safeguard democracy leads to civic improvement. For information, visit the website www.lwvmontcoin.org or the League of Women Voters of Montgomery County, IN Facebook page.
