In one of the worst regions to have a baby, southern universities bet big on midwives

A few years after she became a nurse-midwife, Sharon Holley left Alabama. Her home state had educated her, but it couldn’t employ her.

It was the early 1990s and certified nurse-midwives, who have advanced nursing degrees on par with nurse practitioners, were scarce in Alabama. Holley had just graduated from the University of Alabama at Birmingham’s short-lived nurse-midwifery program.

nurse-midwives were so rare that she was the first one to deliver a baby at the hospital in the mid-size North Alabama town where she worked. Many of the medical professionals she encountered regarded her with skepticism, if not outright distrust.

“But just across the border in Tennessee,” she said, “it was a lot more friendly to work. Tennessee afforded me the opportunities I couldn’t get in Alabama.” Holley joined the faculty at Vanderbilt School of Nursing and later reached a career high point as chief of midwifery at one of the largest hospitals in Massachusetts.

Now, more than two decades after she left, Holley is back in her home state, relaunching UAB’s nurse-midwifery program to begin building a workforce of Southern nurse-midwives.

And UAB isn’t alone: As national attention focuses on improving pregnancy outcomes, colleges across the South are turning to midwifery as a potential solution – and as a financially sound addition to their graduate school offerings.

In states like Tennessee, Alabama and Louisiana, nurse-midwives like Holley are leading those efforts, hoping to improve healthcare in a region long known for some of the nation’s highest rates of maternal and infant death.

But will more nurse-midwives solve complex, systemic healthcare problems like high maternal mortality or racial and economic barriers to accessing care?

They’re not a magic cure-all, said Holley, but nurse-midwives are a critical piece of the puzzle that’s been too long ignored.

“We’ve been trying to solve these problems, but the one thing we haven’t done yet is grow the workforce that can do the job,” Holley said. “Research shows that when you embed nurse-midwives into the healthcare system, (medical) interventions decrease, costs decrease and quality improves for neonatal and maternal outcomes.”

What are nurse-midwives and why aren’t there more of them?

Dr. Kate Fouquier calls nurse-midwives “the best-kept secret” in healthcare. She’s directing the new nurse-midwife program at the University of Tennessee Health Science Center in Memphis. The program launched last fall.

“I feel like women don’t even know what they’re missing,” when they don’t have access to nurse-midwives, said Fouquier. “When they find out, they’re pretty amazed. So the more we educate them on what their choices are and what they should expect from a provider, the better off they are and their famlies, too.”

While certified nurse-midwives are legally allowed to practice in every state, their numbers vary widely from state to state.

Alabama, which has a population of nearly 1 million women and girls of childbearing age, has just 24 nurse-midwives. Tennessee, where Holley found a more welcoming working environment, has 234. Georgia has 627.

Florida, where nurse-midwives are allowed to practice independently, has 977. For perspective: Florida has four times as many women and girls of childbearing age as Alabama, but 40 times as many nurse-midwives.

Nurse-midwives care for people with low-risk pregnancies before, during and after childbirth. They can also do routine gynecological exams, pap smears and contraceptive counseling for patients of nearly all ages, from puberty through menopause and beyond. They can write prescriptions. Depending on state regulations, they practice in medical clinics, hospitals, birth centers and even homes, sometimes working with physicians and sometimes in their own practices.

Midwives attend about 10% of births nationwide, but that masks the wide variation among states. They attend less than 5% of births in states like Alabama, Louisiana and Mississippi, but attend more than 20% of births elsewhere, in states like Alaska, Maine and Oregon.

The reasons why some states have so few midwives are complex. Much of it is cultural: A century ago, states like Alabama and Mississippi were home to thousands of lay midwives, most of them Black, delivering babies for Black and white families. Decades of concerted efforts in the 20th century by physicians and a mostly white medical establishment to persuade women against birthing at home with midwives changed public perception. Midwifery became viewed by many as a choice only for those who couldn’t afford a doctor.

At the same time, to combat high rates of infant mortality, public health officials in some states championed physician-attended hospital births over midwife-attended births at home.

Rebuilding the Black nurse-midwife pipeline

The widest racial gulf in women’s health today is the disparity between Black and white maternal death rates. Black women are three times more likely to die from pregnancy complications than their white counterparts, according to the U.S. Centers for Disease Control.

Nurse-midwives can help address that disparity, said Holley. But the modern-day nurse-midwifery profession is overwhelmingly white. Nationally, about 85% of nurse-midwives identify as white, while less than 7% identify as Black.

This is a problem when you’re trying to improve pregnancy outcomes for Black families, said Dr. Shannon Pfingstag, a certified nurse-midwife who’s directing the new nurse-midwifery program at the Louisiana State University Health New Orleans School of Nursing.

“Black maternal mortality is going to be best addressed by Black midwives and providers,” said Pfingstag. “If we can help create or foster that, then we’ve done some good.”

As LSU’s new program launches early next year, she plans to build relationships with HBCU nursing programs, nursing organizations for people of color, and other community partners to strengthen the educational pipeline for BIPOC nurse-midwives.

Last year, the American College of Nurse-Midwives, the largest national professional organization for nurse-midwives, issued a statement acknowledging a national history of disenfranchising Black midwives and stating its commitment to dismantling structural racism in midwifery programs.

Health systems take notice

In the 18 years she’s been in Louisiana, Pfingstag said she’s seen public interest in midwifery grow “exponentially,” particularly in urban areas like New Orleans and Baton Rouge. Consumer interest translates into an interest from healthcare systems, she said.

“As medicine shifts from private practice to more system-based, many (hospitals and healthcare systems) are aware of the value nurse-midwives can bring, in partnership with physicians and maternal-fetal medicine specialists,” she said.

Case in point: Pfingstag worked for years at the only independent nurse-midwife-owned practice in the New Orleans area. The practice was recently acquired by Ochsner Health, the largest healthcare system in the region.

Greater demand for midwifery care from the public and hospital systems means there’s an opportunity for universities to step in and fill that void in the labor force by creating nurse-midwife graduate programs, said Fouquier, who’s leading the nurse-midwife program in Memphis.

“We are helping with a workforce problem,” Fourquier said. “You can’t spit out enough doctors.” Training a nurse-midwife typically takes 6-8 years, compared with about 12 years for an OBGYN, and costs less.

In regions like the South, many counties are considered maternity care deserts – places without hospitals or birth centers offering obstetric care and without any obstetric providers. In its 2022 report on maternity care deserts, the March of Dimes recommended expanded access to midwifery care as one way to eliminate maternity care deserts.

It’s a model used in the United Kingdom and many European countries. There, midwives attend most of the uncomplicated, vaginal births while obstetricians handle the complex cases, c-sections and those requiring specialized medical attention. Midwives outnumber OBGYNs in the UK’s National Health Service by more than 4 to 1.

Holley said America’s reliance on obstetricians to cover pregnancies that aren’t high risk isn’t a good use of resources from an economic perspective, and it doesn’t make sense for patient care.

“(OGBYNs) are experts at abnormal birth, at addressing problems,” said Holley. “I’m an expert in normal physiologic birth. You show me a physician who is sitting at the bedside supporting people through unmedicated or even medicated birth, and I’m going to ask where they also trained as a nurse-midwife. They don’t know that skill the way nurse-midwives know that skill.”

A large-scale 2019 data study that compared low-risk births in hospitals found that women who birthed at hospitals that used both midwife and physician care were 75% less likely to experience interventions like labor induction and 12% less likely to undergo a cesarean section than those who birth in hospitals that only used physician care.

A place for students

UAB admitted its first class of nurse-midwives in August, with 6 students. Fouquier’s program in Memphis currently has 16 total. The LSU program is also likely to start out small because, as in Alabama and Tennessee, there aren’t enough clinical sites to train more students.

Part of a nurse-midwife’s education involves apprenticing under a certified nurse-midwife in a community setting. In states with few nurse-midwives, that’s a problem.

“There would be more midwifery education programs throughout the United States if we could find clinical sites,” said Fouquier. “But because hospitals and medical practices don’t hire a lot of midwives, there’s no place for our students to go.”

In New Orleans, Pfingstag’s program will be the first to educate nurse-midwives in Louisiana in 80 years. Holley is working to build relationships with nurse-midwives in Alabama and beyond, to increase the number of clinic sites that can train her students. She hopes to offer training in rural areas as well as urban centers. For now, many hospitals and clinics around Alabama – including UAB itself – don’t employ midwives to care for patients. In Tennessee, Fouquier’s program has partnered with Regional One Health, the only healthcare system in the region that employs midwives. She also hopes to connect with midwifery practices in Knoxville and eastern Arkansas.

Ultimately, said Holley, when people have more choices in who attends their birth and where, they’re able to make better healthcare decisions.

“We should be able to figure out a health care system where people can safely birth in a hospital, in a birth center or in the home,” she said. “I want people to know that the idea is to have us at every level of care where you can find people birthing.”

This story was published with support from The Solutions Journalism Network through its Health Equity Initiative.