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Greater Access to Midwives like Jenny: For Women around the World and Here in North Carolina

A few hours after I delivered my daughter three years ago, one of my midwives, Jenny Cox, stopped by to see how we were doing. At that particular moment she found me in tears because I had just been told by a lactation consultant that I would be unable to breastfeed. Despite the fact that she was no longer on duty, Jenny put her purse down and told me that was nonsense. She spent the next two hours helping me and my baby learn to latch on, assuring me we would be able to do it on our own. Then she gave me her home phone number to call if I needed her.

I feel certain I would not have been able to go on to breastfeed my daughter as I had hoped without Jenny's support and encouragement that day. And I don't believe I would have had a vaginal, unmedicated birth without her either.*

As a communications officer for IntraHealth International, I write about the global health workforce shortage and how more health workers in developing countries are needed to provide universal access to vital health services—including more midwives for maternity care. Lately, during events such as the International Day of the Midwife, the Women Deliver conference, and the International Day of Action for Women's Health, I've found myself thinking about Jenny and how lucky I was to receive the care she gave me. So I met with her at the University of North Carolina Women's Hospital, where she now works, to talk about her work as a midwife, and how more women in our own area need greater access to midwives for safe deliveries.

Something different

Growing up, Jenny was intrigued by her uncle and aunt, who were obstetricians. She knew she wanted to do something similar, but different. "I didn't want to be a surgeon; I wanted to be with women, helping them through labor," she remembers.

As an undergraduate, she spent a year abroad in Germany. While reading a book in German, she came across a word she didn't know: Hebamme. She looked it up and discovered it meant midwife. Jenny saw this as a sign: "I was like, hmmm, maybe that's the answer."

When Jenny returned to the US, she finished her biology degree, and then earned a Bachelor's of science in nursing and a Master's in midwifery. She has since practiced midwifery in a naval hospital, a freestanding birth center, and two academic institutions.

"It's really amazing to sit in the presence of somebody who is in labor, doing something amazing and incredible and empowering," she says. "It makes up for all the staying up late at night and missing of your own children and your own family. You feel like you're really helping someone out."

My firsthand account

When I learned I was pregnant for the first time, I read What to Expect books, watched the Ricki Lake documentary about home birthing, and typed up a birth plan. I started prenatal care with an ob/gyn practice, but was concerned by its high C-section rate, and one doctor's blasé explanation of, "It is what it is." While I am grateful to have access to high-quality obstetric care in the case of an emergency, I hoped to have a natural birth. I knew about midwifery care through my job at IntraHealth. After looking into more options in my area, I switched to the group of midwives that Jenny was part of. 

Near the end of an otherwise normal pregnancy, at my 38-week appointment, Jenny felt my stomach and told me my baby had changed into a breech position. This of course jeopardized my ability to have a vaginal birth, and in most cases would mean scheduling a C-section. Jenny, noting my disappointment, went on to recommend several things I could do to turn my baby around: I did handstands in the pool, I went to the chiropractor she went to, I hung upside down. When my baby still didn't budge, she suggested I try an external cephalic version to move my baby into a head down position. She held my hand during the procedure and it worked!

Three weeks later I was able to give birth the way I had hoped. I was able to follow my birth plan and do so safely. I wish more women in the world, and even in my own state, had the same options and same access to a caring, skilled health worker that I did. Unfortunately, that's not the case.   

Helping more women deliver

"In the US, women who die in childbirth are often women with underlying health concerns, or health conditions prior to becoming pregnant," Jenny says. Those high-risk women are primarily cared for by obstetricians. "But to help more women would mean to have more midwives," she adds. "We have a lot of very highly trained physicians who do a lot of really interesting stuff, but normal birth is our expertise."

"We want people to know that midwives are not just there if you want to have an unmedicated birth, whether that be at a birth center, hospital, or home. We're not just there to dim the lights. We're there to help you through your labor and birth, however you choose that to be. Our job at the end of the day is to meet each woman where she's at and help her proceed as safely as we possibly can."

According to a new report released by Save the Children, the US is ranked 30th in the best places to have a baby. Several of the countries where IntraHealth works ranked in the bottom 10: Nigeria ranks 169, Mali ranks 173, and the Democratic Republic of the Congo ranks 176. In the US, our lifetime risk of maternal death is 1 in 2,400. In Nigeria the risk is 1 in 29. In the Democratic Republic of the Congo, it's 1 in 30. And in Mali, the lifetime risk of a mother dying in labor is 1 in 28.

Women need more access to trained midwives

It takes a knowledgeable and well-trained health worker like Jenny to ensure women deliver safely. But women have far fewer choices for giving birth in some countries, and they have limited access to trained midwives or other qualified birth attendants. The United Nations'; Millenium Development Goals Report states that only 65% of births in developing countries are attended by skilled health workers. In some of the areas where IntraHealth works, this rate is even lower—49% in Southern Asia, and 45% in sub-Saharan Africa. 

An additional 350,000 midwives are needed worldwide to ensure universal coverage for maternity care. Up to 60% of maternal deaths could be prevented by universal access to adequate reproductive health services, equipment, supplies, and skilled health care workers. 

Reaching women in rural areas is particularly challenging. Worldwide, women in urban areas are twice as likely to have births attended by skilled health workers than women in rural areas. 

In North Carolina, there are also disparities. "North Carolina has 100 counties, and many have very few or no obstetricians/gynecologists, and almost half have no nurse midwives," Jenny notes. "There are many rural parts to North Carolina. There are many counties that are designated as 'provider shortage areas.' There's a lot of people to take care of."

In fact, 31 counties in North Carolina—a third of the state—do not have obstetric or gynecologic health care providers for the women in need of prenatal care.

What can you do?

North Carolina is one of six US states that require physician supervision in order for a certified nurse midwife (CNM) to practice.This restriction prevents CNMs from providing care in underserved areas, where there is a shortage of physicians.

"If we could remove that barrier, more CNMs could go out into those communities and provide health care to more women," explains Jenny. "It would open up the ability for CNMs to provide care in health departments and in other already-established systems that currently have a barrier to that practice." 

There was a bill that aimed to eliminate the requirement that a physician take on all legal liability for a midwife's practice, but last week that bill was pulled by House leadership before it could be heard on the floor, rendering it done until it can be introduced again in the 2015-2016 General Assembly. 

"Access is an issue for women in North Carolina and will be for a long time to come," Jenny says. "The US clearly is years ahead of other places in terms of access to midwives, but we should not let that make us feel comfortable or complacent about our own outcomes."

So how can we make a difference? Spread the word about midwives. "Anyone who has ever been cared for by a midwife who got safe, effective, standard, or above-standard care should let that be known," Jenny says, "whether that's to their neighbor who's pregnant, to their families, to their legislators, or to anyone that wants to hear that."

I'm sharing my story about my amazing midwife. I urge you to learn more about midwives in your area, share your stories, and find out what you can do to help.

*I was also fortunate to have a wonderful doula who helped me with my daughter's birth, Julie McBurney. She came over at midnight the night I came home from the hospital to help me breastfeed and was available for days after to answer my questions. I will be forever grateful for the excellent care that I received from Jenny and Julie.