More on Rural Midwifery

Practicing sweeping the uterus for retained tissue at BEST

I was chatting about oxygen use in the home birth setting with a Wichita Falls OB friend and he said, “I know you do a great job and provide a much needed service where you are.” 

That’s a high compliment from someone I respect-from someone who’s given me much support and encouragement over the years. But there’s a lot behind that line, too. 

Doing a great job in rural midwifery is very different than doing a great job in DFW, where there are midwife friendly hospitals, clients receiving co-care with a midwife and an OB isn’t unusual, where there are a even a few maternal fetal medicine doctors available for consult who actually try to help women stay in midwifery care if possible. These are just some of the day-to-day differences that affect prenatal care but the big difference that affects birth safety is the distance from a hospital. In the maternity dessert of rural America, it’s not just distance from any hospital, which may be significant, but it’s distance from a hospital that actually offers obstetrical services. I’ve been a part of a birth in a tiny town’s ER that hasn’t delivered babies (on purpose anyway) for two decades. The nurse had to dust off the “OB box” and I’m sure the supplies were out of date. There was no access to an epidural, which was fine in our case, but I’m not sure what they would do with a postpartum hemorrhage-is there any reason for them to have the needed drugs on hand? 

I’ll be doing a birth this fall at a home that is about 35 minutes from the hospital. It might take an ambulance that long to get to us as well. Because they don’t expect to see many home births, EMS staff is not necessarily trained in neonatal resuscitation and I believe the medications they carry vary depending on their agency’s policies. Will they have the right epinephrine dose for the rare instance that a neonate needs it? I asked my brother’s childhood best friend (I appreciate having roots here, y’all) who is now a local paramedic for the nearby town of Bowie and he said they carry it but does Nocona? What about Decatur? And do the volunteer first responders have any medications besides oxygen? Do they even have oxygen?

Speaking of oxygen, it’s going out of vogue in labor. Texas allows midwives to carry it but it’s not mandated, likely because it isn’t proven as evidence based. There’s a camp of midwives who feel that it is too medical for a midwife to use and that if we find ourselves in a situation that warrants it, we should have the mother in the hospital anyway. While this sounds perfectly reasonable if your client is giving birth in a neighborhood with a hospital, what shall we do while getting her to the closest hospital that happens to be a county away? 

Another layer to the conversation is that a community may have practices that are considered standard, even if they don’t perfectly line up with evidence. Using oxygen as our example, if a midwife decides not to use oxygen when the baby’s heart tones are low, which evidence is starting to point to as being a good decision since oxygen may actually constrict the vessels in the placenta, resulting in less oxygen for baby, but her colleagues in the hospital still use it in this situation, she is going against community standards. Midwives are already seen as reckless by the medical world, compounding the lack of understanding as to why midwives do what they do. It’s a hard path to navigate. 

Back to the compliment, though. It’s scary to be a new midwife (and the stress does not go away when you’re a seasoned midwife) in a rural area. We have to be prepared to handle surprise breech deliveries, shoulder dystocias, hemorrhages, and more without any staffed nurses’ station down the hall. We can call for help from our EMS friends but we will possibly  have a long wait until they can reach us and it’s likely we are still the only ones who understand the emergency and how to handle it.

After attending the Birth Emergency Skills Training (BEST) workshop last week, I feel so much more equipped to handle these situations, even out in a rural area. I’ve spent the last few days revising my standing orders-the list of medications I am allowed to purchase, carry, and administer under another OB friend’s license (all Texas CPMs must make this arrangement to carry meds). Our collaborative goal is to equip me with all I need to safely handle unexpected complications out in this maternity desert.

I’ll admit that from the outside, people may wonder why we put forth so much effort in preparation instead of just using the hospital for birth? First, women need options. Birth is not an illness to be treated and studies show the home is as safe, if not safer than a hospital for low risk pregnancies. Second, the hospital carries its own risks such as a much higher chance  for a Cesarean section (with about a 50% chance it’s unnecessary*), MRSA is much more likely to be contracted in the hospital and the fact is, some women will simply not make it to the hospital in labor and will risk a road side delivery with no skilled attendant if they plan to use a hospital for birth.  

I’ve heard from more than one client that if they can’t find a midwife who can serve them, they’ll give birth unassisted at home. This is our reality so midwives must be equipped to serve women even in more challenging locations. With the right team and training, it is possible.

*Calculated using the last known estimate of URHS’s Cesarean rate (just under 30%) compared to the WHO’s suggested 14%.