By Kristin Jones
Kinyata Jackson was happy with her primary care physician when she became pregnant with her first child.
After her cousin “raved and raved” about the maternity care she got from midwives, though, Jackson decided to switch providers. In her third trimester, she moved to a team of nurse midwives at the University of Colorado Hospital in Aurora. She found the midwives easier to talk to, and more willing to listen.
Jackson now believes the move saved her life.
“They immediately noticed the pre-eclampsia,” a potentially life-threatening condition that her first provider had missed, according to Jackson. “I was moving through pregnancy at a very high risk and didn’t know it.”
Jackson is among a growing number of mothers nationwide who are seeking out midwives for their care.
Compared with obstetricians, midwives often spend more time with pregnant mothers before and after a child’s birth. People who seek out midwives often do so for the perception that they can provide a more personal, empowering and culturally sensitive approach to care at an extremely important time of life.
The research largely bears out the safety and effectiveness of care provided by nurse midwives. Countries that have embraced midwifery—like the United Kingdom and the Netherlands—have better outcomes in terms of maternal and infant health, as well as lower costs.
In a recent series published in The Lancet, researchers argued that high-income countries like the U.S. could reduce overall health care costs and improve quality of maternity care by promoting midwifery.
Yet despite the increasing demand, midwifery in Colorado is on shaky ground.
In many rural areas, there’s no local maternity care at all; hospitals are far away, and few other options exist. Even in urban centers, there are stiff financial barriers to midwifery—and profit incentives associated with physician-led care. Both hospital-affiliated and standalone midwifery practices have struggled to stay in business.
When she became pregnant with her second child in 2018, Jackson sought out midwives at Rose Medical Center. But midway through her pregnancy, she received a letter: The midwife practice was closing. Jackson was encouraged to find another provider.
“It was really stressful,” says Jackson. She had just moved to Aurora, and didn’t have a car. She wasn’t sure where she’d find another midwife that accepted Medicaid.
Her baby was coming in a few months, and she didn’t know what she was going to do.
An unprofitable model of care
Part of midwifery’s power derives from its inefficiency as a profit generator.
Midwives can spend 30 to 60 minutes during visits with pregnant mothers. That’s time that might be spent hearing about a mother’s family, how things are going at home, concerns about physical symptoms, or their feelings or worries about the baby.
“The midwifery model cares for the whole person—the eating and sleeping and stress and life quality,” says Heather Thompson, deputy director at Elephant Circle, a Denver-based organization that advocates for better access to midwifery. “It sees birth as a community event, as something that’s physiologic,” rather than a medical event.
It’s a model that emphasizes prevention, which is virtually never reimbursed at the same rate as treating illness. By its nature, too, the midwifery model doesn’t maximize a provider’s patient load—a crucial way that the health care system makes money.
During birth itself, care by nurse midwives is associated with fewer episiotomies (a vaginal incision made during a difficult delivery), fewer cesarean (C-section) births and those assisted by forceps or vacuums. That’s a good thing. While some medical interventions are necessary, there is wide concern that in the U.S., there are too many of them, carrying risks for mothers and their babies.
(Researchers note the difficulty of comparing maternity care, as most studies are observational. Some of the differences in the rate of interventions, for example, may be because people with high-risk pregnancies are more likely to be attended by physicians, and those who desire fewer interventions are more likely to seek out midwives.)
In Colorado, about 27% of births are surgical. The World Health Organization considers an ideal C-section rate to be between 10% and 15%. Reducing the rate of c-sections to 15% nationwide would save around $5 billion, according to a 2013 analysis by Truven Health Analytics.
But despite moves toward reimbursing for performance under the Affordable Care Act, the medical system in Colorado and throughout the nation remains largely fee-for-service.
“Our system is perversely incentivized toward more expensive intervention,” said Monica McLemore, PhD, a San Francisco-based nurse and scholar who has written extensively about race and maternity care. Dr. McLemore believes midwifery has a great deal of underused potential for the care of people of color, in particular.
Maternity care is a huge business for hospitals—and is a leading component of national health spending in general. Childbirth is the most common reason for hospitalization in the U.S. It’s also one of the most expensive reasons.
All told, U.S. hospital charges for pregnancy, childbirth and newborn were $152 billion in 2016, the most recent year with federal data available, on costs of $39 billion. In Colorado, childbirth produced more than $2.6 billion in hospital charges based on $642 million in costs.
When two of the largest midwifery clinics in Denver and Aurora said they were closing last December, they didn’t give a reason, leaving patients and advocates for high-quality maternity care in Colorado to speculate. Both Midwifery at Rose (where Jackson was receiving care) and Colorado Nurse Midwives were associated with HealthONE hospitals, owned by for-profit HCA Healthcare.
Joel Ryan has first-hand experience with the struggles of running a midwifery business. He co-founded Mountain Midwifery Center, an independent birth center in Englewood staffed with certified nurse midwives. The longest-running center on the Front Range, it offered prenatal visits and a birth center, wellness exams, lactation support and classes on childbirth, newborn care and breastfeeding.
But Ryan describes a constant struggle for fair contracts with private insurers as well as with Medicaid. When I spoke to him last February, Ryan said the center was struggling to get Medicaid to pay them for a crucial drug that stops bleeding post-birth. At the same time, they couldn’t secure a single contract with any of the insurers on the state’s health insurance exchange.
Ryan attributed some of the center’s difficulties to their challenging the hospital systems that are insurers’ most important business partners.
“Having a lower-cost option with better outcomes is not rewarded, and actually threatens an established system,” said Ryan.
In October 2019—after 13 years in business—Mountain Midwifery shut down.
A spotlight, and a lucky break
Jackson’s outlook on midwifery is informed by her role as an advocate as well as her direct experience. She is part of a statewide coalition called Raise Colorado, which was convened by child-focused nonprofits Clayton Early Learning and Colorado Children’s Campaign (the latter is a Colorado Trust grantee) to advocate for pregnant people, babies and toddlers and their families. Jackson joined the group as a representative of the Black Child Development Institute, where she worked in community engagement and as a program coordinator for a preschool health and wellness program.
For Jackson, the group has provided an opportunity to get together with others who are interested in looking at some of the biggest challenges facing parents and young children in the state. Most of the struggles facing parents, she said, involve “multiple things working together. How do we get to the root of all those things in a way that doesn’t overwhelm us and make us pull our hair out?”
Raise Colorado hadn’t been focusing specifically on midwifery when they heard the news that the two metro-area midwifery practices were closing last year. But the event came as a shock, and hearing about Jackson’s experience losing care helped spurred the organization to write publicly about it.
“These practices were one of a few ways to provide equal access to midwifery care for both the privately and publicly insured,” wrote Jacy Montoya Price and Christina Walker in an op-ed for The Colorado Sun. “Without them, the inequities women face due to their race or background will continue to be passed on to their infants.”
They cited a recent study of midwifery practices in the U.S., which showed an association between a state’s efforts to integrate midwifery into its health care system and better outcomes for mothers and babies.
Not long after that op-ed was published, Jackson got good news. The midwifery practice at Rose was staying open, thanks to a partnership with The Women’s Health Group, a practice based in the north metro area. “I’m excited,” Jackson told me. “They’ve done their best to coordinate and keep things so that we’re not feeling displaced.”
That was the goal, said Christine Alexander, a spokesperson for HealthONE. Colorado Nurse Midwives, a clinical practice separate from The Medical Center of Aurora, did not re-open, but "we were dedicated to providing seamless care and working closely with patients to identify other providers," said Alexander. She declined to answer repeated questions about why Colorado Nurse Midwives was shuttered.
One of Jackson’s best friends, Shenae McKelvin, had been working at the Rose clinic as the receptionist. At the new clinic, McKelvin was promoted to office manager, which meant that Jackson could look forward to seeing a friendly face every time she went for a check-up.
A tool against racism?
That personal connection was important to Jackson. She has had traumatic experiences with physicians and hospitals as far back as she can remember. As a child, she was hospitalized for asthma.
“I feel like every time I go into an institution, I’m going to be held there against my will,” Jackson said.
That old trauma had flared up again during the birth of her first child, Keegan, six years ago. Jackson went in for a routine prenatal visit about five weeks before her due date—only to be told that she would have to stay at the hospital for an emergency C-section.
“I burst into tears,” she remembers.
Jackson is Black. And for Black mothers in America, birth presents risks that it doesn’t for white mothers. Black mothers are much more likely to die in childbirth, and their babies are more likely to be born prematurely or to die before their first birthday.
Researchers believe the stress of racism—and the structural barriers Black people face throughout their lives—contributes to these inequities. Bias in medical care likely also contributes.
McLemore believes that Black families, in particular, could benefit from a health care system that encourages and integrates midwifery into its practices.
“I do think midwifery has the potential to be a mitigating force in structural racism,” said McLemore. That’s partly because of the social nature of many midwifery practices, which help new mothers build stronger support systems as a crucial time, she said. “That peer-to-peer learning, learning from each other—that’s not how we [usually] deliver one-on-one health care. To me, that’s why I think the midwifery model of care is helpful.”
Results from a survey of more than 2,100 women, published in June 2019, found that mothers are less likely to experience instances of mistreatment at the hands of midwives than physicians—things like being scolded, threatened or having anesthesia withheld during an episiotomy. The same research showed that Black, Hispanic, Indigenous and Asian mothers are much more likely to experience this kind of mistreatment than white mothers.
But nationwide, mothers whose births are attended by midwives are more likely to be white.
Black mothers are often steered away from midwifery precisely because of their higher risk profiles, said McLemore. Because of their increased risk for complications like pre-eclampsia and premature births—both of which Jackson experienced—they’re often pointed in the direction of physicians, hospitals and medical interventions.
Jackson would have preferred a Black provider if she had found one; she made sure she had a Black doula. (Doulas provide non-medical emotional and physical support during pregnancies and childbirth.)
“Having a team in there that looks like you—the midwife or the team that supports the midwife—it’s a breath of fresh air,” said Jackson. “There’s somebody in there that is like, ‘I see you.’”
The birth of Eden
For the birth of her second child, Jackson was seeking what’s called a VBAC—a vaginal birth after a C-section. For a while, she wasn’t sure she’d get one.
At one of her visits to the clinic, a midwife pulled up a calculator app on her phone and punched in some digits, representing Jackson’s risk factors. She was figuring the odds of a successful VBAC, and frowning. She urged Jackson to schedule a C-section, saying her health and her baby were at risk.
But Jackson insisted. And in the end, she didn’t need another C-section. She was in labor for 17 hours, pushing for an hour and a half before baby Eden emerged.
“I was thankful that I just kind of stuck to what I had planned, and honored my body and what I felt like was best,” said Jackson, in her Aurora home a few weeks later, folding laundry as the baby slept.
It was hard, though. The experience made Jackson wonder how mothers keep volunteering for this, given the agony of childbirth.
“I don’t know how there are all these people on the earth,” she said.
What’s more, Jackson didn’t think she’d go back to that midwifery practice if she had another baby. The midwives in attendance for her baby’s birth weren’t the ones she’d connected with in the earlier prenatal visits. Some of them were new to the practice, having previously worked in Thornton or other suburbs. One had made a big deal about pronouncing Jackson’s first name—Kinyata.
“I think [the midwives] are not used to the population here,” said Jackson. “Maybe some of that cultural competency is not there, and isn’t necessarily something they needed in the neighborhoods where they were working before.”
Still, at her six-week visit—after some anxiety about whether she might have been dropped from Medicaid—Jackson and the baby were greeted with excitement at the midwifery clinic.
McKelvin, Jackson’s friend and the office manager, was thrilled to see Eden, and annoyed that the newborn was sleeping so peacefully through the visit. Eventually, the baby woke enough for McKelvin to pull her from her car seat and fuss over her.
The two friends chatted about jobs, husbands and kids for a while until a midwife, Katie Wagner, appeared.
“My favorite!” cried Jackson. The visit was warm and easy. Jackson said they talked about summer plans. Wagner asked about breastfeeding and birth control; Jackson asked about exercise.
Birth in this county isn’t often described as a social event, but of course it is.
Not only does birth introduce a new person into a social world, made up of mothers and families and widening communities that radiate out from them—a baby’s birth also builds new social structures, and tests existing ones. A newborn’s needs are so urgent as to require a tight network of assistance and support.
And so, of course, the relationship between a mother and the person attending a birth matters. Midwifery’s promise—sometimes kept—is that this relationship will be one of mutual respect.
I asked Jackson again whether she’d go back to this midwifery practice. She paused.
“I’d try to make sure it was Katie next time,” she said.