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A helping hand: Infant health in West Virginia


The Register-Herald

BECKLEY, W.Va. — West Virginia’s winding mountain roads often become barriers for access to care in the rural nooks and crannies of the state. Many expectant mothers travel an hour or longer for prenatal and delivery services.

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The West Virginia Perinatal Partnership, a nonprofit based in Charleston working to improve perinatal health, reports there are roughly 180 individuals offering prenatal care in the state, including obstetricians, OB/GYNs, family nurse practitioners and certified nurse midwives.

Christina Smith, left, gave birth to her two youngest children, Evelyn and Cooper, at home. She found her midwife, Angelita Nixon, right, by word of mouth.
(Photo by Jenny Harnish)

Some health care providers believe midwifery could play an important role for those living in rural communities.

But in West Virginia, midwives who aren’t nurses don’t have a way to become licensed.

Angelita Nixon, an Advanced Practice Registered Nurse and Certified Nurse Midwife located in Teays Valley, said West Virginia is one of 21 states without a licensure pathway for direct entry midwives.

A direct entry midwife, according to, is defined as an independent individual trained in midwifery through various sources that may include apprenticeship, self-study, a midwifery school or a college/university program.

“There’s no technical prohibition for a direct entry midwife to practice in West Virginia,” Nixon explained.“But it has an effect on consumers who are evaluating their choices.”

Nixon, a fellow of the American College of Nurse Midwives, said some women are so determined to have a home birth, they are not concerned about certifications. But for many mothers, they want the reassurance of the individual’s expertise.

“There are many skilled midwives who just don’t have credentials.”

Certified nurse midwives have been licensed and eligible to practice in West Virginia for many years, so long as they had a written collaborative agreement with a doctor of medicine (MD) or a doctor of osteopathic medicine (OD). In 2016, the West Virginia Legislature passed a law allowing Advanced Practice Registered Nurses (including certified nurse midwives) the ability to practice independently after a few years in partnership with an MD or DO.

Nixon said the Midwives Alliance of West Virginia has been active with legislative efforts since the early 1990s in trying to establish state licensure for direct entry midwives. Around 2009, she said an application was submitted to evaluate the need. Ultimately, the review board said there were too few direct entry midwives in the state to justify the creation of a licensure process.

One reason, she said, was the expense of creating a licensure pathway. Also, technically, the state doesn’t prohibit midwives from practicing without a license.

Not having a license as a direct entry midwife prohibits the providers from being able to bill insurance or Medicaid. Women who want to utilize direct entry midwifery services must pay out of pocket.

At Wiyama Midwifery, located in Bluefield, Va., which provides services in southern West Virginia, costs range between $2,800 for a basic midwifery package, up to more than $5,000 for in-home prenatal visits and add-on services.

Christina Smith, then 27 and living in Elkview, planned to deliver her first child, Myles, at a CAMC-affiliated birth center located in Hurricane.

She wanted a home birth, but her husband, Michael, preferred a hospital. The birth center, a midwife-led facility designed to be more home-like than a hospital, was their middle ground.

When Smith was 30 weeks along in her pregnancy, she developed Intrahepatic Cholestasis of Pregnancy (ICP), a disorder in which bile is not flowing normally in the liver. The condition categorized Smith’s pregnancy as “high risk,” so she could no longer give birth outside a hospital setting.

“I wasn’t really happy with my hospital experience with Myles,” Smith shared. “Myles was breach (meaning his butt or feet were pointed toward the birth canal instead of the head). I was scheduled to have an external version. They were going to do that, then induce me.”

However, when she arrived at the hospital, she said the doctors were talking about a C-section, although there was no medical reason for the surgery.

“That was something I really did not want. Just the way they presented everything, it was not a pleasant experience.”

Because of the midwives from the birth center, who acted as her advocates, she was able to deliver her baby naturally, as she had planned.

For her second pregnancy with her daughter Evalyn, she wanted to try to have a home birth. She worked with Nixon’s midwifery practice, which helped her to maintain a healthy diet and avoid getting ICP again.

She remained low risk throughout the pregnancy, and gave birth at home at 38 weeks.

Her first birth, at the hospital, was covered almost 100 percent by her husband’s insurance. She said the coverage for her second birth, however, was almost nonexistent.

Her out-of-pocket cost was $4,000 because her nurse midwife was considered an out-of-network provider. Two years later, she’s still seeking reimbursement.

Smith’s third child, Cooper, who was born in May, was also a home birth baby – this time at their Fayette County home near Glen Jean. The Smith family relocated closer to Michael’s job in October 2016.

Although Smith was slightly outside Nixon’s service area, the midwife agreed to continue working with her.

When Smith was around 37 weeks, she experienced some ICP symptoms. Nixon was out of town at a conference, so another midwife, Joanna Davis, located in Bluefield, Va., agreed to see Smith.

After tests revealed high liver enzymes, Davis decided it was time for Smith to be naturally induced. She drank castor oil to help make her uterus contract, and Davis helped to stretch her cervix. She gave birth just a few hours later.

“The difference between the care of a midwife and the care of an obstetrician is like night and day,” Smith said. “She spends an hour with you. She gets to know you and your family.”

She said she never felt rushed or left in the dark by her midwives.

“Angy (Nixon) is very thorough. There’s no comparison to her care and what I had received before. She talks about nutrition, mental health, the whole picture.”

Davis, owner of Wiyama Midwifery, chose to establish her practice in Bluefield, Va., as a certified professional midwife, meaning she has met the educational requirements and standards of the North American Registry of Midwives.

She is licensed in Virginia, a state allowing both direct entry and nurse midwives to practice and be licensed.

Davis offers services in western Virginia, southern West Virginia and eastern Kentucky. She’s registered with each state’s board of health, and is qualified to sign birth certificates.

“Currently, there is legislatively no oversight for midwifery in West Virginia. The reality is there are so few midwives, legislators are not willing to spend time and money on the progression of 20 women.”

She said with the establishment of licensure laws, midwives could accept Medicaid and process private health insurances, which would allow access to a greater number of women.

“Legislation is not going to change the way we practice. All it will do is allow better access to care for our clients.”

Licensure would also allow direct entry midwives to access Department of Health and Human Resources programs for their clients, she said, such as WIC (a supplemental nutrition assistance program for women, infants and children) and lactation consultants.

“Those are not programs we have easy access to, although we refer to them.”

Davis provides home birth services for her clients, either at her Bluefield office or at the client’s home.

“It’s relatively easy to practice in West Virginia, aside from the rural areas. My clients, most of them live in more rural areas. This year, at least half of my clients were in the Bluefield/Princeton area.”

She will drive “pretty much anywhere” in the western Virginia, southern West Virginia and eastern Kentucky region to provide at-home delivery services.

Unless they are willing to pay extra, clients must travel to her office for prenatal care though.

She said with as spread-out as her client population is, she couldn’t possibly travel to each location for prenatal visits, which grow more frequent toward the latter weeks of the pregnancy.

“I’ve delivered babies in Lewisburg, Hico, Rainelle. It really depends on how amenable folks are to driving that distance to me for prenatal care. I have them on the same schedule as an obstetrician.”

Davis said she offers the same tests and education a woman would receive at an obstetrician’s office, but she believes care from a midwife is more personal.

“I don’t do cookie-cutter care for anyone,” Davis said. “We do shared decision-making and informed consent. Clients receive information in an unbiased manner about each procedure, and they can decide if they want it.”

And if an issue arises indicating a pregnancy is “high risk,” Davis said she has unofficial collaborative agreements with several physicians in southern West Virginia.

“They will take my clients who develop risks that are no longer compatible with home births.”

But even if a client is transferred, Davis continues to care for her as an advocate and a doula (someone trained to assist a woman during childbirth and provide support).

Davis believes legislation for midwifery licensure is unlikely to happen in West Virginia until legislators better understand home birth.

A social stigma surrounds home births and breastfeeding, she said.

“I’ve heard social statements such as, ‘That’s what poor people do.’ ‘That’s what ignorant people do.’ We’re working on the language around that in southern West Virginia.”

Ultimately, it’s all about personal choice, Davis said.

“If you don’t know what your options are, you don’t have any. If you don’t learn what your body is doing, you’re at the mercy of whatever whoever is telling you.”

She believes more complications are experienced in a hospital setting because of the interventions, such as narcotics and epidurals, which aren’t available with midwifery services.

“It’s about being where you feel safe and empowered. Midwives empower women.”

Dr. Coy Flowers, an OB/GYN based in Lewisburg, said physicians must work closely with midwives, nurse midwives, nurse practitioners and physician assistants to establish a network of providers for quality care.

“As long as the provider is trained and competent in prenatal care, and working in collaboration or in concert with obstetricians either on site or remotely,” Flowers said. “We need to start approaching these issues as a team. Everyone has a role.”

He said the goal is to have a licensure mechanism in place by 2020 for midwives in West Virginia.

Nixon added that small, midwife-led satellite centers could be an ideal solution for rural areas.

“We’re trying to look where services are needed. Instead of closing them, we need to be beefing them up,” Nixon said. “We need more midwives. We could get them into hospitals, and make (obstetrics units) more functional as a midwives unit.”

To make the study of midwifery more accessible for West Virginia nurses, the Marshall University School of Nursing has partnered with Shenandoah University in Winchester, Va., to offer nurse midwifery as an area of emphasis.

The nurse midwifery emphasis requires 44 credit hours, according to Marshall’s website, and upon successful completion of the program, nurse midwifery graduates are eligible to take the American Midwifery Certification Board Exam.

The number of enrollees in the program was not immediately available, but there is an interest in midwifery among young nursing students.

Sarah Epling, a 19-year-old Glen Daniel resident currently enrolled in Bluefield State College’s nursing program, said she hopes to one day become a midwife.

“I love babies, and I love people,” Epling said. “I think if I could one day deliver babies or help women get to that point, it would be awesome.”

Improving services

The American College of Obstetricians and Gynecologists outlines initiatives to improve services for rural women, including the following:

● Wyoming, a state with no tertiary care centers for pregnant women or infants and few pediatric specialists, approves out-of-state health care providers and facilities as state Medicaid providers, allowing the state to reimburse transport to, and care and delivery in, an out-of-state subspecialty hospital when medically necessary.

● The University of Texas Medical Branch in Galveston’s Department of Obstetrics and Gynecology developed a Regional Maternal & Child Health Program to serve geographically underserved women in multiple off-site clinics. The program addresses culturally relevant services and transportation needs, and uses electronic medical records to facilitate continuity of care.

It also provides housing in its Regional Perinatal Residence for high-risk women (and family members) living in distant locations.

● The Arkansas Medicaid Program and the University of Arkansas for Medical Sciences are collaborating with the state’s medical community to enhance primary obstetric care in rural Arkansas and increase risk-appropriate referrals to maternal-fetal medicine sub-specialists. The system uses telemedicine and clinic networks to facilitate access to maternal-fetal medicine consultation services, and to provide continuing education for practitioners.

● Oregon enacted legislation to offer financial incentives, such as a state income tax credit for rural practitioners and assistance with medical liability insurance, for obstetricians practicing in rural areas.

An evaluation of the program two years after full implementation found that the subsidy had not halted the overall decrease in rural clinicians who performed deliveries in that time frame. Clinicians receiving the subsidy, however, indicated that it was an important reason that they were able to continue maternity care.

● A couple dozen family medicine residency programs have incorporated a rural training track. Graduates of these programs are two to three times more likely to practice in rural areas than graduates of family medicine residencies overall. The majority of those physicians initially selecting rural sites remained in rural locations two years after graduation.

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