I received an email from an out-of-state student midwife today. She is finishing her degree in her current location and weighing whether to stay or return to Wyoming to practice. Her concerns, like so many others, revolve around the issues of burnout and the attitude toward midwives from the medical community. But the deeper question, the real question, is what does the future of midwifery look like in our state? In order to understand this, we have to look at the issues that plague the practice of midwifery in Wyoming.
Maternity Care Wastelands
Most of the Wyoming interior is devoid of any kind of real maternity care, midwifery-based or even hospital-based. Three hospitals closed their labor and delivery units in one year, leaving thousands of women hours from the nearest hospital. When you combine distance with the harsh winter weather that frequently results in the very roads to these resources being closed for hours or days, and you have women who are now stranded while on the cusp of giving birth.
Inadequate Resources to Train New Midwives
The Wyoming Board of Midwifery currently lists fourteen midwives who are licensed in the state, seven of whom reside in the state. The remaining eight midwives live in either Utah or Colorado and provide their birth services primarily to the Wyoming towns and cities that border their home state, such as Cheyenne or Laramie. This leaves large areas of the state far from anyone offering midwifery support and also means there are fewer midwives available to apprentice students who live in the Wyoming interior. In short, if there are fewer midwives to attend births, there are also fewer midwives to train more midwives.
Strict Licensure Requirements for Education
WIth so few midwives licensed in Wyoming, the logical solution would be to recruit midwives trained in other states. Unfortunately, our state licensing regulations present an air of resistance to this very option in the form of their education requirements. For example, to receive a midwifery license as a new graduate in Wyoming, a student must have graduated from an MEAC-accredited school. This requirement is more stringent than our neighboring states of Utah and Colorado, both of whom offer multiple pathways to licensure, most notably the portfolio evaluation process (PEP) option, where an individual’s education, training, and practical experience are reviewed. This option is one that is accepted by NARM (the North American Registry of Midwives), the organization responsible for administering the national exam required for licensure. But it is not one of the options accepted for new graduates in Wyoming. Which raises the question: why would someone come here to be licensed when they can achieve licensure in Colorado, where there are more options, or Utah, where there are also more options and licensure is optional? (side note: licensing fees in Wyoming are $1200 every two years and CPMs - certified professional midwives - also pay a birth fee to the board for each birth they attend).
Licensure Restrictions that Depend on the Medical Model
For those midwives who do choose to be licensed in Wyoming, the licensure restrictions mirror those of states with considerably more resources than ours. Midwives are required to share or transfer care of mothers with a whole host of concerns, including breech, multiple gestations (twins, triplets, etc.), certain VBACs (vaginal birth after cesarean), diabetes, hypertension, and a number of others. This would perhaps make more sense if Wyoming weren’t a state where women are already hours from the nearest hospital or OB/GYN. It would perhaps make sense if Wyoming hospitals weren’t already closing more labor & delivery units than they are opening. But it doesn’t make sense and the biggest reason for that is the fact that these restrictions disregard a woman’s health care autonomy, a fundamental right described in Wyoming’s own constitution. These regulations essentially create a midwifery model of care that is reliant upon and subservient to the medical model, requiring those women who are “risked out” of community-based birth to transfer to the care of an OB/GYN, even if that means traveling to another state, possibly missing work, paying for care for other children, or even relocating their entire families. Or, alternatively, it results in more mothers choosing to birth unassisted. Again, it begs the question: why would a midwife choose to practice in a state with so few resources and so little support, a state that seems blind to the realities of living here and birthing here. In Tennessee, for example, CPMs are able to deliver breech babies within the scope of their license because the state recognizes the high number of mothers who live in rural areas hours from the nearest hospital. Rather than forcing these women to move closer to a hospital or transfer into physician care, the state has allowed CPMs to attend these births at home.
Medical Attitudes Toward Community-Based Midwives and their Clients
Many midwives and student midwives express reluctance to practice in Wyoming, or even outright fear, due to the treatment they have received or witnessed when interacting with hospital staff, particularly in the event of a transfer. One Colorado midwife told me that this very issue is largely the reason that she and many of her counterparts in the state either do not practice under their Wyoming license or choose not to acquire one at all. Rather than viewing a hospital transfer as an opportunity to provide collaborative continuity of care or even as an appropriate use of resources when a community-based birth unexpectedly requires a higher level of care, it is more often the case that both the midwife and the family are treated as negligent or downright dangerous. Many midwives have been reported to the board of midwifery for what a physician deems as inadequate care, placing their licenses and livelihoods in jeopardy. Reprisal from the medical system and even from other midwives is a common theme nationwide, but it is especially problematic in states like Wyoming where resources are already scarce.
So what is the solution? How can we make real and meaningful changes to the practice of midwifery in Wyoming? How can we assure that it not only survives, but thrives? Advocacy and engagement on the part of midwives is important, but even more essential is the action of mothers and families, the very people who are asking for this type of community-based care. These are the people ultilizing Wyoming’s existing maternity care services (if and where they are available) and these are the people who are paying for them, financially and personally. What we need in Wyoming is a grassroots movement, one that starts at home, in our own communities, and grows into a statewide initiative to change midwifery regulations across the board. I’m not talking about improving what we have, but dismantling it entirely and rebuilding legislation from start to finish in a way that truly recognizes the unique challenges which fundamentally influence our state’s birth culture. Women have the power of a collective voice, one that can and should be used to tell our state government and board of midwifery “Enough is enough. We want and deserve better.”
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