Home Birth: Out of Reach for Appalachians

The centuries-old practice of giving birth at home, assisted by midwives, once common in rural areas, has become too costly and too complicated for some Appalachian families.

[Photo: A char sits in front of a blanket that says
In a small room in the back of midwife Angy Nixon’s house, a wooden chair is stationed at the end of an examination table. As Nixon completes an exam, she uses the slope of the chair arms as comfortable stirrups for each patient. Ellee Achten

Lena Cerbone, a Certified Nurse Midwife (CNM) based in Morgantown, West Virginia, feels proud to participate in what she believes to be one of the oldest professions in the world. “Someone had to be there to catch that [first] baby when she came out of her mama,” she said.

Being a midwife consists of more than simply catching babies. Cerbone and other midwives’ schedules fill up with appointments and checkups. They meet with pregnant people, monitor their health, answer questions about the birthing process, and generally prepare patients for delivery. During the weeks close to patients’ delivery dates, midwives are on call all day and all night.

With shows such as Call the Midwife dramatizing and popularizing the profession in recent years, midwifery mostly conjures up images of messy home births: frantic shouts, enormous pots of water boiling on the stove, women in overwhelming distress. In Appalachia, where distance and winding, rural roads can deter residents from reaching hospitals and life-saving health care, one would assume that most pregnant people would elect to deliver their babies at home—or have little other choice.

But Appalachia has some of the lowest rates of home birth in the country. Once a mainstay of traditional rural life, giving birth at home has become too complicated—and too expensive—for many Appalachian parents.

With a history including the Frontier Nursing Service (FNS), where women in Eastern Kentucky rode on horseback to deliver babies in the early 1900s, and granny women taking care of pregnant people and newborns, midwifery used to be synonymous with Appalachia. Midwives were crucial during an age when many individuals died during childbirth. Pregnant people in rural communities had little access to hospitals, with midwives oftentimes serving as their only lifeline to critical medical care.

As of 2017, however, the Centers for Disease Control and Prevention (CDC) estimated that less than one percent of Appalachian births took place at home. While most states’ rates fall around the one percent mark, Appalachia is still below other parts of the country. According to a 2014 study from the CDC, Appalachian states Mississippi and Alabama reported the lowest out-of-hospital birth rates in the region, recording 0.38 percent and 0.39 percent, respectively. West Virginia, North Carolina, and Georgia also ranked below the country’s national average at the time of 1.36 percent.

At first glance, this is a puzzling situation. The largely rural region of Appalachia includes all of West Virginia and parts of 12 other states that span from New York to Mississippi, with difficult terrain that limits access to health care providers—a place that would be greatly served by home births.

But according to Cerbone, a strong supporter of home birth who does not currently attend births at home, but rather at Ruby Memorial Hospital, where she serves as the director of midwifery service, some of the region’s endemic health care issues make it impossible for residents to utilize home births. “I think the specific health care issues of women in Appalachia don’t lend themselves to home birth,” she said.

Throughout the Appalachian region, elevated rates of chronic diseases like diabetes, obesity, and high blood pressure plague residents. These health complications continue into pregnancy for some Appalachians, and unlicensed midwives would not be able to sufficiently—or legally—assist their patients.

[Photo: Angy Nixon points to a portrait of fellow midwife Lena Cerbone in a pamphlet]
Angy Nixon, a midwife near Charleston, West Virginia, points to a portrait of fellow midwife Lena Cerbone who she met when she first began practicing as a midwife in 1999 at the Charleston Birth Center. (Ellee Achten)
“If you are a trained midwife without prescriptive authority, how are you going to write prescriptions?” Cerbone said. “That’s what makes it complicated. If you’re living on the mountaintop or in the holler or are really far, a midwife is good for you. But if you’re a woman with lots of [potential] complications, you need a midwife with a lot of health care accessibility.”

Ruth Ann Colby Martin serves as a Certified Professional Midwife (CPM), based in Spruce Knob, West Virginia, but she received her Licensed Midwife (LM) credentials through the state of Virginia. Midwives in West Virginia cannot receive licensure through West Virginia, even if, like Colby Martin, they practice in-state.

Colby Martin says that CPMs are the only midwives specifically trained to work with home births, yet West Virginia, along with 17 other states and the District of Columbia, does not recognize their certification. According to Colby Martin, professionals like her are “illegal/alegal” because the state only offers certification to CNMs, such as Cerbone. CNMs, who can work in hospitals, can receive certification in all states.

This caveat can create financial complications for families. According to Colby Martin, financial barriers influence whether or not patients can utilize midwives and have home births. “Many people don’t have financial means to pay for a midwife,” Colby Martin wrote in an email to Rewire.News. While midwives frequently cost the same or less as hospital obstetrical care, the prices can be prohibitive to women who are unable to use their insurance plans to help mitigate the costs. “Since there is no license available for CPMs, we cannot bill insurance or Medicaid, so many people do not have the option of working with a CPM or delivering at home.”

[Photo: Angy Nixon folds a sheet on top of an exam table in her home office.]
Nixon folds a sheet on top of an exam table in her home office. (Ellee Achten)
Despite these issues in Appalachia, midwifery has gained popularity nationwide among a surprising demographic: upper-class residents of urban centers who already have greater access to various transportation and financial resources. The midwifery trend has grown throughout the country, but according to Cerbone, it is especially popular in places like Manhattan where young, urban professionals value the flexibility it offers. “Home births have become this yuppie thing,” Cerbone said. “The reason home births have doubled in the last 10 or 12 years is because yuppies want to have home births.”

Cerbone and Colby Martin understand why home births may be more appealing. In general, giving birth at home offers pregnant people more autonomy over body positions and the types of movements they can make while in labor. Similarly, home births are without the rigid rules that exist in some hospitals, such as those that dictate when individuals in labor can eat and drink.

Angy Nixon, a CNM in Scott Depot, West Virginia, said that in her experience, people may want to avoid situations that cause them to feel helpless. This could happen in a hospital setting. “In medical settings, people often … lose their power,” she said. “Some of that is by design and due to acculturation. There are a lot of unspoken ways of giving up power. It’s very subtle, but the effects of that loss of power can be very strong.”

[Photo: Midwife Angy Nixon]
A midwife since 1999, Nixon welcomes patients into her rural home located not too far from the main highway. (Ellee Achten)
Originally conceived out of necessity, Cerbone and Colby Martin believe that births aided by midwives have become attractive again in recent years because of the autonomy they provide new parents.

Nixon agrees. Whether hoping to take control of their own experiences due to previously negative hospital visits or histories with sexual or emotional trauma, Nixon said one of the most appealing aspects about home births is that pregnant people have the ability to design their own experiences.

“Going outside the system—sometimes that really is a prime motivator for people who really are committed to protecting their autonomy,” Nixon said.

Cerbone believes that the free-thinking associated with the Appalachian region should give rise to a population that supports home births and the discretion it provides new parenting.

But a pioneering spirit can only carry individuals so far.

“I think in Appalachia, women are independent and want to make their own decisions,” she said, “But they don’t have the money to go where their insurance doesn’t cover.”