Sarah and Jeff Mashaw were worried they wouldn’t make it from their home in Pratt to their midwife in Yoder quickly enough for their fourth child’s birth, but they wanted a natural, out-of-hospital experience.

With their first child, Sarah’s labor progressed quickly. She was seeing a midwife in Arizona and had a doula, or non-medical birth assistant, who told her when it was time to leave home for the delivery. Even then, Sarah said, she felt the urge to push in the car. She worried that would be the case again.

“One of our biggest fears is that I’ll go really quickly again, and then we’ll be somewhere like Arlington,” Sarah Mashaw said.

“And then the baby’s coming, and I’ll have to stop,” her husband said.

They made it to the Yoder birth center in plenty of time, and Sarah labored for several more hours before their fourth baby was born Sept. 18. For the Mashaws, the low-tech, low-pressure approach of a midwife was ideal.

“Birth is a stressful time as it is, and I didn’t want any added stressers,” Sarah said.

Midwives say that’s what makes their service appealing. Midwives attend a small portion of births — less than 5 percent of those in Kansas in 2013, according to the American College of Nurse Midwives, but certified nurse midwives say they could attend more births and serve women in under-served, rural areas if they were granted independence. They currently have to have a written “collaborative practice agreement” with a doctor in order to practice.

Physician groups disagree.

The Kansas Legislature passed an independent license for certified nurse midwives in 2016 that eliminates the collaborative practice requirement and allows them a more limited form of practice, but it’s still caught up in the regulatory process and not available more than a year later. Midwives and physicians have been working together on an advisory board to help draft the regulations, but the soonest they could be implemented is next spring, said the Kansas Board of Healing Arts’ assistant general counsel, Ryan Hamilton. Midwives criticize the new license’s limitations and regulation.


Expanding access

Cara Busenhart, program director for nurse midwifery and advanced practice at the University of Kansas School of Nursing, said independence could help increase the number of certified nurse midwives and increase access to care for women.

Certified nurse midwives also are advanced practice registered nurses with extensive training, she said.

Though Busenhart teaches at KU, she said she was speaking for herself.

Busenhart said eliminating the collaborative practice agreement wouldn’t mean the end of her work with physicians. She still would work alongside them at KU and consult with them or transfer complicated patients.

“It’s just that midwives and nurse practitioners and others could set up shop, could hang out their shingle in places where they haven’t been able to get that actual, physical signature on a piece of paper,” Busenhart said.

Rachelle Colombo, director of government affairs, said the Kansas Medical Society didn’t support scrapping collaborative practice agreements, and she said midwives in Kansas had broader scopes than in other states. KMS represents physicians.

“We think that that protects patients and ensures that people — all members of the health care team — are working to the top of their scope of practice and that there’s continuity of care, and that protects quality and still provides access,” Colombo said.

Midwives said the law is narrow and confusing. Independent midwives would have smaller scopes of practice regulated by the Board of Healing Arts, but those who aren’t independent would remain under the Board of Nursing with its existing authority. Midwives could hold both licenses.


Midwifery care

CNMs can currently provide “women’s health care through the life span,” including gynecological, prenatal, birth and postpartum care, with a collaborative practice, according to the Board of Nursing.

Midwives said those agreements are difficult to get in rural areas.

Busenhart, a member of the regulation advisory board, said midwives typically have good health outcomes because they care for low-risk women and are less likely to use epidurals, labor induction, forceps and vacuums. And, she said, midwives typically have smaller caseloads and more available time.

Certified nurse midwives practice in hospitals, free-standing birth centers and homes.

“Sure, there are people who are burning incense and wearing Birkenstocks, but there’s also people in business suits and heels and pearls,” Busenhart said.

Busenhart and fellow advisory council member Cathy Gordon, a CNM and founder of New Birth Company’s two free-standing birth centers, said correcting misconceptions and defining midwifery dominated advisory council discussion.

Colombo said it was typical for such regulations to take time. Even common terminology can vary between types of providers and has to be worked out in overlapping regulations, she said.

Natasha Sears, a Salina CNM, said finding a physician to collaborate could be difficult because of misconceptions, though she didn’t struggle to find a collaborator.

“We don’t deliver babies in the field or in the river,” Sears said.

Angel Schmutz, a CNM at the Birth and Women’s Health Center in Yoder, said most of her patients don’t like hospitals or want a more natural birth without induction or an epidural. She delivered the Mashaws’ third and fourth babies.

“Some of them are natural-minded, too,” Schmutz said.

That’s what the Mashaws said they were looking for.

“The tradition of midwives has been passed down, and the body will just naturally do what it needs to do,” Jeff Mashaw said. “And that’s not to say we’re against medical intervention if necessary.”

Schmutz delivered the couple’s third baby in the hospital when Sarah’s labor progressed too slowly to stay at the birth center.

Schmutz said she has privileges to deliver at Rice County Hospital in Lyons and collaborates with a family medicine doctor associated with the hospital. More complex cases may need to go to an obstetrician-gynecologist in Hutchinson or neonatal specialists in Wichita.

Midwives may move patients, consult a physician or even transfer care for complex patients.


Rural access

In rural areas, women may have fewer options for health care.

Michael Kennedy, associate dean for rural health at the University of Kansas School of Medicine, said women in rural areas may drive up to 150 miles for care, and in the last two years, the state has lost nine labor and delivery units, which are expensive to maintain.

Many rural hospitals didn’t delivery any babies in 2016, according to data from the Kansas Hospital Association.

In 2014, 77 of Kansas’ 105 counties lacked an obstetrician-gynecologist, according to the American Congress of Obstetricians and Gynecologists. Family physicians can deliver babies, but Kennedy said fewer residents are opting to get training in maternity services.

That is where Gordon and Busenhart said midwives could come into play.

“We’re losing quality nurse midwives because of this collaborative practice agreement,” Gordon said. “So if they could be independent, it would help more people in Kansas as long as they’re normal and healthy.”

That alone won’t fix the problem, Kennedy said. It could help, but he said midwives would struggle in rural areas because of low population densities.

Rep. Dan Hawkins, a Wichita Republican, drafted the bill intended to be a compromise between midwives and physicians. He said telemedicine and higher reimbursement rates for Medicaid could help rural health access along with midwives.

Sen. Barbara Bollier, a Mission Hills Republican and retired anesthesiologist, said raising those rates and expanding Medicaid could help.

Colombo said collaboration agreements can be — and often are — done remotely, so distance is “not a factor” in midwives ability to practice.

“You could have a nurse in Garden City that has a collaborative practice agreement with a physician in Kansas City,” she said.

Schmutz’s collaborating physician, James Decker, said physicians would be hesitant to collaborate from afar because it would be difficult to provide support in complex situations over the phone. Decker said independence could increase access to care, but patients should know it is risky to live too far from advanced medical care.

“Even a normal, low-risk person can turn high-risk — that’s obstetrics for you — within five minutes,” Decker said.

Concerns over liability can make physicians hesitant to sign a collaborative practice agreement, too, Gordon said.

Midwives carry liability insurance and participate in the Health Care Stabilization Fund, but Colombo said physicians can still be on the hook.


Regulating independence

The law midwives ended up with is a mixed bag with independence granted under a narrower scope, defined as “normal uncomplicated pregnancy and delivery.”

They may not be able to provide gynecological care.

“It improves access to birth, potentially, but it doesn’t improve that really good primary care, prevention,” Busenhart said.

According to a survey midwives presented to legislators, less than 25 percent of the state’s CNMs would seek an independent practice license under the Board of Healing Arts, but Gordon said it would still be beneficial for rural midwives.

Colombo said it gave midwives what they asked for: taking care of healthy women and babies without having to sign an agreement with a physician.

Defining a “normal, uncomplicated” birth has been a sticking point for the advisory council. Some midwives deliver babies vaginally even if the mother has had a cesarean, or c-section, delivery. Schmutz said she provides VBAC — vaginal birth after cesarean — at Rice County Hospital.

The new license won’t allow VBAC. Midwives providing that service still would need to collaborate.

“What’s the point of being independent if you have to have someone go sign a piece of paper again?” Gordon said.

Midwives also objected to being regulated under two boards.

“The biggest barrier for us is: Who is our master?” Gordon said.

Gordon said if something went wrong, the boards could view it differently.

Colombo said midwives were brought under the Board of Healing Arts “so that there was the same standard for all independent providers.”

Hawkins said dual-board regulation may have been a weakness, and legislators would likely return to the issue next session.

Bollier said midwives might be able to increase rural health access but weren’t the answer, and they need to be regulated by the Board of Healing Arts.

“What they’re doing isn’t going to change, but who’s regulating it will — and making sure they’re doing it correctly,” Bollier said.


Moving forward

Even with independent practice, midwives still can face barriers to practicing.

Sears said she doesn’t have privileges at Salina Regional Health Center. She said she can provide gynecological care,has a “thriving” gynecological practice and can manage mothers-to-be during their labor, but a physician with her practice has to perform the actual delivery.

“I’m not allowed to catch the baby, and then baby goes to mom’s tummy, and then I take back over from there,” Sears said.

Sears said that can be frustrating, but she tries to remember that change takes “baby steps.”

Busenhart said it would be at least spring before the council finished its regulations.

“There’s just things in this bill that don’t seem workable to any of us,” Busenhart said.

She said midwives likely will seek a different bill next legislative session.

“Let us help the women of Kansas,” Busenhart said. “Let us help the access issue because we have midwives that would be willing to practice in some of those more rural communities.”