Toni Hill has spent more than a decade working full time, traveling around Mississippi to provide women health care during some of the most dangerous moments of their lives.
She is not, however, a doctor, a paramedic, a nurse practitioner or any other position formally regulated by the state.
Hill is a direct entry midwife, one of several dozen practitioners in Mississippi without formal medical training who take it upon themselves to learn one of the oldest medical traditions – meeting women where they are before, during and after childbirth.
Midwives meet regularly with their pregnant clients to advise them and perform tests, guide them through childbirth – often delivering babies through home birth – and ensure they transition smoothly into postpartum health.
Today midwives learn the trade through an informal apprenticeship process and individual study, but a bill proposed this legislative session aims to ensure the profession establishes minimum standards with a formal licensing process.
“My daughter was a baby on my back when I first went down to the capitol to talk about licensure 18 years ago,” Hill said. “There was a bill to take (midwives) out of the medical code. And that’s kept happening. There was one just two years ago. I’m on call every minute of every day, I don’t have time to go down to Jackson every year to fight for my ability to care for my clients.”
House Bill 927 is the leading edge of that fight today, sponsored by the District 39 Rep. Dana McLean (R-Columbus). The House approved the bill Feb. 13, and it now sits in the hands of the Senate Public Health and Welfare Committee.
The bill contains language covering a wide variety of topics, ranging from insurance to best practices and the establishment of a board, all boiling down to the establishment of midwifery in Mississippi as a regulated, licensed practice.
It’s the culmination of years of work from local midwife organizations and their partners in Jackson. McLean spoke with The Dispatch the day after the bill passed the House, saying it’s an important step toward fixing the state’s drought of maternal care.
“Most of the issues I really try to address are those that affect women,” she said. “Mississippi is at the bottom of the list on maternal health care, maternal death, infant mortality. If there’s someone calling themselves a midwife who doesn’t have the adequate experience and know what they’re doing, it could potentially cost a life. We have licensure for barbers, for tattoo artists, social workers, speech pathologists, and we should certainly have licensure for someone who holds themselves out as a midwife.”
Midwives in Mississippi
Deanna Smith, another midwife who works in the Golden Triangle, said Mississippi has long struggled with the field of midwifery and with maternal care more broadly. She said the state once had thousands of midwives, but numbers dwindled to less than 10 by the 1990s. Today the estimated total has grown to roughly 30, though an exact count is difficult because some operate independently, she said.
Midwives generally handle a few clients at a time, staggering their stage of pregnancy so the due dates don’t overlap. Smith said midwives tend to charge roughly $4,000 for 12 or so appointments over the course of a pregnancy, including the birth itself and more in-depth visits immediately postpartum.
Smith has nine children of her own, many of which were risky pregnancies requiring hospital births. After the last of her kids left home, she decided to give women the chance she never had to give birth in a familiar environment. Today, she cares for women in towns where the nearest hospital can be hours away.
“We only take the low-risk people. You don’t want someone with a lot of health risks to have a baby at home,” she said. “… But up in this part of the state, there are some pretty wide gaps in delivery care. A lot of counties in our state no longer have medical services, especially for labor and delivery. … Some of these people are a two-hour drive from a hospital if they’re in labor.”
Hill’s great-aunt was a midwife, and Hill said her aunt faced substantial stigma as midwifery began to decline and be replaced by centralized hospitals. People would say midwives were dirty or couldn’t spell, and Hill’s grandmother eventually opted for a hospital instead of relying on her sister.
Hill found out about midwifery at 14 reading a book about prairie life. When she graduated school in the ‘90s and asked a local OB, she was told midwife wasn’t a position that still existed.
Hill went into maternal health care nevertheless, working as a doula – a woman who helps guide pregnancy without formal obstetric training – until she found out via social media that there were still practicing midwives. She landed an apprenticeship, and 12 years later she works with the Blooming Moon midwifery outfit in Tupelo and leads the Association of Mississippi Midwives.
Effects of potential legislation
The law would require midwives to set thresholds for when a pregnancy becomes high-risk and requires a hospital, define some medications they can handle, require they stay in contact with the board and share data, prohibit surgeries other than episiotomies and their repairs, and ban other actions like assisting unlicensed midwifery or acting against a client’s health.
Most of the field’s regulation, however, would be up to a board mostly consisting of six midwives that will write the rules governing their practice, with priority given to nominees from the six organizations that helped push this bill through. That includes sections like exceptions for less intensive maternal providers like doulas and a catchall “cultural and religious role.” That undefined language includes most of the specifics of licensure itself, and McLean, Smith and Hill all said a lot hinges on how exactly those rules are written.
McLean said she isn’t worried about legislation suppressing new midwives, arguing that the bill, which has an explicit cutout for apprenticeships, would make it easier to start and increase public trust in the field. While Hill operates in Mississippi, she is also licensed in Tennessee and has experienced firsthand the benefits of formalizing midwifery into existing medical structures.
“In Tennessee I can just call a physician up and say I’ve got a client I’m bringing in because they have collaborative care positions that work directly with our practice,” Hill said. “(In Mississippi), someone can move from low-risk to high-risk in a moment, and my transfer is to just show up at the ER. … Some hospitals here don’t even ask me questions when I’m there with the woman’s chart.”
The bill doesn’t define practicing without a license as criminal, but it would come with a civil penalty and $1,000 fine. While McLean assumed it would eventually be added to the criminal code, Hill objected to the idea.
“If women are going to birth their babies, they should be able to choose who’s there with them,” Hill said. “If they choose an unlicensed midwife who’s got no training, no CPR and no neonatal resuscitation who’s only ever caught two babies, so be it. There shouldn’t be any criminalization.”
Smith walked a similar line between optimism that licensure is getting traction and caution over how the language would actually be implemented.
“Licensure would be beneficial in Mississippi, if we can get it done in a good way,” she said. “There are direct entry midwives that are amazingly good, they’re knowledgeable and take care of their clients with a lot of skill and education even if they didn’t go to a four-year college. I’d hate to see us lose midwifery here in Mississippi.”
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You can help your community
Quality, in-depth journalism is essential to a healthy community. The Dispatch brings you the most complete reporting and insightful commentary in the Golden Triangle, but we need your help to continue our efforts. In the past week, our reporters have posted 44 articles to cdispatch.com. Please consider subscribing to our website for only $2.30 per week to help support local journalism and our community.
