Moms know all too well: Giving birth rarely goes exactly to plan. But imagine being a mom-to-be who lives counties away from the closest OB-GYN. How much harder would it be to take time off work, including travel time, for regular appointments? How much harder would it be to get labor timing right on the big day when a long drive stands in the way?
This is the reality for over 10 million women. That’s the number of women who live in counties without a single OB-GYN to provide women’s wellness, maternal, and prenatal care — more than half of the counties in the United States. Half of women who live in rural areas need to drive more than 30 minutes to reach perinatal care; more than 10% drive 100 miles or more.
This shortage of doctors impacts more than childbirth, of course. OB-GYNs provide services to women of all ages, including prenatal care, cancer screenings, birth control prescriptions, reproductive consultations, and hormone replacement therapies. For millions of women, long drives create barriers that separate them from essential care — requiring them to request unpaid time off from work, get transportation, and arrange child care. These barriers mean that some women who need care can’t receive it.
A solution offers hope — and help — to women across the country. As the number of physicians declines in rural and low-income areas, the number of women’s health nurse practitioners and certified nurse-midwives in those areas is increasing. In 24 states and the District of Columbia, legislation allows these skilled providers, known as advanced practice registered nurses (APRNs), to practice without barriers requiring them to enter into a contract with a doctor. APRNs are registered nurses who obtain master’s degrees or doctorate degrees in nursing, and they include certified nurse-midwives who specialize in childbirth and women’s reproductive health. They perform pap smears, prescribe birth control, deliver babies, and more.
Yet in 26 states — many of which are affected by OB-GYN shortages — these APRNs face laws that restrict their practices. Now four of those states (Florida, Kansas, Kentucky, and Mississippi) have proposed legislation that, if passed, will allow APRNs to practice without unnecessary barriers, giving patients more choices for safe and quality care closer to home. (To learn how to support APRNs supporting women in your state, click here.)
Byline: Jen McGivney
Why Supporting Nurse-Midwives is So Vital
Sue Rooks knows better than anyone the challenges facing moms-to-be who lack care, as well as exactly how to help them. Rooks delivered about 2,000 babies during her 41-year career as a certified nurse-midwife. Before her retirement in 2018, she worked in South Dakota in rural and underserved areas, in small towns and on reservations. South Dakota needs clinicians like Rooks: almost two-thirds of its counties don’t have a hospital with a single OB-GYN.
“A lot of services an OB-GYN provides can be provided by nurse-midwives. I estimate that we can perform about 80% of OB-GYN services,” Rooks says. “We put in IUDs, do colposcopies after abnormal pap smears, things like that.”
Until 2017, South Dakota required APRNs to maintain collaborating agreements with physicians in order to treat patients. These agreements seemed to Rooks to be merely bureaucratic formalities, until one day, a clerical mistake at Rooks’ clinic showed how restrictive the agreements can be. This error resulted in a lapse on her collaborating physician’s license. Rooks was among three advanced practice clinicians (two APRNs and a physician’s assistant) who, because of these restrictive laws, couldn’t practice either. The clinicians had licenses in good standing, but the collaboration agreement tied their ability to work to their collaborating doctor.
“None of us could practice for two days until another physician could sign a collaboration agreement with us,” Rooks says. “In the meantime, we couldn’t do any patient care.” For two days, patients in rural South Dakota were down three capable providers to provide vital services.
This experience shows how vulnerable APRNs practice and patient access to care can be when states require such agreements. Rooks went on to lobby state lawmakers to change South Dakota’s law. In 2017, just a year before her retirement, her efforts succeeded. South Dakota joined the states that allow APRNs like Rooks to practice without a doctor’s oversight, known as Full Practice Authority.
More Options for Women’s Healthcare
Now, with Florida, Kansas, Kentucky and Mississippi state legislatures introducing bills that, if passed, would grant APRNs full practice authority (FPA), moms-to-be and women in general in these states could finally get the access to care they need and deserve.
These are critical areas, with urban and rural areas in the states affected by lack of care. Of the top ten metropolitan areas that are most likely to experience an OB-GYN shortage, two are in Florida: Orlando and Miami. Of the 105 counties in Kansas, 77 lack a single OB-GYN. In Kentucky, 76 of its 120 counties lack an OB-GYN. Mississippi is already ranked as the worst state for health and physician availability.
Lifting these unnecessary restrictions will not mean ending collaboration between nurses and doctors. Even in FPA states, certified nurse-midwives handle healthy pregnancies and consult with physicians as needed for patient care, sometimes co-managing or transferring complicated pregnancies to OB-GYNs.
“It was always a team effort when I worked with physicians,” Rooks says. “That's how collaboration works. You just don't need a piece of paper to delineate it.”
To learn how to support APRNs delivering babies and caring for the health of women in your state, click here.
