Annie is having a baby.
She’s crying out as she has contractions. Her stomach rises and falls with labored breaths. A monitor tracking her vital signs beeps in the background.
“One more contraction,” says Angela Sojobi, a certified nurse-midwife and assistant professor at Cal State Fullerton. And with one more push, the baby is born.
“Congratulations!” Sojobi says.
But Annie can’t hear her, because Annie isn’t a human. She’s a state-of-the art mannequin that can simulate birth, and used to train midwifery students at Cal State Fullerton’s School of Nursing.
This blinking, breathing robot with silicone skin and flexible limbs can simulate a variety of birth conditions, including breech births, preeclampsia, shoulder dystocia and other obstetric emergencies. While students perform the simulated delivery, professors watch from a neighboring room to give feedback. Annie won’t deliver her baby unless the students are doing it right, Sojobi said.
When people hear the word “midwife,” Sojobi knows what they’re thinking, she says: long hair, Birkenstocks, even voodoo.
Here’s what they don’t picture: annual cohorts of about 45 nursing students who, by the time they graduate from Cal State Fullerton’s master’s program in nurse-midwifery, have delivered 40 babies and have seen at least 100 pregnant patients in a clinic setting.
In the program, which lasts at least two years, students also learn about the spectrum of women’s care, from puberty to post-menopause. Sojobi herself has delivered more than 5,000 babies, including her own granddaughter. She’s not sure of her total count — she stopped tallying more than 25 years ago.
‘Much-needed profession’
This fall, she and other professors will welcome 45 students, including 17 new ones. Midwifery is a “much-needed and valuable profession,” Sojobi said, perhaps now more than ever.
By 2030, California will be short more than 1,000 OB/GYNs, according to a report on maternity care in the state. It’s part of an overall trend nationwide — in the next decade, it’s estimated that 44 states won’t have enough OB/GYNs to attend to the number of births, according to a study published in January in the journal Obstetrics & Gynecology.
In recent years, maternity care deserts have spread in California, and maternity wards in the state have closed faster than the average U.S. rate. The problem is particularly pronounced in inland and rural areas — in general, there are more physicians in coastal areas than there are in the Central Valley and Inland Empire, said Janet Coffman, co-associate director for policy programs at the UC San Francisco Institute for Health Policy Studies.
Midwives could help alleviate that gap, Sojobi said. Rather than replacing OB/GYNs, midwives can “complement” them, she said.
“Having a baby is a physiologic process,” she said. “In most cases, you don’t need much intervention, you just need support and good care.” Physicians can step in when complications take hold. “As nurses, we care; as physicians, they cure,” Sojobi said.
Having midwives handle lower-risk pregnancies “frees up OBs to really focus on those pregnant people who are at higher risk for poor birth outcomes,” Coffman said.
“Midwives are an untapped resource,” especially considering that they tend to improve birth outcomes, agreed Amelia Cobb, a senior program officer at the California Health Care Foundation. “We are the only progressive country that doesn’t lean into midwifery the way all the other countries do.”
Some limitations
While certified nurse-midwives are nurses who complete additional midwife training, aspiring midwives also can become licensed through a three-year direct education program. While nurse-midwives often deliver babies in hospitals, licensed midwives are more likely to work in birth centers or in patients’ homes.
For out-of-hospital births, there are limitations — for example, midwives can’t administer epidurals, and, if unforeseen complications arise, patients may need to be transferred to a hospital mid-delivery for a C-section or other emergency care.
As a nurse-midwife, Sojobi delivers babies in a hospital where she knows a physician can step in immediately if things go wrong. “We don’t claim to be able to do it by ourselves,” Sojobi said.
But for pregnant patients in rural communities, licensed midwives can care for patients in cases where there otherwise would be little or no prenatal care, she said, reducing the number of times a patient would have to travel to a hospital or doctor’s office before birth.
New programs coming
In California, training programs for midwives are hard to come by. Cal State Fullerton offers one of the only midwife training programs in the state, and it’s the only master’s program for nurse-midwives on the West Coast, Sojobi said. UC San Francisco offers a three-year doctoral program for nurse-midwives.
Until recently, no programs for licensed midwives existed in California, but two new programs are expected to launch within the next year.
California “is trying to advance the number of midwives that are in our state,” Cobb said.
Though access to midwives is sparse in California, many expectant mothers have indicated they want that model of care: A 2018 survey by the California Health Care Foundation found that although fewer than 10% of California women went to midwives for prenatal care or birth, more than half of participants said they definitely want or would consider adding midwives to their future birth care team.
‘Relationship-based’ care
“The midwifery model is a relationship-based model built over time,” said Holly Smith, co-lead of Midwifery Access California. Midwives offer “more intensive care personally,” she said, including longer prenatal and postpartum visits.
Sojobi agreed with that characterization — she’s delivered multiple generations within the same family, she said. She recently had a former patient message her to say that her granddaughter is pregnant.
Though the Inland Empire has only about 11 midwives per 10,000 births — one of the lowest rates in the state — the region is particularly well-suited to the midwifery model of care because of its “unique geography,” said Yuli Smith, a midwife based there.
Because the area is so vast, “people are still having to drive in both Riverside and San Bernardino County over an hour to get to their birthing facility,” she said. “It’s really scary when you’re in labor.”
Midwives, on the other hand, can do home visits for prenatal and postpartum care, as well as home births, if the patient wants. “It makes care more accessible for folks, especially in rural or remote areas,” Smith said.
Insurance issues
There’s a gap between those who want to rely on midwives for care and those who can afford it, said Liz Donnelly, chair of the Legislative Action and Advocacy Committee for the California Nurse-Midwives Association.
Because midwives spend more time with their patients, they’re able to see fewer patients, which sometimes means they’re not making enough money to survive. “What’s being reimbursed cannot sustain a practice like that,” Holly Smith said.
Birth also can be high-risk. OB/GYNs are some of the most frequently sued physicians, which makes malpractice insurance prohibitively expensive for independent midwife practices, Donnelly said.
In the state, Medi-Cal covers 41% of women giving birth, but insurance providers pay “a grossly low wage,” Donnelly said, so many midwives can’t take insurance. “The bulk of community-based midwifery, at this point in time, is people paying out-of-pocket,” she said.
Medi-Cal reimbursement for one birth is about $3,500, Yuli Smith said, and malpractice insurance alone can cost tens of thousands of dollars. “The amount of clients that I would need to have would be a lot more than I would like to take, just to be able to cover my malpractice insurance,” she said.
Though she does not accept Medi-Cal, Smith said she’s come up with creative ways to accommodate patients — she’s accepted payment plans, offered fee reductions and embedded midwifery care into other reimbursable activities. “You have to get innovative,” she said.
Kimberly Durdin co-founded her practice, Kindred Space, in South Los Angeles at the start of the pandemic. It was a “long-held vision” to create a birth center for underserved communities. “Everything was pointing to, of course we’re going to take Medi-Cal,” she said. “It wasn’t as easy or straightforward as it seemed.”
Reimbursement rates were “abysmally low,” she said. “There would be no way we could keep our business open.” Between hourlong appointments, a 24-hour labor, and four postpartum visits, receiving a $2,000 reimbursement wasn’t sustainable.
When Kindred Space opened in 2020, a nonprofit called The Victoria Project stepped in to help fund the center. “For a couple of years, that really sustained us,” Durdin said. Since then, the facility has relied largely on grants for support. “We spend a lot of time writing (applications for) grants and bringing in money so that we can keep our doors open,” she said.
At its Los Angeles location, Durdin said, Kindred Space has delivered — or caught, as some midwives prefer to say — more than 150 babies. At least half of the center’s clients are on Medi-Cal.
Midwives aren’t looking to get rich when they choose this career path — instead, many describe it as a calling.
Sojobi glows while talking about the “bond” she develops with her patients and their babies. As the midwife, “you get to see the baby first, you get to touch the baby first,” she said. “It’s the most incredible thing.”
“It’s the best job ever,” Sojobi said. “I love what I do.”