Emily Scott describes her first delivery as nothing short of traumatic. As her daughter struggled to be born, she tilted in the birth canal, her path blocked by Scott’s pelvic bone with each contraction. After nearly 40 hours of labor, doctors performed an emergency cesarean section.
That was in 2016. Then, in 2019, Scott prepared to welcome her second daughter into the world. She wanted a vaginal birth, despite the complications that can arise following a C-section. This time, she relied on nurse midwives instead of doctors to help her through the delivery at Centra Virginia Baptist Hospital in Lynchburg.
“[The midwives] took such great care of me from the very first appointment up until after she was born. The difference between the births was night and day,” Scott said.
The debate over whether nurse midwives should practice independently without doctors’ oversight has been a contentious one in the past, balancing safety concerns, access to care and professional autonomy.
Hospital boards, often led by doctors, usually advocate for maintaining some level of oversight, while midwives push for full practice authority, stating that their training prepares them for most outcomes. In the case of complex pregnancies, the mother is referred to a physician early on.
Certified nurse midwives are registered nurses who have a master’s degree, specializing in women’s health and childbirth. They typically practice in hospital settings. Some rural hospitals are turning to midwives to help tackle challenges in labor and delivery rooms.
However, restrictive hospital bylaws and Virginia state code prevent midwives from working independently, said Katie Page, a nurse midwife at Centra Farmville and legislative representative for the Virginia Affiliate of the American College of Nurse-Midwives.
The need to diversify the labor and delivery workforce most recently came to light in late 2024 as a Southside Virginia hospital paused its delivery unit for a weekend. A state law requiring hospitals to have an on-call pediatrician within 30 minutes of the facility contributed to the shutdown.
A bill introduced during the 2025 General Assembly session aims to address state laws that prevent nurse midwives from practicing to the full scope of their training. HB 1904, introduced by Del. Rodney Willett, D-Henrico County, and signed into law by the governor this month, allows nurse midwives to fulfill the 24-hour duty roster requirements for nursery care if a doctor is unavailable.
It’s now up to hospital boards to implement a system that allows midwives to practice more independently — a process that could take time. Social and political factors often influence these decisions, and hospital boards have the authority to impose stricter rules that may limit midwives from practicing to the full extent of their training.
An unexpected closure
When Sovah Health Danville’s labor and delivery unit unexpectedly closed down one weekend in November, Elissa Orr grew concerned. She works as a certified professional midwife, helping women who opt for home births or free-standing birth centers over a traditional hospital setting. One of her clients was within her due date window, and the Danville hospital, five minutes away, was designated as the emergency backup. Home births are safer when there’s a hospital nearby in case there are problems during the delivery, but it’s not required by law.
Orr stayed up late the night she heard about the temporary closure, calling hospitals in North Carolina to see if they’d be willing to take a patient with Virginia Medicaid in case of an emergency.
The temporary pause of labor and delivery services at Sovah Danville occurred when the doctor scheduled to work had a medical emergency that required surgery. The hospital’s two other providers were out of town, causing the hospital to temporarily turn away women in labor, said Steve Heatherly, market president at Sovah Health.
This was the only pause in delivery services Sovah Health Danville enacted in 2024, according to Heatherly.
As more rural labor and delivery units close permanently, more patients rely on the dwindling number of health systems that still provide these services. Only eight of the state’s 28 hospitals offer care for laboring mothers.
That doesn’t mean births stop completely at rural hospitals. Instead, more births are occurring in emergency departments at Virginia facilities that don’t have obstetric specialists, said providers at Roanoke-based Carilion Clinic.
[Disclosure: Carilion is one of our donors, but donors have no say in news decisions; see our policy.]
A new state law will open possibility for midwives, but real change could take time
OB-GYN Associates of Danville, a private medical practice unaffiliated with Sovah, announced on its social media that it had offered midwife coverage for the hospital during the temporary suspension in its labor and delivery unit, but the health system declined the proposal, according to the post.
Maternal health challenges in rural Virginia
Cardinal News reporter Emily Schabacker has been exploring the health care challenges faced by pregnant women in Southwest and Southside Virginia.
Read her coverage here:
- Virginia’s pregnant women must travel farther as the maternity care crisis grows. Doulas are stepping in to fill gaps.
- ‘Please let this be the last time’: Pregnant women battling addiction in Southwest Virginia face barriers to care despite available funds.
- Why is it so hard to use opiate settlement funds in rural communities?
Even if Sovah Health had accepted, it wouldn’t have been able to legally deliver babies without a pediatric physician within 30 minutes of the hospital. This is due to a state law that requires a specialized doctor to be nearby at all times in order to keep a delivery room and a general nursery open.
According to the Virginia State Code, the law dates back to at least 1993. While online records prior to 1995 are unavailable, documents on the state code website indicate that the law was amended in 1995.
Sovah Danville employs two full-time pediatricians and four additional traveling pediatricians to perform newborn care, Healtherly said.
Rural hospitals often rely heavily on traveling providers, health care professionals who work temporarily in a health system to fill gaps in staffing. Staffing shortages are persistent. Many health care workers choose higher-paying and better-resourced jobs in urban areas.
Hospitals that struggle to maintain pediatric coverage may be forced to temporarily close their services if there’s an unexpected gap in staffing.
The legislation introduced by Willett removed this state law, allowing nurse midwives to deliver healthy newborn babies from uncomplicated pregnancies. HB 1904 allows nurse midwives on the 24-hour duty roster for nursery care if a doctor is unavailable and permits the use of telehealth for physician consultations.
The bill moved through the General Assembly with little opposition and was recently signed into law by the governor. It goes into effect July 1, 2025.
But it could take time to amp up the use of midwives, Page said.
Hospitals are free to enforce stricter policies than state law requires. Many health systems and regulatory boards, and the general public, favor physicians over mid-level providers such as nurse practitioners or nurse midwives, according to Kathryn Haines, health equity manager at the Virginia Interfaith Center for Public Policy.
Haines added that both the public and health care leaders have been trained or socialized to believe physicians are the best options for quality care.
“There is a growing body of research that shows that integrating midwives into the system of maternal health care leads to better outcomes such as lower rates of maternal mortality, lower rates of preterm birth, and lower cesarean rates,” Haines said over email. “The bills that passed this General Assembly that will increase the integration of midwifery care will absolutely improve access to midwives if implemented with fidelity and the result will be better outcomes for moms and babies.”
Births in rural areas are still happening, just outside of specialized delivery units
The loss of labor and delivery rooms doesn’t halt births; instead, more deliveries occur in hospitals that lack obstetric specialists. A 2018 study in JAMA Network found that rural counties that lost hospital-based obstetric services experienced higher rates of preterm births and deliveries in facilities without dedicated specialists.
Women in rural areas are more likely to experience delays in prenatal care and have more pregnancy-related hospitalizations. The decrease in care paired with the increase in stress due to distance from an obstetrics unit can result in preterm birth, according to the JAMA Network study.
The number of preterm births in Virginia has fluctuated in recent years but has largely increased since 2018, according to 2024 data from March of Dimes.
Five labor and delivery units closed in Virginia from 2018 to 2024 due to the financial strain of maintaining these services and a decreasing number of births in rural areas. In 2023, 9.8% of live births were preterm, up from 9.4% in 2018.
Access to prenatal care has declined in Virginia. Over a three-year period, 2021 to 2024, inadequate access to prenatal care increased by 16%, according to data from March of Dimes.
Carilion Roanoke Memorial Hospital has absorbed an increasing number of births from neighboring communities as rural delivery rooms have closed their doors. The influx has occasionally overwhelmed its capacity.
There were two months in the latter half of 2024 when the hospital’s labor and delivery unit reached full capacity more frequently than ever before, resulting in temporary halts to incoming transfers, according to Dr. Jaclyn Nunziato, an OB/GYN at Carilion Clinic.
Roanoke Memorial has 14 beds for delivery and 10 beds reserved to treat pregnant women with high-risk pregnancies. Capacity depends on a number of factors, including staffing and the severity of the patient’s health, said Hannah Curtis, a spokesperson for Carilion.
When this happens, mothers often have to consider hospitals in North Carolina. For those covered by Virginia Medicaid, it can be difficult to find hospitals in another state willing to accept out-of-state public insurance. Or, mothers give birth in Virginia hospitals that don’t have obstetrics services.
To support its rural satellite facilities, Carilion initiated delivery training programs about 10 years ago, designed to equip emergency room doctors with the skills to manage childbirth and common complications. These training sessions are conducted upon request from the satellite hospitals and have gained urgency as more labor and delivery units have shuttered across Southwest and Southside Virginia.
Carilion Roanoke Memorial Hospital and Carilion New River Valley Medical Center are the only two of Carilion’s seven Virginia hospitals with dedicated labor and delivery units, making them the primary facilities for maternity care.
Carilion Franklin Memorial Hospital, in particular, has amped up its training efforts in response to the rising number of on-site births. The Rocky Mount facility stopped offering labor and delivery in 2011.
Like many other maternity units, the service ended when births declined in the area and it was no longer reasonable to maintain the 24-hour staff needed for obstetrics services.
The hospital averages about three unexpected deliveries per year, said Stephanie Hodges, the nursing director for the emergency department.
“It’s something that will just continue to rise,” Hodges said.
Hodges initiates these training sessions on an annual basis, inviting everyone from the hospital to attend. With just three deliveries a year, emergency room workers are unlikely to be proficient in assisting labor without training.
Hodges said if you don’t encounter a type of medical situation, like assisting labor, on a regular basis, it’s not going to be something you feel is your strong suit. “The more training we can get to the staff, the more comfortable they’ll feel taking care of those patients.”
Other rural hospitals have created systems that integrate more nurse midwives into their obstetric care teams in order to keep services operational.
Centra Southside Community Hospital relies on certified nurse midwives to take on the bulk of women’s health and obstetrics care, Page said. Physicians from urban areas rotate through the hospital to offer necessary supervision and meet the state requirement.
Typically, babies born at rural delivery units are healthy
The babies born at rural hospitals with delivery rooms — meaning the hospital has specialists, designated spaces and equipment needed for birthing women — are typically healthy, uncomplicated births, Page said.
That’s because women who have access to prenatal care from specialists are more likely to have potential complications detected early. When risks arise, they can be referred to facilities equipped to provide a higher level of care before labor begins.
Nurse midwives are trained to handle typical, uncomplicated births, Page said, and are well suited to fill in gaps in rural hospitals that face persistent challenges in hiring doctors. A study published in Obstetrics and Gynecology found that greater use of midwives could ease the national obstetrician shortage. Currently, the U.S. needs about 8,000 more obstetricians to meet demand, a gap that could grow to 22,000 by 2050.
Hospital bylaws could present a barrier to expanding midwifery care. While nurse midwives in rural Virginia can open private practices for women’s health appointments and prenatal care, hospital policies may restrict their ability to attend in-hospital deliveries. To fully integrate midwives into the maternity care system, hospitals may need to revise their policies to allow midwives to serve as primary providers for low-risk pregnancies.
Nurse midwives are trained to deliver newborns under normal circumstances and consult with a doctor or refer out for complex pregnancies and births.
“Our scope of practice is normal newborns,” Page emphasized.
There are other types of midwives who are licensed to practice in Virginia but offer services in different settings.
Orr, for example, is a certified professional midwife, an independent practitioner trained and licensed to support in home births or in birth center settings.
Professional midwives meet certification requirements of the North American Registry of Midwives, which is accredited by the National Commission for Certifying Agencies, but they aren’t typically found in hospital settings and would not be covered by the newly signed law.
Midwife experience made a night and day difference
After losing multiple pregnancies following the birth of her first child, Emily Scott sought support in a group for women who had experienced similar losses. That’s where she first heard about midwives.
At the time, she assumed midwives primarily assisted with home births — an option she never considered because she didn’t like the idea of giving birth at home. But as her pregnancy with her second daughter progressed, curiosity led her to schedule an appointment. After that, she never went back to an obstetrician.
Determined to have a vaginal birth after her emergency C-section, Scott knew the risks but felt strongly about her decision. Her midwives understood its importance to her and supported her throughout the process.
Again, Scott needed to be induced, but she dreaded the use of Pitocin, a drug that brings on labor, but one that had made labor especially difficult for her. This time, she told her midwives she wanted to explore every alternative.
“One thing they did was, every step of the way they would ask me before they would even do anything. I felt like with the first time around the doctor would just tell me what they were going to do to me,” Scott said.
The midwives tried more natural methods to induce labor — and it worked.
Over the phone, Scott’s voice quavered as she remembered the midwives moving quickly around the room in the final moments before her daughter, Laurel, was born.
“I got to pull her out,” Scott said. “It was beautiful.”
Emily Schabacker reported this story while participating in the USC Annenberg Center for Health Journalism’s 2024 National Fellowship and its Fund for Reporting on Child and Family Well-Being.
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Correction 9:42 a.m. March 31: Carilion New River Valley Medical Center has a dedicated labor and delivery unit. An earlier version of this story incorrectly omitted it from a description of Carilion’s services.