Erin Ballinger went into labor with her third child at 5 a.m. She didn’t rush to a hospital or birthing center. Instead, medical care came to her.

Certified professional midwife Robin Massey drove more than an hour to assist Ballinger through the birthing process.

“If I’m having a baby naturally, I’m going to be in pain by the time I need to drive 45 minutes to the hospital,” Ballinger said. “Once I get there, I’m doing the same thing that, in my mind, I could be doing from the comfort of my own home.”

Ballinger is not alone in her decision forgo a traditional hospital birth. Whether by choice or necessity, in Cooper County, 82.39 out of every 1,000 live births occur in a non-hospital setting, according to data from the Missouri Department of Health and Senior Services. Statewide, this number is much lower: only about 19.65 out of every 1,000 live births occur outside a hospital. In Audrain County, this number is closer to 73.75 out of 1,000. Randolph County is even lower, at 20.3 births out of each 1,000. In neighboring Boone County, only 13.55 out of every 1,000 live births occurs out of hospitals. This statistic includes any births that occur at clinics, homes or in ambulances.

For women who do choose to give birth in a hospital, ambulances can provide medical care during a potentially lengthy drive. Kevin Swartz, EMS director for Cooper County, estimates that his staff respond to about 12 childbirth-related calls each year. The average ambulance ride is a $1,500 base rate, plus $14 a mile, Swartz said.

“We treat it like we would every other call,” Swartz said. “We do everything we can to provide care as we drive them to the nearest hospital, which is in Columbia.”

In Missouri, 69 out of the state’s 101 rural counties lack any OB/GYN beds. In Cooper County, the closest OB/GYN facility is the Women’s and Children’s Hospital in Columbia. This means a 30-minute drive in a situation where every second counts.

Like Ballinger, more women are opting to avoid this lengthy drive and instead seek obstetric care from a certified professional midwife.

“[Homebirth] is slowly starting to become more popular,” said Sabrina Bias, a certified professional midwife based out of Columbia. “I know that there are a lot of areas across the state where midwives can be very valuable, but we just don’t have enough to serve those areas. It is a problem, because we have a lot of small hospitals shutting down or refusing to deliver babies, and it’s really hurting the outcomes for moms and babies.”

Certified midwives undergo years of medical training, unlike doulas, who mainly provide emotional support to laboring mothers. In order to receive a certification from the North American Registry of Midwives, candidates must undergo three to five years of apprenticeship-style training, attend and document at least 50 births and sit through an eight-hour board exam.

“I think the number one thing that people don’t understand about midwives is that we are trained, medical providers,” said midwife Robin Massey.“We are trained to handle normal pregnancy and childbirth, and when things go outside of normal, we absolutely know when to transfer to a medical facility.”

Massey owns and operates BirthWorks, a midwifery practice based out of Pilot Grove, Missouri. As a certified professional midwife, she is able to run labs, provide basic ultrasounds and administer emergency medications. She estimates that 99 percent of her clients come from rural areas.

“I think that not wanting to drive to a hospital that’s far away is a big part of it,” Massey said. “You don’t want to drive there and then get sent home if you’re not far enough along [in the labor process]. In rural areas, a lot of our little hospitals don’t have an OB on call. Once patients get there, they’re not sure they’re going to get adequate care, because they’re just dealing with a triage nurse and not an obstetrician that can provide specialized care.”

For decades, assisting in a home birth was illegal in Missouri. In 2008, Missouri became the 38th state to allow professionally certified midwives to provide services in home settings. On average, midwife-assisted home births cost $2,000-3,000. By contrast, the average hospital vaginal birth in Missouri costs $5,842, according to data from FAIR Health. Planned out-of-hospital birth is associated with higher rates of unassisted vaginal births, lower rates of obstetric procedures and lower odds of admission to a neonatal intensive care unit, according to a study published by the New England Journal of Medicine. 

The same study did, however, demonstrate that the rate of neonatal seizures was slightly higher in babies born at home. Babies born at home also had a higher mortality rate than babies born in the hospital: 3.9 vs. 1.8 per 1,000 deliveries. Statistics like this concern some in the medical field.

 “When an expectant mother has trouble accessing a delivery hospital, it’s likely that she hasn’t been able to access adequate prenatal care,” said Dr. Bill Carey, a neonatologist at Mayo Clinic. “This is important, because certain maternal or obstetric factors are associated with high-risk delivery. If these aren’t managed, or even identified, before delivery, a baby might be inappropriately considered ‘standard risk.’”

Additionally, midwives may lack the staff to handle any unanticipated emergencies that can arise. “Mothers who deliver at home are typically tended by a single midwife or delivery attendant,” Carey said. “If a baby needs assistance to breathe, or advanced resuscitation, that one delivery attendant would be in the difficult position of having to manage two patients at once. Rapid and expert transport services make a big difference for babies who need resuscitation. When a delivery attendant makes a call from home to the nearest hospital, delays are unavoidable.”

When emergencies occur on Massey’s watch, she has a plan in place.

“We are trained to handle normal pregnancy and childbirth,” she said. “When things go outside of normal, we absolutely will transfer to a hospital.”

Like most midwives, Massey keeps her client base relatively small to allow more individualized attention for each patient. On average, she delivers three to four babies each month

“We monitor [our patients] in a really holistic way,” she said. “In labor, it’s easier to monitor them, because we know what’s normal for them and for that baby. If during labor and birth it looks like anything is falling outside of that normal range, it’s easier for us to catch that early and arrange that transport to the hospital.”

In the event that a hospital transfer is necessary, Massey will call ahead to inform the facility. In Missouri, licensed midwives can carry and administer medicines that might be needed in an emergency. Massey has IV’s and oxygen available if needed, and is trained in CPR and neonatal resuscitation.

“The majority of things that can happen, we have a plan in place,” she said.

Bias operates under similar protocols and also brings to each birth equipment to deal with emergencies like a hemorrhage or a baby born in distress.

“The reality is, birth has risks no matter where you’re at,” Bias said.