Over 30,000 Miles, a Midwife Navigates West Virginia’s Maternity Deserts

But for her, the job comes with additional risks.

West Virginia is one of 13 states that do not license midwives unless they are nurses, even if they have been nationally certified, as Ms. Quentrill has. With no laws around midwives who aren’t nurses and no available state licensure, Ms. Quentrill is left to operate in what she considers a “sort of legal gray area.” In other states, midwives in similar positions have faced charges of practicing medicine without a license. In Georgia, one woman was threatened with a $500 fine for each time she called herself a midwife.

Still, Ms. Quentrill believes the work is too important for her to stop. Today in West Virginia, as in a growing number of states, there is a need for people who know how to deliver babies.

More than a quarter of the state’s hospitals have closed their delivery units since 2010. More than 60 percent have no obstetric care. In nearly half of the state’s counties, there are no birthing hospitals, and not a single practicing obstetrician. The state is also home to only one birth center, a childbirth facility typically run by midwives. Pregnant women spend hours driving to appointments. Babies are born on the side of highways and in emergency rooms. When due dates approach, women sleep on other people’s couches to be close to a hospital.

One delivery at a time, Ms. Quentrill and other midwives are trying to provide another option, by reviving the region’s culture of community-based care.

Nationally, a small but growing number of women are giving birth at home, and West Virginia is no exception. In the United States, most of these home births are overseen by people with Ms. Quentrill’s credential: certified professional midwife. The North American Registry of Midwives, the credentialing body, does not require a nursing license or university degree, though some of the midwives have one or both. But the certification does call for extensive training, including attending at least 55 births under the supervision of an experienced midwife. It is also the only certification that requires out-of-hospital birth experience.

Many doctors and nurses are opposed to certified professional midwives and home births in general, seeing them as unnecessarily risky. But Beth Redden, who for years was the rare midwife with a nursing license attending home births in West Virginia, said she found practitioners like Ms. Quentrill “provide evidence-based, safe, effective, high-quality care.”

“Every year West Virginia fails to license them, they’re failing their constituents,” she added. “They’re failing Appalachian people who are just looking for care.”

Before Ms. Quentrill joined the profession, midwives delivered her own babies. She had the first four of her seven children at the birth center. But because the risk of complications rises after a certain number of deliveries, the center’s policy at the time was to refer women having a fifth baby to the hospital.

Instead, she had her fifth baby at home with midwives, and then two more. The experience gave her a feeling of unwavering support and complete autonomy. In 2020, Ms. Quentrill decided she wanted to pass on that feeling to others.

In the early 20th century, though, that community came under attack, part of a broader push to shift the birthing process out of the home and into hospitals, and to curb high infant and maternal mortality. In 1925, West Virginia began requiring midwives to apply for a license. The same year, a nurse named Mary Breckinridge established what became known as the Frontier Nursing Service, which trained nurses as midwives and deployed them, on horseback, to families in Appalachia.

Ms. Breckinridge is sometimes hailed as the “mother of American midwifery.” But she refused to hire or educate Black midwives, and denounced those still practicing in Appalachia.

In West Virginia, the state said midwives had to be able to read and write, possess a diploma from a midwifery program or have a doctor verify their skills and prove their cleanliness and moral character.

For many community-based midwives, the educational criteria were difficult to meet, and their numbers dwindled. In the 1970s, West Virginia amended the 1925 law, removing any path to licensure for midwives who were not nurses.

Nationally, midwives moved into hospitals and birth centers, and the home birthrate dropped below 1 percent. Appalachia’s culture of community midwifery died off almost entirely.

Learning of this history, Ms. Quentrill decided not to pursue a nursing degree, though she understood that meant she’d be practicing without legal recognition in her state.

“I knew I wanted to focus specifically on home birth and being in the community,” she said. “Especially when it comes to Black midwifery, this is our birthright.”

On a warm afternoon earlier this year, Ms. Quentrill sat in Carmen Squires’s living room as a 9-week-old Rottweiler sniffed around her ankles.

Ms. Squires, who is Black, said she sought out Ms. Quentrill because it felt more comfortable to have “a midwife who looks like me.” Thirty percent of Black women report mistreatment during pregnancy and childbirth, according to the Centers for Disease Control and Prevention. Many feel ignored, their concerns dismissed. Ms. Squires felt that working with Ms. Quentrill might insulate her from that possibility.

The traditional obstetric care Ms. Squires received during her first three pregnancies often felt rushed. Appointments with Ms. Quentrill felt more like a visit between friends. Ms. Squires’s two youngest children drifted in and out of the room. Her older children’s laughter spilled from the kitchen. The puppy fell asleep leaning against Ms. Quentrill as the two women talked.

It was close to 45 minutes before Ms. Quentrill opened her backpack full of supplies. Eventually, Ms. Quentrill drew some blood from Ms. Squires, 35, for routine first-trimester testing, then moved closer on the couch to sweep a hand-held Doppler wand along Ms. Squires’s belly.

Because she doesn’t have a state license, she has had to figure out workarounds. Unable to bill insurance, she charges $5,000, though she and other midwives sometimes offer discounts or barter midwifery services for car repairs or landscaping. She’s accompanied by another midwife or birth assistant at each delivery. If a patient needs antibiotics or other medications, Ms. Quentrill brings a nurse to administer them.

She said she does carry and, when necessary, injects clients with a synthetic oxytocin to stop postpartum hemorrhage. Because the drug can be lifesaving, she said she’s willing to defend the choice to administer it herself, should that ever become necessary.

Dr. Kimberly Farry, an OB-GYN in Buckhannon, W.Va., said that in her experience, certified professional midwives were “for the most part, pretty darn good at really assessing the risks of their patients.” If they were licensed, she could imagine calling on them to check on clients deep in West Virginia’s hills in the event of an emergency. And for some women with low-risk pregnancies, Dr. Jeremy Applebaum, an OB-GYN at Brigham and Women’s Hospital in Boston, said home birth is a good option.

Ms. Quentrill said she has never had a mother or baby die on her watch. And some studies have found planned home births to be relatively safe for women with low-risk pregnancies. But they do often list midwives as co-authors, and the official stance of the American College of Obstetricians and Gynecologists is that the safest place to give birth is a hospital or accredited birth center.

The organization cites research by Dr. Amos Grünebaum and Dr. Frank Chervenak, both professors of obstetrics and gynecology at Zucker School of Medicine at Hofstra/Northwell, which found home births are associated with an increase in the risk of infant death.

“There’s no way to get around this,” Dr. Chervenak said. “It is risky to deliver at home. There are many clinical scenarios where things can go wrong.”

Still, Dr. Grünebaum said state licensure of community midwives could potentially help make home birth safer, by creating a pathway to connect midwives to doctors and hospitals, or requiring that they carry insurance and accept only low-risk patients.

For years, Beth Redden, the nurse-midwife who attended home births in West Virginia, covered nine counties, often driving three hours to get from one client’s home to another. It was a recipe for burnout, and led her to lobby for years for certified professional midwives to be licensed.

In at least seven states, certified professional midwives are vying for licensure. This year, Ms. Quentrill and two other midwives worked on a state bill, which passed unanimously in the West Virginia Senate but was removed from the House agenda without explanation a few days before the end of the session.

Soon after, Ms. Redden closed her home birth practice and went to work at the birth center. Without licensure to draw more midwives into the profession, she said she felt like help simply wasn’t coming.

“You get tired after a while of beating your head against the wall,” she said. Though she feels guilt over the decision, “when nothing was changing, it was like ‘Man, I can’t do this anymore.’”

But Ms. Quentrill isn’t quitting. She intends to get a bill reintroduced early next year and, if needed, “every single year until it passes,” she said. In the meantime, she’ll keep showing up when mothers call.

“It’s necessary,” she said, “and we’re going to continue to do it.”

Audio produced by Sarah Diamond.