The number of Texas midwives is increasing — but advocates say the state needs more

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DENTON — It was early in the COVID-19 pandemic when Tereé Fruga received a call from an expectant mother inquiring about an at-home birth.

The woman on the other end of the phone call told Fruga, a registered midwife, she had never considered giving birth outside a hospital. But she was scared about the level of care she’d receive as a Black woman. COVID-19 precautions at the time would have prevented the pregnant mother to have an extensive support system in the hospital.

“There was such a fear of having nobody, or not having an advocate,” Fruga recalled in an interview with The Texas Tribune.

Fruga, who is also Black and works in the Dallas suburbs, understood. Black women in Texas are twice as likely than white women to die during childbirth. It’s one of the reasons Fruga entered the midwifery profession 11 years ago and why she is now a part of a state board that is advocating for easier access to become a midwife.

“Every woman deserves a midwife, and I stand by that,” Fruga said. “Midwifery is not just for those who choose to birth outside of the hospital.”

The Department of State Health Services recently updated its methodology for how it tracks midwives. The data, first reported by the Tribune, shows the number of midwives in Texas has increased steadily over the past decade — 66.7% over a 10-year period. But the total number of midwives — almost 500 nurse-midwives and over 300 professional-midwives — is a fraction of what advocates would like to see in a state as large as Texas.

The five most populous counties, which make up 43% of the state’s population, also contain 56% of nurse-midwives in Texas. Only 20 counties in Texas have more than five nurse-midwives, and the county with the most nurse-midwives per capita, Delta County, has just one midwife.

Over 46% of counties in Texas are defined as maternity care deserts, according to a March of Dimes study, with some women in Central Texas and the Panhandle needing to drive more than an hour to the nearest birthing hospital.

“It's such a burden and a hardship on some of these women in the rural parts of Texas to get the good care and good coverage,” said Laurie Fremgen, Austin-based midwife and presiding officer of the Texas Midwives Advisory Board.

Fremgen said she and other midwives often drive hours across county lines to reach patients in rural areas, where hospitals offering maternal care services are cutting back programs or shutting down entirely.

The increase has opened the door for more women to consider alternative maternal health care.

There are two kinds of midwife certifications in Texas, each with their own regulations. Certified nurse midwives, which require graduate degrees, often work in hospitals and can administer medication, whereas direct-entry midwives, also known as certified professional midwives, require no degree but do require attending a midwifery program. Professional-midwives usually work outside of the hospital at home births or birthing centers and are less common than nurse-midwives.

For “low-risk” pregnancies, midwives have proven benefits to new mothers, as their patients are less likely to need an induced labor, require a cesarean section, or medical assistance according to multiple studies. The benefits apply both during midwife-attended births in hospitals, as well as home births, although out-of-hospital births still hold risks.

Texas’ midwives amid the state’s maternal health crisis

The United States, which has the highest maternal mortality rate among high-income countries, uses midwives significantly less than its international counterparts — in most other countries, midwives outnumber obstetricians and gynecologists, according to a report from the Commonwealth Fund.

And although the number of midwives is increasing in the state and across the country, Texas is utilizing them at a much lower rate: only 5.3% of births in the state were assisted by a midwife in 2021, less than half the national average, according to a report from the U.S. Government Accountability Office.

Regulation of midwives varies significantly across the U.S., especially for nurse-midwives. While the American College of Nurse-Midwives provides states with professional standards, specific rules on midwifery are left to states.

For Fruga, who is also a certified midwife in Oklahoma, access to medicine in Texas is more difficult. State law in Oklahoma gives midwives access to a predetermined list of certain medications they can administer to patients. In Texas, however, midwives need a doctor to prescribe every medication.

“There shouldn't be a hurdle in having the autonomy as a provider,” Fruga said. “Not every patient is giving birth in a city where there's a hospital right around the corner. Some of these people are in rural areas, and you need to be able to have quick access to those things.”

“Growing and growing and growing”

A new program is turning to midwifery as an alternative answer to the maternal health care crisis. In Austin, Huston-Tillotson University partnered with several nonprofits and health insurance company Blue Cross Blue Shield to create a program designed to address disparities in maternal health care and research factors that influence maternal health inequity.

The Boldly B.L.U.E. program, which began in October, seeks to train new midwives, doulas and lactation consultants. Training for new doulas and community health workers began in October, and the program is looking to implement its midwife training program within a year, said Amanda Masino, Boldly B.L.U.E. project lead and chair of the university’s natural sciences department.

“We want to make sure that it's midwife training that is very culturally competent, very grounded in health equity and health disparities, that we are equipping people who are able to work in the communities most impacted,” Masino said.

Boldly B.L.U.E. will also be conducting long-term research on the help its newly-trained midwives and doulas provide to understand better ways to strengthen systems of maternal care in an equitable way.

Increasing equity in maternal care is part of what drove Fruga to enter the field, who was initially an OB tech before entering her training as a midwife. At the time, she said there was only one other Black midwife in her community.

“I want to do this because women like me are dying,” Fruga said.

The Texas Department of Licensing and Registration also approved a reduction in the costs to become a licensed midwife. That reduction goes into effect on Jan. 1. It came about at the recommendation of the Texas Midwives Advisory Board, of which Fruga and Fremgen are both board members. This small change, along with Huston-Tillotson’s program and other initiatives, are all designed to make midwifery more accessible.

Collaborative care between midwives, traditional health care providers and support workers like doulas can provide a support network for new mothers. Still, miseducation about their roles, especially among patients and traditional providers, can get in the way of caring for patients.

“A lot of people have that misperception about doulas and think that doulas are the ones managing labor, which they are not, they are support workers,” Masino said. “They think that midwives only do home birth, which is not the case either.”

Masino said increasing the number of midwives and providing more opportunities to train midwives will not only allow more options for patient care, but also will spread awareness about how these roles actually operate, keeping women informed about what options they have for their care.

“That’s the ideal, right? To have collaborative care between support workers like doulas, care providers like midwives and then, their OBs if they're involved or the family practitioners,” Masino said.

Fremgen, the Austin-based midwife who has been a midwife for over two decades, said the change in the midwifery community has been noticeable, both in the number of patients and in other midwives.

“There's midwives here that I don't even know anymore,” Fremgen said. “This used to be a small-knit community where we all knew each other, and we just keep growing and growing and growing.”

Disclosure: Huston-Tillotson University has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.