Rachel Bruns is a maternal health advocate in Iowa.
Earlier this year, I wrote a three-part series for the Des Moines Business Record’s Fearless publication titled “From Personal Experience to Policy Change: Fighting for Improvements in Maternal Health Care in Iowa.”
With that series, I was excited to highlight, in part 1, promising practices at hospitals across the country that were making positive improvements in maternal health care – improving both patient satisfaction and outcomes. In part 2, I highlighted ongoing policy issues impacting maternal health, and in part 3, I examined the consequences of mistrust in medicine.
While I have had to step back from my engagement on maternal health advocacy, I am still paying attention, and there is a lot to pay attention to.
Since I wrote the series, three Iowa hospitals have announced closures of their labor and delivery units: Southeast Iowa Regional Medical Center in Fort Madison, MercyOne Clinton Medical Center, and CHI Health Mercy Council Bluffs. OB-GYN provider shortages and the financial impacts of the so-called “One Big, Beautiful Bill” on hospitals have been cited among the reasons.
Then, on August 5, Floyd County Medical Center in Charles City ended its midwifery program when it terminated the employment of its two certified nurse-midwives, Judi Halbach and Danielle Wadsworth. The decision ended hospital-based midwifery care in the community.
A local mother, Adison Kapping, launched a petition with more than 1,900 signatures (as of August 23) asking the Floyd County Medical Center to reinstate the midwifery program.
The petition states:
“Like many other mothers in our community and the surrounding areas, I didn’t receive a phone call or a statement explaining what was happening to my care. Instead, I found out online. I was left feeling shocked, heartbroken, and uncertain during a time when every pregnant mother deserves stability, support, and clear communication.”
The petition goes on to describe the midwives as more than health care providers, emphasizing the meaningful relationships they built with patients and the personalized care families specifically sought.
To be clear, Floyd County Medical Center has said that its obstetrics program and birth center are not closing. The hospital continues to provide labor and delivery services and says it intends to continue providing obstetrical care through a “physician-led model.”
But keeping labor and delivery open is not the same thing as maintaining the same range of maternity-care options. Floyd County Medical Center is not the first Iowa hospital to eliminate hospital-based midwifery care. In 2023, MercyOne Des Moines ended its midwifery program as well, although its labor and delivery services continued.
Iowa isn’t only losing maternity-care capacity. In some communities, it is also losing the range of maternity-care models available within the hospitals that remain.
Floyd County’s program was successful
The Floyd County Medical Center’s midwifery team, which started in 2019, was one of only 39 midwifery units in the country to receive the Best Practices–Triple Aim Achievement in 2023 from the American College of Nurse-Midwives. The honor recognizes midwifery units that improve patient experience, reduce cost of care, and improve the health of populations. The Floyd County center celebrated that recognition, with CEO Dawnett Willis calling the award evidence of the professionalism and expertise of the midwives.
So why eliminate a program that had received repeated national recognition since its creation in 2019?
A hospital spokesperson said the (now former) midwifery model they had been implementing was creating challenges with physician recruitment, because some physician recruits wanted a more “active role” in labor and delivery.
Hospitals are operating in an extraordinarily difficult environment. Recruiting and retaining physicians and other health care professionals is challenging, particularly in rural communities.
That said, it is difficult to reconcile the idea that midwives are a barrier to physician recruitment with the growing emphasis on team-based maternity care.
The American College of Obstetricians and Gynecologists and the American College of Nurse-Midwives have jointly stated that quality of care is enhanced by collegial relationships characterized by mutual respect, trust, professional responsibility and accountability.
If prospective physicians are unwilling to work collaboratively with certified nurse-midwives, eliminating midwifery care should not be the default solution.
Instead, it raises questions about whether medical education and residency programs are adequately preparing physicians to work within the collaborative models needed in rural communities—and whether hospital leadership is providing the structures and culture necessary for effective team-based care.
The physician recruitment challenge raises another question too: If rural communities already struggle to recruit enough obstetricians, does it make sense to build a maternity-care system that depends exclusively on physicians?
The Commonwealth Fund has identified midwives as part of the solution to the nation’s maternity-care workforce shortage. Nearly half of U.S. counties lack a single OB-GYN, according to the report, and the authors argue that fully integrating midwives into maternity care could help address provider shortages.
In a rural community, that isn’t about replacing physicians. It is about making the best use of every qualified member of the maternity-care workforce.
Iowa says it needs more midwives
That is particularly relevant because Iowa has been actively investing in expanding the state’s midwifery workforce.
In 2023, the University of Iowa launched the state of Iowa’s first nurse-midwifery program, with a focus of placing more midwives in rural communities. Previously if you wanted to be a nurse-midwife you had to go to graduate school outside the state of Iowa. The program was launched in response to Iowa’s shortage of maternal health care providers and was initially funded by a $10 million grant from the federal Health Resources and Services Administration.
The goal is to build a workforce in which both midwives and physicians are available and work together – leveraging their professional expertise to meet Iowa’s maternal health care needs. Hospital-based care is already the norm for midwives in the United States. According to the Commonwealth Fund, 87 percent of midwife-attended births in 2020 occurred in hospitals, in collaboration with nurses and physicians, and 95 percent of the U.S. midwifery workforce reported working exclusively in hospital settings.
The Commonwealth Fund also recommends that hospitals allow midwives to serve as principal providers for low-risk pregnancies while collaborating with physicians when risk factors arise. That is not a choice between midwives and physicians. It is a division of expertise.
The physician can focus on the patient who needs a physician’s expertise. The midwife can focus on the patient whose pregnancy is progressing without complications. And when the patient’s needs change, the team can respond accordingly.
The decision by Floyd County Medical Center stands in contrast to promising practices emerging in other rural communities, where hospitals are expanding midwifery care as part of a collaborative model designed to improve access to maternity care while allowing physicians to focus their expertise on higher-risk births.
If Iowa is investing millions of dollars to train more midwives for rural communities, why are established rural hospitals eliminating the midwives they already have?
The numbers
I’ve continued my efforts to obtain Iowa hospital labor and delivery cesarean and VBAC data from the state, data that I believe the state should make publicly and readily available.
The Floyd County Medical Center had a cesarean rate of 26.8 percent in 2025. While still below the state rate of 30 percent, that represents a substantial increase from their 2024 cesarean rate of 17.7 percent.
A hospital’s cesarean rate, by itself, does not tell us whether individual cesareans were appropriate or whether a hospital is providing good or bad care. Patients have different risk profiles, and cesareans can be lifesaving. But hospital-level data can help identify trends that deserve closer examination.
Iowa’s health care payment system creates an uncomfortable financial paradox for rural hospitals like Floyd County Medical Center.
Hospital payment methodologies can assign different reimbursement weights to cesarean and vaginal delivery hospitalizations. At the same time, Iowa Medicaid reimburses certified nurse-midwives at 85 percent of the physician fee schedule. According to the American College of Nurse-Midwives, all of Iowa’s neighboring states reimburse midwives at 100 percent of the physician fee schedule.
Taken together, these policies raise an uncomfortable question: Does Iowa’s reimbursement system create financial incentives that make higher-intervention care more attractive while simultaneously valuing the professional services of midwives at a lower rate than physicians?
When rural hospitals are already struggling financially, these policies can further exacerbate their challenges by making evidence-based, collaborative models of maternity care harder to sustain.
That does not mean Floyd County Medical Center is performing cesareans for financial reasons. Nor does it mean the hospital’s decision to end its midwifery program was driven by reimbursement rates.
It does mean that Iowa should examine whether its payment policies are aligned with the kind of maternity-care system it says it wants to build. If Iowa wants hospitals to provide evidence-based, team-based maternity care, its reimbursement policies should reinforce that goal—not work against it.
What do we want to build?
Ultimately, providing maternal health care shouldn’t be about choosing midwives over physicians. It isn’t about suggesting every birth should be a vaginal birth or that cesareans aren’t sometimes lifesaving. It is about asking whether Iowa’s maternal health care system is structured to support the full range of evidence-based care that women and their families need.
If we say we want better maternal outcomes, stronger rural hospitals and greater patient trust, then we need to examine whether our workforce policies and reimbursement systems are actually moving us toward those goals.
We need midwives. We need physicians. We need nurses, doulas, lactation specialists, physical therapists, and other members of the maternity care team.
Rural communities (and really all communities) in Iowa, need hospitals that can bring these health care professionals together rather than forcing patients to choose between models of care.
Because eliminating options doesn’t solve a maternity-care shortage. It simply gives families less access to the care options they deserve.
Top image of pregnant woman talking with midwife is available via Shutterstock.