An appointment room stands empty at the Planned Parenthood in St. Louis' Central West End (Anna Spoerre/Missouri Independent).I am riding on the front of a train barreling into a distant land. Physically, I am at home, in an inflatable pool cushioned by warm water, entering birthland. As my son emerges, I am in awe. We are surrounded by nothing but love: my husband, my certified nurse midwife (CNM), and doula. I feel whole, and present.
My hospital births nearly a decade earlier were, per my chart, textbook experiences. Yet after both, I felt hollowed out. Pushing under the deadened gaze of a resident physician and medical students hiding yawns at three in the morning felt humiliating. Two years later, an anesthesiologist shrugged off my husband and turned back to his charting after I lost consciousness.
It took years as a nurse and women’s health nurse practitioner, a clinical and quality director at Planned Parenthood, a home birth, and countless conversations to understand that hollow feeling. I wasn’t the problem. The problem is our system that too often treats birth as an economic function and reproductive care in America as a stratified risk, where access to care — and sometimes outcomes — can depend on where you live.
Despite holding a doctorate and more than a decade of experience caring for women, I cannot practice independently as an advanced practice registered nurse (APRN) in Missouri. To prescribe medications and provide treatment under Missouri law, APRNs generally must work through a collaborative practice arrangement with a physician. Some APRNs pay physicians for those agreements, which also operate within geographic and prescribing restrictions.
There are also no licensed freestanding birth centers in the state, even though Missouri has a licensing framework for them. In my view, those requirements create unnecessary barriers to opening and operating one. Further, education and credentialing requirements can make entering midwifery difficult for women without the time or resources to pursue them.
Missouri, as of this year, has one doctoral certified nurse midwife (CNM) program, and a handful of small, private certified professional midwife programs. Certified professional midwives are not nurses, but are trained to provide pregnancy-related services. They are not licensed by the state, so they are not eligible for insurance reimbursement.
The shift away from community midwifery and toward hospital-based childbirth did not happen solely because women chose hospitals. Historians have documented how professionalization, regulation and the growth of hospital-based medicine marginalized many traditional midwives over the 20th century. Today, access to abortion, birth centers and midwifery still varies dramatically by state.
Historically, Missouri’s legal treatment of midwifery has shifted as well. In 2007, lawmakers enacted a law allowing people with qualifying national certification to provide pregnancy-related midwifery services. Physician groups immediately challenged the law, but the Missouri Supreme Court ultimately rejected the lawsuit because the groups lacked standing. Missouri still requires physician collaboration for many APRN services. APRN advocates have repeatedly sought to loosen those restrictions in the legislature, with limited success.
I learned the abortion side of this story at Planned Parenthood. I worked at the facility during some of the most tumultuous and litigious years, fighting for our license while being assailed daily by state legislators, surveyors, and protesters. Missourians voted for reproductive freedom in 2024, but many preexisting abortion regulations remained in effect while litigation continued. By the time Missouri’s abortion ban took effect in 2022, only one clinic in the state was still providing abortions. In June, a circuit judge struck down most of the abortion regulations challenged by Planned Parenthood and the ACLU, while leaving in place requirements that abortions be performed by physicians and that patients seeking medication abortion meet with a doctor in person.
The professionalization of health care also carried a racial dimension. The U.S. midwifery workforce today remains predominantly white, while historians have documented how Black midwives were marginalized as childbirth moved into hospitals and professional credentialing expanded. Those changes disproportionately affected communities that had long relied on community midwives. Birth attendance has become the province of a few highly credentialed people, while profound racial disparities in maternal health remain. In Missouri, Black women die from pregnancy-related causes at 2.5 times the rate of white women, and nearly 80% of pregnancy-related deaths in the state’s latest review were found to be preventable.
MO HealthNet covers certified nurse-midwife services and freestanding birth-center care. Yet where does a woman go when there are no freestanding birth centers, and access to midwives is limited in many communities? The result is a system that often funnels women into hospitals whether or not that is their preferred setting. This system wasn’t built with women at the table. It was built to put them on it.
Our political debate has not fully addressed reproductive liberty across the entire arc of pregnancy. Paid leave and abortion access receive sustained attention; birth autonomy gets far less. My home birth required resources that most women don’t have. Choices such as home birth, IVF or traveling out of state for miscarriage or abortion care can depend heavily on money, geography and insurance. For women who can’t afford this, their reproductive liberty ends with their paycheck.
Missouri’s fights over reproductive policy will continue in legislatures, courtrooms and elections. But reproductive liberty is broader than any single policy fight. It includes whether women can decide when to become pregnant, what providers can care for them, and where and with whom they give birth. Until those questions are treated as part of the same reproductive-health conversation, the consequences will continue to fall hardest on people with the fewest resources and the least ability to demand alternatives.
