Tiffany Vassell, a labor and delivery nurse, left a Boston hospital two days early after giving birth to her son seven months ago, exhausted by what she described as inadequate care that forced the Black maternal health advocate to relentlessly protect her and her baby’s wellbeing.

As her unborn child went into distress for 10 minutes, Vassell herself watched the heart rate monitor, instructing a nurse to not increase a medication used to induce contractions.

And Vassell halted a frenzied recommendation about an emergency C-section, a procedure she later had to undergo to deliver her 10-pound baby, as she lobbied for a “very controlled atmosphere” to reduce the likelihood of infection. Vassell later had to request stronger painkillers — rather than the Motrin she was given — and heating pads as she complained of “excruciating pain” following the abdominal surgery.

Throughout her pregnancy, Vassell managed to make decisions for herself, backed by a maternal care team that extended well beyond the hospital to the home birth midwife and doula she’d hired out-of-pocket. Those professionals became Vassell’s “girlfriends,” with close bonds formed through empowering prenatal visits that are the norm for the midwifery model of care, which advocates say must be expanded and regulated in Massachusetts.

Vassell had wanted to give birth to her son, Cash, in her Mattapan home, in a mode that became increasingly popular amid the COVID-19 pandemic.

She felt confident in her birth team and the personalized support she was receiving — as she intentionally steered away from the traditional physician-led care route that’s fueled maternal health inequities, including higher rates of mortality, among people of color.

But Vassell’s labor at home wouldn’t progress, prompting the hospital intervention she’d envisioned only in emergency situations.

“Even though my birthing experience with my son didn’t go as planned like with a home birth, I felt good because I tried. I had this whole dream in my head, and I felt good because I attempted it,” Vassell said. “And that’s what makes me feel OK about having the C-section because I tried it my way first.”

Yet most birthing people in Massachusetts lack the freedom to try it Vassell’s way, viewing the hospital and compressed clinical visits throughout pregnancy as their only affordable route to having a baby, maternal health advocates say.

Vassell paid $5,000 for her home birth midwife, which she called an “absolute hurdle” as she cared for her older daughter and paid off student loans. She also spent $2,000 out-of-pocket for a doula, who offered added emotional support and advocacy throughout the birthing process.

Vassell supplemented the home midwife — whom she learned about by word of mouth at a Black maternal health conference — with a certified nurse midwife she saw at a clinic, as she wanted a record of her prenatal care in case of an emergency.

Certified professional midwives — who are trained to work in settings like home births and birth centers, which represent a more homey or spa-like environment for labor compared to hospitals — are allowed to practice in Massachusetts. But they’re not officially licensed here, even if they’ve received formal education and national credentialing from the North American Registry of Midwives.

A path to licensure in the Legislature

Several pieces of legislation filed on Beacon Hill this session could rectify that licensure gap, creating a board of registration in midwifery that would standardize a process for issuing, renewing or revoking licenses. The bills — filed by state Reps. Kay Khan and Brandy Fluker Oakley, as well as state Sen. Becca Rausch — would also require that certain insurers, including Medicaid and MassHealth, cover midwifery services throughout prenatal care, child birth and postpartum care.

“When there’s midwifery-led care, when it’s integrated into the health system, we see fewer maternal deaths, fewer infant deaths, fewer unnecessary C-sections, fewer postpartum complications, fewer premature births,” said Emily Anesta, co-founder of the Bay State Birth Coalition, which advocates for licensing midwives and ensuring equitable insurance reimbursement rates, among other priorities.

“Both of my births were home births, and I had the opportunity that it feels so few people are experiencing right now, which is to enter parenthood each time feeling strong, feeling supported, feeling confident in myself, my decision-making, my body, my intuition,” Anesta continued. “People are ending up feeling pushed into procedures they didn’t necessarily want, maybe not given time to make decisions or feel that they were making an informed choice about their care.”

Midwifery could also yield major cost savings, with Anesta referencing a study that found shifting 1% of births from hospitals to homes nationwide annually would save at least $320 million.

In the wake of the Duxbury tragedy, in which 32-year-old Lindsay Clancy is facing charges for strangling her children to death as she suffered postpartum depression and postpartum psychosis, there’s heightened urgency on Beacon Hill to tackle what lawmakers see as a mounting maternal health crisis.

Massachusetts may be a beacon for legal abortions in the aftermath of the Supreme Court’s decision to overturn Roe v. Wade, but lawmakers must expand their view of reproductive care by strengthening access to full-spectrum pregnancy care, signaled state Sen. Liz Miranda.

Miranda, Senate co-chair of the Ellen Story Commission on Postpartum Depression, has filed a birthing justice omnibus bill that would create a board of registration in midwifery, implement insurance coverage for midwives, establish a workforce development trust fund for doulas, provide coverage for universal postpartum home visiting services, and overhaul regulations that are impeding birth centers from opening in Massachusetts, among other provisions.

The bill, which seeks to collate the slew of more tailored maternal health proposals before the Legislature this session, is a work in progress, as Miranda gathers feedback from fellow commission members and elected officials to “build stronger measurement outcomes.”

As Miranda sees it, Massachusetts is “resource rich” for medical care but “coordination poor.” Black women, for example, are about twice as likely to die from pregnancy or postpartum complications than white women — and Black babies have the highest infant mortality rate in Massachusetts compared to white and Asian counterparts, the Boston senator said as she cited data from March of Dimes, a nonprofit focused on maternal and infant care, and a report from the state’s Special Commission on Racial Inequities in Maternal Health.

“With our new governor and lieutenant governor, I’m hoping to make this a priority. I’ve also heard that the Senate president’s office is very interested in this bill,” Miranda said. “People don’t have the access to the care that they need. We’re not centering the communities most impacted and solving the issues with birthing justice and maternal health.”

State Sen. Cindy Friedman, who last year spearheaded legislation to strengthen protections for abortion providers and patients, has now filed a bill for health insurers to cover comprehensive pregnancy care, including for abortion, prenatal care, pregnancy loss, childbirth and postpartum care. In a separate bill, Friedman proposed insurance coverage of postpartum depression screenings by pediatricians for up to one year after an individual gives birth.

“We don’t take postpartum depression seriously — we haven’t, and it’s something that many, many women suffer from and they suffer alone,” Friedman said, who signaled the chamber could take up a big maternal health care bill this session. “I’m getting the sense from the Senate president and other colleagues that maternal health is critically important and high on the list of things we need to look at.”

Friedman said she supports licensing midwives and advancing other models of maternal care that are culturally competent.

The midwifery model of care

Through licensure, certified professional midwives in the commonwealth would gain greater access to prescribing medication, including treatments that clients can administer by themselves, said Rebecca Herman, a Massachusetts-based midwife who’s licensed in New Hampshire. They would also develop more streamlined plans to transfer their clients to hospitals if necessary — alleviating what can currently be hostile birthing experiences when nurses and doctors do not fully recognize midwives within the maternal care landscape, Herman said.

Herman estimates there are about 50 certified professional midwives scattered throughout Massachusetts.

But without state licensure and transparency for midwives, Herman said pregnant people may be wary of vetting their professional background and using their services — plus scrounging up the funds to cover out-of-pocket, out-of-hospital expenses. Herman said she regularly talks with prospective clients about her midwifery credentials, as they try to understand whether she’s legitimately trained.

“The cost barriers are very well documented. We are unlicensed — there’s just kind of a social risk to that,” said Herman, who tries to offer care on a sliding pay scale. “You need a certain level of social privilege to take that risk, so even when cost isn’t the barrier, I’ve definitely had folks, especially if they’re undocumented or worried about authorities probing into their circumstances, they get nervous.”

Still, the benefits of midwifery are clear, too, advocates say. While prenatal care visits with midwives mostly echo appointments at doctors’ offices — aside from longer, more personalized interactions — postpartum care comes with vast differences.

When people are discharged from the hospital after giving birth, they’ll go to a six-week check-in with their OB-GYN. As Herman said, “and that’s it.”

But once Herman’s clients give birth, she’ll make two to three home visits within the first week, usually staying for about two hours to observe “mom and baby together, and the whole adjustment.”

Herman will space out those visits throughout the next five weeks — or longer, depending on the new parents and baby — to foster family bonding, as well as physical and mental well-being. She’ll also look for potential symptoms of postpartum depression and other disorders, relying on clues such as whether household chores like laundry and dishes are going undone — and if the new mother is crying more than usual.

“There’s a lot more continuous engagement through that really critical first month,” Herman said. “That’s where I find there’s no replacement for sufficient observation time of just watching dynamics — how does someone react when baby cries, who gets up to comfort and soothe — all of these sort of interaction points that allow us to pick up on things.”

Vassell, who serves on the board of the Bay State Birth Coalition, recalled that her home birth midwife came to visit her the day after she returned home from the hospital. Vassell’s doula helped her stay comfortable in bed and move around after the C-section, with both professionals guiding her with breastfeeding.

It was another way Vassell found she could control her environment and lessen any potential trauma surrounding giving birth. Vassell said lawmakers have the opportunity this session to save lives by licensing midwives.

“Black and brown people, when they’re going into the hospital to have their babies, they’re feeling many times that they’re not listened to, their needs aren’t being met, their pain is being ignored or being reduced,” Vassell said. “We take their power away, so I think putting power back into the birthing person’s hand will help some of these disparities. If I wasn’t a labor and delivery nurse, if I didn’t have these experiences of being a birth provider and being in a hospital, I don’t think I would have been listened to.”

A lack of birth centers

It’s a human right, Herman said, for people to decide where to have their babies. That applies to birth centers, which could be staffed by certified professional midwives — not nurse midwives or physicians acting as supervisors — should they gain licensure and grow a larger workforce in the commonwealth.

For now, the Seven Sisters Midwifery and Community Birth Center in Florence is the only birth center operating in Massachusetts, following the closures of the North Shore Birth Center in Beverly and the Cambridge Birth Center.

Nashira Baril, who comes from a family of midwives, is leading a project to open the Neighborhood Birth Center in Roxbury, which she said is intentionally created by and for people who are Black, queer, disabled, immigrants or low-income.

“We’re actually explicitly saying let’s make sure that we are designing to consider all of the ways that we address inequity at an individual and at a policy level, and from there, we’ll create a birth center that works well for everyone,” said Baril, who feels “hamstrung” about who she’s allowed to recruit under current state regulations.

If the Boston birth center were to open tomorrow, Baril said she could only hire nurse midwives or labor and delivery nurses with experience over the last 12 months — not certified professional midwives “who may be the most desirable” for the low-intervention setting.

Regulating midwifery is not the “silver bullet” to resolve the dearth of birth centers in Massachusetts, Herman said, but it would help make the facilities more feasible.

“Licensure in and of itself doesn’t guarantee lots more birth centers — it’s more complicated than that,” Herman said. “But without licensure, we can’t staff them. We know that’s a first step.”