Yeah. You write in the book in 2017, one out of every 62 births took place outside the hospital. And that number grew somewhat during the pandemic. So birthing centers and midwives are starting to serve more and more mothers. I wonder if you can talk to us about how, after being sidelined, they were able to come back and do more and more births, and also how state laws affect their ability to do their jobs.

Right. So kind of picking up almost from where I left off earlier when I was talking about some of that history, there was a concerted campaign in the US to really stamp out midwives and midwifery, except for a period of time in places where they were the only real providers of health care. And so in that case, I'm really particularly thinking of the South, where the majority of the midwives who were referred to as grand midwives, they were taking care of their communities. They had incredible rates of safety and of health. And so I read a whole slew of midwifery memoirs for the book and referenced some of them. But midwives like Margaret Charles Smith or O'Lilogan who delivered thousands of babies and just had remarkable success rates. And so there were sort of these communities or these clientile populations that doctors weren't willing to serve. Or they were sort of happy to let the midwives continue to be the caretakers for those communities. And then for the most part around the 70s, partly as a result of Medicare and Medicaid. And so that there were more people, poorer people, were able to have access to insurance and have greater access to the health care system, which was also in effect of the Civil Rights Act with integration. That kind of created the opportunity for states to actually get rid of the practice of midwifery altogether. So they would stop issuing midwifery licenses, which meant that if you were practicing as a midwife without a license, you were kind of like a rogue practitioner. And so there was a really concerted effort, as I said, to stand out midwifery. But then around the same time that that was happening, there was also a resurgence of interest in midwifery. But that was predominantly among white middle class women, many of whom were kind of associated with the hippie movement. So there was a lot of this ideal of more authentic living and getting back to the land and not kind of wanting the man involved in the birth experience. And so there was this resurgence of midwifery around that same time. And so when it re-emerged, it was kind of more of a white lady thing. And that has been the pattern for the past couple of decades. But I also think that that's really starting to shift. And there's a lot of really incredible work that's being done on Black midwifery and community birth centers or even just community dual organizations or organizations that are there. And so state laws really do have a big impact because they affect who is able to practice or if people are able to practice at all as midwives. And before I started working on this book, but one of the stories that I reported that got me interested in this subject was about Alabama women who were crossing state lines to give birth with midwives. So at the time, Alabama did not allow the practice of direct entry midwifery. So that meant that if you wanted an out of hospital birth, you had to go out of state. So most of the people that I interviewed for that story, they were going to Tennessee. So they were renting cottages over the state border. They were driving hours when they were in labor, many of them in order to make it to the cottage so the midwife could meet them there. And that goes back to sort of the safety thing I was talking about before too. If you're criminalizing or preventing the practice of midwifery, people are going to go to great lengths to access it. And then that creates its whole issue. So I think today there's like 13 or 14 states that don't allow the practice of direct entry midwifery, but slowly every year or so, every couple years, more states are changing their laws. And that's really important to making midwifery more accessible, which I think is really important. Right.

And it isn't accessible with Medicaid in many places, right?

Yeah. A lot of public and private insurance don't cover any form of out of hospital midwifery care, at least. So Oregon is, I think, a little bit unique in that many of the private insurers will cover out of hospital birth or particular practices. And then the state public insurance, the Medicaid does ostensibly cover it. But I know through reporting and speaking with folks at the birth center that the reality of that can be quite a challenge. So actually getting, having a patient get approved to be eligible for it or actually getting the birth center reimbursed, it's not like a perfectly smoother seamless situation, but certainly that's a crucial step in order to make midwifery accessible. Because otherwise, people have to pay out of pocket. So even if it's cheaper in terms of total costs than a hospital birth, it still might be $3,000, $5,000, $7,000. And that's a lot of money. Right.