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Gianna DeJoy is a PhD candidate in anthropology and environmental policy at the University of Maine, where she studies the relationship between climate change, access to care, and rural resilience.
Maine has much in common with our eastern neighbor. Both Maine and New Brunswick are largely rural places with relatively small, aging populations. We share heritage industries as well as cultural and geopolitical history. Expansive forestland and a rocky coastline span the international border to underpin a regional nature-based tourism economy. Our many similarities make Maine and New Brunswick an apt natural laboratory for one of our more prominent differences: health care.
Unlike the U.S., Canada has a universal health care system, administered in New Brunswick by the provincial Department of Health and regional health authorities. That means every New Brunswicker with a health card is eligible for no-cost services that are delivered by their health authority.
As Mainers we might feel understandably envious. Our largely private national health care system has no shortage of glaring issues, one being the loss of rural maternity services. In Maine, nine hospitals have stopped delivering babies since 2020, leaving parents in parts of the state with hours-long drives between birthing hospitals. Would a universal health care system protect rural communities from such losses?
The answer is not an easy yes. While New Brunswick hospitals seem less hasty than ours to end maternity services for good, they do institute frequent temporary closures that redirect laboring patients to larger hospitals and can sometimes last for months. Even though Maine experienced a more dramatic wave of obstetric closures in recent years, my research found we still have twice as many maternity hospitals overall than New Brunswick. Today, only two Maine counties are entirely without hospital-based obstetric services, while the same is true of nearly half New Brunswick counties. Despite their universal health care system, rural New Brunswickers do not have abundant access to maternity care.
How do both Maine and New Brunswick differ from places that do manage to provide robust, accessible maternity care, even to rural populations? Now that’s an easy answer: Midwives. Nordic countries with stronger networks of birthing facilities — and with maternal mortality rates a tiny fraction of those in the U.S. or Canada — also have comparatively whopping midwifery workforces; there are about four midwives for every 1,000 births in the U.S. and Canada versus 53 per 1,000 in Norway.
Norway knows that not every birth has to take place in a hospital and operates freestanding midwifery-led units (fødestuer) to fill in the geographic gaps. Maine (like most states) makes it hard to finance freestanding birth centers, as MaineCare and many private insurers don’t cover out-of-hospital services provided by independent midwives. Our approximately 40 independent midwives mostly offer home births, but some are reluctant to do so within the care “deserts” formed by hospital obstetric unit closures. New Brunswick didn’t even hire its first registered midwife until 2017. Today, there is a single formal midwifery practice in New Brunswick, but it is not a birthing facility; the Fredericton midwives attend hospital births and home births that are restricted to the Fredericton area.
A recent report from the Center for Healthcare Quality & Payment Reform was not unusual in its focus on insurance policy as a way to save rural maternity care. CHQPR’s proposals — like “standby” payments to low-volume hospitals that lose money keeping their obstetric units open 24/7 — are good and important. But these kinds of changes alone might not be the sustainable solution needed to maintain maternity services long-term for our smaller communities. Even New Brunswick’s hospitals, which are fully government funded, struggle to provide consistent access to maternity care in rural areas.
Vanishing rural maternity care is a workforce issue as much as a funding issue. An international perspective shows the need to reimagine who should provide the bulk of women’s health care. Midwives provide high-value care with great outcomes, even for out-of-hospital births in rural and remote areas. To strengthen our health care infrastructure and protect rural communities, Maine should boldly envision a maternity care system designed to serve small and disperse populations — with midwifery at its core.
