In the dimmed light of a hospital room in Nevada, the placenta — blue and shining — has just delivered. I coaxed it gently, spinning the warm, bloody organ and twisting the trailing membranes into a compact coil, leaving nothing behind. Even a small fragment of placenta or membrane can prevent the uterus from contracting properly, failing to squeeze shut the great vessels that have spent 40 weeks surging with blood to feed a growing baby. If those vessels do not abruptly close, blood continues pumping into the empty uterus and a hemorrhage begins.
I am always vigilant for bleeding — but today I am also uneasy. My patient has made it clear that she does not consent to blood products, even in an emergency. She will not risk receiving blood from a donor who has been vaccinated against Covid-19. No hospital or blood bank tracks donor vaccine status, because it poses no known transfusion risk — but no fact will change her mind.
It was during a prenatal appointment in 2021 that I first encountered this growing movement: patients planning to refuse blood transfusions unless the donor could be confirmed as unvaccinated. I was perched on a rolling stool in the exam room, and I remember the particular stillness of that moment — recognizing that vaccine hesitancy had traveled somewhere I had not anticipated. Whether a patient chooses vaccination or not, the motivation I hear most often is the same: They are doing what they believe will best protect their family.
As a nurse-midwife and a committed advocate for patient autonomy in sexual and reproductive health, I have learned to hold two truths at once — respecting a patient’s right to choose while watching preventable harm become more likely.
I now practice a couple thousand miles east, in the Blue Ridge Mountains of North Carolina, where measles recently made an appearance. It traveled a familiar tourist corridor up from South Carolina, winding between the mountains and crossing the state line in a pattern anyone would recognize: a highly contagious airborne pathogen moving steadily through an under-vaccinated population. Though now officially declared over, it was the region’s largest measles outbreak in 30 years. Measles, whooping cough, and chickenpox are all on the rise — diseases that few in my generation grew up fearing, precisely because childhood vaccines had made them rare. Herd immunity, which once protected even those who could not be vaccinated — the very young, the pregnant, the immunocompromised — is steadily eroding.
Midwives are uniquely positioned among clinicians to meet this moment. Rooted in a tradition of bridging the gap between communities and the medical system, midwives have long practiced the art of holding space — listening without judgment, honoring autonomy, and building trust over time. This relational foundation is exactly what vaccine-hesitant patients need: not a lecture, but a clinician who genuinely trusts them and meets them where they are.
That work is needed more than ever. Labor and delivery units are closing across the country at an average of more than two per month, while the United States holds the grim distinction of the highest maternal mortality rate among all high-income nations. More than 80% of those deaths are considered preventable — and the burden is not equally shared. Black women are more than three times as likely as white women to die from pregnancy-related causes. As public confidence in medical institutions frays and gaps in maternity care widen, midwives offer something rare: clinical credibility paired with community-centered care.
My own path into nurse-midwifery felt less like a career choice and more like a calling. I was captivated by birth from an early age — catching glimpses in after-school sitcoms, stumbling across rare mentions in middle school chapter books. In college, shadowing a labor and delivery nurse and witnessing my first birth only deepened this passion. When I discovered nurse-midwifery, the blend of art and science felt like an exact match. I am drawn to the evidence-based protection of physiologic birth, to the holistic lens midwifery places on the whole person, and to the privilege of bearing witness to the raw, transformative power of birth. And I am moved by the immense impact that access to compassionate, affirming sexual and reproductive health care can have for people who have too often been overlooked by the systems meant to protect them.
Many patients who seek midwifery care are drawn to low-intervention birth — and honoring that philosophy does not mean ignoring the lifesaving advances of the last century. A cornerstone of patient-centered care is offering the best available evidence and then trusting patients to make the decision that is right for them. Vaccines are no exception.
When I talk to patients about vaccination, I am realistic. In an era when vaccine decisions have become entangled with political identity, influencer culture, and conflicting public health messaging, I hold modest expectations about what I can accomplish in a 15-minute appointment I am already running late for. But I have come to believe that changing a mind is rarely the point. Planting a seed is.
Earlier in my career, I might have met hesitancy with statistics, dismissed unreliable sources, and moved on. Today I know better. There is quiet power in simply listening — in letting a patient feel heard before they are counseled. I share my own experiences, keep the exam room free of judgment, offer my evidence-based recommendation plainly, and ask whether there are questions she has been sitting with. I cannot control what patients decide. But I can make sure that when they are ready to ask, they know exactly where to turn.
Because I share patient care with colleagues, I cannot always trace a direct line between my counseling approach and a patient’s health decisions. I consider it a win when a patient who holds very different views on vaccination — and who knows my own recommendations — still feels welcomed in my clinical space to talk about it. Some patients who were initially resistant now bring their vaccine questions to an appointment, or ask about whether a particular source is trustworthy — every so often, TikTok is surprisingly evidence-based. These patients are still doing their own research, but when I’m seen as a person who could provide insight, these seemingly casual patient questions become the crack of a door opening for consideration.
Back in Reno, I sit at the end of the bed, dabbing at the perineum with a blood-soaked gauze. In my mind I am replaying all the postpartum hemorrhages of my career — the moments when a peaceful room suddenly fills with tense clinicians enacting the drills we have practiced, calling the blood bank for more units, more plasma.
But the uterine fundus beneath my hand is firm. The vessels that once fed the placenta have closed. The monitors confirm stable vitals, and the single, well-placed IV drips quietly. Across the room, a new family takes turns cooing at the tiny person who has just taken their first breath. I breathe easily too — everyone is fine this time. I clean up the delivery table counting each gauze and stacking the used instruments, and think about the next prenatal appointment, and the one after that, and all the small unremarkable conversations that are, in the end, some of the most powerful tools I have.
Mara Evans, D.N.P., C.N.M., is a nurse-midwife in North Carolina and is on faculty at Georgetown University’s Berkley School of Nursing. Her work centers on global midwifery and health equity.
