When Rhonda Okoth and her husband decided to stop using birth control, Okoth called her friend Nikia Grayson, a certified nurse midwife in Memphis.

“If I end up getting pregnant, you’re going to be my midwife,” she told Grayson. The two joked about the possibility — but a couple of months later, Okoth found out she was expecting.

She and Grayson began planning for a home birth, something that Okoth had her heart set on since the arrival of her son, Preston, in 2015. After he was born, Okoth dedicated herself to healing from a traumatic hospital birth that ended in an emergency Caesarean section.

As her family prepared to welcome another child, Okoth, 37, wanted “a completely different experience,” she said. The pandemic only solidified her decision to give birth at home. During labor and delivery, her husband, doula and midwifery team encouraged her, repeating words of affirmation that Okoth had hung up on her living room wall. On July 21, Okoth welcomed her daughter, Everlee Mae Lillian, into the world. Everlee is named after her two great-grandmothers, both of whom gave birth to multiple children at home.

Her name represents strength and redemption, Okoth said.

Home birth is not for everyone, and access can be extremely limited depending on the state and one’s insurance. Pregnancies must be considered relatively low-risk, and getting a C-section at home is out of the question. In the United States, about 1.6 percent of births do not take place in hospitals; most of them occur in people’s homes or at free-standing birth centers.

After covid-19 became a nationwide concern, out-of-hospital births seemed to surge.

We spoke to Grayson and seven other midwives who work in community settings about their experiences throughout the pandemic. Some reported doubling — or even tripling — the number of home births they attended last year. A majority said that, so far, they’ve stayed busy throughout 2021, too.

Here’s what they had to say about scrambling to meet patient demand, resorting to Airbnbs for home births and providing fertility services to clients when some clinics shut down.

Memphis

The phone wouldn’t stop ringing when covid-19 first came to Memphis.

“Home birth requests went through the roof,” said Grayson, director of clinical services at the Choices Memphis Center for Reproductive Health. “People were afraid to go to the hospital.”

Grayson’s team had to act quickly. Some callers were nearing their due dates, and it didn’t make sense to change providers when they were already 36 weeks along. To help people feel more empowered, her team developed a list of questions for pregnant individuals to ask the hospital in advance and gave partners tips on how to advocate for their loved ones.

Although Grayson, 45, accepted some new patients, her growing midwifery staff could only accommodate so many people. They already had clients who were counting on them and a pre-pandemic waiting list for their services.

Ultimately, Choices took on more births in 2020 than it had in years prior — and the pace hasn’t slowed in 2021, especially since Choices opened its long-awaited birth center in February.

Despite witnessing an influx of home birth requests at the beginning of the pandemic, Grayson doesn’t think covid-19 is “a factor in people choosing midwifery or out-of-hospital birth options,” she said. Over the past few years, she’s noticed a shift across the country, especially within the Black community.

“People really started saying, ‘We want more say in our care,’” she added.

Respect is embedded in the midwifery model of care, which recognizes patients “as the expert of their body and their life,” Grayson said. She builds lasting relationships with patients: She’s seen babies grow into toddlers and watched parents evolve into doulas and lactation counselors. A few are even pursuing midwifery. Since Grayson joined Choices in 2017, she’s focused on creating training opportunities so that “we can see more Black midwives in the South again.”

“I never thought that we would be growing [midwives] from our patient population,” she said. “That part is really important because we can do only so much. We have to empower the community to pick that mantle up as well.”

Tupelo, Miss.

Toni Hill, a traditional midwife, fortunately had some extra supplies on hand for her small practice last spring. But like so many essential service providers, she still had to compete with larger institutions for personal protective equipment.

Hill, 43, searched Harbor Freight Tools and Lowe’s for gloves. Certain items, such as birth tubs and bag valve masks to help patients breathe, were on back-order. When municipalities started putting curfews in place, Hill mailed her team of birth assistants name badges, masks and letters stating that they were essential workers. She also fielded calls and texts from fearful families who were trying to birth at home at the last minute.

“People [were] really thinking midwifery was like in the ’40s,” Hill said, “that you could just call the midwife and she would show up at your house for free to catch your baby.”

To answer common questions about home birth, Hill recorded a video that she shared with families who expressed interest. She also spent time reassuring people that they could safely deliver at hospitals.

Although Hill is receiving fewer calls from panicked families now, most nearby hospitals are still limiting laboring people to one support person. Over the past year, Hill has transferred a few clients to hospitals, something that happens to about 1 in 10 women planning a home birth. If transfers occur, it’s common for midwives to stay with their clients until after the baby is born. Hospitals’ covid-19 policies are disrupting that practice, which Hill said is “disheartening” for parents, midwives, doulas and mothers who want to support their adult daughters during labor and delivery.

Lacey, Wash.

During her two years of clinicals to become a certified professional midwife, Terri Chi-Lee doesn’t remember having a single conversation about racial injustice with patients.

But over the past year, Chi-Lee has engaged in discussions with expectant couples about navigating tough conversations about race. As a Chinese and Cambodian American who is in a mixed relationship, Chi-Lee said she is able to draw from her own experience.

Providing clients with the time and space they need to talk about these issues is important, said Chi-Lee, who is the only midwife of color in the area she serves. She saw firsthand how the country’s ongoing racial reckoning — paired with a global pandemic — affected patients’ health.

“I saw stress manifesting in people’s bodies in new ways,” said Chi-Lee, 39.

After getting licensed to practice in May 2020, Chi-Lee took the summer off. When she started accepting clients, she reached her maximum caseload almost immediately.

Some clients who sought her home birth services lived several hours away. Near their due dates, they resorted to renting Airbnbs or hotel rooms so that Chi-Lee could attend their births. Others lived in multi-generational homes with minimal privacy, or lacked running water.

Her clients needed a birth center, Chi-Lee decided, so she renovated a small space near her office and completed construction in early March. The last step is gaining Washington state approval.

“A birthing center is not another fad for some of these families,” Chi-Lee said. “They have to have that space. They don’t have an option at home to birth.”

Hanover, Ind.

When certified professional midwife Amanda Chandler started taking clients during the pandemic, fear came over her. Chandler, 39, has multiple sclerosis, a disease that affects the central nervous system and leaves patients immunocompromised.

“I didn’t want to work,” said Chandler, who recently entered a remission period. “I wanted to close down my practice and tell everybody they had to go to the hospital.”

But because Chandler lives in a “maternity desert,” where the nearest hospital is 45 minutes away, she ultimately kept serving her rural clients. To protect herself, she set firm boundaries and asked clients to follow covid-19 guidelines, including social distancing. At first, Chandler facilitated prenatal and postpartum appointments over Zoom, through windows or outdoors. She changed her clothes between in-person interactions, frequently washed her shoes and even plastic-lined her car.

Some expectant families were scared, too. They had questions about the potential side effects of covid-19 on pregnancy, and Chandler spent hours scouring the Internet for the most up-to-date information.

Chandler also dealt with other challenges. Keeping tabs on patients from Indiana’s Plain communities remained difficult, especially during a virtual-centric pandemic. As Christians who choose to live simply, Plain people don’t typically use the Internet, and some do not have phones on their property. With telehealth out of the question, then, Chandler had to ask certain clients to walk to a nearby phone so that she could conduct prenatal appointments.

As the pandemic wore on, Chandler decided to make another change to ease her workload: Instead of driving to clients for in-person appointments, she asked them to come to her home office.

For the first time, clients got a glimpse of her life. They started to realize “there’s a person behind the midwife,” said Chandler, a mother of four. Her children have continued attending school online, and the nature of their parents’ work has affected who they interact with. Emotions have run high throughout the pandemic, Chandler said, but her family has adapted. To decompress, they go on hikes or do yoga, and everyone contributes to the household.

“We have found a balance in our home that [pre-pandemic], we would have never found,” Chandler said.

DeSoto, Tex.

Adrian Mills spent the first half of 2020 juggling multiple jobs: She took on hospital shifts as a labor and delivery nurse, worked at a birth center, and began building her own midwifery practice.

In June, she stopped taking nursing shifts. The birth center was busy, and Mills had additional home birth clients through her independent practice.

Then, in an August dream, she had a conversation with her late mentor, who told her: “You have everything you need to start your own business and be successful.” Mills slowly shed her responsibilities at the birth center and stepped out on her own.

“I’m glad I did, because it’s like the women have been waiting for someone like me,” said Mills, 40, who was a social worker for more than a decade before switching careers. She spent her first year as a certified nurse midwife adapting to covid-19 protocols and listening to pregnant people voice their fears in Texas and beyond. Black pregnant people in Florida, Louisiana, Michigan and North Carolina have reached out to Mills seeking guidance. Although Mills couldn’t provide out-of-state care, she helped them navigate through the fear of giving birth during a stressful time.

Mills has also witnessed how the pandemic is disrupting people’s access to reproductive health care. She’s seen patients who were told they would have to wait three to six months to see an OB/GYN who could prescribe birth control.

“On one end, that helped me, because there were more babies,” said Mills, who can also offer people a range of contraceptive methods. But she recognized the strain a new baby put on some patients who “thought they weren’t going to have any more children.”

Bath, Maine

When Morgan Miller arrived in Maine to start her own midwifery practice, she planned to take her time. But the explosion of covid-19 coincided with her move — and it changed everything.

Miller, 35, quickly introduced herself to Maine’s community of midwives and supported them as needed. After opening her practice, Miller started taking her own clients, and 60-hour workweeks became the new norm.

Business hasn’t slowed since, and Miller doesn’t expect it to.

Miller worked in Oregon before moving to Maine, where state rules and regulations allow certified professional midwives to offer reproductive health care across the life span. When there was a “full halt” on fertility care and clinics shut down early in the pandemic, Miller was able to provide insemination services.

“People that had been planning and planning for years [and] saving money to do this were suddenly left to wait,” she said. “Waiting when you’re trying to get pregnant is an issue. Time is of the essence.”

Charter Township of Oakland, Mich.

When Colleen Maheswaran was working in Florida, she was busy. When she was in Massachusetts, out-of-hospital midwives had fewer clients and were still fighting for recognition. Then, when Michigan started licensing certified professional midwives in 2019, Maheswaran moved back to her home state. She began working at a birth center, but business was slow — until she decided to branch out on her own.

Within a week of opening her practice in early March of 2020, she had her first client, and the referrals kept coming as covid-19 spread. Maheswaran, 42, found herself driving an hour and a half to people’s homes. It was hard to say no at first, she said: Midwifery in Michigan is a “big lake with only a couple fish in it.”

But with two children at home, Maheswaran realized that the grueling commute wasn’t going to be sustainable. Now, she only serves clients who live closer to her.

The economic impact of the pandemic has also affected how she practices. When families can’t afford her services — Medicaid and many private insurance companies do not cover home birth in Michigan — she sometimes lowers her rates or gets creative.

Recently, a client’s partner put a new roof on her house in exchange for midwifery services. (Maheswaran paid the difference.) Maheswaran does her best to accommodate clients, she said, because she’s been in their shoes.

“When I was having my home birth, I was living in Massachusetts, and we had no money,” Maheswaran said. “So I knew what it was like to … stretch the payment plans to be able to afford that kind of birth.”

New York

As covid-19 tore through New York City, certified nurse midwife Yuen Kwan Chan and her team answered plenty of panicked phone calls. But they also encountered patients who had been curious about home birth but never pursued it, partly because of family members’ concerns. With covid-19 rampant, previously hesitant family members grew more supportive of home birth.

The shift represents one positive aspect of the pandemic, said Chan, 37. Now, a new generation of people will recognize home birth as an option.

“It’s a choice,” Chan said. “Where do you feel safe?”

This story was funded by the O’Brien Fellowship in Public Service Journalism at Marquette University. Marquette University and administrators of the program played no role in the reporting, editing or presentation of this story.