Jessie Mazar squeezed the grab handle in her husband’s pickup and groaned as contractions struck her during the 90-minute drive from her home in rural northeastern California to the closest hospital with a maternity unit.

She could have reached Plumas District Hospital, in Quincy, in just seven minutes. But it no longer delivers babies.

Local officials have a plan for a birth center in Quincy, where midwives could deliver babies with backup from on-call doctors and a standby perinatal unit at the hospital, but state health officials have yet to approve it.

That left Mazar to brave the long, winding road — one sometimes blocked by snow, floods, or forest fires — to have her baby. Women across California are facing similar ordeals as hospitals increasingly close money-losing maternity units, especially in rural areas.

Midwife-operated birth centers offer an alternative for women with low-risk pregnancies and can play a crucial role in filling the gap left by hospitals’ retreat from obstetrics, maternal health advocates say.

Declining birth rates, staffing shortages, and financial pressures have led 56 California hospitals — about 1 in 6 — to shutter maternity units over the past dozen years.

But midwives say California’s regulatory regime around birth centers is unnecessarily preventing new centers from opening and leading some existing facilities to close. Obtaining a license can take as long as four years.

“All they’ve essentially done is made it more dangerous to have a baby,” said Sacramento midwife Bethany Sasaki. “People have to drive two hours now because a birth center can’t open, so it’s more dangerous. People are going to be having babies in cars on the side of the road.”

Last month, state Assembly member Mia Bonta introduced legislation to streamline the regulatory process and fix what she calls “a broken system” for licensing birth centers.

“We know that alternative birth centers lead to often better outcomes, lower-risk births, more opportunity for children to be born healthy, and also to lower maternal mortality and morbidity,” she said.

The proposed bill would remove various bureaucratic requirements, though many details have yet to be finalized. Bonta introduced the bill in its current form as a jumping-off point for discussions about how to expedite licensing.

“It’s a starting place,” said Sandra Poole, health policy advocate for the Western Center on Law & Poverty, a co-sponsor of the legislation.

For now, birth centers struggle with a gantlet of rules, only some clearly connected to patient safety. Over the past decade, the number of licensed birth centers in California dropped from 12 to five, according to Bonta.

Plumas County officials are trying to address one key issue: how far a birth center can be from a hospital with a round-the-clock obstetrics unit. State regulations say it can be no more than a 30-minute drive, a distance set when many more hospitals had maternity units.

The first-of-its-kind “Plumas model” aims to take advantage of flexibility provisions in the law to address the obstacle in a way that could potentially be replicated elsewhere in the state.

But the hospital’s application for a birth center and a perinatal unit has been “languishing” with the California Department of Public Health, which is “looking for cover from the legislature,” said Robert Moore, chief medical officer of Partnership HealthPlan of California, a Medi-Cal managed-care plan serving most of Northern California. Asked about the application, a CDPH spokesperson said only that it was under review.

The goal should be for all women to be within an hour’s drive of a hospital with an obstetrics unit, Moore said. Data shows the complication rate goes up after an hour and even higher after two hours, he said, while the benefit is less compelling between 30 and 60 minutes.

Numerous other regulations have made it difficult for birth centers to keep their doors open.

Since August, birth centers in Sacramento and Monterey have had to stop operating because their heating ducts failed to meet licensing requirements. The facilities fall under the same state Department of Health Care Access and Information regulations as primary care clinics, though birth centers see healthy families, not sick ones, and don’t need hospital-grade ventilation, said midwife Caroline Cusenza.

She had spent $50,000 remodeling the Monterey Birth & Wellness Center to include state-required items, such as nursing and hand-washing stations and a housekeeping closet. In the end, a requirement for galvanized steel heating vents, which would have required opening the ceiling at an unaffordable cost, prompted her heart-wrenching decision to close.

“We’re turning women away in tears,” said Sasaki, who owned Midtown Birth Center in Sacramento. She bought the building for $760,000 and spent $250,000 remodeling it in a way she believed met all licensing requirements. But regulators would not license it unless the heating system was redone. Sasaki estimated it would have cost an additional $50,000 to bring it into compliance — too much to keep operating.

She blamed her closure on “regulatory dysfunction.”

Legislation signed by Gov. Gavin Newsom last year could ease onerous building codes such as those governing Sasaki’s and Cusenza’s heating systems, said Poole, the health policy advocate.

The state has taken two to four years to issue birth center licenses, according to a brief by the Osher Center for Integrative Health at the University of California-San Francisco. The state Department of Public Health “works tirelessly to ensure health facilities are able to be properly licensed and follow all applicable requirements within our authority before and during their operation,” spokesperson Mark Smith said.

Bonta, an Oakland Democrat who chairs the Assembly’s health committee, said she would consider increasing the allowable drive time between a birth center and a hospital maternity unit as part of her new legislation.

The state last updated birth center regulations more than a decade ago, before hospitals’ mass exodus from obstetrics. “The hurdle is the time and distance standards without compromising safety,” Poole said. “But where there’s nothing right now, we would say a birth center is certainly a better alternative to not having any maternal care.”

Moore noted that midwife-led births in homes and birth centers are the mainstay of obstetric care in Europe, where the infant mortality rate is considerably lower than in the U.S. More than 98% of American babies are born in hospitals.

Babies delivered by midwives are more likely to be born vaginally, less likely to require intensive care, and more likely to breastfeed, the California Maternal Quality Care Collaborative has found. Midwife-led births also lead to fewer infant emergency room visits, hospitalizations, and neonatal deaths. And they cost far less: Birth centers generally charge one-quarter or less of the average cost of about $36,000 for a vaginal birth in a California hospital.

If they catered only to private-pay clients, Cusenza and Sasaki could have continued operating without licenses. They must be licensed, however, to receive payments from Medi-Cal and some private insurance companies, which they needed to remain in business. Medi-Cal, the state’s Medicaid health insurance program, which covers low-income residents, paid for about 40% of the state’s births in 2022.

Bonta has heard reports from midwives that the key to getting licensed is hunting down the right state health department advocate. “I don’t believe that we should be building resources based on the model of ‘Where’s Waldo?’ in finding a champion inside CDPH,” she said.

Lori Link, director of midwifery at Plumas District Hospital, believes the Plumas model can turn what’s become a maternity desert into an oasis. Jessie Mazar, whose son was born in September without complications at a Truckee hospital, would welcome the opportunity to deliver her planned second child in Quincy.

“That would be convenient,” she said. “We’re not holding our breath.”

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

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Over the past two years, a simple but baffling request has preceded most of my encounters with medical professionals: “Rate your pain on a scale of zero to 10.”

I trained as a physician and have asked patients the very same question thousands of times, so I think hard about how to quantify the sum of the sore hips, the prickly thighs, and the numbing, itchy pain near my left shoulder blade. I pause and then, mostly arbitrarily, choose a number. “Three or four?” I venture, knowing the real answer is long, complicated, and not measurable in this one-dimensional way.

Pain is a squirrely thing. It’s sometimes burning, sometimes drilling, sometimes a deep-in-the-muscles clenching ache. Mine can depend on my mood or how much attention I afford it and can recede nearly entirely if I’m engrossed in a film or a task. Pain can also be disabling enough to cancel vacations, or so overwhelming that it leads people to opioid addiction. Even 10+ pain can be bearable when it’s endured for good reason, like giving birth to a child. But what’s the purpose of the pains I have now, the lingering effects of a head injury?

The concept of reducing these shades of pain to a single number dates to the 1970s. But the zero-to-10 scale is ubiquitous today because of what was called a “pain revolution” in the ’90s, when intense new attention to addressing pain — primarily with opioids — was framed as progress. Doctors today have a fuller understanding of treating pain, as well as the terrible consequences of prescribing opioids so readily. What they are learning only now is how to better measure pain and treat its many forms.

About 30 years ago, physicians who championed the use of opioids gave robust new life to what had been a niche specialty: pain management. They started pushing the idea that pain should be measured at every appointment as a “fifth vital sign.” The American Pain Society went as far as copyrighting the phrase. But unlike the other vital signs — blood pressure, temperature, heart rate, and breathing rate — pain had no objective scale. How to measure the unmeasurable? The society encouraged doctors and nurses to use the zero-to-10 rating system. Around that time, the FDA approved OxyContin, a slow-release opioid painkiller made by Purdue Pharma. The drugmaker itself encouraged doctors to routinely record and treat pain, and aggressively marketed opioids as an obvious solution.

To be fair, in an era when pain was too often ignored or undertreated, the zero-to-10 rating system could be regarded as an advance. Morphine pumps were not available for those cancer patients I saw in the ’80s, even those in agonizing pain from cancer in their bones; doctors regarded pain as an inevitable part of disease. In the emergency room where I practiced in the early ’90s, prescribing even a few opioid pills was a hassle: It required asking the head nurse to unlock a special prescription pad and making a copy for the state agency that tracked prescribing patterns. Regulators (rightly) worried that handing out narcotics would lead to addiction. As a result, some patients in need of relief likely went without.

After pain doctors and opioid manufacturers campaigned for broader use of opioids — claiming that newer forms were not addictive, or much less so than previous incarnations — prescribing the drugs became far easier and were promoted for all kinds of pain, whether from knee arthritis or back problems. As a young doctor joining the “pain revolution,” I probably asked patients thousands of times to rate their pain on a scale of zero to 10 and wrote many scripts each week for pain medication, as monitoring “the fifth vital sign” quickly became routine in the medical system. In time, a zero-to-10 pain measurement became a necessary box to fill in electronic medical records. The Joint Commission on the Accreditation of Healthcare Organizations made regularly assessing pain a prerequisite for medical centers receiving federal health care dollars. Medical groups added treatment of pain to their list of patient rights, and satisfaction with pain treatment became a component of post-visit patient surveys. (A poor showing could mean lower reimbursement from some insurers.)

But this approach to pain management had clear drawbacks. Studies accumulated showing that measuring patients’ pain didn’t result in better pain control. Doctors showed little interest in or didn’t know how to respond to the recorded answer. And patients’ satisfaction with their doctors’ discussion of pain didn’t necessarily mean they got adequate treatment. At the same time, the drugs were fueling the growing opioid epidemic. Research showed that an estimated 3% to 19% of people who received a prescription for pain medication from a doctor developed an addiction.

Doctors who wanted to treat pain had few other options, though. “We had a good sense that these drugs weren’t the only way to manage pain,” Linda Porter, director of the National Institutes of Health’s Office of Pain Policy and Planning, told me. “But we didn’t have a good understanding of the complexity or alternatives.” The enthusiasm for narcotics left many varietals of pain underexplored and undertreated for years. Only in 2018, a year when nearly 50,000 Americans died of an overdose, did Congress start funding a program — the Early Phase Pain Investigation Clinical Network, or EPPIC-Net — designed to explore types of pain and find better solutions. The network connects specialists at 12 academic specialized clinical centers and is meant to jump-start new research in the field and find bespoke solutions for different kinds of pain.

A zero-to-10 scale may make sense in certain situations, such as when a nurse uses it to adjust a medication dose for a patient hospitalized after surgery or an accident. And researchers and pain specialists have tried to create better rating tools — dozens, in fact, none of which was adequate to capture pain’s complexity, a European panel of experts concluded. The Veterans Health Administration, for instance, created one that had supplemental questions and visual prompts: A rating of 5 correlated with a frown and a pain level that “interrupts some activities.” The survey took much longer to administer and produced results that were no better than the zero-to-10 system. By the 2010s, many medical organizations, including the American Medical Association and the American Academy of Family Physicians, were rejecting not just the zero-to-10 scale but the entire notion that pain could be meaningfully self-reported numerically by a patient.

In the years that opioids had dominated pain remedies, a few drugs — such as gabapentin and pregabalin for neuropathy, and lidocaine patches and creams for musculoskeletal aches — had become available. “There was a growing awareness of the incredible complexity of pain — that you would have to find the right drugs for the right patients,” Rebecca Hommer, EPPIC-Net’s interim director, told me. Researchers are now looking for biomarkers associated with different kinds of pain so that drug studies can use more objective measures to assess the medications’ effect. A better understanding of the neural pathways and neurotransmitters that create different types of pain could also help researchers design drugs to interrupt and tame them.

Any treatments that come out of this research are unlikely to be blockbusters like opioids; by design, they will be useful to fewer people. That also makes them less appealing prospects to drug companies. So EPPIC-Net is helping small drug companies, academics, and even individual doctors design and conduct early-stage trials to test the safety and efficacy of promising pain-taming molecules. That information will be handed over to drug manufacturers for late-stage trials, all with the aim of getting new drugs approved by the FDA more quickly.

The first EPPIC-Net trials are just getting underway. Finding better treatments will be no easy task, because the nervous system is a largely unexplored universe of molecules, cells, and electronic connections that interact in countless ways. The 2021 Nobel Prize in Physiology or Medicine went to scientists who discovered the mechanisms that allow us to feel the most basic sensations: cold and hot. In comparison, pain is a hydra. A simple number might feel definitive. But it’s not helping anyone make the pain go away.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

Subscribe to KFF Health News’ free Morning Briefing.