RIDGWAY, CO – Heather Toth struggles to remember everything that happened that May morning in 2015 when she first rode in a police car from Ridgway to Montrose, Colorado. But she remembers sitting in the back seat, alone and humiliated, as law enforcement carted her away from home, away from the people who cared about her.

The trip itself takes over 30 minutes from Ridgway, and even farther from Ouray, the other municipality in rural Ouray County. From unincorporated parts of the county, it can be even longer. While a daytime drive to and from Montrose can promise beautiful views of the mountain, the same trip up the unlit U.S. Highway 550 can be dangerous in inclement weather and deadly during a winter snowstorm.

But Toth had little choice.

The rest of the day was a blur as strangers tried to gather evidence from the night before. They were professional but it felt cold and strange. In a chilly, sterile-smelling room, she couldn’t call a friend to comfort her or bring her a snack or a change of clothes.

Toth didn’t commit any crime that night. She was the evidence, a survivor of sexual assault about to undergo another difficult experience.

Her police car ride to Montrose Regional Hospital piled on the complicated mix of emotions she experienced on her way to the sexual assault forensic exam. While she wasn’t handcuffed for the ride, she couldn’t shake the feeling that maybe she was the one who did something wrong.

“You already feel ashamed because, you know, society tells you it’s your fault when you’re sexually assaulted,” she said, sitting at a table in her Ouray-based cafe Mojo’s Coffee, Chai and Teas. “And now you have people in the medical field who are removing pubic hairs from your body, and are taking pictures and video, and sticking things inside of you and giving you medication.”

Time is of the essence for survivors seeking exams, commonly referred to as “rape kits.” Survivors must be seen as quickly as they can to preserve possible evidence. They’re also advised to avoid showering, eating, drinking, changing clothes and brushing teeth before the exam.

In Ouray County, survivors must also drive half an hour or more to obtain exams. Like more than half of Colorado counties, Ouray doesn’t have a trained sexual assault nurse examiner (SANE) or forensic examiner (non-nurse exam provider, known as SAFE). Local officials, prompted by advocacy groups, have been seeking a solution since last summer.

But this isn’t only a local issue — the shortage of exam providers is nationwide. There is no database of SANEs and SAFEs in the U.S., but International Association of Forensic Nurses’ (IAFN) Chief Operating Officer Megan Lechner estimated that 20 to 25% of hospitals have a provider. In Ouray County, one of many rural places without a single hospital, the availability of those trained to perform exams is even scarcer. There is a disparity between urban and rural communities across the country, according to Lechner. However, without a national database it is difficult to pinpoint exactly how severe that divide is.

Even when nurses are available, arranging the exams isn’t always easy.

“Many hospitals across the nation expect staff nurses (especially ED [Emergency Department] RNs) to incorporate this care into their normal shiftload, and I have met nurses who have said that they were simply handed an evidence collection kit and expected to ‘figure it out’ when a patient presented after a sexual assault,” Colorado SANE/SAFE Project Director Sarah Hagedorn said via email.

In Colorado, the 64-hour training to become a provider is free through UCHealth. According to Hagedorn, the program has tried to support rural communities by offering tele-SANE services in areas like Montrose, which allow local providers to conduct exams while on call with a more experienced professional.

The first solution Ouray County considered was advocating for statewide legislation allowing direct-entry midwives – professionals who already live in rural areas who are accustomed to being on call 24/7 with experience in obstetrics, gynecology and trauma-informed care – to become providers. However, trying to expand the practice of these providers, even to offer a service so many communities lack, hit a wall in part due to reluctance from the IAFN to allow them to earn certification.

Meet the midwives

Local advocates first proposed allowing midwives in Ouray County to perform exams, recognizing the unmet need for a provider.

Jaime Doty, founder of San Juan Midwifery in Ridgway, tried to get UCHealth training two years ago at the request of the Victim Advocate Support Alliance. The program required participants to be advanced practice providers or nurses, and with a master’s degree in midwifery and her own practice, she figured she’d qualify.

She didn’t. One reason is Doty is what’s considered a ‘direct-entry midwife.’ She trained specifically for midwifery instead of getting a nursing degree first, and she’s not licensed for nursing in Colorado. Despite state and nationally regulated training, they are “registered” healthcare providers, a compromise that ended a century-long battle and still impacts their practice today. For example, many insurance companies will only partner with licensed providers, making home birth difficult to afford for many Centennial State mothers, said Durango-based midwife and naturopathic doctor Joy Frazer.

Nationally, direct-entry midwifery programs are accredited by the Midwifery Education and Accreditation Council. Providers can become certified through the North American Registry of Midwives by completing an accredited program and test, applying with existing nurse midwife or U.K. certification or by undergoing an evaluation process and test if they didn’t attend an accredited program.

“The truth of women’s health is that midwives were purposefully, intentionally pushed out of the healthcare system, and that’s specific to the United States,” Doty said.

The exams

Doty knew, if she was allowed to take on the role of providing exams to Ouray County, that it would be a big commitment requiring her to be on call 24/7. But after years of working with women, providing trauma-informed care, and developing an understanding of the unique challenges of rural healthcare, she was prepared for the responsibility.

According to Toth, the exam itself is another ordeal for survivors. And whoever the provider may be, compassion in addition to professionalism and knowledge is crucial.

At Montrose Regional Health, patients are usually screened by a physician for signs of physical injuries, especially those that may need immediate attention, before the forensic exam begins.

Then they undress in a private room; even their clothes may be collected for evidence. Over the next several hours of evidence collection follow, as providers check vital signs, evaluate and photograph signs of injury, swab areas that may have been touched for semen or saliva and conduct internal and genital exams that include taking pictures with a special camera. Patients are also offered emergency contraception and treatment aimed at preventing disease.

Jennifer Eckerman, Montrose Regional Health’s Family Center director and SANE/Sexual Assault Response Team coordinator for Colorado’s 7th Judicial District, said because human bodies are designed for sexual activity, sexual assault isn’t always accompanied by injuries — and that doesn’t make a survivor’s experience any less valid.

According to Eckerman, each step is taken with consent and aims to give patients closure and autonomy. If they wish, patients can have a victim advocate present.

For Toth, the ordeal took six hours. A victim advocate was there for her, but Toth only realized this months later when the woman told her she’d been at the appointment.

“I wish you could see the photos that they took of me. My face is empty. It was brutal,” she said. Undergoing the exam in Montrose, in a neighboring county, pulled Toth out of her comfort zone at a time when she was already undergoing a trauma so severe it impacted her short term memory.

“I was in such shock that I don’t remember a whole lot except that I didn’t want to be there. It’s a different experience to be in the hospital when you’re sick and people are caring for you. versus being in the hospital when somebody is using your body as evidence,” she said.

A century-long struggle for acceptance

The fight for the recognition of midwifery goes back at least 100 years, though midwives have been around much longer.

“Midwifery is the way people have dealt with the conundrum of birth forever,” said Indra Lusero, director of birthing justice advocacy group Elephant Circle, who uses they/them pronouns.

But in the late 1800s and early 1900s, as Colorado became a state and the medical industry began to rise, things started changing. In the first decades of the 1900s, Colorado began licensing professionals including midwives.

Largely male, almost entirely white doctors had other ideas. Around the 1920s, a national campaign against midwives picked up steam, and birth became medicalized. Obstetricians pushed against the idea that women, particularly women of color, could do their job. At the time, Black women around the country had cared for pregnant people of all races for decades, while Indigenous and minority communities also commonly used midwives.

Colorado stopped licensing midwives in the 1940s, though already-licensed professionals could still practice. By the mid 1950s, over 90% of births in the U.S. took place in hospitals, though for nonwhite populations this rate was closer to 65%, according to the Journal of the American Medical Association.

But in the late 1900s, old ways re-emerged. Nurse midwifery sprang up, though nurse midwives still operated mostly in hospitals. In the late 1900s traditional midwives, branded as “direct-entry,” began pushing for their right to practice. Colorado again recognized the field in 1993, and it took around a decade to get there. But midwives didn’t get to be licensed providers, with the privileges that term comes with. Instead they had to settle for a new label: “registered.”

The idea to lessen shortage

The first avenue Ouray County Commissioner Jake Niece explored toward getting a certified sexual assault exam provider in Ouray County was proposing a legislative initiative to Colorado Counties Incorporated. The organization includes representatives from 60 counties and picks priorities to lobby for each year to the state legislature. The goal was simple: change the word ”registered” in state statute to “licensed” regarding direct-entry midwives, with the intention of qualifying them for UCHealth SAFE training for licensed professionals.

The proposal didn’t go as planned, and commissioners scrapped it after realizing they were facing an uphill battle. According to Lechner, the IAFN, the only organization in the country that certifies SAFEs, wouldn’t let a direct-entry midwife sit for the exam, licensed or not. Niece said in a September meeting that if the group won’t budge, trying to push through legislation requiring UCHealth to train midwives could cause the IAFN to stop supporting the training program entirely, potentially jeopardizing the legitimacy of its training and certification.

More than six months later, Niece said Ouray County still doesn’t have a provider, and it’s not only because of the pushback to this particular initiative. The county doesn’t have any medical facilities that are willing and able to host this kind of professional, who needs to be on call and granted access 24/7. And, Niece explained, another challenge is that forensic exams sometimes must be accompanied by screenings and treatments from physicians on-site, something the county’s facilities aren’t equipped to offer.

“The sad reality (is) that sexual assault is sometimes paired with violent physical assault where a patient requires more than a SANE/SAFE exam, but a full body examination that may include treatment of injuries in a hospital,” he said in an email.

Though Colorado is now about halfway through its legislative session, and Lusero still believes midwives could be capable providers, Lusero said that particular idea is dead in the water. At least for now, this won’t be the year direct-entry midwives become licensed by the state.

According to Lusero, the dynamic between the state and IAFN creates a complex situation.

“In the whole ecology of healthcare we have states which license providers, then we have private organizations that provide credentials. A lot of statebased requirements are tied to those organizations which makes it complicated,” they said.

If the IAFN has a monopoly on training and exams, denying direct-entry midwives training could potentially violate antitrust laws, they added. Elephant Circle will continue to push for the rights of midwives.

Lechner voiced concern regarding direct-entry midwives’ ability to conduct exams, and believes their scope of care is limited to pregnant women. Practicing as a SANE requires nurses to operate at the height of their abilities, and allowing direct entry midwives to practice would undermine the certification process, she said.

Lusero disagreed. “So, the ‘bare minimum’ for this is a registered nurse, but direct-entry midwives have more training, hours and patient contact than a registered nurse so I would think they could do it,” they said.

Nurses can sit for the National Council Licensure Examination to become a registered nurse with two-year associate’s degrees. Direct-entry midwives typically take three to six years to complete training and must attend 30 births before they can practice.

These midwives receive training on female anatomy and care that is not specific to pregnancy. This includes training on caring for women’s health in general, not specific to pregnancy. This equips direct-entry midwives to perform well-woman checkups on patients who are not pregnant.

However, Hagedorn said not all survivors of sexual violence are women, and all patients deserve high-quality care.

Indeed, Doty doesn’t work with men and children. In Ouray County another provider, retired thoracic surgical oncologist Dr. Carolyn Dresler, volunteered to undergo SAFE training as well, planning to take early cases involving men and children.

But Dresler isn’t willing to become the county’s sole provider, especially with Doty waiting in the wings. “We have a perfectly situated person who can be trained in this and is willing to do it. And then we have a political inability to do that,” Dresler said.

Cascade provided a more critical evaluation of the situation.

“Carolyn is a thoracic surgeon who hasn’t done gynecology in God knows how long, but she can be a SANE provider,” she said. “But Jaime, who does gynecological stuff every day, can’t do it. That doesn’t make logical sense.

As for Toth, when asked how she would feel about Doty performing her forensic exam, she cracked a smile. Toth knows Doty— she’s a member of this small rural community. And as Toth would tell it, she’s humble, present and an amazing caregiver, one who Ouray County would be “eternally blessed” to have on call.

“Oh my God!” she said. “If Jaime had been the one to do my rape kit … I would have felt way more confident for sure.”