midwives, certified professional midwives, and physician’s assistants who practice full scope maternity care. (4) For purposes of this subsection, the term maternity care health professional shortage area means— (A) an area in an urban or rural area (which need not conform to the geographic boundaries of a political subdivision and which is a rational area for the delivery of health services) which the Secretary determines has a shortage of providers of maternity care health services including those referenced in paragraph (3) or an urban or rural area that the Secretary determines has lost a significant number of such providers during the 10-year period beginning with 2004 or has no obstetrical providers licensed to provide operative obstetrical services