This Black-owned birth center just welcomed its first baby as Alabama threatens to shut it down

Keonta Battle didn’t know her baby girl was going to make history.

When Battle was pregnant, she and her husband decided this new baby would be their fourth and final child, a little girl named Peyton who would join three older brothers to complete their family. Keonta even had pink t-shirts made for herself, her husband and their sons that announced this birth was their “last rodeo.”

But the Battle family’s last rodeo was also a first for Alabama: In October, Peyton Battle became the state’s first baby born in a freestanding birth center.

Keonta delivered Peyton with the help of midwives at the brand-new Oasis Family Birthing Center in Birmingham, Ala. It’s one of the first birth centers to open in a state that only recently legalized out-of-hospital midwifery care.

What Keonta didn’t know at the time was that her choice of a birth center sits at the center of a growing statewide fight over how and where people can safely give birth.

This summer, as Oasis prepared to open its doors, the Alabama Department of Public Health quietly proposed a set of birth center regulations that would prevent licensed professional midwives like the one who delivered Peyton from working in Alabama birth centers. The regulations are still under consideration by the State Board of Health, which is set to issue a revised version in the coming weeks.

The proposed regulations have drawn public outcry from midwives, physicians, nurses and birth advocates around the state, who say the proposed rules are so needlessly stringent that they would jeopardize the three birth centers currently open or in development around the state, including Oasis. They would also prevent certified professional midwives, like the one who delivered baby Peyton, from working in birth centers.

Regulations are a good thing, said Dr. Heather Skanes, the OBGYN who founded Oasis. Their purpose is to ensure a safe environment for birthing people and their babies, like Keonta and Peyton.

But Alabama’s regulations as they’re currently written would harm the people they’re ostensibly supposed to help, she said. Skanes knows Alabama’s grim statistics: Alabama has among the highest rates of maternal death and infant death of all states. For women of color, the outcomes are worse. Nationally, Black women are three times more likely and Native American women are twice as likely as white women to die from a pregnancy-related cause. Statistics like those drive Skanes, a young Black physician who recently moved back to her hometown of Birmingham with the goal of improving access to reproductive care for communities of color.

To Skanes, freestanding birth centers staffed with midwives aren’t a problem; they’re a solution.

“Women of color deserve equal access to midwifery care,” she said, “and Alabama needs better outcomes.”

The OBGYN & the midwife

Skanes opened Oasis Women’s Health in June of last year on Tuscaloosa Avenue, in Birmingham’s historic and majority-Black West End neighborhood. She set up her practice there specifically to address racial disparities in birth and reproductive care.

“It’s important in medicine for people of color to not be the ‘other,’” she said. “I had a patient who came into the office and who said she loved coming here because she felt validated as a person, because the space is curated for someone like her as a person of color.”

While Skanes has detailed five- and 10-year plans for Oasis Women’s Health, one of her first goals was to open an adjacent midwife-run birth center. When she was a medical resident at Morehouse School of Medicine, part of the OBGYN training included working with midwives.

“Being able to see the differences between what the obstetricians were doing and what the midwives were doing showed me (midwifery) is a good option for some people,” she said. “We have evidence that midwifery care works. So if physicians aren’t willing to go with the evidence, (patients) are going to go to (providers) who will.”

In Birmingham, Skanes connected with Jo Crawford, a certified professional midwife who worked in Tennessee and Virginia before moving with her family to Alabama in 2019. Crawford said she was drawn to Skanes because Skanes wanted to open a midwife-run birth center focused on serving communities that Crawford also wanted to serve: those who wanted out-of-hospital births but lacked access or the financial resources to choose that option.

Crawford said when she began practicing in Alabama, she saw a wide disparity between the families that wanted midwifery care and the ones that could actually afford it.

“I quickly realized there was a demographic that was not being served and didn’t have the option for out-of-hospital birth,” said Crawford. Prenatal, birth and postpartum care from a certified professional midwife can cost $5,000-$6,000 out of pocket. In Alabama, it’s not covered by Medicaid nor by most private insurance.

In 2020, she’d renovated the basement of her home into a birthing suite, where she and the two student midwives apprenticing with her offered their midwifery services on a sliding fee scale. It was a solution to the affordability problem, but it wasn’t easily scalable, she said. A midwife in solo practice can only attend a few home births in a year. Plus, the state’s lack of regulations for non-hospital birthing centers had created a legal gray area around anything other than a birth at the client’s home: “I caused a bit of a stir with my basement birth suite,” she said.

A birth center is born

Skanes hired Crawford full-time as the Oasis birth center’s midwifery director. They hired another midwife on a part-time basis, and Crawford supervises two student midwives, including Charity LaRae, who delivered Keonta Battle’s daughter Peyton.

They hope to soon hire a certified nurse-midwife to add another level of care to their center. With midwives running operations at the birth center, said Skanes, she can dedicate her time to her high-risk patients, while serving as backup care for the low-risk midwifery clients.

She also sees her role at the birth center as primarily a fundraiser: Earlier this year, Oasis won a $100,000 grant from Magic City Match, a Birmingham-based grant program that supports Black small business owners. Skanes brought home first place out of more than 800 Black business owners who applied. She’s secured two other grants, including a 2022 fellowship from entrepreneurial funding organization Echoing Green. She plans to direct the funding toward renovating and adding on to the birth center so that it can handle more clients.

The state steps in

When Skanes first read the state’s proposed birth center regulations earlier this summer, her heart sank.

“It was discouraging,” Skanes said. “I was like, how are we going to be able to do all of this?”

The regulations are still under consideration by the State Board of Health. During a public hearing earlier this fall, many of the midwives, doctors and nurses who spoke against the regulations say that some of the requirements – such as hospital-grade building specifications or strict requirements for physicians – would make it nearly impossible for any entity other than a hospital to open a birth center.

But one of the biggest issues is that the regulations don’t mention certified professional midwives (CPMs) at all, even though the state recognizes them and licenses them to work “in any setting except a hospital.” A spokesperson for the health department told Reckon that a birth center is considered a “hospital” under state law, which would prohibit CPMs from working in one. It’s a legal interpretation that Crawford and others have questioned.

But it would mean Crawford, a licensed CPM, could no longer work at Oasis. Her plans for hiring and apprenticing more certified professional midwives would be finished, too.

It just doesn’t make sense to cut CPMs out of Alabama’s fledgling birth center industry, she said.

“The only people who would be allowed to run birth centers are the ones with no experience in out-of-hospital birth,” Crawford said. Alabama’s proposed regulations differ from those in states like Tennessee and Texas, and countries like Britain, where licensed professional midwives are allowed to lead and work in birth centers.

Skanes said the regulations, as they’re currently written, dismantle the type of collaborative environment that she and Crawford are working to build, where certified professional midwives, certified nurse-midwives and physicians work together to provide varying levels of care for birthing people. It’s a model she said has demonstrated positive outcomes for pregnant people and their babies.

Skanes was already planning to pursue national accreditation for her birth center through the Commission for Accreditation of Birth Centers. She’d like to see the health department use the CABC’s national standards to license birth centers, rather than the regulations currently under consideration.

The health department is working on a revised set of regulations, according to a department spokesperson, who declined to give details about changes. Once those are finalized, they’ll be made available online and the public will be able to submit comments before the board’s leadership votes on them.

Until a final set of regulations are approved, Crawford and Skanes said they’ll keep moving forward with their plans for growing the birth center.

“This is a calling to help people here, so if we’re going to take that faith walk, we have to keep going and take things as they come,” Skanes said. “So we decided to continue.”

‘It’s worth the effort’

Skanes’ main focus is making the birth center self-sufficient within a year. If the interest continues, she plans to build out the birth center space to accommodate more births and offer more services to more deeply integrate Oasis into the community it serves.

“We want to add on breastfeeding classes, child safety classes and other (ways) the community benefits from the center, outside of birth.”

When Oasis shared a post on Facebook celebrating Peyton’s midwife-attended birth in October, patients and prospective clients flooded the clinic’s phone lines, email inbox and social media channels with questions about the birth center. Some said it was the option they’d been looking for, said Skanes. Others said they’d thought out-of-hospital birth was illegal in Alabama.

The Oasis staff is offering informational sessions to help people understand what an out-of-hospital birth involves and what kind of pregnancies are eligible. Midwifery care and out-of-hospital births are only appropriate for low-risk pregnancies that meet certain qualifications, Skanes said. The process for determining who is a good candidate for midwifery care or a birth center birth “is very stringent,” she said. “You have to meet certain criteria based on evidence, and we expect a certain level of commitment from the patients, to be compliant with their diet, physical activity, their appointments. Those types of things help us to know who’s going to be a good candidate.”

She’s also working on creating a nonprofit arm of Oasis that will help the center offer services to more under resourced families and to support training more midwives of color.

“If you look at which students aren’t able to find a preceptor (a midwife to train under), it’s more likely to be a student of color,” said Skanes. “We can’t even the playing field for those who give birth if we don’t even it for the providers.”

Ultimately, she wants to show the public and the medical community that her birth center model could not only improve birth outcomes, but could be replicated elsewhere in Alabama:

“When we’re able to collect our data, we hope to show not only is this possible, but it’s worth the effort.”

This story was published with support from The Solutions Journalism Network through its Health Equity Initiative.