Alabama wants to make birth centers harder to open. Midwives and birth workers are pushing back.

In August, a small band of midwives gathered beneath Montgomery, Ala.’s towering Mothers of Gynecology monument and a sky that threatened rain.

The monument’s three sculpted metal figures, reaching 15 feet tall, honor Anarcha, Lucy and Betsey, enslaved women who underwent painful gynecological surgeries in the 1840s at the hands of a white Alabama doctor, without consent or anesthesia.

The modern-day midwives and their supporters who’d gathered that afternoon – most of them Black, some white – stood quietly in the monument’s courtyard, ignoring the first drops of rain and soaking in the history, about a mile from the Alabama State Capitol.

They’d just come from a packed public hearing downtown. Several of them were among the nearly two dozen people who spoke against proposed state regulations that would prevent most Alabama midwives from working in a freestanding birth center.

For these women, this was a new fight with a familiar opponent.

The power to decide how they can practice rests with the state health board which is – by a weird Reconstruction-era law – entirely controlled by a private association of physicians. That association has historically and systematically opposed midwifery practice in Alabama.

The midwives’ speeches at the hearing marked the opening salvo in a battle brewing over reproductive choices in a state with limited options for reproductive care and some of the nation’s worst pregnancy outcomes: How birth centers should be run, and who gets to run them.

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Birth centers are an option for low-risk pregnant people that lies somewhere between home birth and hospital birth. In other states, they’re typically staffed by nurse-midwives or professional midwives. Alabama hasn’t had any birth centers – until this year.

At least three are currently in development around the state, all spearheaded by Black women. The state health department, which has no birth center regulations on the books, is rushing to put some in place before those centers begin delivering babies.

But the regulations proposed by the state’s physician-led board of health are so stringent they would likely keep all three birth centers from opening, say their owners.

For many of the midwives and birth advocates gathered at the monument that day, it feels like a repeat of history: Birth workers and Black obstetrical providers being systematically pushed out of a growing industry by a state-sanctioned, majority white medical establishment.

Alabama has only about 45 midwives working across the state. Roughly half are certified nurse-midwives and the other half are licensed professional midwives who attend home births. Most are white.

A century ago, Alabama had more than 3,000 lay midwives, most of them Black, delivering babies for Black and white women alike.

By the 1980s that number shrank to zero.

After decades of concerted, documented efforts by white physicians to persuade white women against birthing at home with Black midwives in favor of doctor-attended hospital births, the state effectively outlawed lay midwifery in 1976. Non-nurse midwives – common in other states – couldn’t legally practice again in Alabama until advocates won passage of a new law in 2017.

“Too often has Alabama found itself on the wrong side of history as it pertains to civil and women’s rights,” said Dr. Heather Skanes, an OBGYN and Alabama native who is Black and is building a birth center in Birmingham. “What (the health department is) proposing today puts us again on the wrong side.

“Our state recently said no to a woman’s ability to choose whether they want to continue a pregnancy, and now you are limiting their ability to choose their provider, their birth location and their model of care.”

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Stephanie Mitchell, the first Black professional midwife licensed in Alabama since the 1970s, is building a birth center in rural Sumter County. It’s a majority-Black, west Alabama county on the Mississippi state line where many residents live an hour’s drive from the nearest hospital with obstetrical services.

“I think regulations are a great thing,” said Mitchell. “The goal is to keep people safe. But if the regulations are too stringent, you run the risk of not ever being able to open.

“These antiquated rules, as written, eliminate the possibility of my birth center and these other birth centers in the state to operate.”

Mitchell was one of about 75 people – including nurse-midwives, professional midwives, OBGYNs, doulas, birth activists, media, and representatives from state agencies – who crowded into the conference room at the Montgomery offices of the Alabama Department of Public Health on Aug. 18 for the public hearing on the state’s proposed birth center regulations. Birth advocates lined the hallways outside, many with their babies and young children.

The hearing attracted attention from across the nation. The president of the American Association of Birth Centers flew in from Colorado, bringing members of her board with her. An epidemiologist traveled from Boston. A documentary film crew arrived from Los Angeles.

No one during the two-hour hearing spoke in favor of the proposed regulations. Many blasted the document’s “grossly outdated” medical terminology; the regulations are based on state regulations that were originally written in the late 1980s and later allowed to sunset because the state had no birth centers. Speakers cited examples like the use of the word “toxemia,” an outmoded term for the pregnancy complication now called preeclampsia. Some said requirements for written agreements with nearby hospitals would make birth centers unworkable in rural areas. Others said the strict building specifications would make it nearly impossible for any entity other than a hospital to open a birth center.

But the biggest point of contention: The regulations don’t mention professional midwives at all, even though the state recognizes and licenses them to work “in any setting except a hospital.”

“If adopted, these rules would effectively prohibit licensed midwives from starting or even working in any birth center in Alabama,” Noel Leithart, chair of the Alabama State Board of Midwifery, said during the hearing.

The proposed rules allow only a physician or a nurse-midwife who works with a physician to deliver babies in a birth center.

That contrasts with states like Tennessee and Texas, and countries like Britain, where licensed professional midwives are allowed to lead and work in birth centers.

To Leithart and others, the regulations would violate the 2017 state law that allows midwives to work outside of hospitals.

But the state health department doesn’t see it that way. An attorney for the Alabama Department of Public Health told Reckon that birth centers meet the state’s definition of a “hospital” and would therefore not be a place where professional midwives could deliver babies without a physician’s supervision.

That legal interpretation would deal a fatal blow to Mitchell’s birth center, The Birth Sanctuary at Gainesville. She worked as a certified nurse-midwife in her native Boston, but chose to become a licensed professional midwife when she moved to Alabama in 2020. That’s because Alabama doesn’t allow nurse-midwives to work independently from physicians.

She believed that getting credentialed as a professional midwife would allow her the freedom to open a midwife-led birth center in a region with few obstetric providers. Sumter County is designated as a maternity care desert by the March of Dimes, meaning it has no hospitals or birth centers providing obstetric care, no OBGYNs and no certified nurse-midwives. The health outcomes in Sumter are among the worst in a state that consistently ranks near or at the bottom in the nation in maternal and infant health measures.

“All of the statistics that you’ve seen for what occurs to people when they are pregnant in this state belong to a system that’s already in place,” Mitchell said.

“We have maternity care deserts in Alabama where women have to drive two hours to access care,” said Sheila Lopez, a nurse-midwife who works in Birmingham and is president of the Alabama affiliate of the American College of Nurse-Midwives. “A large portion of counties in our state have no obstetrical provider.”

In shutting professional midwives out of birth centers and limiting the practice of nurse-midwives, Lopez said, Alabama is “missing an entire workforce of proven, safe, evidence-based obstetric care providers” for low-risk pregnancies. A federal study released in 2020 from the Centers for Medicare & Medicaid Services found that low-risk women who birthed in birth centers had fewer infant emergency department visits, fewer c-sections, and their babies had lower rates of preterm birth.

She believes Alabama’s reluctance to support midwifery care is rooted, at least in part, in historically racist attitudes toward its Black midwives.

“Because that (attitude) keeps getting passed down, there’s this great misunderstanding of what midwives do, what they’re capable of, what their outcomes are” when they’re fully integrated into the healthcare landscape of a region, she said.

“We’re just ignoring that there is a way to help fix (Alabama’s poor maternal outcomes) by integrating midwives into the system, all because we’re scared of the word ‘midwife.’”

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The fate of the birth center regulations lies in the hands of the 16-member committee that governs all Alabama public health matters, from rabies control to hospital licensing.

And this is where Alabama is unique to all other states, and where critics take issue:

That committee represents the larger State Board of Health which is – by state law – composed of all 7,000 members of the Medical Association of the State of Alabama (MASA), a private professional organization of Alabama physicians.

“It is a private, dues-paying club in total charge of a state agency,” said State Sen. Jim McClendon, who chairs the Alabama Senate’s Healthcare Committee and has butted heads legislatively with the medical association. Last year McClendon tried to pass a bill that would have restructured the State Board of Health and other public health leadership to curtail MASA’s control. His bill failed.

Alabama’s got an unusual setup. Dr. Jeffrey Levi, professor of health management policy at the Milken Institute School of Public Health at George Washington University, said he knows of no other states “where a governmental function is essentially turned over to a private interest group.

“To my knowledge, Alabama is the only state where the state medical society is actually the board of health.”

Mark Jackson, MASA’s longtime executive director, said there’s no issue because the MASA board members keep their dual roles separate.

“When there is association business, we deal with that at the association. When there’s public health business, that is dealt with and talked about at the Department of Public Health,” he said.

But the birth center regulations illustrate the potential conflict of interest, some advocates say.

For more than a decade, MASA led medical groups around the state to fight against legislation that would allow professional midwives to legally practice in Alabama. Midwifery advocates eventually found enough champions in the state legislature to get a legalization law passed in 2017. In the years since, MASA has continued to lobby against any legislation that would expand midwives’ scope of practice. The association has done the same to other healthcare professions, successfully killing bills that would have benefitted podiatrists, optometrists, physical therapists and nurse practitioners, among others.

“It’s notorious,” said McClendon, “the number of these smaller provider groups that come forward (with a bill) only to be squelched by the lobbying power of MASA. They want to be the authority over every other profession that deals with healthcare. Legislatively, they’re managing to pull it off.”

MASA’s own governing board members get to take 12 of the 16 spots on the state public health committee, the group that will vote on the birth center regulations. The remaining four committee seats come from other state councils and include a dentist and a veterinarian.

None of the midwives or other stakeholders who spoke with Reckon said they’d been contacted by the committee for input before the proposed regulations were published.

A representative from the state health committee declined to comment for this story.

Jackson acknowledged MASA’s longtime opposition to certified professional midwives: “We’ve had concerns with the level of training and education that the certified midwife has versus the level of training a physician has, or even a nurse-midwife has. There’s no secret that we have discussed those concerns over the years.”

Still, he said, he believes MASA’s state health committee members will review the birth center regulations “not from a medical association perspective but from a public health perspective.” He pointed out that the regulations will also need final approval from a licensure advisory board, which includes members appointed by MASA and a few other organizations, like the Alabama Hospital Association.

In the coming weeks, the committee will review all public comments that were submitted at the hearing or in writing, then decide whether to revise the regulations or adopt them.

“We need collaborative discussions, a coming together of Alabama licensed maternity, birth, newborn providers and community to create rules and regulations that meet (current national standards) for a birth center,” Nancy Megginson, a certified professional midwife who works in North Alabama, said during the hearing.

The committee isn’t expected to make a decision until its September or October meeting.

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Most of the women gathered around the Mothers of Gynecology monument on that August afternoon hadn’t met each other before the hearing. Many belong to midwife and birth advocacy groups that tend to stay in their own lanes, pursuing their own policy agendas. Some have preferred to work behind the scenes, not wanting to rock too many boats.

But the atmosphere felt different this time.

The state’s attempt to cut midwives out of birth centers has united groups and individuals from across the maternal health spectrum in Alabama and beyond: obstetricians, nurse-midwives, home birth midwives, academics, advocates and consumers.

As the rain fell and they finally departed the monument to catch flights and car rides back home, they left with new business cards exchanged, phone numbers shared, alliances formed.

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