Midwifery grows in Alabama amid maternal health challenges

Kate Petty, a 41-year-old mother, has had two hospital births and two home births after that.

In her second hospital birth, her newborn baby, Eliza, passed away just a few hours after being born.

She didn’t understand how that happened to Eliza when her pregnancy was without complications up to that point – what she called a textbook and picture-perfect pregnancy. But after 18 hours of labor and feeling like she was coerced into taking more labor drugs than she wanted, she was determined not to have another hospital birth.

“It was hell,” said Petty, 41. “I repeatedly told them that I was dying. And they just kept acting like I was being a drama queen. When I mean – looking back – I was completely telling the truth. Nobody was listening.”

Options for women who prefer a more natural form of delivering a baby now include home births and birth centers. These practices have recently grown in popularity after Alabama in 2017 lifted a four-decade ban on midwifery and passed a law regulating and allowing midwives to practice in the state. 

The Alabama Department of Public Health (ADPH) recently proposed rules to govern birth centers, often looked as an in-between option for mothers not completely comfortable with home births or the medical setting of a hospital. There are three birth centers in the state.

The public comment period for the proposed rules ended on Aug. 4. The timeline to finalize these rules is unclear.

The proposed rules would require birth centers to have oversight by a physician or medical director. It would also require them to be within 30 minutes of a hospital with OB-GYN services. Midwifery advocates say that could make it harder to open and operate birth centers, since requiring a birth center to be near a hospital with OB-GYN services could make it difficult to provide midwifery services for low-risk pregnancies across the state, especially in rural areas.

And in rural areas, maternal care is increasingly hard to come by. An ADPH analysis concluded that 16 of the 54 counties considered rural had hospitals providing OB-GYN services in 2019. That number decreased from 1980, where only 10 rural counties did not have a hospital providing OB-GYN services.

Only 21 counties are considered to have access to maternity care, according to the March of Dimes. The remaining counties are considered to be either a maternity care desert or have low access to care.

Midwives

A midwife is a healthcare professional who collaborates with women to provide support, care and guidance throughout pregnancy, childbirth and the postpartum phase.

The midwife assumes a significant role in health consultation and education. It encompasses prenatal education and preparing for parenthood, and can include women’s health, sexual and reproductive health, and childcare.

Midwife care is specifically for low-risk births, and midwives are trained to assess when medical intervention from a physician is required. For high-risk pregnancies, a midwife would counsel the patient for going to an OB-GYN, but most transfers to a hospital from birthing centers do not occur because of emergencies.

There are about 22 licensed CPMs in Alabama. These midwives were responsible for just under 320 out-of-hospital births in 2022. That has more than tripled since 2019, when under 100 births occurred out-of-hospital, according to Noel Leithart, chair of the Alabama State Board of Midwifery.

In 2022, Reckon News reported that about 50% of midwives are certified nurse-midwives, while the remaining 50% are licensed professional midwives who primarily assist with home births. Most of these midwives are white.

Danne Howard, deputy director for the Alabama Hospital Association, said that it’s important that the mother is close to a hospital with OB-GYN services during delivery. Even with low-risk pregnancies, things can “happen at the turn of the dime,” she said.

“When there is an emergency, which can happen without any notice at all in delivering a baby, it will be important and paramount for the safety and well-being of the mother and the baby, that a provider such as a birthing center be within a certain amount of time from a hospital that has obstetrical and neonatal services,” Howard said.

A slow return

From the time of the colonial era until the Great Depression, a significant share of births in the United States were attended by midwives. In the colonial period, the process of giving birth was seen more as a communal or social occasion rather than a medical occurrence, according to a 2004 historical and legal analysis from Stacey Tovino, then a professor at University of Nevada Las Vegas, now based at the University of Oklahoma School of Law.

Around one hundred years ago, Alabama boasted over 3,000 lay midwives, with the majority being Black. These midwives provided childbirth services to both Black and white women.

But as time progressed, the number of midwives sharply declined. 

In the 1940s, Tovino wrote, white doctors in Alabama initiated targeted efforts aimed at convincing white women to avoid having Black midwives attend their births. In 1976 the state acted to essentially prohibit lay midwifery after the Legislature passed a law that ended the legal practice of lay midwifery. Within five years, there were virtually no lay midwives practicing in the state.

It was only in 2017, after advocates successfully pushed for a new law, that non-nurse midwives, or certified professional midwives – a practice common in other states, were allowed to legally practice in Alabama.

The Newborn Screening Test Challenge

Despite the changes, midwives still face restrictions on their practice.

Newborn screening aims to identify illnesses that may impact a child’s health or life in the long run. According to ADPH guidance, the first screening should be done between 24-48 hours after birth, typically when a new mother is under the care of a midwife.

By detecting these conditions early on, it becomes possible to prevent potential fatalities or disabilities, allowing children to fully develop and thrive.

In the United States, millions of infants undergo routine screening each year. The test involves a few drops of blood from their heel, done similarly to pricking the finger for a diabetes blood test, to test for specific genetic, endocrine, and metabolic disorders. These screenings also include assessments for hearing loss and critical congenital heart defects (CCHDs) before the babies are discharged.

Alabama allows a birth attendant to administer these tests if a physician is not present but does not allow midwives to buy them in-state, limiting their ability to conduct the tests.

Wes Stubblefield, the district medical officer at ADPH, cited a department rule saying that “the licensed midwife shall instruct the client regarding requirements of the newborn health screening by the Department of Public Health and they should order those tests in any rule by the State Board of Health.”

He said that neither the rules or regulations explicitly say that a licensed midwife is authorized to administer the newborn screening tests.

When Petty delivered her fourth baby by home birth, she called her pediatrician’s office, but was told that they don’t do newborn screening in the office. The pediatrician suggested she go to a hospital to get the screening test.

Petty said no.

“I don’t go there,” she said. “I don’t go to that hospital. You know, that’s the last place in the world I want to be. It’s too traumatizing.”

By the time she got an in-person appointment, she asked about the screening again. The pediatrician told her that there was no longer a use in getting the test done because any disorder would have presented itself.

Stephanie Mitchell, a nurse-midwife based in Gainesville, said that because of her training as a nurse practitioner, she is qualified to perform these screenings and will continue to do so.

On top of being a certified professional and nurse midwife, Mitchell also has a Doctor of Nursing Practice.

She contracts with a lab in Mississippi, which allows midwives to purchase the screening. Mitchell then ships the tests back to the lab in Mississippi for analysis.

“If you’re out here delivering babies, surely you can do a heel prick. I’m not going to pay any attention. I’m going to just do my work,” she said.

Limited Access

Those opting for home birth generally pay out of pocket. In Alabama, Medicaid and private insurance do not cover home births, and the price can range from $4,000 to $7,000.

To keep Eliza’s memory alive, Petty established Eliza’s Legacy Alabama, a non-profit that provides low-income families with financial support for home births.

E-Licia Herndon from Tuskegee, whose recent home birth was partially funded by Eliza’s Legacy, said that she qualified for Medicaid and could have birthed her baby in the hospital for free.  But she didn’t want to take that chance as a new Black mother.

She heard the statistics too often: Black mothers and newborn babies have some of the highest mortality rates in the country. In the South, and particularly Alabama, the situation is particularly grim: among white Alabamians, infant mortality was 5.8 per 1,000 live births in 2021. Among Black Alabamians, it was 12.1 per 1,000.

A 2020 ADPH report that reviewed 80 maternal deaths in Alabama, more than 55% of the deaths were preventable.

“If you are Black, poor and in the South, you have the highest risk factors, as far as socioeconomic and social determinants,” Herndon said. “We are unfortunately the highest to die in childbirth.”

She developed a close relationship with her midwife, who would check in on her and keep her accountable if she didn’t take her supplements or needed to follow a better diet. At one point, they even had a food journal.

“It’s just different when someone comes to your home, sits on your bed, on your couch, is making themselves comfortable — I mean offering tea at times, and that in itself just brings a different comfort, a different type of trust, a different type of relationship,” Herndon said.

Looking back, she is confident she made the right decision, and she “would not trade it for the world.”

Mitchell said that Herndon’s experience is not unlike other Black women. She said that in a place like Alabama, where maternal health tends to be at the “bottom of the bottom” and where black mothers are at a higher risk of mortality, it is not a surprise to see more Black women opting for these services.

“That puts people in an automatic situation of ‘what are my alternatives to opt out of the current narrative, which places my Black body at an additional risk,’” Mitchell said, who is Black. “So you’re going to always see Black people showing up for this because we want to be safe. We want our outcomes to match everybody else’s outcomes,” Mitchell said.

When she was pregnant a third time, Petty was determined to have a homebirth after her traumatic experience with Eliza. At the time, midwifery was not legal or regulated in the state of Alabama, so her options were limited in state.

She found a midwife in Georgia through a friend, and because the midwife couldn’t come to her, Herndon asked the midwife she would meet them over the state line if they bought a camper. The midwife said, “yes.”

So Petty said that they lived on a “pencil-thin budget” at the time to make that happen. They financed a used camper with her mom’s signature as a co-signer.

“But one way or another, I was going to do it,” she said.

So they named the camper the “Baby Wagon” and met a midwife on the Alabama-Georgia, where she birthed her third child.

“I can’t tell you how much healing happened in that camper in the hours that we spent in it,” Petty said. “After his birth, I think that I had the mentality of ‘okay, I can’t wait to do this again.’”