By CAROLINE BECK, Alabama Daily News
MONTGOMERY, Ala. – Midwives can now practice in the state of Alabama, but they say there is still work to be done to fully support their work and help ensure mothers have access to safe out-of-hospital deliveries and maternal care.
In January, the newly-formed Alabama State Board of Midwifery issued the first licenses to midwives since 1976. There are nine certified professional midwives in the state who are able to practice, but those who practice say the state still has a long way to go in fully supporting midwifery.
“Hospital birth is not wrong or bad, but for some women they choose not to give birth in a hospital, and for them I wanted to be able to provide another option, one that they felt empowered and that they felt listened to and that their needs were taken seriously,” said Rebekah Myrick, a certified professional midwife in Birmingham.
Prior to a 2017 law change that created the board and licensing rules, the only type of midwives who were allowed to practice in the state were certified nurse midwives, who are registered nurses that work in hospitals alongside obstetricians.
Now, out-of-hospital midwives can help expecting mothers give birth in their homes.
Currently, 33 other states have recognized CPMs and allow them to practice midwifery, but there are still restrictions on what midwives can do in Alabama.
Alabama’s CPMs can only attend to low-risk births and are required to transfer the mother over to an obstetrician if complications arise. They are not allowed to treat mothers expecting twins or triplets and can’t help women who have had previous C-sections who want to try delivering vaginally.
Opposition to Midwifery
Most of the opposition to allowing midwives to be licensed and practicing in the state comes from concerns that it’s not a safe enough option.
Sen. Larry Stutts, R-Tuscumbia, has been a practicing obstetrician for more than 25 years and was one of the lawmakers against the passage of the 2017 licensing law.
Stutts believes that at home births with midwives is a more dangerous option for expecting mothers.
“I’ve practiced obstetrics for 27 years, and I’ll certainly admit that a lot of deliveries are very routine. But, you never know the ones that are not going to be routine until they are not,” Stutts said.
“If you don’t have the ability to do an emergency C-section or the ability to respond to an emergency, you’re in big trouble.”
Noel Leithart, Chairwoman of the Alabama State Board of Midwifery, said that the board had a dialogue with the Medical Association when they were first creating the rules and regulations and that they understood what was being decided upon.
“Some of this stuff always ends up to be an agree to disagree situation,” Leithart said.
Another problem Stutts had with the new legislation is that if part of the goal was to have more midwives so they can reach more rural areas where there are not readily available obstetrician services, then that isn’t being accomplished by the new law either.
Most of the nine CPMs in Alabama are either located north of Birmingham or within an hour radius of Birmingham, but that is because most of them had to travel to Tennessee in order to practice.
Some midwives like Myrick have to travel up to two hours to get to some of her clients which she says are both in rural and urban areas of the state.
Crook also says that since midwives haven’t been allowed to practice in the state for so many years it is going to take time to get them in more of the rural areas like the Black Belt and Wiregrass.
“You can’t expect, in a state that has actively prosecuted midwives, to have an immediate swell of midwives ready to go,” Crook said. “Who wants to move to a state where you can go to jail for doing your job.”
The Medical Association of Alabama, which represents physicians in the state, was also against the legislation in 2017 and thinks that the new regulations the state midwifery board has put in place do not fall into line with what was established in the new law.
“The Medical Association feels like the board went beyond the scope of practice allowed by the law and proposed dangerous regulations that were specifically prohibited by the statute,” said Mark Jackson, the Executive Director of the Medical Association of Alabama.
“The Medical Association continues to have concerns with midwives who have no formal medical or nursing training, providing medical care to women during delivery or medical care to a newborn child, especially in high-risk circumstances. Too many things can go wrong to the mother and/or child that requires immediate attention by medically trained professionals.”
The midwives disagree, arguing that home births are perfectly safe during normal pregnancies. If complications do arise, midwives have been trained in how to handle those situations as well, they said.
“When something arises that is not within the normal parameters of what is a normal pregnancy, we are trained to look out for these things and then we get the mother the appropriate help,” Myrick said.
“If the conditions at home are not safe for the mom and baby, we’re not going to just stay at home and see what happens, we’re going to get her to where she needs to be as well as for the baby.”
Outstanding issues
The VBAC issue – vaginal births after cesarean – is a big sticking point for midwives but, there are also less complicated procedures and practices, like a newborn blood screening test, that are prohibited by the Alabama Public Health Office.
“Allowing midwives to be able to practice to the full extent of our scope of practice, like providing the new born screening and providing access to the drugs that midwives are trained to carry and administer, is something that needs to be done for midwives in the state,” Myrick said.
Prior to 2017, some licensed midwives traveled to Tennessee with their clients to give birth.
“The women in the state who have wanted to give birth out of hospital have been doing it, regardless of what the law has said, so what this state has done is made it safer for those moms,” said Jennifer Crook, a member of the Alabama Midwives Alliance and has lobbied on behalf of midwives in Alabama for many years.
Some midwives still do practice in Tennessee, like Karen Brock, who is a certified professional midwife based out of Cullman. She said Tennessee is a more hospitable state to work in as a midwife.
“Working in Tennessee, the government there was more midwifery friendly and they allowed us to do the new born screening test, which every state wants every new born to undergo and I have been doing in Tennessee, but Alabama doesn’t want to make it easy,” Brock said.
Crook believes there is still some anxiety felt by the midwifery community in Alabama since the previous law was very strict about who could help expecting mothers. Fear of prosecution as a midwife has also been an issue.
“It was legal for moms to have their babies wherever they wanted to have their babies. What was illegal was for me who is a national certified and trained midwife to be there with her,” Crook said. “It was legal for the plumber to do it or the taxi driver or the mailman to do it because they were protected under the good samaritan law, but I could go to jail for doing it.”
Crook said that while at-home births may only count for around 5% of deliveries in other states that have allowed midwives to practice, at least now Alabama midwives can work without the fear of prosecution and help in areas where maternal care is really needed.
“This isn’t something the vast majority of moms are going to choose, but at least we’ve taken the step to make this option safer so at least they’re not driving in the middle of the night to another state or they’re not having their babies at home unassisted which a lot of families were choosing to do,” Crook said.
Another big barrier for the recruit of new midwives is the fact that they have to provide their own malpractice insurance, which can be a hefty financial burden when the profession already doesn’t pay that much.
“The biggest issue is insurance because it’s so daunting to start a new business and have to pay around $8,000 in insurance right off the bat, which doctors aren’t even themselves required by state law to have malpractice insurance,” Brock said.
Brock said that home births with midwives can cost on average between $3,000 to $5,000, and it differs between the midwives since they are independent contractors and set their own prices. She also said that hospital births could cost families more.
“I think this is just the beginning of an improvement but we’ve got a long way to go,” Crook said. “There’s a lot to do here in Alabama, and midwives aren’t going to be the solution for everything but I think they can be a big part of the puzzle.”