As birthing hospitals close, Alabama's maternity care crisis is a warning for the rest of the nation

The United States is in the midst of a maternal health care crisis, one made even worse by states who refuse to listen to those who have been in the birth trenches for centuries: midwives. This is currently playing out in real time in Alabama, where the state’s Department of Public Health missed the opportunity to alleviate the maternal health care emergency residents are facing.

According to a recent March of Dimes study, 37.3% of counties in Alabama are considered a “maternal care desert” and 31.3% have low or moderate access to maternal care. This means that almost 70% of the population is living in areas without a hospital or birth center, making access to appropriate preventive, prenatal and postpartum care difficult. On top of this scarcity of care, Alabama has the third highest rate of maternal mortality and the fifth highest rate of infant mortality in the country. State officials should be doing everything in their power to fix this. Instead, recent news reports indicate that three hospitals in the state will soon close their maternity units, including one in a predominantly Black neighborhood.

We know that midwives are a proven solution to increase access to safe, quality care with better outcomes for low risk pregnancies and births. However, the state has made it difficult for Alabama midwives to do their work.

Last year, the Alabama Department of Public Health (ADPH) resurrected antiquated regulations from 1985 to control who is able to provide care at freestanding birth centers in the state. Without inviting any midwives to the table, a group of hospital connected, non-obstetric nurses, non-OB physicians and non-midwifery professionals amended the proposed birth center regulations to their own interpretations. These regulations are not in line with any current standard of pregnancy and birth care in North America.

Over the summer, the ADPH hosted a two hour public hearing regarding these regulations. Birth workers and allies did what they’ve always done: show up. The room was packed, and it was full of midwives, doulas, physicians, OBGYNS, community members, mothers, and other supporters who traveled to Montgomery to speak truth to power.

Not a single person spoke in favor of these archaic regulations. And yet the regulations remained.

In response to the state’s inaction, a handful of doctors and midwives (including Dr. Stephanie Mitchell), filed a lawsuit in AL state court challenging the ongoing actions by the ADPH, arguing that the state has made it impossible for birth centers to even attempt to obtain a license, creating a dilemma that is both unlawful and unjustified. On September 30th, the Fifteenth Judicial Circuit Court issued a ruling, blocking the ADPH from continuing to prevent the operation of midwife-led birth centers in Alabama. This will allow midwives in the state to do their jobs for now, and will provide Alabama residents with access to much-needed care.

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Unfortunately, Alabama is not unique, and our entire country is suffering similar maternal care challenges. The U.S. has the worst rates of maternal mortality among highly resourced countries, and this rate only continues to increase. We know that 84% of pregnancy-related deaths are preventable, yet systemic change is too slow and severely lacking. And, like Alabama, many states have regulations surrounding midwifery, making it difficult for them to provide care in an independent setting.

Even when birth trauma and tragedy strikes those in the spotlight (such as Serena Williams and Tori Bowie), their stories make waves for a moment, we condemn the system, but then nothing changes. The crisis continues, and in many cases, it’s getting worse, particularly for those most at risk: Black women.

In Alabama, the ADPH’s regulations were rooted in racism and oppression. They were an attack on Black birthing bodies and the Black providers that are creating solutions and working to lower the high rates of maternal and infant mortality in the state. Black women in particular have a disproportionately higher rate of birth complications and maternal mortality, and Alabama has an opportunity right now to expand culturally competent care in the attempt to save more lives. These regulations threatened to discourage solutions to existing poor outcomes and limited access to care. They eliminated the possibility of midwives from operating within the defined scope of practice and expertise. These barriers reinforced the fact that this is not about access to healthcare for pregnant people or about better outcomes for birthing families.

When those in charge failed to do the right thing, it was birth workers who organized and activated for change. Instead of listening to the experts when they had the chance, the ADPH needed a court order to prevent them from enforcing their outdated and harmful regulations. However, the injunction isn’t a permanent solution. We don’t know whether the ADPH will continue to withhold licenses or try to enforce their rules. Until these regulations are completely off the books, the fight for better, safer pregnancy and birth care continues. 

Alabama is currently at a precipice when it comes to birth, and the rest of the nation must be invested in the outcome. This southern state – one that continues to have poor outcomes when it comes to birth – has the chance to start shifting the narrative. Instead of lamenting our high rates of maternal mortality, we should be celebrating how a southern state is leading the way in allowing skilled, professional midwives to do the work they’ve been trained to do, while helping to fill in the care gaps that plague the state. Alabama has an opportunity to show the rest of the country what can happen when birth providers work together for the betterment of their communities.

The alarm bell has been sounding and it’s time to listen and follow the lead of those who have been in the birth trenches for centuries. We do not have the leisure to wait while Alabama — and this country — falls further into a maternal care crisis.