The Alabama Department of Public Health is seeking public comment on new proposed regulations that could limit the role of midwives and birthing centers in Alabama.
Midwives are licensed medical professionals who oversee healthy, low-risk pregnancies. Birthing centers are healthcare facilities that operate as alternatives to hospitals. These centers offer a homey environment for pregnant women who do not like the clinical, hospital setting. Midwives often work in birthing centers.
Birthing centers were introduced to the state in 2017, when the Alabama Legislature approved the practice of Certified Professional Midwives (CPMs). They are unregulated in the state, and ADPH seeks to change that. The state agency released its proposed restrictions late last month. If certified, birthing centers will require at least two registered nurses and a physician to give births. The regulations also limit the authority of midwives, who would lose their ability to oversee births. Instead, midwives would assist the births of physicians and nurses.
Noel Leithart is the chair of the Alabama State Board of Midwifery and a former midwife herself. Leithart opposes ADPH’s proposed regulations for several different reasons.
“Their proposal has 57 pages, even to the extent of telling you what size a room has to be for a mother to give birth in, which is kind of ironic because mothers give birth in cars sometimes,” she said. “Another [regulation] is staffing, where they're requiring two registered nurses to be there. That's because they feel, in my opinion, that the midwife is not going to show up until delivery. But that's [not] what midwives do. CPMs are licensed in the state of Alabama. [They have] been given statutory authority to be the one in charge at a birth.”
One proposed regulation that Leithart particularly takes issue with involves hospitals. ADPH requires that all birthing centers be in contract with a hospital that is 30 miles away or closer. Leithart said this negatively impacts rural Alabamians, who often already lack access to reliable medical resources.
“We already have a rural health crisis,” she said. “Midwives are going into many of the rural communities and delivering babies since the statute was passed in 2017. It would be nice for them to be able to set up a freestanding birth center that could accommodate more than one woman in some of these rural areas. Those might not even be as close as 30 minutes to a hospital because hospitals are shutting down in rural areas. That would effectively keep midwives from opening more centers.”
ADPH held a public hearing on July 13 for midwives, birthing centers and advocates to express their concerns about the regulations. However, two attorneys for ADPH held the meeting rather than members who wrote the regulations. Leithart said this is a problem and that ADPH’s proposed regulations are antiquated and misinformed.
“I know that a number of midwives are very upset,” she said. “Midwives are experts in out-of-hospital deliveries, and, yet, they were not consulted in the writing of these rules. We have asked to sit at the table [and] to be a part of the discussion because we are the experts in that field. It feels odd to have people who aren't involved in low-risk, normal, physiological, unmedicated births to be writing up the rules. That's a big deal for a lot of the people who are opposing these.”
In its proposed regulations, ADPH states restrictions on birthing centers are required to prevent health and safety risks to mothers and their newborns. However, Leithart said birthing centers already protect women and children.
“Proposing these rules would make [birthing centers] effectively just birthing hospitals,” she said. “[The regulations are] not really for the health and safety of the baby, because the babies are already safe and healthy with the home birth. To give [ADPH] the benefit of the doubt, I think they honestly believe that home birth is unsafe. However, for thousands of years, babies were born at home. Last year, there were only a little over 300 babies born at home, but Alabama has almost 60,000 babies born a year. It doesn't make sense to me why they're trying to [stop] midwives from being successful, especially when we're going into areas [where] there are no hospitals.”
This is not the first time ADPH has introduced regulations to restrict birthing centers in Alabama. ADPH introduced similar restrictions last summer but failed to get them certified.
Leithart said there are better alternatives to ADPH’s proposal, including guidelines enforced by the Texas Department of Health. In Texas, birthing centers have standards for licensing procedures, including denial, probation, suspension and revocation as well as qualifications for facility personnel, organizational structure requirements and record keeping requirements. Leithart said birthing centers can be regulated, as they are in Texas, so long as they remain independent.
“[Texas] has over 90 midwife-run birthing centers and has an excellent statistic for babies and mothers, and, yet, these are all run by midwives,” she said. “We already have a template. They don't have to rewrite everything. We’re not opposed to them being regulated in a sense, but not regulated as a hospital. [They should be] regulated as a freestanding birth center.”
ADPH released a media statement addressing its proposed regulations. The state agency said nothing is set in stone.
“The process will not be complete, even at the end of the public comment period,” ADPH said. “As the public comment period remains open until Aug. 4, 2023, ADPH cannot provide further information at this time.”
Once the public comment period ends next month, the rules will return to the State Committee of Public Health for final approval. Regulations may be modified based on public comments filed. If approved, the rules will head to the Legislative Council for certification.
Despite possible restrictions on birthing centers in the state, Leithart said it is important that any Alabamian entering healthcare consider midwifery as a profession.
“There are always more pregnant women than there are midwives to serve them,” she said. “I hear of the midwives having to turn women away because they're so busy as it is. One of the biggest drawbacks to midwives being licensed in the state is that we're the only state that requires liability insurance, and it's very costly. That has kept some midwives from coming here. But otherwise, we need it. We have a number of student midwives on the verge of graduating. A lot of African American women are coming along, and they're really excited to serve the African American community in the state.”
More information on midwifery in Alabama can be found on the Alabama State Board of Midwifery website.
