Today, July 13, 2023, is the much-anticipated hearing in Montgomery, Alabama, about proposed birth center regulations in a state where there are currently zero. As folks flood the hearing in person, we are hosting an action call via Zoom to support Alabama families’ and birth workers’ efforts for sound and reasonable regulations that would allow birth centers to open. (Register here to join.)
The proposed birth center regulations in question today, created by non-midwives and non-experts, are neither sound nor reasonable. Most notably, they require physician authority and explicitly forbid the authority of Certified Professional Midwives–the only licensed professionals specifically trained to attend births in a birth center setting. Advocates are demanding the department rescind the proposed regulations and redraft them with input from midwives and experts.
Follow Dr. Stephanie Mitchell on Instagram as she fights the proposed regulations that would block her efforts to open Birth Sanctuary Gainesville.
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Below are some actions you can take, and more information on the proposed regulations themselves.
Alabama advocates’ demands
Alabama families and communities deserve midwifery led birth center care. The state is in the middle of a maternal and infant care crisis and to deny these families this critical access is shameful. The proposed birth center regulations from the Alabama Department of Health would effectively prevent any birth centers from opening. They are outdated, non-evidence-based, and represent clear harm. In response to these terrible proposed regulations, we have two demands:
- We are demanding they be abandoned with the intent to draft new regulations that support the midwifery led birth center care model.
- We are demanding that these new regulations be drawn up by a committee of local and national stakeholders with expertise in birth center and midwifery care.
Here’s what you can do:
Advocate collectively in person at the hearing on July 13 at the Montgomery County Health Department, 3060 Mobile Highway, Montgomery, AL 36108.
Sign the petition at https://www.change.org/p/birth-sanctuary-gainesville
Call the department at (334) 206-5366 or (334) 206-5868
Email the department at
P.O. Box 303017
Montgomery, AL 36130-3017
The Proposed Regulations
View the proposed regulations at https://www.alabamapublichealth.gov/about/assets/420-5-13.pdf
Comments by Barbara Christians BSN, RN, PMH-C, CLC, CBE:
The current proposed regulations of essential health services and facilities provided by midwives and free standing birth centers creates significant barriers and hardship for the people and families of Alabama. The regulations are restrictive and unsafe, unethical, and potentially illegal.
- requiring physician oversight while there are notably several counties in the state of Alabama that do not have any licensed OB-Gyn MDs available for oversight or competent in overseeing midwifery practices; this gap is worse in the area known as “the Black Belt”;
- completely excluding Certified Professional Midwives in a state whose population wouldn’t exist as it is without the knowledge, skills, and actions of community based midwives, who were historically Black;
- requiring written contracts for transfer of care between birth centers and a hospital are unethical when the Emergency Medical Treatment and Labor Act of 1986 “imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs. If a hospital is unable to stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented.” (CMS, 2022) This also applies to critical access hospitals such as those in rural areas that would be served by free standing birth centers.
- limiting CPMs to assistance personnel required to work under MDs or CNMs, an action against Alabama’s own CPM scope of practice.
- requiring two nurses to be present for births, this is not a routine standard of care in hospital based birth (labor units are historically understaffed and rarely consistently implement patient ratios that meet safety thresholds defined by the Association for Women’s Health Obstetric and Neonatal Nurses (AWHONN); in addition labor/ obstetric nurses are not educated or trained in midwifery models of care.
These regulations are NOT aligned with National Birth Center Standards or Accreditation requirements. They are also at odds with regulations in other states whose maternal morbidity and mortality rates are significantly better than those in Alabama. With this context, it is clear these regulations are racist and medically neglectful to the health and welfare of the public of Alabama. Hopefully the direct impact of these proposed regulations was unintentional and the Alabama Department of Public Health will pause the integration of these unsafe and unethical regulations until a midwifery peer review can be conferred with and have midwifery oversight of proposed regulations of midwifery/birth centers.
Midwives provide a variety of services beyond prenatal, childbirth, and postpartum care. These can include but aren’t limited to preventative reproductive services and education like screening for cervical cancer. Restricting midwifery practice additionally conflicts with ADPH’s own strategic plan to reduce and eliminate cervical cancer as evidenced by one of the overall strategic actionsImproved availability of appointments for cervical cancer screening/follow-up and HPV vaccination at County Health Departments, Federally Qualified Health Centers (FQHCs), and other local health care providers (midiwves being local health care providers). ADPH continues with the rationale by reporting Alabama ranks thirdwhen it comes to mortality and incidence of cervical cancer in the U.S., with great disparities across race and counties.1, 2 In fact, cervical cancer age-adjusted incidence and mortality in Alabama have not changed in the past 20 years (10.1/100,000 in 1999 compared to 10.1/100,000 in 2019). Unfortunately, age-adjusted cervical cancer mortality shows the same pattern (2.6/100,000 in 1999 compared to 2.5/100,000 in 2019).1
Midwives as community based and centered providers are uniquely equipped and capable of addressing the ADPH’s identified barriers to the state’s priority regarding cervical cancer screening:
- Lack of perceived risk – (e.g., monogamous, no sexual partner, belief that family history is a risk factor for cervical cancer)
- Lack of knowledge that cervical cancer is preventable
- Lack of understanding of what cervical cancer screening consists of – Patients do not know the difference between a pelvic exam and a Pap, and much less about HPV testing
- Pap tests being “coupled” with STI screening – Either patients do not get screened because they do not have STI symptoms and/or perceive Pap and STI screening as the same
- Primary care providers who do not perform cervical cancer screening – (particularly in rural areas) The reasons provided by primary care providers included lack of time, lack of a place to refer in the event of abnormal results, complex reimbursement process, and dealing with so many other health problems among their patients
- Limited availability of gynecologists – Particularly in rural areas
- Women do not go for regular check-ups after they stop having children or during inter-conception
- Limited capacity at the County Health Departments – Some counties have a nurse practitioner who provides family planning and screening 2-3 days per month
- Lack of communication between local primary care providers and the County Health Departments – Resulting in a lack of continuity in care and difficulties in tracking screening results
- Confusing cervical cancer screening guidelines as well as frequent changes (including age)
- Stigma – Survivors do not share their stories and women do not
- “know” anyone with cervical cancer
The proposed regulations conflict with Alabama Perinatal Excellence Collaborative’s (APEC) mission statement:
To lower infant mortality and improve maternal and infant health in Alabama through
- Implementation and utilization of evidence-based obstetric care guidelines (ACOG supports and recommends midwifery care for low risk individuals)
- Assessment of meaningful quality benchmarks (midwives are capable of contributing to community health assessment and quality improvement initiatives)
- Enhanced communication and collaboration with providers, both primary and sub-specialty, and patients
Proposed regulations go directly against the state of Alabama’s own laws regarding midwifery scope as publicly outlined and clarified by the state attorney general.