For Alabama midwives, the wait is over

After a decade of lobbying Alabama lawmakers to make her profession legal in the state, Jennifer Crook is one of Alabama’s nationally certified professional midwives celebrating the signing of the Childbirth Freedom Act this past May.

The bill, enrolled as House Bill 315, began as a decriminalization bill, but was amended on the final day of the legislative session to include a regulatory board. 

“It’s beautiful for us as midwives because what we ultimately wanted was a licensure bill. It’s not ideal, obviously, but at the end of the day we got what it is we’ve been working for, for more than a decade,” said Crook, a Vestavia Hills resident. “It was a beautiful gift at the 11th hour to get it amended with the licensure bill.”

She says the success in 2017 is a culmination of decades of work, long before she first got involved. 

“It’s been a remarkable thing to be a part of, going from a group of 20-40 members on an email distribution to achieving this amazing accomplishment. It’s been something to watch,” Crook said. “This is what grassroots looks like. That’s all this was, persistence, never giving up and giving a voice to constituents. That’s what did it.”

Since news of the bill passed, Crook has been fielding questions.

“I’m getting plenty of calls, texts and emails asking if I’m going to practice,” she said. “We’ll see. I will certainly be involved in whatever extent is needed.”

The Cahaba Heights native began her training as a midwife in 2001 and moved to Tennessee, where she had two of her own children back-to-back. She wasn’t planning to return to Alabama, but did in 2003 and completed her certification the following year. Over the next few years, Crook traveled back-and-forth across the Tennessee border to practice as a midwife. This grew increasingly difficult as her efforts in Montgomery increased in 2007 when she began getting more active with the Alabama Birth Coalition’s legislative efforts for midwifery. 

“I’m a single mom, so it was really hard when my phone would ring at 3 in the morning and then four hours of driving on top of that,” Crook said. “It’s hard to take clients when you know you’re going to be in Montgomery four months or five months out of the year. It really limited my ability to be a good midwife.”

Five years ago, Crook stepped away from practicing as a midwife to devote her time and energy to building a grassroots effort for better childbirth options statewide. She became a voice for midwives and supporters during the movement, often testifying in front of Senate and House committees in Montgomery, meeting with legislators and working to educate the public about midwives. Over the years, she’s been interviewed by almost every in-state media outlet and has helped provide national coverage to outlets such as Washington Post and Yahoo.

“The continuing media attention statewide and nationally on Alabama’s maternity crisis helped,” said Crook of the bill’s progress in 2017. 

How did we get here?

After the adoption of the Code of Alabama 1975, permits for midwives began to disappear from county health departments, leaving certified nurse midwives as the only legally licensed midwives in the state. According to the Alabama Midwives Alliance, efforts to legalize direct-entry midwifery and certified professional midwives have been active since the early 1990s. The Alabama Birth Coalition was founded in 2002.

Advocacy, like Crook’s, for legislation increased over the last decade as midwives began to practice along the state’s borders or “underground” out of concern of their legal status. 

Just as in years past, Rep. Ken Johnson (R-Moulton) sponsored the Alabama Birth Coalition’s legislation in the Alabama House of Representatives. But this year, the bills garnered wide support, including a co-sponsorship by newly appointed Speaker of the House Mac McCutcheon. 

“I felt this session was a perfect storm. I think some things happened politically that were beneficial,” Crook said. “I think there were some changes in leadership that impacted it and constituent outreach to personal legislators was really high this year.”

It all seemed to add up, as, for the first time ever, a bill to decriminalize midwives — HB 315 — cleared a House subcommittee and went to the floor for a vote, where it passed April 25 by an 84-11 vote. 

A month later, on May 19, the bill cleared the Senate unanimously after a near six-hour debate and conference resulted in a compromise between opponents and supporters for an amendment to establish a regulatory board and state licenses. Gov. Kay Ivey signed the bill the following Wednesday.

“As signed into law, HB315 strikes the appropriate balance of removing regulations to allow midwives to practice, while also making sure offered services are safe for and in the best interests of mothers and children,” Ivey said her in her statement. “The debate on this bill brought all parties to the table and is a perfect example of the people of Alabama playing an active and effective role in lobbying their government.”

“The irony was not lost on me that it was a female governor that signed this bill,” Crook said. “If her office had called me and asked me to a press release about this bill, I could not have written a better one.”

Why midwives? 

Crook and other supporters say passage of the bill will help educate more expecting mothers of midwives as another birth option in Alabama, along with OB-GYNs and certified nurse midwives, especially if the mother is considered low-risk and is seeking an intervention-free birth. 

“I certainly love to see the interest in midwifery education. That pleases me to no end. We need lots of midwives. We’ve got lots of underserved areas in this state that need midwives,” Crook said. “I love seeing lightbulbs go off in [a woman’s] head. We have been so separated from the process of pregnancy and childbirth, let’s teach and educate. And if we educate, people can truly make informed decisions.”

With Alabama currently not having any freestanding birth centers, the push for midwives is to extend care in the rural counties of Alabama where obstetrics care has faded over the years and provide an additional choice in urban communities. In 1980, all but nine of Alabama’s 67 counties had a hospital with obstetrics care, according to the Alabama Birth Coalition. Today, only 29 Alabama counties have such care. According to the Alabama Rural Health Association, only 16 of the 54 counties classified as “rural” had hospitals providing obstetrical care as of March 2016.

Another concern midwives expressed over the past year is Alabama’s failing grade on the March of Dimes Preterm Birth Report Card. Alabama is one of three states in the nation to receive an “F” on the 2016 report, ranking 47th in the nation with a preterm birth rate of 11.7 percent. Jefferson County also received an “F” at 11.6 percent. The hope is that midwives will be able to provide more individualized care by taking on only three to six births a month, based on national averages, and extended prenatal visits to help educate mothers on nutrition to remain low-risk and avoid preterm labor.

Once the law goes into effect this fall, Alabama will be the 33rd state to license certified professional midwives, but will become the first state in the U.S. to establish a fully independent board of midwifery, according to Crook.

Under the law, the board will be appointed by the governor and will consist of four certified professional midwives, a certified nurse midwife, a nurse practitioner and a person who has used the services of a CPM. Supporters are expecting it to take about a year before the state can begin issuing licenses.  

Midwives wishing to practice in Alabama must be certified by the National American Registry of Midwives (NARM), which requires completion of a portfolio evaluation of a potential midwife’s training, which require 40 births and newborn screenings and 75 prenatal visits under the supervision of a qualified preceptor. Candidates must also complete the NARM Written Examination. Those wishing to learn more about becoming a midwifery can visit narm.org 

Legally, mothers in Alabama can have a home birth without assistance of a midwife, but passage of the Childbirth Freedom Act will allow certified professional midwives to attend the birth, which are traditionally only for low-risk births. The bill places restrictions on which births can be attended by a midwife: twins, breech deliveries and vaginal births after a cesarean (VBAC) were all considered safety concerns and are not eligible. The bill also requires midwives to carry liability insurance of no less than $100,000 per occurrence.

Crook admits the bill isn’t perfect. While she doesn’t plan to return to Montgomery in 2018 for midwifery legislation, she says her advocacy doesn’t end with the passage of this bill. 

“I have a heart and passion for this stuff, and there’s a lot to do in this state,” Crook said, mentioning the establishment of birth centers and improving maternal and child health as just a few items.

For specific questions related to Alabama’s certified midwife process, the Alabama Birth Coalition can be emailed at alabamabirthcoalitioninfo@gmail.com.