BIRMINGHAM, Ala. — Karen Brock had been delivering babies as a midwife in Alabama for five years when in 2002, during what was supposed to be a routine birth, the mother's uterus ruptured and the umbilical cord preceded the baby, an exceedingly dangerous condition known as cord prolapse. Brock drove to the hospital with her hands still cupped inside the mother. The baby died, but Brock said the receiving doctor told her, “What you did probably saved [the mother's] life. If you hadn’t been there, she wouldn’t have lived.” Still, Brock was charged with a misdemeanor for practicing nurse midwifery without a license. She pleaded guilty, was sentenced to 18 months of unsupervised probation and stopped delivering babies in Alabama.
In Alabama giving birth at home is legal. Having a licensed obstetrician or midwife attend a home delivery, however, is not. Brock is one of two midwives who have been prosecuted for practicing midwifery without a license. There is no state law specifically against midwifery, but after the first case, in 1992, it became illegal by precedent.
Until 1976, midwives were licensed in Alabama. But with the establishment of Medicaid in 1970, public health departments in the state slowly and unsystematically stopped issuing midwives licenses. Alabama does allow for certified nurse midwives, or CNMs, to collaborate with obstetricians to deliver babies in hospitals. Another class of midwives, known as certified professional midwives, or CPMs, are not licensed in Alabama or 21 other states. The difference is that CNMs have graduated from nursing school and specialize in midwifery, whereas CPMs have learned midwifery through informal study and apprenticeship. However, there is not a single CNM training program in the state, and only 20 CNMs are licensed in Alabama. In addition, in 2014 the personal finance social network Wallet Hub ranked Alabama the worst state to deliver a child on the basis of price and treatment of moms and babies.
Throughout the U.S., midwifery has seen a spike in popularity in the past decade. According to the CDC, though still accounting for fewer than 1 percent of the country’s nearly 4 million yearly births, home births have been regularly increasing since 2004.
From 2011 to 2012, out-of-hospital births, which include delivery at home, a midwife-staffed birthing center or a doctor's office, increased in the U.S. from about 49,800 to some 53,800 births. Home birth has become an increasingly popular option in Oregon (nearly 2.4 percent of deliveries) but remains rare or unreported in Rhode Island, Mississippi, Alabama and Louisiana (about 0.2 to 0.3 percent).
Several factors drive the popularity of home births, including the comparatively low cost ($2,500 to $5,000, compared with $10,000 for a conventional delivery) and the desire for a nonmedicated, natural birth. Some women, furthermore, simply want to be at home.
Brock, a small, energetic woman, wears Chaco-style hiking sandals and loose skirts as she darts around her office. At the time of her prosecution, she was caring for 27 pregnant women, so she decided to get a CPM license in Tennessee. Today when her patients go into labor, they call her and she drives with them to Elkton, a tiny square of a town just over the state line in Tennessee, where Brock can legally attend the delivery.
Brock estimates that she has delivered about 1,500 babies. Most of her patients, she said, are Mennonite women who avoid hospitals for cultural reasons and “hippy-yuppies” who want a natural birth and “didn’t like the pressure put on them in the hospital” to undergo procedures they didn't want. She said she has always had a doctor on call in case something goes wrong and her patient needs hospital admittance.
Brock said a local obstetrician she used to work with once joked with her that “Ninety percent of the women who walk through my door do not need me. But don’t tell them, because I won’t have a business.”
“[Midwives] are the first step, is the way I look at it,” Brock explained. “And many times the first step is all women need.”
But Alabama’s medical community disagrees.
Dr. Joseph R. Biggio Jr. has been delivering babies for 15 years and heads the division of maternal and fetal medicine within the department of obstetrics and gynecology at the University of Alabama at Birmingham. He said he has partnered with several CNMs at the university’s hospital and vouches for their care.
He said he is not attacking midwives, though he does question the scope of their training. His main problem is the birth venue — at home — and the time it takes to transfer a woman to a hospital in an emergency.
“Once you do enough of them, you are going to have a problem that you are not going to be able to handle rapidly enough to prevent an adverse outcome, as opposed to if you were in a hospital,” Biggio explained.
He sits on the local board of the American Congress of Obstetricians and Gynecologists (ACOG), which has long stressed the dangers of home birth and discourages the use of CPMs.
In a small population of low-risk women, the outcomes of births at home and in a hospital will be similar, Biggio said. But he and other health professionals worry that once that number is extrapolated across an entire state or the nation, home births will result in complications and deaths.
Research findings on the safety of home births varies, depending on the side funding it — either doctors and hospitals or midwives and their national associations. Biggio cited research published in 2013 in The American Journal of Obstetrics and Gynecology that children born at home are 10 times as likely to be stillborn and four times as likely to have serious neurological problems as babies born in hospitals.
Along with the ACOG, the Medical Association of the State of Alabama (MASA) has lobbied yearly against repeated bills that would decriminalize midwifery and create a licensing program for CPMs. MASA spokesman Niko Corley said, “If the state were to legalize [home births], it would give people a false sense of security that this practice is safe, when we know it is not.”
The MASA and the ACOG argue that CPMs want to be able to practice medicine without the training required of obstetricians and without malpractice insurance. “They want all the benefits of practicing medicine,” Corley said, “without any of the responsibility.”
On the other side, a study partly funded by the Foundation for the Advancement of Midwifery and published in 2005 in The British Medical Journal followed 5,000 women who planned to deliver at home with a CPM. In the course of the study, there were no maternal deaths, and the infant mortality rate was a low 1.7 per 1,000 births. In addition, 97 percent of mothers reported that they were pleased with their delivery.
Midwives are quick to point out that Southern states, where midwifery is largely illegal, have some of the highest infant mortality rates in the nation. Alabama’s infant mortality rate is 8.6 per 1,000 births (compared with a 6.0 average nationwide). Also, 37 of Alabama's 67 counties have no hospital or obstetrician, meaning many pregnant women must travel hours to see their doctors and deliver their babies.
Doctors counter that midwives would not improve these health care disparities because most midwives do not live in such rural areas and cannot work with high-risk patients.
Dr. Lynda Gilliam answered the phone after a 12-hour shift in which she performed a cesarean section and a natural birth (during which the woman delivered on all fours) and was awaiting a slowly progressing labor. Gilliam said she supports natural birth but not CPMs. She believes decriminalizing the practice would put mothers at risk.
“Essentially, you are practicing medicine without a license,” she said. “You don't have a nursing license. You're not under the state nursing board. You're not under the state medical board. So who are you going to be accountable to? Because we have to protect the patients too.”
Instead, Gilliam, who is a member of the ACOG, supports birthing centers staffed by midwives with a physician backup. Currently, there are no such birthing centers in Alabama.
She said she is disheartened with midwifery advocates and their refusal to compromise on demands like requiring midwives carry malpractice insurance and passing a state certification exam.
“The people who you are talking about, that’s not what they want,” Gilliam said, exhaling exhaustedly. “They want home birth with no regulation.”
The midwifery question sometimes dances on the edge of the debate about the personhood of a fetus versus the autonomy of a mother. Dr. Pippa Abston, a pediatrician in North Alabama, says for years she remained undecided about home birth. A few years ago, she started to research midwifery and documented her experience on her blog. Ultimately, Abston said, the midwives convinced her.
“It’s wrong to prevent a woman from making her choice about her own body,” she said. “We don’t tell people who have cancer, ‘You have to have chemo.’ It’s really paternalistic to tell a woman what she has to do with her body. It’s a scary road to go down.”
Abston would like to see a CPM license created in Alabama so that the women who prefer home birth can choose a midwife who is regulated and monitored by the state.
Whether the state agrees to license CPMs or not, some Alabama women are choosing to give birth at home with a midwife. About 600 babies a year are born in Alabama homes, and countless women drive out of state to work with midwives.
Ella Cooper drove three hours to a midwife in Tennessee who delivered all three of her children. “It's definitely unsettling,” she said, “not to know when you are going to have your baby and having to drive out of state.”
As she rested on her sofa at her home in Birmingham, her youngest, Oren, only a few weeks old, scrunched close to her breast, nursing, burbling and sleeping. Cooper described herself as “crunchy,” and before her first pregnancy, she did a lot of reading about home versus hospital births.
“It's supersimple to have a birth outside of a hospital, but that's not the culture we live,” she said. “They teach you that birth is scary and dangerous. It’s not. It’s natural. It’s the way our bodies work. We were made to do it.”
As she flipped through photos of the birth of her son, Cooper recalled that when her labor started, her midwife told her to go take a walk. So she and her husband hiked up to a ridge in the middle of the Tennessee woods and waited for their son to be born.