Midwives and the Birthing Community

Picture yourself as a woman in 1896. Alabama has just recently created a state flag, and now the state’s first public tech school to train girls for careers is about to open its doors. Meanwhile, you are very pregnant, and your water has just broken. The midwife is called, and she provides emotional and physical support to deliver your baby in the home, alongside a few close female relatives and friends. Your midwife has attended thousands of births and knows your family and your community intimately. It would be unthinkable to go to a physician or hospital- in fact, going to one of these facilities was a near guarantee of death due to high infection rates.

Fast forward 100 years, and this model was flipped on its head. As medicine, technology, and hygiene protocols improved, physicians became the primary agents of care, including reproductive care, and even pregnancy became medicalized. Doctors and eventually the public came to view pregnant women in equal measures as ill or incapacitated, but also as healthy and life-bearing. As a paper diploma from a university (which women could not access) began to hold more authority in the eyes of hospitals and the public than the years of lived experience held by midwives, women were pushed out of the birthing space, and male physicians monopolized and monetized maternity care.

“Why people have been so adamantly opposed to midwifery here is all rooted in racism and exclusion.” -

In 1978, Alabama placed further roadblocks in the way of midwifery practice by outlawing it entirely after intense lobbying from the Medical Association of the State of Alabama and other physician-run organizations, severely restricting access to care for many marginalized populations. This outlawing closely parallels an alarming decrease in access to rural obstetric services (from 47/54 rural counties in 1980 to just 14/54 in 2024) and remaining high mortality rates for mothers and infants in Alabama. However, after much public advocacy from citizens, midwifery institutions, and supportive physicians, Governor Kay Ivey relegalized midwifery care in 2018. Why did this switch occur, and how can you take advantage of this new expansion of services if you are expecting?

Midwifery care has been proven to improve a variety of health and well-being outcomes for birthing people, including reducing pre-term birth rates, fetal loss, and neonatal death. The midwifery model of care has no negative drawbacks and strong support from many doctors in the state, but still faces structural resistance from the state in the form of a lack of educational support and interpersonal resistance from providers not familiar with the job of a midwife.

WHO Report on the benefits of midwifery care

But what exactly is the job of a midwife? The practice of midwifery in Alabama is defined as "care for the mother during pregnancy and labor providing continuous physical and emotional support and continuous evaluation of progress throughout labor and delivery" [Ala. Code § 34-19-2]. Essentially, this just means that midwives work as a part of the care team to provide emotional and physical support and monitor the birther closely to improve outcomes. They are trained professionals who are required to be certified through Alabama’s midwifery board. Certified professional midwives (CPMs) usually attend home births outside of the hospital or in birth centers[CK6] , and typically serve people with low-risk pregnancies. They are trained to transfer care to a hospital if complications arise. Certified nurse midwives (CNMs) work more closely with physicians in a hospital setting to attend births.

There are currently 26 CPMs registered to serve in Alabama, and as of 2020 they provided obstetric services to 41 of the state’s 67 counties, bridging care inequities for rural counties. Many midwives are associated with a particular midwifery organization, although some work independently, but in all cases, the midwife works collaboratively with the rest of your care team and provides a more personal approach to your care. They will meet with you regularly from your first meeting in the prenatal period and through the post-partum period, sometimes even up to 2-3 years post-partum. They are trained advocates who ensure that your birthing experience goes smoothly and that your birthing choices are respected and implemented if care must be transferred to a hospital. In other words, your midwife has your back!

If midwives have so many proven medical benefits and provide such amazing resources, you might wonder why they are not more popular in the state. Perhaps one of the most practical reasons is that Medicaid in Alabama does not cover midwifery services, and so services may end up costing $3000-4000 per birth. Only about 50% of births in Alabama are covered by insurance, and adding midwifery costs on top of this is very prohibitive for patient populations who may need the extra professional support during their birth most. Midwifery organizations, physicians in support of the midwifery model, and other key stakeholders and researchers in maternal health are still in the process of advocating for more expansive Medicaid coverage of maternal care services, including midwifery services. But it can’t just be academics who show their support for midwives- as community members, we must show support for these all-stars who support us in our most vulnerable, beautiful, and emotional times.

Midwives were common before the 1950s, and they’re making a resurgence today due to their proven medical benefits. Combining their patient-centered, holistic training with modern medical advances has the potential to give birthing people the best outcomes and birth experiences in history. Let’s thank the midwives of the past for bringing our ancestors into the world and support the midwives of the future so our children have healthy, happy births too!