Alabama Politics in
Doc’s Political Parlor
& Home of Lawn Mower Repair

MONTGOMERY — Tales of women slipping across the border to have their babies are often associated with illegal immigrants, not middle-class women from Alabama.

These women aren’t going to Mexico.

They’re going to Tennessee and Florida, where they legally can have their babies with the help of a certified professional midwife, CPMs.

That’s because it is unlawful for CPMs, or midwives who have been nationally trained and certified in the practice of midwifery to work outside of hospital settings, to practice in the state of Alabama.

The state recognizes nurse midwives, nurses who have had additional training as midwives. These midwives work in hospitals, and their work is supervised by a physician.

State Health Officer Dr. Don Williamson wants to keep it that way.

For the last 10 years, the Alabama Birth Coalition has tried to change the status of CPMs in the state, but the concerns of Williamson and members of the Medical Association of the State of Alabama always have prevailed.

Things were no different at a recent public hearing on the issue before the House Committee on Health, where the bill failed to pass muster.

In the upcoming legislative week, members of the coalition have one more opportunity to get their point across with the Senate Health Committee, but any success still would mean a showdown with members of the House.

Bill sponsor Rep. Laura Hall, D-Huntsville, said while it might help, the bill isn’t about solving the state’s dearth of rural medical care, or about the great numbers of pregnant women who don’t have health insurance.

She said the bill is about giving Alabama women a choice when it comes to where and how they want to deliver their babies.

Hall said if the state doesn’t address the issue, women will find a way, as they do now, to have their babies in the manner that they see fit.

“We’ll just have more women commuting to other states,” she said. “Those are children who rightfully should be Alabamians, but are statistically counted as being born in another state.”

If the House Health Committee is any indication, 2008 will be another tough year for certified professional midwives who want to practice in Alabama.

The committee cited such issues as the bill’s lack of a provision for a state-sanctioned educational program, insurance liability, and the lack of access to delivery services in rural communities as reasons for the thumbs down.

Jennifer Crook Moore, a certified professional midwife from Birmingham, said those are the same reasons the bill is killed every year.

She said those concerns have been studied nationally, and have been determined to be valid, but insufficient.

“They don’t get it or they don’t understand that women don’t necessarily have better outcomes just because they give birth in a hospital,” she said.

A 2000 study published in the “British Medical Journal” found that North American mothers who used a CPM to deliver at home had lower rates of medical intervention, but similar rates of infant mortality as mothers who delivered in hospitals.

Safety vs. Choice

Alabama health officials have heard the arguments for licensing midwives in the state, but their reason for opposing it remains consistent: safety.

“I understand the choice issue, but the only issue for the Department of Public Health is the safety of the mom and the baby,” Williamson said. “There are 20 or more counties in this state that do not have delivery service. There is no guarantee that a low-risk pregnancy will stay low-risk.”

That’s certainly true for Alabama, with its mix of rural communities, high poverty and lack of insurance factoring into the equation of which babies survive their first year of life.

Though the majority of Alabama babies are born in hospitals — more than 62,000 in 2006 — the state has an infant mortality rate that is hardly the envy of other states at 9 percent.

While lack of prenatal care plays a large role in infant mortality, Williamson sees certified professional midwives as a mechanism for raising the state’s infant mortality rate rather than lowering it.

Lobbyist Mark Jackson said the state’s Medical Association sees the issue the same way.

“This is not a debate about who can deliver a baby when everything goes great,” he said. “This is a debate about who can deliver a baby when things go wrong.”

Alabama Birth Coalition member Sarah Perdue said there is simply no evidence that points to less successful outcomes for mothers who use certified professional midwives, or that CPMs aren’t equipped to handle emergency situations.

In fact, she said, some ambulance teams are starting to work with midwives to learn how to better handle out-of-hospital births.

“Of the 24 states that have licensed certified professional midwives since 1976, none of them have rescinded their programs,” she said. “That’s because they work.”

Midwifery outside of hospitals wasn’t always such a sore subject in Alabama.

In the 1920s and into the mid-1970s, the Department of Public Health licensed and provided training for what were then called lay-midwives.

The term “lay-midwife” today is synonymous with “untrained,” and CPMs are anything but that, Moore said.

An Uncommon Event

Moore said before the shift to giving birth in hospitals began in the 1940s, birthing at home was commonplace.

In the 21st century, it is a much rarer occurrence, though nearly 170 out-of-hospital births occurred in Alabama in 2006.

Statistics from a 2006 Alabama Center for Health Statistics report don’t divulge whether those births were intentional or in the back of ambulances, but the number of such births was greater in counties with higher concentrations of people, such as Jefferson, Mobile and Montgomery counties, which had 52 such births.

However, in Pickens County all five of the births recorded in 2006 happened outside any hospital.

Out of 1,914 births in Calhoun County in 2006, four were out-of-hospital, putting the county in the top 10 for out-of-hospital births.

Hall said if people are going to have babies outside of the hospital, the state should regulate the practice and make certain it’s safe.

Rep. Pebblin Warren, D-Tuskegee, said her concern is that out-of-hospital births are happening, and there are women doing it alone.

As the sole woman on the House Health Committee, Warren’s other concern is that the state is denying residents the right to make their own choices.

“This is still America,” she said. “Let the people choose.”

Home births

Top 10 counties for out-of-hospital births:

Jefferson — 24

Mobile — 14

Montgomery — 14

Marsha — 8

Etowah — 7

Shelby — 6

Baldwin — 6

Pickens — 5

Cullman — 5

Calhoun — 4