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This is the second story in a two-part series about midwifery making a comeback in Alabama–where it was criminalized for 40 years—and how the state's maternal care crisis is tied to race and class. Read the first story here.
What's happening here doesn't look like a solution to a healthcare crisis: Nine women gathered in a hospital staff break room, munching on hummus and carrots, waiting for a group prenatal session to begin.
But that's exactly why I'm here, on the third floor of the Simon Williamson Clinic on the west end of Birmingham on a July afternoon. I'm here to understand how something as simple as a group prenatal might save a mother's life.
Among today's mothers, there's Melissa Lee, a 32-year-old former teacher turned stay-at-home-mom, who's pregnant with twins, her fifth and sixth children. She tells the group her family is part of an upcoming documentary. "I'm Black. My husband is white. He's deaf. I'm hearing-abled. My kids are all bilingual: sign-language. We've got a lot going on," she jokes.
There's Amber Pitts, a white 31-year-old health food store manager, wearing a T-shirt with a cartoon avocado and a caption that reads, "Holy guacamole, I'm pregnant!" Her 8-year-old daughter is here too, asking each of us who's having a baby and who isn't before skipping to the clinic-provided childcare room. There's Kenya and Erica, two black moms in their early twenties (who didn't want their last names shared). They designate themselves "the pessimist" and "the optimist," officially, for the group.
From the perch on the top floor, the mothers have a view of the Birmingham skyline a few miles to the east. Most of the women say they don't live in the city limits. For some, this clinic is the closest provider to their rural homes. For others, like Melissa, who drove from her small hometown about 20 miles away, they've passed multiple hospitals to be here. They've come to see the nurse midwives responsible for establishing a different model of care for birth givers in Alabama, adopted from a model that's gaining traction nationally and proving successful.
The program's goal is this: Instead of identifying and managing illness during pregnancy (as is the model for standard obstetric care), they're hoping to prevent many of the conditions that lead to unfavorable outcomes in the first place.
In Alabama, it's an ambitious goal. From low birth weight and preterm birth to Cesarean sections and breastfeeding success, maternal and infant rates are poor across the board here, rivaling statistics in developing nations. A 2014 study determined Alabama to be the worst state to have a baby. In 2016, infant mortality rates here actually increased.
Here and elsewhere in the country, the worst outcomes fall disproportionately on rural folks and on people of color, specifically Black mothers and their newborns. Recent reports show 33 of Alabama's 67 counties currently don't have practicing OB-GYNs and more than half of Alabama mothers drive more than an hour for care. Black women and babies are twice as likely to die than whites in the U.S. and three times more likely to die in Alabama. National attention is slowly turning to this crisis thanks to ongoing reporting from multiple media outlets. In August, Sen. Kamala Harris introduced a bill that offers some solutions to the racial disparities in birth outcomes.
As the birth crisis rages across the U.S., progressive care providers in Alabama believe the solution to the country's problem is rooted in our past: relying on midwives to tend the majority of births.
Until the mid-70s, rural women in Alabama predominantly gave birth at home, attended by a midwife.
The shift toward criminalizing midwifery in Alabama began in 1970, coinciding with Medicaid's beginnings. Because Medicaid covered the cost of childbirth, folks who hadn't been able to afford care or hadn't been allowed in hospitals because of racial discrimination now had access to obstetrics. But it also meant there was new money to be made in hospital births, and medical associations started to push the narrative that homebirth was always, undeniably unsafe.
In Alabama, the Black, rural women who'd relied on midwives for generations were suddenly being shuffled into an institution they were once banned from entering. And the Black midwives who'd built a profession for themselves were now without work, deemed dirty and illegitimate by the white leaders of the state.
Today, local reproductive justice advocates think the institutionalization of birth forced Black families into a system where the model of care is clearly failing them. For rural areas, the same system that once promised community care is now shuttering providers across the state, as profits prove impossible, in part, because Republicans continue to reject Medicaid expansion.
The system's failures led to bi-partisan activists organizing to re-legalize Certified Professional Midwifery, midwives who attend home births. Last May, lawmakers approved their bill after a two-decade effort, but details remain unclear for those providers, including whether or not insurance will cover homebirth. One activist, midwifery student Hope Hamilton, said she and others aren't waiting for top-down solutions; instead, they think we need a culture shift, an emphasis on competent, comprehensive care over things like baby swag. "What if everyone who came to the baby shower or the sex-reveal party brought a monetary gift to pay the midwife and prepare for a birth on the birth givers terms?" she asked.
Meanwhile, Certified Nurse Midwives like Sheila Lopez and Hamilton Yarbrough here at the clinic, who are trained to attend births in hospitals with overseeing OB-GYNs, are developing integrative care within the system.
As the class begins at the clinic, moms Melissa Lee and Amber Pitts are helping the other moms take their blood pressure and record it on a ledger. They chat about their aches, the sleeplessness. This is one mom's second pregnancy, and when she tells the group she had severe postpartum depression with her first, everyone nods, offers a word of support or condolence. "This is our second set of twins," Melissa says. "With our first set, we lost one."
This openness and comradery is exactly what the midwives are hoping for. The mothers are grouped by month, according to their delivery date, so they're able to share the woes and joys of each milestone together, even postpartum. In today's session, they work through discussion on common complaints and remedies during pregnancy, stress management techniques, and exercises to help during childbirth and postpartum recovery. When the midwives are leading a how-to for proper Kegels (a pelvic floor exercise where you clench and release as if you're "starting and stopping pee"), the women squirm a bit, a little awkward until midwife Sheila offers, "I've got a pelvic floor of steel!" and everyone laughs.
During every visit, women attend a 2-hour appointment providing both one-on-one time with a midwife and a group wellness class in an environment that encourages participants to take charge of their own health.
Later, Sheila tells me, "The families who participate in this model are more satisfied, feel more empowered, feel more prepared for birth, initiate breastfeeding at higher rates and have fewer low-birth weight babies." The overseeing physician tells me the program's communal spirit also offers women from rural communities a chance to connect with other pregnant women, turning a potentially isolating experience into an opportunity to create friendships that last long into postpartum.
Recent studies show for many women, it's this communal feeling of support that leads to lower stress levels and overall better health during pregnancy. Most of all, Sheila says, "Group care may be able to remove racial disparities in birth outcomes."
If that's true, if this midwife-led care is able to achieve equitable outcomes here in Alabama, the implications for maternal care in the U.S. would be huge. And the group prenatals are a small part of a much bigger vision.
Oddly enough, one of the most influential people advocating midwifery in Alabama isn't a midwife but the overseeing OB-GYN at Simon Williamson, Dr. Jesanna Cooper.
On a Friday morning, I meet Dr. Cooper at her home before she drives south to Andalusia for the weekend, where she works once a month to relieve the only obstetrician at a regional hospital. When I pull up to her two-story brick tudor in a historic Birmingham neighborhood, she's on the porch having coffee in a T-shirt and sweats. We chat about the neighborhood, how she was considering leaving, how it's shifting: whiter, richer. Dr. Cooper is both white and, by most standards, rich. A physician whose income is dependent upon the number of deliveries she oversees, she's not exactly the expected poster child for a movement to deinstitutionalize birth.
(She is, full-disclosure, the physician who oversaw my own prenatal and postpartum care, a decision based in part on recommendations from reproductive justice advocates.)
Dr. Cooper agrees with physicians who say birth outcome disparities are caused by complicated problems, including Alabama's high rates of diabetes, hypertension, and obesity, which are higher in rural populations and among people of color. But poor birth outcomes are also caused by physicians who are conditioned—or literally positioned (concentrated in urban centers)—to treat populations differently, she says. Offering her own missteps as an example, Cooper says physicians treat people based on assumptions derived from data.
"What I noticed is that I was not counseling young Black women [about breastfeeding] the way I was counseling young white women. And the reason was that I'd already learned the stats of who breastfeeds and who doesn't breastfeed—rather than looking into and see how we could change that stat."
After making changes, her own clinic saw an increase in their exclusive breastfeeding rate, jumping from 13 percent to 57 percent, "which shows if you standardize the kind of care you give people, your numbers will come up despite the demographics across the population," Cooper says.
Like the group prenatals, standardized counseling is a low-cost intervention to a big problem. Her other plans are more ambitious. Cooper is working to reform the structure of maternity care in the state. She's critical of what she calls "ICU-style labor and delivery" being the norm. The current system is built on the fear that the worst will happen during labor, but Cooper says focussing on the very small percentage of mothers who need high intensity, round-the-clock care actually leads to worse outcomes for all, creating what's called the "cascade of unnecessary interventions" which happens when a person in labor is confined by nonstop monitoring.
"You could change population health just by investing in the community health. It's very inexpensive. Hospital care is expensive. C-sections are expensive. Formula feeding is expensive. Transfer is expensive. But if you didn't put so much money into every single birth, then your system can afford to do this," Cooper says.
"The answer is to come back to the midwives."
Currently, an OB-GYN is legally allowed to have up to four midwives under her leadership. Cooper wants to change that, giving midwives—both certified nurse midwives like those at her clinic and certified professional midwives who attend homebirths—more autonomy.
To describe her ideal model of care for mothers, Cooper says, "Picture a pyramid." The base is made up of midwives. The majority of mothers, termed low-risk, would receive prenatal care in their own community, either at home or in a birthing center, attended by midwives.
The next tier would be community hospitals where family doctors can perform necessary C-sections when birthing center and home birth clients need to transfer if something were to change late in pregnancy or during labor.
The next step up would be hospitals like Princeton Baptist, where Cooper currently oversees patients with conditions like preeclampsia or preterm birth.
Finally, the smallest sector, the tip of the pyramid, would be tertiary care centers with maternal and fetal specialists who can tend to the sickest patients in a setting similar to the ICU. To connect each level of care, Cooper says each provider must integrate, instead of "operating in silos."
To achieve all of this, Cooper says the state needs better telemedicine, transfer systems, and reimbursement reform (obstetricians are currently paid per delivery, not for prenatal care, which de-incentivizes transfers or collaboration). As of 2016, 52 percent of Alabama births were covered by Medicaid. Those mothers, Cooper says, also deserve access to the same level of care as private insurance holders.
Someday, Cooper would like to oversee a network of birthing centers throughout rural Alabama, where women can train to be midwives, doulas, and lactation consultants, continuing to serve their own neighbors in their own community, reclaiming a practice with deep roots here.
"You have to invest in the people in the community," Cooper says.