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This is the first 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 follow-up here.

The first homebirth Stacey Pernell-Fluker witnessed was her baby brother's in 1979. Then another brother in a birth center in 1980, and again in 1982—a sister this time—in their kitchen as her mom delivered on a bean bag chair.

Stacey herself was born in a hospital in Ohio a few years before, and when the obstetrician didn't make it into the room in time for her delivery, her parents felt cheated. The family lore, according to Stacey, goes like this: "My dad was like, 'Psh! We paid all this money, and the doctor didn't even show up? We can do this ourselves.'"

When her siblings were born, Stacey was there to help, filling pans of water, holding her mom's hand. Just like that, she was on the path to become a birth worker.

Today, Stacey would tell you she works in the healing arts: "Anything to do with mamas and children." She's a doula, a massage and Thai yoga practitioner, and she homeschools her three kids on her acreage in rural Blount County with her husband Tommy.

We met at a homebirth event this past February in Birmingham, where Stacey told an audience how empowered she felt seeing her mom give birth, how strong a connection she felt to her own body and to her elders. Stacey has this calm confidence when she talks, but she's also funny, a good storyteller. I was struck by the way she commanded the crowd, the way she could get a laugh or cheer with the lift of an eyebrow. If in 20 years, you told me a generation of back-to-the-landers developed a cult-following for Stacey, I wouldn't be surprised. She's that charming.

That night, Stacey's mom, grandmother, and daughter were all in the front row. Her mom simply nodded, solemn, lifting a fist as Stacey talked about the ways we need to shift birth practices in the United States to address the systemic racism that leads to disproportionate death rates for Black mothers and babies, who are twice as likely to die than white babies in the United States and, in Alabama, three times more likely to die.

We're in a moment of radical change for birth workers and activists in this state. For decades, Alabama was one of 23 states where out-of-hospital midwifery was a crime. In May of 2016, the state passed a law decriminalizing the practice of midwifery by licensed Certified Professional Midwives (CPMs), who may attend homebirths. Practicing without those credentials is still a criminal offense here in Alabama and elsewhere.

Even though Stacey is happy more parents might choose homebirth, she's one of many birth workers in the state worried the new law places an unreasonable economic burden on midwives—the cost of certification, licensure, and insurance—when the profession's earning power isn't equivalent to obstetrics.

She's worried, too, that the law continues to ignore issues of access for people of color and people who live in rural areas—people like her.

Stacey Fluker-Pernell, homebirth advocate, looks at her childbirth scrapbook in Kelly Ingram Park in Birmingham, Alabama, where homebirth midwifery is now legal for the first time in 40 years. Photo by Katherine Webb-Hehn.

A few weeks after I saw her speak, Stacey and I met at Kelly Ingram Park in Birmingham to talk about her personal history with homebirth and how it relates to what's happening in Alabama now. It felt important to be in that space, a historic site adjacent to the city's Civil Rights Institute and the 16th Street Baptist Church where four little girls were murdered in a bomb blast by Klansmen in 1963. Today, along the park's meditation walk are commemorative statues of the Movement, stone figures of police dogs forever lurching at the children who sought basic rights.

Stacey and her siblings spent their childhood as the only Black kids in a tight-knit Portland, Oregon, community where homebirth, usually attended by a midwife, was the norm. She was an adult when she learned most babies are born in hospitals. When she and her husband Tommy got pregnant with their first child in 2006, they were living here in Birmingham.

At the time, hiring anyone—a midwife, an OB, a friend—to attend a homebirth was illegal in the state. By then, Stacey had seen friends give birth in hospitals. She had seen the ways they felt restricted during labor, unable to move freely or resist unnecessary interventions.

As long as Stacey and her baby remained healthy, she was determined to birth at home. But finding a midwife proved challenging.

"It was like… middle-of-the-night knocking on doors on the hunt for this clandestine community," Stacey said. Many women she spoke to had traveled across state lines to deliver in a birthing center or in a loved one's home. But surely, Stacey and Tommy figured, midwives had to be attending births in Alabama underground.

After all, Stacey had read the history of the Black "granny midwives" in rural Alabama, and about women who learned midwifery from a mentor. One of those women, Margaret Charles Smith, literally wrote the book on homebirth, having delivered 3,000 babies in her career. As documented in the 2006 book, The Life Story of an Alabama Midwife, Smith had a historic infant and maternal mortality success rate, losing only a few babies and no mothers during her career, all the while serving people—mostly Black women like herself—whose lives, by her own account, were not being lived in an environment that led to good health.

Smith worked until the state stopped issuing licenses to midwives in 1976. The shift toward criminalizing midwifery in Alabama began in 1970, coinciding with the birth of a new program in the state: Medicaid. Because Medicaid covered the cost of childbirth, folks who hadn't been able to afford care or hadn't been allowed in hospitals due to 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.

The same thing played out across the country, hitting Southerners hard. As the government subsidized birth costs, and hospitals sought a previously ignored clientele, a counterculture wave of women began to distrust the institutionalization of birth. These folks saw unnecessary interventions for healthy pregnancies—episiotomies, inductions, etc.—and the over medicating of mothers as a way to rob people of a potentially empowering experience. They also feared long-term effects associated with health risks of unnecessary interventions and rising rates of Cesarean sections.

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 had built a profession for themselves were now without work, deemed dirty and illegitimate by the white leaders of the state.

"Maybe it's naïve, but I like to think these granny midwives are still out there, passing the practice on hand to hand, to women who have the intuition for it," Stacey said.

She and Tommy never found a Black midwife. At the time, there was a lot of fear among midwives about who to trust. Just a few years before Stacey's pregnancy, in 2002,  a well-known white midwife was arrested. Ironically, that same year, Margaret Charles Smith was inducted into the Alabama Women's Hall of Fame.

Eventually, they did meet and hire a white midwife (who no longer lives in this country) and her apprentice.

Stacey's friends and family weren't entirely supportive of the decision. She said she was surprised her loved ones would be "so far removed from our roots." As she put it, "Black women were forced to have homebirths back in the day. Rural women didn't have an option. So, that practice was birthed out of necessity."

Today, Stacey thinks the institutionalization of birth has forced Black families into a system where the model of care is clearly failing them.

Stacey Pernell-Fluker points to a photo of midwife Layla Brown, taken during Stacey's second child's birth when homebirth was still illegal and Layla worked underground. Photo by Katherine Webb-Hehn.

A few times, as Stacey tried to make a point about race, she simply waved her hand toward the commemorative statues in Kelly Ingram Park.

Stacey doesn't have to say it.

The United States is one of 13 countries in which maternal mortality rates have gotten worse over the past 25 years, according to the CDC, which recently reported that 700 women die every year in childbirth. Even though research suggests those numbers plateauing, Black women and their babies die at rates three to four times higher than white women and their babies.

As another birth worker told me: "Even for Black birth-givers who live in well-resourced communities and who have similar education and economic ability, they still have adverse outcomes compared to their white counterparts."

As for Alabama? A 2014 study determined the state to be the worst place to have a baby. In 2016, infant mortality rates here increased—and they are twice as bad for Black babies as white babies.

Advocates for midwifery believe its alternative model, which emphasizes more holistic health practices and community support during pregnancy and post-partum, can be part of a solution to this crisis. The thinking is this: If healthy pregnancies are attended by midwives, as they are in other parts of the world, and complicated pregnancies are attended in hospitals, then better care can be provided to all.

That's only true if all birth-givers have the opportunity to be served by midwives in their communities. Nearly 1.3 million Black people live in Alabama, but in my research and interviews for this story, I didn't connect with any Black CPMs in the state. The number of CPMs working (and any demographic information about them) is not officially tracked, so it's certainly possible that women of color are working as midwives in Alabama, and simply are not opening themselves or their practice up to a white journalist. As for white CPMs, I spoke to three who work in the Birmingham area and know of others throughout the state already practicing or taking steps for certification.

Reproductive justice activist Melodi Stone in Birmingham is looking to central Florida midwife Jennie Joseph for an integrated model of care. Photo courtesy of JennieJoseph.com.

At the same event where I first saw Stacey speak, people kept referencing an underground midwife who attended their homebirths—"I don't want to say her name, but she's here tonight," they said, all wink, wink—until finally a woman stood up and gave a dramatic wave. "You can say my name! Layla Brown!"

Before the law passed last May, Layla was one of a handful of midwives attending homebirths here. She was the apprentice at Stacey's first birth, the midwife at the next.

Layla is an Alabama native with an unmistakable accent. She's white and short with a big smile and bigger personality. A registered nurse and mother of six, Layla has spent most of her adult life attending births here underground. When we met for an interview, she was eager to be "out" after so many years of working in isolation. Those were lonely years, she said, especially after the woman who trained her moved away, and the few other midwives she knew were scattered across the state. There wasn't anyone to call for backup, no one to grab coffee with to rehash a birth or talk shop.

Layla recently earned her CPM and became one of three women in Alabama certified by the North America Registry of Midwives to train and sign-off on new midwives. "I felt like I wasn't seen as a professional until I had that little piece of paper. It's like I had to prove myself for something I've been doing for 15 years."

Until last May, Layla arrived in secret on her clients' doorsteps. Tucked inside her bag were the things she'd need to assist in delivery: gloves, a stethoscope, sterile scissors and a cord clamp, a Doppler, a flashlight, the mom's charts. She also carried equipment for emergencies: a backboard in case of neonatal resuscitation, a needle and syringe for hemorrhaging. In the few hundred births she attended, Layla had to call 911 twice to transfer moms into hospital care when hemorrhaging was beyond her control. (Both of those women and their babies were ultimately OK.) When paramedics turned up, she pretended to be a friend. "But they knew. Of course, they knew."

If anyone ever turned Layla in, she would have been charged with a misdemeanor. Caught repeatedly in Alabama, Layla could have faced a felony charge.

Legalization means Layla doesn't have to work in fear of being arrested anymore, but she said it won't solve the problem of access to midwifery. In all those years, most of Layla's clients were white families, either in the city or its suburbs, who could afford to pay her $3,600 fee out of pocket. That fee may rise depending on the state's new policies. Whether or not individual insurance companies in Alabama will cover midwifery care is still unknown. Based on current speculation, Layla says her overhead next year could be equivalent to the cost of half her births.

Right now, Layla and other homebirth advocates are in limbo, waiting for official regulations to better understand if legal practice will be sustainable. A state-sanctioned board of midwives and medical professionals is establishing the requirements for state licensure, a process that comes with its own tensions and debates, in particular what constitutes a legitimate education.

There are generally two pathways to become a CPM: attending a special university or direct-entry. Direct-entry midwives learn through an apprenticeship similar to the hand-to-hand education of "granny" midwives that also requires supplemental college coursework. Layla is an advocate for the apprenticeship model as it allows midwives to remain in their communities throughout their education, and it costs significantly less than the sometimes six-figure tuition fees of midwifery universities. Opponents of direct-entry fear that learning from a single preceptor limits the student and puts them in a situation where they're paying to work or working for free. But midwives like Layla value the ability to learn the practice without leaving their homes, families, and jobs. Of the dozen midwifery schools in the United States, the closest to Alabama is in Gainesville, Florida or Summertown, Tennessee.

Beyond educational styles, beyond fees and regulations, what birth workers are really contending with is the ongoing question of access: When licenses start being issued again to midwives, who will be welcome to practice midwifery and who won't? And who might lose out, or be left out of the conversation?

A mother and her newborn after a homebirth in 1952 featured in The Life Story of an Alabama Midwife, a book about Black midwife Margaret Charles Smith who delivered 3,000 babies in her career in rural Alabama.

Melodi Stone is a doula in Birmingham who got interested in reproductive justice in college.

"It was the ah-ha moment where my work as an organizer, public health education, survivor, and social justice educator came together," Melodi, who uses the pronouns they and them, told me recently in an online chat. I reached out to Melodi because they're one of the few people of color active in the predominantly white birth-worker community here in a predominantly Black city. Melodi comes from an activist background and is thinking through approaches to integration—both how to take the practice of midwifery from an underground profession to the mainstream public, and how to include communities of color in that change.

They're hoping more white people will join in the necessary work of creating pathways to a solution, not just acknowledging that a racial problem exists. "There honestly needs to be more of professional reparations because white women now have been able to take over this art and turn it into a market, and the people who the model of care originated with in the first place have been denied entry into the profession via social and financial barriers," Melodi said.

Melodi believes now is the time to do this work, as the professional framework for the state is being laid.

"We need to create a pathway for the people who live in the most underserved communities and the people who have the cultural competence to do the work to gain entry into the profession," Melodi said. That pathway, they added, should include scholarships, a mentoring network, business network, and a professional association offering technical support to birth workers in those communities.

Melodi looks to Jennie Joseph as a mentor, a Black CPM who lives and works in central Florida, where her integrated model of care, focused on uninsured and low-income families, has had positive effects on low birth weights and premature births in all racial and ethnic groups.

Melodi wants to make programs like that possible in Alabama, "Whether that's through embracing cooperative economics as a means to operate the birth business, or creating more funding streams for rural Black birth centers, or whether that is through public health advocacy to urge the state to help these small southern Black midwives to reduce maternal mortality, to make the work more effective, to help them conduct their research," they said. "We need more Jennie Josephs in Alabama."

For Melodi, the law is just the first step. "Now we need to make sure as this profession opens, that it's open to everyone."

Katherine Webb-Hehn

Katherine Webb-Hehn is a mama, multi-media journalist and artist in Birmingham, Alabama.