Laying the groundwork

More than a 25 years ago, David and Desiree Smolin of Homewood began advocating for Alabama midwives. While the parents of eight were not part of the successful legislative effort earlier this year to overhaul the state’s law on midwifery, they are excited to now have certified professional midwives legal in Alabama with the passage and signing of the Childbirth Freedom Act in May. 

“I was totally amazed because I’d almost given up,” Desiree Smolin said. “I have a lot of faith in the legislators in our state that if they actually hear the arguments, they actually are very open minded, but the key is getting it to the floor for them to hear it.”

The Smolins have testified for midwifery support since 1991, including David Smolin, who has testified several times over the past two decades — both before and after the establishment of the Alabama Birth Coalition, which organized the passage of this year’s bill.

“I just admire their tenacity and am excited beyond measure that they’ve succeeded,” said David Smolin, a constitutional law professor and director of the Center for Children, Law and Ethics at Cumberland School of Law. “The kind of genius of this generation’s approach was educate them year-by-year and don’t give up.”

The Smolins’ path to home birth advocacy began in 1990, when they chose to deliver out of hospital after a “horrible birth” experience at a Birmingham-area hospital three years earlier. In 1987, their Vaginal Birth After Cesarean (VBAC) attempt turned into another C-section after a chain reaction of medical interventions. Sickness and a bad overall experience came from the birth.

“You have to come to the point of being willing to question the medical establishment, and we were at that point. The second birth, and everything around it, was so bad,” David Smolin said.

After nearly six months of studying in the local medical school library, the couple educated themselves on World Health Organization standards, C-section rates and ways to prevent them. They put together a low-intervention birth plan for another attempt at an in-hospital VBAC. Limited on doctor choices due to their HMO, they landed at a different Birmingham-area hospital, but the birth plan was not well received. 

“‘Don’t worry about that, little lady, I’ll take care of you,’” Desiree Smolin recalled the doctor saying. “‘If it were that easy to give birth, women would be having their babies under trees.’”

The family found another doctor willing to follow the birth plan, but he was not covered by their insurance. Faced with the decision to use the doctor covered by the HMO, who she was receiving prenatal care from, or pay out of pocket for the other physician, a friend floated the idea of a home birth, something Desiree Smolin once said she’d never do.

That September, she gave birth to her third son at home with a midwife. 

“It was one of the most amazing things in my life,” Desiree Smolin said. 

And when her prenatal OB-GYN called to inquire about her birth, she said, “you know what, it was that easy.”

The whole process of learning more about child birth options was an eye-opener for the Smolins.

“The whole basic question was, ‘Is childbirth a natural event?’ Fundamentally, yes, it’s a natural event where things can go wrong, but it is fundamentally, for a healthy woman and a healthy baby, a natural event,” David Smolin said.

They recognized that OB-GYNs provide a set of skills and care, which includes life-saving C-sections, but so do midwives, who aim to deliver naturally when possible. 

The setting at home was different for Desiree Smolin. She said instead of being told what she couldn’t do, she was encouraged about what she could do. 

“It was very, very empowering, special … and healing,” Desiree Smolin said. “It’s like a choreographed dance where the midwife is the choreographer and she knows how to bring you along. She knows the emotional stages of labor.”

But the home birth euphoria didn’t mean that was the only way. For birth No. 4, now that her insurance had changed, Desiree Smolin delivered at the hospital with the OB who previously approved her birth plan. When they found out they were expecting a fifth child, they consulted with their doctor about having another home birth. He signed off on it and continued prenatal care simultaneous to the midwife’s prenatal care. 

When labor began, the midwife quickly realized the baby was footling breach, a high risk situation, and transferred care to the doctor, who discussed options openly with the midwife prior to going into a C-section. 

“The doctors were extraordinary with their cooperation, and that is critical,” said David Smolin.

This kind of open dialogue between midwives and hospital personnel is what the Smolins hope to see increase now that certified professional midwives will be legal and licensed. 

“That will be the challenge with having this midwifery law is having doctors who are open-minded enough, because midwives are very, very smart, and they know when to throw the towel in and they know the signs that this is a woman who needs to be somewhere else,” Desiree Smolin said.

How the journey unfolded

The Smolin’s home birth was before the courts ever attempted to prosecute a midwife in Alabama.  

After the adoption of the Code of Alabama 1975, permits for midwives began to disappear from county health departments, leaving certified nurse midwives as the only legally licensed midwives in the state.  

“When you stopped licensing them, it wasn’t that women’s health care was replaced by other people, it just simply stopped. There was nobody giving prenatal care,” Desiree Smolin said. “We were very aware there was this big gap in women’s healthcare in Alabama. We realized this was a treasure we used to have, and it’s not there anymore.”

However, advocates argued the statute was not clearly against non-nurse midwives. That changed when midwife Toni Kimpel was charged with multiple misdemeanors for practicing without a nurse-midwifery license in the early 1990s. While Kimpel won her case at trial, the state appealed to a higher-court and won. Kimpel’s appeal to the Alabama Supreme Court was denied in 1995, thus establishing the legal precedent in Alabama. 

In 2002, another midwife, Karen Brock of Cullman, was prosecuted under the same charges as Kimpell, which revamped the legislative efforts, leading to the formation of the Alabama Birth Coalition. 

Advocacy for legislation increased over the last decade as midwives began to practice along the state’s borders or “underground” out of concern of their legal status. 

After 13 years of trying, a midwifery bill, HB315 to decriminalize midwives, cleared a House subcommittee and went to the floor for a vote for the first time ever this year. It passed the House on April 25 by an 84-11 vote. A month later, on May 19, the bill cleared the Senate unanimously after a near six-hour debate and conference resulted in a compromise between opponents and supporters for an amendment to establish a regulatory board and state licenses. Gov. Kay Ivey signed the bill the following Wednesday.

From February to May, supporters of the bill showed their faces in Montgomery, meeting with legislators, encouraging emails from Alabamians across the state and even sitting in the Senate gallery nearly every day during the final week of the session until the bill was passed on the final day. 

“The women that went down this year, I really think the group of them did it in the end,” Desiree Smolin said. “We laid the groundwork, but it took them pushing it over the edge.”

Why midwives? 

Supporters say passage of the bill will help educate more expectant mothers of having midwives as another birth option in Alabama, along with OB-GYNs and certified nurse midwives, especially if the mother is considered low-risk and is seeking an intervention-free birth. 

With Alabama not having any free-standing birth centers, the push for midwives is to extend care in the rural counties of Alabama where obstetrics care has faded over the years and provide an additional choice in urban communities. 

In 1980, all but nine of Alabama’s 67 counties had a hospital with obstetrics care, according to the Alabama Birth Coalition. Today, only 29 Alabama counties have such care. According to the Alabama Rural Health Association, only 16 of the 54 counties classified as “rural” had hospitals providing obstetrical care as of March 2016. 

Another concern midwives expressed over the past year is Alabama’s failing grade on the March of Dimes Preterm Birth Report Card. 

Alabama is one of three states in the nation to receive an “F” on the 2016 report, ranking 47th in the nation with a preterm birth rate of 11.7 percent. Jefferson County also received an “F” at 11.6 percent. The hope is that midwives will be able to provide more individualized care by taking on only three to six births a month, based on national averages, and extended prenatal visits to help educate mothers on nutrition to remain low-risk and avoid preterm labor.

Once the law goes into effect this fall, Alabama will be the 33rd state to license certified professional midwives, but will become the first state in the U.S. to establish a fully independent board of midwifery, according to long-time advocate and certified professional midwife Jennifer Crook of Cahaba Heights.  

Under the law, the board will be appointed by the governor and will consist of four certified professional midwives, a certified nurse midwife, a nurse practitioner, a person who has used the services of a CPM. Supporters are expecting it to take about a year before the state can begin issuing licenses.  

Midwives wishing to practice in Alabama must be certified by the National American Registry of Midwives (NARM), which requires completion of a portfolio evaluation of a potential midwife’s training, which require 40 births and newborn screenings and 75 prenatal visits under the supervision of a qualified preceptor. Candidates must also complete the NARM Written Examination. Those wishing to learn more about becoming a midwifery can visit narm.org 

Legally, mothers in Alabama can have a home birth without assistance of a midwife; however, the passage of the Childbirth Freedom Act will allow certified professional midwives to attend the birth, which are traditionally only for low-risk births. 

The bill places restrictions on which births can be attended by a midwife, taking twins, breech delivers and vaginal births after a cesarean (VBAC) off the table, which were all concerned safety concerns by opponents. 

The bill also requires midwives to carry liability insurance of no less than $100,000 per occurrence.

While Desiree wishes VBACs, like hers, were an option, she says she recognizes the need to concede on certain items to pass the bill. She hopes one day VBACs will be more common in Alabama through all birth options and locations.

For specific questions related to Alabama’s certified midwife process, the Alabama Birth Coalition can be emailed at alabamabirthcoalitioninfo@gmail.com.