Aly Bolin

POLI 4967

Dr. Hunt

November 22, 2014

Introduction

Though American mothers increasingly seek alternative, less medicalized prenatal

care and birthing practices, the American healthcare system, as well as legislation

regulating that system, lags behind. This paper explores the motivations for alternative

birth practices, specifically midwife assisted home births, examines the scientific

evidence regarding the safety of these practices, and analyzes American maternal

healthcare policies. The analysis of American healthcare policies focuses specifically on

Alabama, the state with the most restrictive midwifery and home birth regulation.

Alternative Birth Practices

Motivations

The specific motivations for choosing a home birth or a midwife-assisted birth

vary, as mothers make the choice based on their own individual values and beliefs. Many

women base their choice on personal or religious beliefs, and some make the choice

based on scientific evidence. Many mothers choose a midwife-assisted home birth in

order to avoid the medical interventions that are commonly associated with hospital

births, as many of these interventions have both short and long-term consequences for

mother and baby (Watterberg, 2013). The American Academy of Pediatrics recognizes

the loss of control mothers experience in a hospital as “a factor consistently reported as

the number one reasons why women choose home birth”. According to The Big Push for

Midwives, a nonprofit organization advocating for the expansion of out-of-hospital

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maternity care in the Untied States, the leading reasons women opt for out-of-hospital

birth are safety concerns and the desire for an intervention-free birth. Other primary

motivations are previous negative hospital experiences and the need for a sense of

personal control during birth.

Demographics

Dinah Meyer, practicing psychologist and contributor to Psychology of Women

Quarterly, eloquently summarizes the popular view of women who choose alternative

birth practices when she writes, “today, the mention of a midwife as the primary

childbirth practitioner conjures up images of long-haired, colorfully dressed women who

wear Birkenstocks and insist on drumming throughout the labor process” (Meyer, 2007).

This image complements the stereotype that women choosing midwife-assisted or home

births are uneducated or uninformed and, therefor, do not understand the risks and safety

concerns of home or midwife-attended births. This stereotype is frequently

used as part of the counter-argument presented by those who oppose out-of-hospital

births. (Declercq, 2012). This argument is entirely unfounded, as shown by the statistical

information available about women who have midwife-assisted or home births. Mothers

who choose out-of-hospital births are also primarily middle to upper class, educated

women, with most having received a college degree (Alabama Midwives Alliance,

2009).The vast majority of mothers opting for out-of-hospital births are Caucasian, with

one in ninety Caucasian births taking place out-of-hospital, as compared to one in three

hundred fifty seven African American births and one in five hundred Hispanic births

(The Big Push for Midwives, 2014). This dispels the historical argument that midwives

are primarily utilized in poor, African American communities and, therefor, were usually

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unhygienic and unsafe. Though this was previously the case, that trend ended with the

passage of Medicaid legislation in the 1960s, which allowed poor African Americans, as

well as poor whites, to give birth in hospitals (Alabama Midwives Alliance, 2009).Today,

midwife-assisted birth other alternative birth practices, are primarily utilized by the

middle and upper class. The increasing rates of home and midwife-assisted births are

associated with the growing health consciousness of Americans, but these practices are,

currently, mostly accessible to individuals of higher socioeconomic status, as financial

barriers to alternative care exist (Amnesty International, 2010).

Financial Barriers

Along with lack of awareness, societal attitudes and misinformation, finances are

one of the leading reasons why American women so disproportionately give birth in

hospitals. Twenty-seven states have no requirement for medical insurance corporations to

reimburse midwives, regardless of the practitioner’s certification. In the other thirty-three

states, private insurers must provide reimbursement for midwives, but the amount of, and

requirements for, reimbursement are determined by the insurance company. Many

insurance agencies will only provide reimbursements for midwife care administered in a

hospital, which does not fit the birth plan of many women who choose midwife-assisted

births (Amnesty International, 2010).In Living with Risky Coverage Gaps, the author

interviews Kavita Daswani. Daswani, a successful novelist and fashion writer, moved to

the United States from Hong Kong in 2001. With the purchase of health insurance,

shortly after her move, Daswani and her husband experienced their first shock over the

insurance agency’s maternity care policy. The agency required new customers to wait at

least twelve months from the purchase of their policy before receiving any maternity

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benefits. In other words, the company required Daswani and her husband to wait a year

before conceiving, if they wanted Daswani’s prenatal care to be covered by the agency.

Daswani learned she was pregnant before the twelve month period was over and she

recalls a heated conversation she had with the agency- “I told them a company shouldn’t

dictate when a client gets pregnant.” After successfully arguing her way to receiving

maternity care benefits, Daswani received her second shock; her insurance company

would not provide coverage for a midwife or home birth. Daswani opted to have a

midwife assisted home birth anyway, though she and her husband would have to pay the

costs out of pocket. The estimated out-of-pocket cost for prenatal midwife care, a doula,

birth assistance, and follow-up visits totaled around $5,000. After thirty-six hours in

labor, Daswani’s midwife recommended she have a Cesarean Section at the local

hospital. In an ironic twist of fate, because her delivery was an emergency procedure,

Daswani’s insurance company provided almost full coverage of the costs, paying almost

$17,000 of the bills. Daswani learned a great deal about the American health insurance

industry, telling the interviewer, “insurance is a potential minefield. The reality is, it’s up

to the consumer to identify what they need” (Wilson, 2004). In an excerpt from a

personal interview in Amnesty International’s Deadly Delivers, a Wisconsin resident

describes the cost of her daughter’s home birth and the insurance company’s refusal to

cover the expenses, despite the fact that the home birth cost far less than a hospital birth-

“My daughter chose to have a midwife deliver her baby at home, for a cost of $2,500. In

the hospital system it would have cost $12,000, but because it was at home, insurance

wouldn’t pay for it” (Amnesty International, 2010).

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The Case for Alternative Birth Practices

According to the Canadian Medical Association, “Few issues in maternity care

remain as contested and unresolved as the debate surrounding the safety of home birth

versus hospital birth” (McLachlan & Forster, 2009). The American Academy of

Pediatrics notes that caution should be exercised when drawing conclusions or making

generalizations about any birth practice, as safety, or the lack of, is not a “dichotomous

outcome”. Not all instances of any one birth practice are safe, nor is any one birth

practice significantly safer than others (Watterberg, 2013). The idea of safety is

extremely complex, as safety has different meanings for different individuals (McLachlan

& Forster, 2009). Home birth, as well as midwife-assisted birth, is a very difficult topic to

research, as it is a “profoundly intimate subject, and is fraught with personal

significance” (Declercq, 2012).

The primary argument of opponents of midwife assistance and home birth

involves safety concerns. Many are uncomfortable with the idea of birth taking place

outside of the hospital and have misconceptions about the risks associated with home

birth. Those opposed to alternative birth practices, such as midwifery and home birth

must be unaware that scientifically-sound studies have proven that midwife assisted

home births are no less safe than hospital births, when responsibility and caution are

exercised.

One of the most comprehensive studies of the outcomes of midwife assisted home

births, midwife assisted hospital births, and physician assisted hospital births, published

in the Canadian Medical Association Journal, found that perinatal death rates associated

with midwife-assisted home births were very low and comparable to perinatal death rates

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associated with hospital births. Researchers studied 862 planned midwife-assisted home

births, 571 midwife-assisted hospital births, and 743 physician assisted hospital births.

The resulting data concluded that the perinatal death rate among the planed home births

was .35, the rate among midwife-assisted hospital births was .57, and the rate among

physician attended hospital births was .64. The study also concluded that planned

midwife-assisted home births had reduced rates of medical intervention and negative

maternal outcomes, such as perennial tears or hemorrhages (Janssen, Saxell, Page, Klein,

Liston, & Lee, 2009).

Opinions of Medical Communities

Most developed countries recognize, and support, the need for personal choice for

pregnant women, though this notion seems contradicted by the lack of birthing options

women in developed countries actually have. Throughout the developed world, most

women give birth in hospitals. The highest rate of out-of-hospital births occurs in the

Netherlands, with over one-third of mothers giving birth at home (McLachlan & Forster,

2009).

American medical schools, including those that specialize in obstetrics and

gynecology, widely oppose home birth. Internationally, Australian and New Zealand

medical colleges are also primarily opposed to home birth practices. The United

Kingdom’s Royal College of Obstetrics and Gynecology, as well as its Royal College of

Midwives, supports the practice of home birth in uncomplicated, low-risk pregnancies.

Australian, New Zealand, and Canadian midwife associations and colleges also support

home birth for low-risk pregnancies. The Society of Obstetricians and Gynecologists of

Canada has avoided issuing a blanket statement of support or opposition regarding home

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birth, citing the need for further research (McLachlan & Forster, 2009). Both the

American Academy of Pediatrics and the Canadian Medical Association recognize the

limitations of the existing research both in support of and in opposition to home birth and

midwife-assisted birth. According to the American Academy of Pediatrics, many existing

studies are based on Apgar scores and birth certificate information (Watterberg, 2013).

Apgar scores are based on a brief examination of an infant within five minutes of birth.

Possible Apgar scores range from one to ten and are based on the infant’s breathing, heart

rate, muscle tone, reflexes, and skin color (Medline Plus, 2011). The American Academy

of Pediatrics notes that the medical community widely recognizes the Apgar score as an

inadequate measure of an infant’s health, making it an inappropriate measure on which to

draw conclusions about birthing practices. Birth certificate data also has its limitations,

according to a National Vital Statistic Report published by the U.S. Department of Health

and Human Services (Martin, Wilson, Osterman, Saadi, Sutton, & Hamilton, 2013). The

Canadian Medical Association further notes the limitations of existing studies, citing

selection bias and the lack of comparison groups, statistical power, and certainty about

data submission. According to the Canadian Medical Association, “a well-designed,

well-conducted, and adequately powered randomized controlled trial would assist in

answering many questions about home birth”, concluding their statement on home birth

with, “the debate about the safety of home birth cannot be driven by ideology. The call

for better evidence remains” (McLachlan & Forster, 2009). Despite the limitations of

current data, both the Canadian Medical Association and the American Academy of

Pediatrics have concluded that planned home birth is safe for women with low risk

pregnancies who are cared for by qualified midwives with access to a hospital in the

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event of an emergency (McLachlan & Forster, 2009). A 2006 study by the United States

Department of Health and Human Services found that 83% of women in the United

States have low-risk pregnancies, yet less than 1% have out-of-hospital births and only

8% have midwife-assisted births (in or out of hospital) (Martin, Hamilton, Sutton,

Ventura, Menacker, Kimeyer, & Matthews, 2009).

Midwifery in the United States

In the United States, individual states, not the federal government, possess the

authority to regulate birth practices, including midwifery and home births. Given that this

authority lies with the states, there are no uniform policies, rules or regulations, or

licensing boards. Instead, there are fifty unique sets of policies, rules and regulations, and

licensing boards. This fragmentation presents a challenge when studying maternity care

and maternal health policies at a national level.

There are five classifications for American midwives- Certified Midwife,

Certified Nurse-Midwife, direct-entry midwife, Certified Professional Midwife, and

traditional midwife (Association of Midwifery Educators). Certified Midwives (CMs) are

certified as such by the American College of Nurse-Midwives. In order to receive this

certification, certified midwives must demonstrate experience and knowledge in the

discipline of midwifery. There are no training or education requirements for this

certification. Certified Midwives are only able to legally practice in three states (The Big

Push For Midwives, 2014).

Nurse-midwives, often referred to as Certified Nurse-Midwives (CNMs) are

licensed nurses who have undergone additional midwifery training. Nurse-midwifery

resulted from a conscious effort among the midwife community to establish educational

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standards and credentialing for midwives (Meyer, 2007). Nurse-midwives are legally

authorized to practice in all fifty states, though specific restrictions apply in each state. In

many states, nurse-midwives are only able to practice in conjunction with a licensed

physician or in a hospital. Furthermore, most states do not allow nurse-midwives to

prescribe medicine (The Midwives Alliance of North America).

Midwives who have not attended nursing school are considered direct-entry

midwives. This is not to say these midwives are untrained, as they usually complete self-

studies, apprenticeships, or various other midwife-training programs (The Midwives

Alliance of North America).The legality of direct-entry midwives depends on the specific

categorization of the midwife, as direct-entry midwives are further categorized as

Certified Professional Midwives, Certified Midwives or Traditional Midwives.

Certified Professional Midwives (CPMs) are direct-entry or Certified Nurse-

Midwives who have met the certification standards of the North American Registry of

Midwives. The certification process for Certified Professional Midwives is the only

process requiring extensive understanding and experience in out-of-hospital settings (The

Midwives Alliance of North America). Certified Professional Midwives are able to

legally practice in twenty-eight states, making them unable to legally practice in twenty-

two. Within these twenty-two states, fourteen currently have active legislation to legalize

midwifery and three have planned legislation. The remaining five states are continuing to

organize their advocacy efforts and political activity (The Big Push for Midwives, 2014).

Traditional midwives are the rarest form of practicing midwife in America.

Traditional midwives have no official certification or license, often refusing these

qualifications based on religious, personal, or philosophical reasons. According to the

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Midwives Alliance of North America, traditional midwives “believe that they are

ultimately accountable to the communities they serve; or that midwifery is a social

contract between the midwife and the client/patient, and should not be legislated at all; or

that women have a right to choose qualified care providers regardless of their legal

status” (The Midwives Alliance of North America).

The Political Issue

According to Eugene Declercq, Professor of Maternal and Child Health at Boston

University’s School of Public Health, home birth, as a political issue, is unique in two

primary aspects. Based on his extensive research on the subject, Declercq concluded that

home birth policy debates are not split over typical partisan lines, but are increasingly

being treated in the same manner as many other current political issues- with gridlocked

votes and a lack of real action.

Declercq argues that, because of the issue’s personal nature, it does not “fit neatly

into classic models of political ideology” (Declercq, 2012). Policies involving birth

practices have various representations depending on one’s political philosophy. For

political conservatives, midwifery and home birth may be linked to family values,

religious values, and personal liberties and freedoms. For political liberals, these practices

can represent a challenge to societal norms by allowing women a sense of control over

their bodies. When analyzing existing research, Declercq found that a state’s political

makeup is not a significant indicator of its home birth policies. For example, in states

where midwifery is legally regulated, 54% of legislators are Republican, as compared to

51% in states where midwifery is illegal. Declercq references a 1995 study by John

Kingdon, which found that the power of personal experience, often utilized by lobbying

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firms, dictates agenda-setting. In an interview conducted as part of the study, one

Congressman tells Kingdon that lobbyists representing the medical community, research

firms, and insurance companies, “know which congressman’s mother died of which

disease, and which one’s wife has which disease, and they play on it” (Kingdon, 1995).

Declercq also references a previous study of his own, in which he asked United States

legislators why they voted as they had on a policy involving early postpartum discharge.

Almost every response included a reference to a personal experience involving childbirth

or the experience of someone the legislator knew, even if the exact experience was

irrelevant to the particular policy. Declercq summarizes his conclusions nicely, writing,

“the ideological fight over home birth is not between political liberals and conservatives,

but rather, over differing perspectives on birth” (Declercq, 2012).

Despite the unique nature of home birth, Declercq describes how the issue is

being increasingly handled similar to other current political issues. Though home and

midwife-assisted births are, in themselves, apolitical events, they have become

increasingly politicized. Current political debates involving alternative birth practices

often culminate in gridlocked decisions following heated, emotional disputes. The

political debates stem from “professional battles between midwives and the medical

community, with each side seeking legislative allies, drawing on personal ties, etc.”

(Declercq, 2012). As with most political issues, financial capabilities have a strong

influence on the success of a campaign. In 2010, The Big Push for Midwives, spent

$20,000 on legislative efforts, compared to the Obstetrics/Gynecology Political Action

Committee, which spent over $380,000 (The Big Push for Midwives, 2014).

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Declercq blames the lack of political action on the insularity of both sides of the

debate- the medical community and the alternative birth community. Both sides are very

passionate and, therefor, unwilling to concede to the other. Declercq concludes this

article with a call to action “for grater willingness for all sides to approach home birth

less as an ideological mission and more as a health policy challenge” (Declercq, 2012).

Declercq encourages health care policy makers to abstain from unproductive approaches,

such as emotional debates and unwillingness to compromise, and focus on making an

effective policy on alternative birth practices. As consumers increasingly want more

integrated health care, the system must heed those wishes. The final sentence of

Declercq’s article perfectly summarizes a frequent critique of the United States

healthcare system, as he writes, “families deserve better from a maternity care system as

rich in resources and committed to improving outcomes as the United States” (Declercq,

2012).

History of Midwifery and Home Birth in the United States

“In the U.S. in the 20th century, a midwife attended nearly all women who gave birth at

home, regardless of race, ethnicity, or socioeconomic status. No obstetricians, hospitals,

or fetal heart monitors were used, and everyone usually did just fine” (Meyer, 2007).

At the turn of the twentieth century, as the medical community grew into a

medical market, Americans increasingly sought care from licensed physicians. According

to a physician interviewed in the documentary The Business of Being Born, “in the

United States, when birth went into the hospital, midwives didn’t go with it” (Epstein &

Lake, 2007).

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At this time, many American women, especially in the rural South, could not

afford a physician-attended hospital birth, and so they continued to rely on midwives to

safely deliver their babies. Segregation provided yet another obstacle for African

American women to access to hospitals and licensed physicians, as did poverty, for both

black and white women. These factors resulted in the trend of African-American

midwives, often referred to as “granny” midwives at this time, serving poor populations

(Alabama Midwives Alliance, 2009). Trends such as this made it possible for the medical

community’s smear campaign against midwives in the early 1900s. Hospitals and doctors

dissuaded women from giving birth with a midwife, portraying midwives as untrained,

unhygienic, and unsafe (Epstein & Lake, 2007). In the North, anti-midwife propaganda

often portrayed midwives as uneducated, “old country” immigrants, while campaigns in

the South utilized the image of the illiterate, poor black woman. Southern anti-midwife

campaigns often went so far as to suggest that black midwives might intentionally harm

white mothers and infants (Epstein & Lake, 2007). Despite the medical community’s

anti-midwife stance, statistical information has shown that, in the early 1900s, it was

actually safer to give birth with a midwife than in a hospital. Many doctors graduating

from medical school at this time had never actually seen a live birth (Epstein & Lake,

2007). The implementation of Medicaid legislation in 1965 provided physicians and

hospitals with a new source of income- poor citizens. Poor women, previously the

primary demographic served by midwives now gave birth in hospitals, rendering

midwifery a virtually nonexistent practice (Alabama Midwives Alliance, 2009). In the

1970s, there was a surge of enthusiasm over alternative health care options, including

maternal health care. To meet the renewed demand for midwives, American women

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began studying and training to be midwives. Many organized into professional groups,

founding The Midwives Alliance of North America and The North American Registry of

Midwives. In 1994, the North American Registry of Midwives created the Certified

Professional Midwife qualification, the first national certification for American

midwives.

In the past decade, American women have once again increasingly embraced

alternative maternal care. Though less than 1% of births in the United States today take

place outside of a hospital, the rate of these births increased nearly 30% from 2004-2009

(MacDorman, Matthews, & Declercq, 2012). No conclusive data has been published, but

experts expect out-of-hospital birth rates have continued to rise since 2009. With this

renewed interest in alternative maternal health care, advocacy groups across the nation

have made great strides to reform out-of-date policies regulating home and midwife-

assisted births.

Alabama

History of Midwifery and Home Birth

The history of midwifery and home birth in Alabama is mirrors the national

experience. Until the early 1900s, midwives attended the births of nearly every

Alabamian (Alabama Midwives Alliance, 2009). Alabama issued its first set of

regulations for midwives in 1931. These regulations had a significant impact on

midwives practicing in Alabama at the time. At the direction of the state, county health

departments implemented a demanding screening process for midwives, reducing the

number of state-recognized practicing midwives by more than 50%. It should be noted

that midwives who did not pass the rigorous screening process were still allowed to

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practice, but were not officially recognized by the state. The midwives who passed the

screening process were required to attend a nine month training course and pass a written

exam. Once state-certified, midwives had to adhere to strict rules, including the required

adoption of a standard white uniform and the periodic inspection of their equipment and

homes. These midwives were also required to attend monthly meetings held by local

health departments. These requirements presented substantial barriers for Alabama

midwives, especially in rural areas, where midwives most often practiced. Despite these

obstacles, Alabama midwives still served their communities with “vigilance and skill,

quietly rising above their undeserved reputation as ‘ignorant, filthy, and crude’”

(Alabama Midwives Alliance, 2009). As previously mentioned, the 1965 Medicaid

legislation deprived midwives of their primary clientele. In Alabama, as in most rural,

southern states, midwifery still remained a viable practice for several years.

Racial tensions in Alabama reached an all-time high during the Civil Rights

Movement of the 1960s and 1970s. During this time, racially motivated laws and policies

became an increasingly utilized tactic with which to antagonize the African American

community in Alabama. In 1975, the Alabama legislature begins granting licenses only

to Certified Nurse-Midwives, allowing independent midwives to continue practicing with

valid permits issued by the Alabama Department of Public Health. In 1976 Alabama

legislators enacted Title 34, Chapter 19 of the Code of Alabama, which sought to

virtually eradicate midwifery in Alabama. The law legislatively redefined midwifery to

include only the practice of Certified Nurse-Midwives and created strict regulations that

preventing a nurse-midwife from practicing independently. The policy, still in place

today, allows nurse-midwives to practice only under the authority of a hospital or

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licensed physician. Like most state-wide policies, local agencies were charged with the

implementation of Title 34, Section 19. County health departments inconsistently

enforced the policy, with some actively revoking permits while others continued to

endorse midwifery. Though health departments could no longer issue permits to legally

practice midwifery, most officials failed to explain the new policies or the legal

implications of continued practice to midwives. Many midwives continued to practice

openly through the 1990s, unaware of the potential legal consequences.

During this time, Alabama, like the rest of the nation, was experiencing a

“renaissance of out-of-hospital birth” (Alabama Midwives Alliance, 2009).American

mothers increasingly sought maternal care alternatives. These mothers, mostly middle-

upper class, college educated, Caucasian women, replaced the previous clientele of

Alabama midwives. To meet the growing need for practicing midwives in Alabama, as

many “granny” midwives were retired, Alabama women began pursing midwife

certifications.

Toni Kimpel, of Mobile, became Alabama’s first nationally Certified Professional

Midwife, meeting the North American Registry of Midwives’ Professional Midwife

Certification requirements. In 1995, Kimpel became the first Alabama midwife to

charged with unlicensed practice of midwifery. Karen Brock, of Cullman, became the

second midwife to face charges in 2002. Both women left Alabama to legally practice

midwifery in other states.

Midwifery and Home Birth Today

The only legal form of midwifery in Alabama today is nurse-midwifery, which

can only be practiced in hospitals or with licensed physicians. Alabama nurse-midwives

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practice in “the most restrictive environment in the nation”, according to a 2004 Health &

Human Services study (Alabama Midwives Alliance, 2009). Other forms of midwifery

are practically nonexistent in Alabama. Midwives remaining in Alabama often travel

across state lines in order to legally assist their clients during birth, with many traveling

to Tennessee (Alabama Birth Coalition, 2014). Some Alabama mothers reported having

unassisted home births rather than asking a midwife to take a costly legal risk (Alabama

Midwives Alliance, 2009). Alabama’s midwifery policies are largely unenforceable and

midwives usually face prosecution only after seeking emergency medical attention for a

mother or infant. The legal implications could result in delayed action in the event of an

emergency, as midwives and mothers may attempt to weigh the costs of the urgency of

the situation and the legal consequences, which include fines and possible jail time.

Advocacy Organizations

There are several advocacy organizations working to change Alabama’s

restrictive policies on midwifery. The Alabama Birth Coalition, founded in 2004, is a

“consumer group advocating for the legalization of midwives with Certified Professional

Midwife credentials” (Alabama Birth Coalition, 2014). The Alabama Midwives Alliance

(ALMA), a professional organization for independent midwives, aims to “preserve the art

and craft of midwifery and to act as a self-governing body for those interested in the

practice of midwifery” (Alabama Midwives Alliance, 2014). ALMA has “formulated

practice guidelines for out-of-hospital midwifery, facilitated ongoing educational

opportunities, and provided accountability through regular peer review for practicing

midwives” (Alabama Midwives Alliance, 2014).

Current Political Activity

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The Big Push for Midwives publishes practical suggestions tailored for individual

states. The organization’s suggestions for Alabama include improved consumer education

and increased grassroots involvement in the political process (Big Push for Midwives,

2014). Both The Alabama Birth Coalition and The Alabama Midwives Alliance

participate in these activities, educating women about alternative maternal care and birth

practices and organizing political efforts to legalize nationally-credentialed midwives.

In recent years, support for the relaxation of anti-midwife legislation in Alabama

has grown (Alabama Birth Coalition, 2014). In 2013, bills that would reform Alabama’s

policies on midwifery were introduced in the Alabama House and Senate. Senate Bill 246

sought the legalization of midwives and establishment of a State Board of Midwifery,

which would be responsible for licensing and regulation. The bill had bipartisan

sponsorship, with four Republican sponsors and two Democratic sponsors (S., 246,

2013). The Senate bill’s companion bill, House Bill 178, had the same goals and was

sponsored by a Republican representative (H.R., 178, 2013). Both bills survived their

first reading and were passed on to sub-committees. The House bill received a public

hearing, but failed to pass. The Senate bill did not make it to the public hearing phase

(Alabama Birth Coalition, 2014). According to The Big Push for Midwives, “both bills

died due to staunch opposition and political pressure from the state medical society” (The

Big Push for Midwives, 2014).

In the 2014 legislative session, Senate Bill 99, The Home Birth Safety Act, and its

accompanying bill, House Bill 601, both seeking to legalize midwives and establish a

State Board of Midwifery, met the same fate as the 2013 bills (Alabama Birth Coalition,

2014). Once again, the Senate bill received bipartisan sponsorship and the House bill was

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sponsored by a Republican representative (S., 99, 2014; H. R., 601, 2014). Despite the

seemingly successful public hearing for Senate Bill 99, the bills failed to make it to the

voting stage. Three similar bills were introduced in 2014, all failing to make it past

committee deliberations (Alabama Birth Coalition, 2014). In January 2014, Alabama

Governor Robert Bentley, a retired physician, stated he would not oppose the legalization

of midwifery in Alabama, provided there was adequate regulation. Bentley told an

interviewer, “I feel that midwives that at least have the proper training, that have back up

so that if there are any problems, they could get the mother- in those one or two percent

of births- to the hospital quickly, (then) I have no problems with that” (Sell, 2014).

Maternal Health Care in the United States

A 2014 report on health care quality by The Commonwealth ranked the

United States last among eleven developed Western countries, the same ranking it

received in prior reports, published in 2010, 2007, 2006, and 2004 (Davis, Stremikis,

Schoen, & Squires, 2014). One of the measures used to calculate this ranking was infant

mortality rate, of which the United States had the highest. Among the eleven countries

studied, the United States had the highest shortage of physicians and ranked last in

overall safety of care, measures that are relevant to maternal health care. These

shortcomings exist despite the fact that the United States spends more on health care per

capita than any other Western country. Annually, Americans spend $8,508 per capita on

health care. The country closest to the United States in health care spending is Norway, in

which residents only spend $5,669 per capita and enjoy a much higher quality healthcare

system (Davis et al., 2014). The Big Push for Midwives eloquently summarizes their

frustrations with the high cost of America’s low quality maternity care, stating “the

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United States can no longer afford a system that produces inferior results at premium

costs. The nation needs safe and less-costly maternity care now.”

Deadly Delivery: The Maternal Health Care Crisis in the USA

Maternal health statistics in the United States are so grim that they have been

designated a crisis by Amnesty International. In 2010, Amnesty International concluded

an intensive two-year study of maternal health care in the United States, publishing a

report entitled Deadly Delivery: The Maternal Health Care Crisis in the USA. As

Amnesty International is a human rights organization, this report largely focuses on the

right to health, frequently equating the right to maternal health with the right to personal

choice. The report found that, in the United States, “an individual woman’s ability to

actively participate in her care is hampered by a lack of information about care options

and the failure to involve women in decision-making regarding their own health care”

(Amnesty International, 2010).Researchers conducting the report found that the United

States has failed to reduce its maternal mortality rate in over twenty years, noting that this

clearly indicates a healthcare system that is not actively addressing the needs of its clients

(Amnesty International, 2010). The report concludes with key recommendations for the

healthcare system in the United States. “Decisions by women to choose a midwife or a

physician as her maternity care provider should be respected” is included in those

recommendations (Amnesty International, 2010).

Conclusion

On January 18, 1993, I was born via an emergency Cesarean Section resulting

from nuchal cord complications, which occur when the umbilical cord wraps around a

fetus’s neck in utero. As I owe my very existence to emergency medical intervention, I

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certainly appreciate the necessity of hospitals and medical intervention. I also, however,

believe that American mothers deserve the same basic right as the rest of the developed

world- the right to personal choice. I believe that, for far too long, American women have

been taught to fear a natural process that their bodies were, quite literally, made for. The

American medical community systematically oppresses women during what is arguably

the most vulnerable time(s) of their life.

I was interested in healthcare and health policy before this project, recently

completing an internship with a private health insurance corporation, but my interest has

increased substantially. I am especially interested in American maternal health, as it

combines my personal interests, as well as my three primary areas of study- Political

Science, Community and Civic Engagement, and Women’s Studies.

Though it seems dramatic, perhaps even hyperbolized, Amnesty International is

100% right- maternal healthcare in the United States is in crisis and something must be

done. Throughout the course of my research, I found that many Americans simply aren’t

aware of the facts- I shared statistics, frightening facts about medical interventions during

birth, and other unsettling discoveries I made with my friends, family, and colleagues.

Very few people were familiar with the things I shared. This project has shown me that

the need for change in our healthcare system is urgent, and that perhaps it must start with

education. Women in America, especially in Alabama, need to be told the truth about

maternal healthcare and reminded that there are choices for prenatal care and birthing

and, ultimately, “she, not the practitioner, is the best expert on her own body” (Meyer,

2007).

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