It’s advocacy day at AMN for the state of Alabama. Alabama is historically a hard state for midwifery. Stringent regulations have prevented licensure, practice and birth for many decades.
But, there is light on the horizon.
Dr. Stephanie Mitchell is a doctoral prepared certified nurse midwife that moved to Gainesville, AL to open up the state’s first midwifery owned birth center. It’s been a rocky road.
While on her road, the Alabama State Committee of Public Health is hosting a hearing this week, on August 18th, to review regulations related to birth centers. Stephanie asked for advocacy, so I gave it my best shot.
I can’t attend the meeting, but I can send letters to the entire board as well as use my position on the blog and social media to spread awareness. This is how advocacy gets done!
Here’s my full letter I sent to the board (16 letters in total by snail mail!) if you’re curious or looking to advocate for this cause or a similar cause in your state:
August 15, 2022
To: Alabama Department of Public Health
c/o Jacqueline Milledge
PO Box 303017
Montgomery, AL 36130-3017
Dear Alabama State Committee of Public Health Board Members,
My name is Jamie Guertin and I am a doctoral prepared certified nurse midwife (CNM), Air Force veteran/current Air Force spouse and mother of three children. I am passionate about increasing midwifery in the United States and want to offer comments on Birthing Center Rules 420-5-13 (https://www.alabamapublichealth.gov/about/assets/420-5-13.pdf). Although I currently do not live in the state of Alabama, I have been stationed there twice and am a national advocate for the profession of midwifery (amidwifenation.com).
Alabama’s first midwifery owned, freestanding birth center, The Birth Sanctuary, as well as future birth centers in Alabama, will cease to exist as a result of non-evidence-based regulations from the Alabama State Committee of Public Health.
This is an evidence-based recommendation for policy change.
General, 2. (u), page 5: “Staff Physician”
- Recommend removing the requirement that the staff physician “must have hospital obstetrical privileges with the hospital that is party to the Birthing Center’s Transfer Agreement…” This statement is restrictive and not recommended by the American Association of Birth Centers (AABC). See comments below on section 2.
- Recommend removing the requirement that “A birthing center is ineligible for licensure unless it has an Alabama licensed physician on the medical staff or a valid agreement with a consultant physician” is not recommended by the AABC.
- Physicians are rarely trained in birth center or home birth settings are hesitant to agree to serve on birth center’s medical staff (AABC, 2021).
- Simply requiring a written collaborative agreement also restricts access to the birth center because many physicians are unwilling to consider signing such agreements due to fears regarding liability (AABC, 2021).
- Additionally, consider these comments on the current regulation:
- Physicians often have privileges to multiple hospitals; the location of the hospital should not be the priority or dictate where the mother or infant needs to transfer to if transfer of care is needed. Transfer should occur to the facility that is closest and most appropriate for the reason for transfer.
- A birth center should not be withheld licensure because an Alabama licensed physician is not on the medical staff – recommend removal, or change to optional, but this regulation should not require a collaborative agreement and a birth center should not be licensed because a physician is not on staff.
- A consultant physician is part of the scope of practice of a CNM’s care and is inherent in CNM training. Many physicians are happy to consult – and this is a cornerstone of collaborative practice – but very hesitant to sign a collaborative agreement. Revise this section to reflect the AABC recommendation: “Birth centers should cultivate and strive for good working relationships with consulting physicians for the safety of their clients” (AABC, 2021, p.3).
- CNMs in the state of Alabama currently require a collaborating physician agreement; view the agreement here: https://www.abn.alabama.gov/wp-content/uploads/2018/05/Certified-Nurse-Midwife-Standard-Protocol.pdf.
- Recommend careful attention to language in the Birth Center Rules that a collaborating physician for the CNM does not have to be the same as a consulting physician to the practice. In practice, the CNM could have the same collaborating and consulting physician, but requiring a physician to sign a collaborating and consulting agreement is going to be a barrier for many CNMs to practice.
General, 2. (v), page 5: “A birthing center is ineligible for licensure unless it has a Transfer Agreement with a licensed, qualified hospital.”
- The AABC does not recommend that regulations require birth centers to secure written contractions or agreements with transfer hospitals.
- First, these contracts reduce access to birth center care because hospitals can/do refuse to enter into such agreements (AABC, 2021).
- States with required regulations regarding transfer agreements have “fewer birth centers and fewer birth center births than starts without this requirement” (AABC, 2021, p.3).
- On the hospital side of the transfer from a birth center, the patient’s safety should be the priority and if transfer from the birth center is indicated, there should not be any barriers placed in the way of this transition (AABC, 2021).
- Regulations and birth center policies should require a plan for transfer. It is well known that 10-15% of women or babies will transfer from birth center care. Therefore, seamless and safe plans for transfer are inherent in any birth center’s policies. Alabama regulations should require a plan for transfer for the mother or infant from the prenatal (antepartum), laboring (intrapartum) and post-birth (postpartum) stages of care.
- Additionally, 25 miles may not be a reasonable distance for all existing or future birth centers in Alabama. The state should perform a current assessment of rural areas in the state before imposing a limitation of 25 miles. This barrier may prevent future birth centers from opening in areas that are rural or maternity care deserts and may benefit from additional options for maternity care.
- Some maternal transfer forms are available online. Alabama should work to standardize a transfer form across existing and future birth centers in the state. The form could be included in the regulations once standardized.
- Home Birth Summit: https://doh.sd.gov/boards/midwives/assets/MaternalTransportForm.pdf
Medical Staff (2) (a) 1.
- As reviewed above, revisit the (1) Transfer Agreement, and (2) restriction that a consultant physician must have hospital privileges at the hospital chosen for transfer should be revised.
Medical Staff (2) (a) 4.
- Denying licensure to a birth center because a physician is (1) not on the medical staff, or (2) because a physician is willing to serve as a consultant but not sign an agreement restricts access to birth centers in the state of Alabama. See comments above and consider revising the policy based on the evidence provided (AABC, 2021). This also applies to Medical Staff (2) (c).
Medical Staff (2) (i) 3.
- The language is outdated. The National Association of Childbearing Centers is the AABC. Update the language to reflect the current name of the national organization.
Prenatal Visits (2) (b) “Breast and pelvic exams”
- A breast and pelvic exam is not always indicated at the first prenatal visit. Additionally, patients always have the options to decline these exam components. Revise this section to reflect more recent guidelines regarding breast and pelvic examinations (please review Guidelines for Perinatal Care, 8th Edition; review “First Visit” and “Appendix A” sections; breast and pelvic exams are not required components but guidelines for the prenatal visit). Many women have history of trauma, rape or birth trauma and these exam components may not be appropriate in those populations.
- For further review, reference the American College of Obstetricians and Gynecologists’ (ACOG) “The Utility of and Indications for Routine Pelvic Examination” (ACOG, 2018b).
Prenatal Visits (2) (c) 3. “Cervical cytology”
- Cervical cytology, or pap smears, are completed per ASCCP (American Society for Colposcopy and Cervical Pathology). The Alabama policy is unacceptable and not reflective of current evidence-based medicine. A pap smear is a screening that deserves counseling and shared decision-making between the provider and the patient. Screening is not started until age 21, and if cytology is normal, is generally completed only every 3 years. After age 30, screenings move to every 5 years if cytology is normal. Revise this statement to reflect the national organization that publishes the guidelines for cytology screening and that screening is recommended, not required.
Prenatal Visits (2) (b) “Urinalysis”
- The American College of Obstetricians and Gynecologists states that “this testing is both unnecessary and time consuming, and the high false positive rates may lead to added stress on the patient that could reasonably be avoided” (ACOG, 2017, p.1).
- Update the language to reflect the current standard of care from this ACOG guideline: Usefulness of Urine Protein Dipstick Testing as Part of Routine Prenatal Care.
Postpartum Care (1) “Eye prophylaxis”
- Although eye prophylaxis is recommended, it cannot be required without patient/parent consent. Revise the language in this regulation or referencing current practice guidelines/recommendations.
- See guidance here from the United States Preventative Services Task Force: https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/ocular-prophylaxis-for-gonococcal-ophthalmia-neonatorum-preventive-medication#:~:text=The%20USPSTF%20found%20convincing%20evidence,can%20prevent%20gonococcal%20ophthalmia%20neonatorum.
Postpartum Care (4) “Vitamin K injection”
- Although the vaccine is recommended, it cannot be required without patient consent. Revise language in this regulation or referencing current practice guidelines/recommendations.
- See guidance from the American Academy of Pediatricians here: https://publications.aap.org/pediatrics/article/149/3/e2021056036/184866/Vitamin-K-and-the-Newborn-Infant
Postpartum Care (10) (b) 2. “Hemoglobin and hematocrit”
- Hemoglobin and hematocrit levels are not indicated for the majority of low risk women and should be completed as appropriate depending on the woman’s exam, symptoms or birth history. ACOG does not recommend this as a routine component of postpartum care (ACOG, 2018a). Additionally, if the blood work is not indicated, this is an inappropriate use of resources, cost to patient, and additional work for a small business.
Postpartum Care (10) (b) 3. “Bi-manual pelvic exam”
- A bi-manual pelvic exam is often not indicated at a postpartum visit and the intervention should be tailored to the woman’s symptoms, concerns or birth history. ACOG recommends a pap smear if indicated/due for screening at the postpartum visit but does not make mention of a bi-manual exam (ACOG, 2018a).
Postpartum Care (15)
- Reword language here from refuse to decline.
- This list should have links to evidence and guidelines to support reasons for transfer. Additionally, the terms toxemia and chorioamnionitis are out of date and should be updated to reflect current language.
I would like to offer some final comments regarding midwifery and the future of the state’s midwifery profession.
The state of Alabama has yet to fully recognize the value of midwifery. Recognition of the value of midwifery is a first step, with many to follow. Data on midwifery in Alabama is limited because data collection did not start until 2019. The first midwifery licenses were issued in January 2019. Prior to 2017, licensed midwifery in Alabama was not legalized, despite laws supporting midwifery practice in dozens of other states. In 2019, 105 births were attended by licensed midwives and in 2020, that number rose to 196 births. Neither year reported any infant deaths from births attended by licensed midwives in the state of Alabama (Alabama Department of Public Health [ADPH], 2021). Alabama had a total 57,647 births across the state in 2020 which means that midwives only attended 0.0034% of the state’s births (Centers for Disease Control and Prevention, 2021).
In comparison, in the states of Alaska, New Mexico, Vermont and New Hampshire, midwives attend 26.8%, 24.9%, 20.8% and 18.9% of births, respectively. These states value midwifery care and have few restrictions or barriers to midwives.
Midwifery care is valuable to women and Alabama has yet to recognize the value. Midwifery care is associated with: “lower rates of cesarean birth, lower rates of labor induction and augmentation, significant reduction in third- and fourth-degree perineal lacerations, lower use of regional anesthesia (epidurals), and higher rates of breastfeeding” (American College of Nurse-Midwives, 2012, p.4). Women that receive care from midwives when compared to physicians are more likely to receive prenatal education focusing on health promotion risk reduction behaviors, a more hands on approach with a closer supportive relationship with their provider during labor and birth, and fewer technological and invasive interventions” (ANM, 2012, p.4). When systematic reviews compared the midwife-model of care to the physician-led model of care, midwife models of care had higher chances for “a normal vaginal birth, fewer interventions and successful initiation of breastfeeding” (ACNM, 2012, p.4).
Data from the National Center for Health Statistics at the Centers for Disease Control in Prevention ranks the state of Alabama with third highest maternal death rate in the United States (the maternal death rate in Alabama is 36.4 compared to the national average of 17.4). Infant mortality rates in the state have remained higher than the national average since 1970 and the percentage of preterm births, a birth before 37 weeks, have increased in the state from 2016 to 2020 (rates increased from 12.0% to 12.9%) (ADPH, 2021). Up to 27% of pregnancies in the state of Alabama are not receiving adequate prenatal care (generally defined as at least five prenatal care visits during the pregnancy) and 2.6% of pregnant women in Alabama in 2020 had no prenatal care (ADPH, 2021). Alabama must change policies to reduce maternal death rates, infant mortality rates and preterm birth rates, otherwise trends will remain unchanged or worsen.
Dr. Stephanie Mitchell is a doctoral prepared certified nurse midwife that completed an additional and unnecessary training pathway in the state of Alabama to bring midwifery care and a birth center to the state. Few midwives would be as tenacious and persistent in a state with so many barriers and restrictions to midwifery care. The Commission should hear what she has to say August 18th, 2022, and recognize the opportunity to improve Alabama maternal and infant health care. Additionally, the University of Alabama’s School of Nursing launched an MSN Nurse-Midwifery Pathway that enrolls its first cohort of nurse-midwife students in Fall 2022. A midwifery program is only as successful as the state and community that supports it; do not miss this opportunity to support nurse-midwives in Alabama!
If the Alabama state policies are meant to encourage maternal and infant health, the commission should revise Birth Center regulations on a regular basis. The regulations were reviewed in 1987, 1990, and then not again until 2010. These few reviews have hindered the number and type of birth providers, birth centers, and access to prenatal care throughout Alabama. A certified nurse-midwife and a licensed midwife (CPM or otherwise) should be on the committee. Maternal health conversations demand that every eligible party have a seat at the table. If the committee seeks to prioritize maternal health, consider having more midwives at the table; it’s the best investment you can make in Alabama’s maternal health.
Dr. Jamie Guertin, CNM, RNC-OB
Alabama Department of Public Health (2021). Infant mortality Alabama 2020. https://www.alabamapublichealth.gov/healthstats/assets/im_20.pdf
American Academy of Birth Centers. (2021). Frequently asked questions: Birth center licensure & regulations. https://cdn.ymaws.com/www.birthcenters.org/resource/collection/547BB090-5481-4CC0-8BC3-015E4F01CFAA/AABC_FAQ_-_Birth_Center_Licensure_and_Regulati.pdf
American College of Nurse-Midwives. (2012). Midwifery: Evidence-based practice. A summary of research on midwifery practice in the United States. https://www.midwife.org/ACNM/files/ccLibraryFiles/Filename/000000002128/Midwifery%20Evidence-based%20Practice%20Issue%20Brief%20FINALMAY%202012.pdf
American College of Obstetricians and Gynecologists. (2017). Usefulness of urine protein dipstick testing as part of routine prenatal care. https://www.acog.org/education-and-events/creog/curriculum-resources/cases-in-high-value-care/usefulness-of-urine-protein-dipstick-testing-as-part-of-routine-prenatal-care#:~:text=ACOG%20recommends%20that%20women%20have,so%20early%20in%20prenatal%20care.
American College of Obstetricians and Gynecologists. (2018a). Optimizing postpartum care. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care
American College of Obstetricians and Gynecologists. (2018b). The Utility of and Indications for Routine Pelvic Examination. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/10/the-utility-of-and-indications-for-routine-pelvic-examination
Centers for Disease Control and Prevention. (2022). National center for health statistics: State and territorial data. https://www.cdc.gov/nchs/fastats/state-and-territorial-data.htm
Here’s the email I sent in hopes that my letter will forward to the committee before the snail mail arrives next week:
Why post all of this on the blog?
There’s power in transparency – that’s what I’m hoping to achieve.
Want to send some snail mail or emails personally? Here’s the list of the Commission’s members and contact information/addresses.
Better yet, share on your social media platforms. Advocacy is slow, but it matters. Alabama cannot afford to lose the benefits of midwifery led birth centers.