Home at last
One Hoover mother recently gave birth to a baby boy at home this summer. Courtney Sirmon, vice president of the Alabama Birth Coalition, helped lead the charge to make certified professional midwives legal in Alabama this past legislative session, all the while planning a midwife-assisted water birth for her fourth child, who is expected this summer.
“I’m very excited about it. It’s something we’ve been wanting to do for a very long time. This will be our first ‘Sweet Home Alabama Birth,’” Sirmon said before the birth. “I’m planning a home birth because I feel that is what’s best for me, for my baby and my family at this time … We believe that birth is not a medical procedure. It’s a miracle, and we feel most comfortable in the safety and privacy of our home.”
The signing of the Childbirth Freedom Act by Gov. Kay Ivey on May 24 guarantees legality for certified professional midwives to assist at a home birth in Alabama and will establish a state board to license and regulate those midwives – an effort that has been in the works for more than two decades.
“I’m personally just overwhelmed with emotion that we’re at this point that we can move forward as a state to start to improve maternity care in Alabama,” said Sirmon, who practices as a doula, which provides physical and emotional support to a mother during and after childbirth.
“I’m so thankful that this option will be available for other women that they won’t have to make the decisions that I’ve had to make.”
When Sirmon had her first child in Mississippi, it was not unlike most births — induced in a hospital and with an epidural. Her second child was born in a birth center in Texas and assisted by a certified nurse midwife, which is a registered nurse who has received training and a master’s degree in midwifery.
After she became pregnant with her third child, she hoped to have a home birth in Texas, but relocation to Hoover in 2013 changed that based on the availability of midwives due to their illegal status. The third child was delivered in an Alabama hospital.
“It was impossible to even find a midwife for me. If there were any, they were so underground, and I was a new person coming into town,” she said.
For Sirmon, while her experiences with an OB-GYN and nurse midwife went well, she desired a home birth with the expertise of a CPM, which specializes in low-risk, full-term natural births out of hospital.
“I look back at [my first birth] and I say, ‘OK, I was a low-risk mother with a healthy pregnancy, and I put myself in to such a high-risk situation with the choices I made in childbirth,’” Sirmon said. “It was through that and the research I made after that birth experience that I started looking into low-intervention births and out-of-hospital births.”
Shortly after the birth of her third child, she became a supporter of the Alabama Birth Coalition and became the Central Alabama coordinator to push for change in Montgomery. In 2016, the Auburn grad with a degree in communications was appointed to the organization’s board.
Birth Coalition President Kaycee Cavender says Sirmon has helped change the tone and message of the midwifery legislative effort with her vast experience of births and communicating that message visiting with legislators and families local and statewide over the last year.
“Before, with the Alabama Birth Coalition supporters, myself included, came to midwifery through pain. We either had a bad experience in a hospital or had a bad experience with a physician that led us to this point,” Cavender said. “It was refreshing to have her on our board, because she brought a new perspective that no one is greater than the other. Let’s celebrate the expertise that each of them [OB/Gyns, nurse midwives and CPMs] have, embrace it and work together to provide the maternity care that is going to improve our outcomes and help our families here immediately.”
Sirmon truly believes what made 2017 different than the previous dozen legislative attempts was the people of Alabama gaining education on the differences in care, mainly through exposure in the media and social media, and spreading the word.
“I think there’s been an overall shift of the public and from the medical community for out-of-hospital births. It’s come to that point now where it’s much more accepted publicly,” Sirmon said.
How the bill became law
The path wasn’t easy.
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. According to the Alabama Midwives Alliance, efforts to legalize direct-entry midwifery and certified professional midwives have been active since the early 1990s. The Alabama Birth Coalition was formed in 2002.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.
Just as in years past, Rep. Ken Johnson (R-Moulton) sponsored the Alabama Birth Coalition’s legislation in the Alabama House of Representatives. But this year, the bills garnered wide support, including a co-sponsorship by newly appointed Speaker of the House Mac McCutcheon. For the first time ever, a bill to decriminalize midwives, HB 315, cleared a House subcommittee and went to the floor for a vote, where it passed on April 25 by an 84-11 vote. The next hurdle cleared came in the Senate, where the bill went to the floor on the final day of the legislative session.
The night before the final day, Cavender, Sirmon and other women from across the state gathered in the Senate gallery for a sit-in from the moment the doors opened until the Senate adjourned at midnight, listening as an automated machine read a lengthy redistricting bill. They were right back the next morning in hope for a vote.
“We just believed that what was important was physical presence. We didn’t rely on any professional lobbyist. It was just about Alabamians caring about issues, being there and talking to our representatives and senators and educating them on the issues and it turned out to be very successful in the end,” Sirmon said.
On the Senate floor, several amendments were added to turn the bill into a regulatory bill. Similar to years past, opponents pushed back on the bill, raising concern of midwives’ training and education, safety on certain procedures, liability of doctors when a birth is transferred to a hospital and more. Legislators worked with supporters and opponents of the bill to find a compromise during a three-hour conference to produce a favorable amendment, which led to the passage of the bill, nearly six hours after it was introduced on the floor.
Gov. Ivey signed the bill the following Wednesday.
Why midwives?
Supporters say passage of the bill will help educate more expecting 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 currently not having any freestanding 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.
“There really is a rural access care issue, and if we have midwives all over the state of Alabama, it gets mothers closer to care options,” Sirmon said.
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 and 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 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.
For specific questions related to Alabama’s certified midwife process, the Alabama Birth Coalition can be emailed at alabamabirthcoalitioninfo@gmail.com.