Deep in the Alabama Black Belt, the tiny town of Gainesville (population: 163) hugs the banks of the Tombigbee River not far from the Mississippi state line.
On a sunny Thursday morning in February, a man in overalls washes a firetruck parked outside city hall. Next door, at Rogers & Son Grocery, a handful of regulars visit at tables by the window.
A little further down the road, one of Gainesville’s newest residents, Boston-born Stephanie Mitchell, walks out the front door of her family’s barbecue restaurant, a mug of coffee in hand. It’s a beautiful day and Mitchell’s commute is a five-minute walk.
She heads up Webster Street to check the renovation progress at a 187-year-old antebellum home, which she plans to open as Alabama’s first freestanding birth center.
Mitchell is a midwife. When she and her husband Jamie, a Gainesville native, moved to Alabama from Boston to open their restaurant in July 2020, Stephanie hoped to find a job working as a certified nurse-midwife in a birth center. But as she researched her employment options in Alabama, she found…nothing.
“I was flabbergasted to realize Alabama didn’t have any birth centers, period,” Mitchell says. “That took the wind out of my sails. I was like, do y’all not have women here? You deserve to have a birth center as an option.”
So Mitchell set out to build one instead.
But in a state that only recently legalized out-of-hospital midwives, Mitchell has encountered barrier after barrier, navigating a health system that wasn’t designed to give birthing people options other than a doctor-attended delivery in a hospital.
She is the first to admit she’s ruffled some feathers in the process.
“I’ve been told if I was nicer, I would get a birth center,” she jokes. “After waving flags, making noise, being nice and not being nice, showing up and building relationships, and trying to usher in the idea that a birth center is an OK thing to do, it hasn’t happened.
“So I had to go about it another way.”
From ‘granny midwives’
Freestanding birth centers like the one Mitchell is building are typically staffed by midwives who provide pregnancy and birth services to low-risk pregnant people in a home-like setting. They’re called freestanding when they’re not connected to a hospital.
Birth centers only account for about 0.6% of all births in the United States, according to the CDC; about 98% of births occur in hospitals, with another 1% occurring at home.
In states like Texas and Florida, birth centers are integrated into the healthcare system. In Florida, for example, nearly 900 births occurred in birth centers attended by midwives in 2020.
Alabama is one of a few states that doesn’t have any birth centers.
But interest in midwifery has grown in popularity in recent years: some Alabama women have even chosen to cross state lines into Georgia, Tennessee or Florida in order to deliver babies with midwives. The University of Alabama at Birmingham is launching a certified nurse-midwife training program.
That increased interest has led a few providers to look at the feasibility of a birth center in Alabama. Back in 2019, a group of Florence, Ala.-based midwives and doulas began working to open a birth center but were unable to secure enough funding. In December 2021, a North Alabama OBGYN, Dr. Yashica Robinson, announced she plans to open a birth center at her Huntsville clinic in late 2022.
Out-of-hospital midwifery wasn’t legal in Alabama until state law changed in 2017 and Alabama began issuing licenses in 2019. Prior to that, the state hadn’t issued an out-of-hospital midwifery license since 1976.
While the demand for midwifery is higher in some of Alabama’s more urban areas, Mitchell said there’s more of a learning curve in her area of rural Alabama. Older folks have a strong connection to midwifery; they tell her they were delivered by granny midwives.
“But the folks of reproductive age are not necessarily aware of what midwifery even is,” said Mitchell.
“So you know me, I’m happy to tell them.”
The making of a midwife
Mitchell was 16 and pregnant the first time she met a midwife. In Boston, where she lived, many obstetrical practices offer women with low-risk pregnancies a choice for their provider: a doctor or a midwife.
Mitchell investigated her options and chose the midwife.
“The respect and care she had for my body, which was carrying a child for the first time – that piece stuck with me,” Mitchell said. And as she raised her infant daughter while taking college classes, Mitchell decided midwifery was the career she wanted.
She earned a nursing degree and worked several years as a registered nurse in a hospital labor and delivery unit in Boston. Later, she pursued a master’s-level nursing degree to become a certified nurse-midwife in 2018.
When the pandemic hit in early 2020, Mitchell and her husband, Jamie, were already talking about leaving the city. Jamie grew up in Gainesville but had spent the past 30 years working in Boston. In recent years he’d turned his side hustle into a successful catering business, barbecuing Alabama-style ribs for hungry Bostonians. He wanted to open a full restaurant.
Mitchell worked as a certified nurse-midwife in a medical clinic but was frustrated with what she saw as the “industrial” nature of obstetrics. She sometimes saw 25-30 patients in a day and didn’t get to spend the kind of time with them she believed they needed.
“I knew in-hospital midwifery care wasn’t going to be the rest of my career,” she said. She dreamed about opening a birth center, staffed with certified nurse-midwives like herself, to provide holistic care at a slower pace.
While the Mitchells visited Gainesville for a funeral in early 2020, they considered what it might mean to launch the restaurant, and even a birth center, right there in Sumter County. They’d traveled back and forth to the area for years to visit Jamie’s relatives. And Stephanie Mitchell had always loved the idea of living in the country.
Their two daughters were nearly grown, but their two sons hadn’t yet hit high school. Gainesville, with its slower pace of life, community ties and plenty of opportunities for fishing and hiking seemed idyllic to Mitchell, compared to life in the city: “I wanted my sons to be rooted in a community that can support them growing into strong, hardworking men like their father.”
The family moved to Gainesville on July 4, 2020. They built their restaurant, Alabama Rib Shack, on one of the main highways that cuts through the town.
Then a historic fixer-upper down the road, one Mitchell had always thought would make a beautiful birth center, came up for sale. The price was right, the timing perfect. They bought it.
“Nobody’s going to come knocking on your door,” she said. “But when you have something in your mind and start taking steps toward it, it’s amazing how things unfold.”
One of the biggest barriers to opening a freestanding birth center in Alabama has to do with the way the state regulates the two main types of midwives.
Certified nurse-midwives like Mitchell have always been allowed to practice in Alabama, though few do, relative to most other states. Just 21 nurse-midwives are currently licensed to practice in Alabama, according to the Alabama Board of Nursing. Georgia has nearly 600, Tennessee 234.
A nurse-midwife is a registered nurse with masters-level education credentials on par with a nurse practitioner. Nurse-midwives can write prescriptions and work in hospitals, medical clinics and, in states like Georgia and Texas, in birth centers.
Alabama requires nurse-midwives to work in collaboration with a physician. But few physicians work in Mitchell’s region, and none that she contacted were willing to collaborate with her at a freestanding birth center.
“I think the highest level of care that people can get is in a collaborative system,” she said. “If physicians and midwives can work together as needed, you have the best outcomes.”
Instead, Mitchell went with Plan B: Become a different kind of midwife.
Certified professional midwives care for low-risk pregnant people and deliver babies outside of a hospital setting. These are the midwives who have been able to legally practice in Alabama since 2019. The state currently has about 19 of them.
Professional midwives aren’t required to have nursing degrees, so they can’t write prescriptions or administer most medications. But they’re required to undergo training and apprenticeship before they can be licensed to practice. In a quirk of the law, they aren’t required to work under the supervision of a physician, unlike nurse-midwives.
In late 2021, Mitchell became Alabama’s first Black certified professional midwife, meaning she can legally care for low-risk birthing people and deliver babies in out-of-hospital settings.
But Mitchell won’t have the same privileges – such as the ability to prescribe medications – that she would have had as a nurse-midwife in Massachusetts.
In March 2021, a complaint was filed against Mitchell with the Alabama Board of Nursing. A representative from the board declined to comment. Mitchell said the report accused her of illegally calling herself a nurse-midwife – she is not licensed as a nurse-midwife in Alabama but was licensed and board-certified in Massachusetts – and that she was running an illegal birth center.
Mitchell says she’s done nothing illegal, and points out that the birth center isn’t open yet. She’s hoping the board will close the case soon.
‘Continuously a grassroots effort’
On the same recent February morning, Mitchell’s contractor, Jon Toler, greets her as she walks up the front lawn of what will one day be The Birth Sanctuary.
Most of the interior walls have been taken down to the studs. Vines grew inside the front rooms (“I’ve never had to prune a house before,” Toler jokes) and the front porch was in such bad shape that it’s had to be completely removed and rebuilt. The roof, plumbing, electrical and HVAC systems have all been replaced.
But the process has given Mitchell the opportunity to create the kind of family-oriented center she wants – parlors turned into private labor and birth suites, office space upstairs, a sitting room for family members, and the removal of unnecessary walls to allow more space for walking around while in labor.
After Mitchell meets with Toler, she films a quick update video to share on Instagram. The Birth Sanctuary has 8,600 followers; Mitchell herself, 20,000.
Through a GoFundMe campaign, she and her supporters raised $150,000 to pay for the renovations. Some of that money has also been invested back into midwifery training for other community based midwives.
Fundraising is ongoing.
“There was no Daddy Warbucks, nobody coming to save us,” she says. “It is continuously a grassroots effort.”
Once the center is ready to open, there will be regulatory barriers. Because there’s never been a birth center in Alabama, the state has no regulations or requirements tailored for one.
And then there’s the affordability issue. In Sumter County – and in the rest of the Black Belt – most pregnant people qualify for Medicaid to pay for prenatal care and birth services.
In Alabama, Medicaid doesn’t cover care by professional midwives. Out-of-pocket costs for midwives can average around $5,000.
A lack of Medicaid coverage keeps midwives like Mitchell from being able to take on low-income clients unless she finds a revenue stream that would pay for their care.
Midwifery – once the only choice for poor Alabamians, and for Black Alabamians who weren’t allowed into white hospitals – is no longer an option for low-income people.
“Midwifery had this stark transition in Alabama from primarily what they called ‘granny midwives’ to something that is now more associated with affluence,” said Mitchell. “I believe it is the highest level of care you can get, but it’s something now associated with folks who can pay for it.”
She’s considered turning The Birth Sanctuary into a nonprofit, but ultimately wants to see Medicaid and other insurance providers cover services like hers.
Building The Birth Sanctuary in Alabama’s Black Belt has been a labor of love. For Mitchell, it’s a way to reconnect Alabama with birth traditions that go back generations.
It’s also the way she believes she can help improve maternity care in an under-resourced area of a state with historically high rates of infant and maternal mortality, and poor maternal health outcomes. Gainesville is nearly 50 miles from the nearest hospital with a labor and delivery department.
Mitchell said she’s not intimidated by the barriers still facing her or the birth center.
“It never crossed my mind not to do it,” she said. “I’m not going to wait for somebody else. I am somebody else.”