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Birth in Alabama: midwives, mortality rates and birth options

-a9e57e40345f9509If you are a pregnant woman in Alabama, your baby is more likely to die within its first year than a baby born in any other state, with the exception of Mississippi. A baby born in Alabama is nearly three times more likely to die than a baby born in Alaska.

In Alabama, according to the Centers for Disease Control, there were 8.73 infant deaths per 1,000 live births in 2010. That’s 524 babies who died, statewide, before their first birthdays.

The national average was 6.14 per 1,000. Mississippi’s rate was highest, at 9.62 deaths per 1,000. Alabama’s rate is worse than the rates of Russia, Kuwait, Qatar and Serbia.

And while Alabama has improved its infant death rate from 9.53 in 2005 it has a long way to go to catch up with the rest of the country.

A recent WalletHub survey looked at 22 metrics that included hospital delivery charges, access to pediatric care, maternal and infant mortality, and number of child care centers per capita.

The study ranked Alabama as the worst place in America to have a baby.

A lack of options

The reasons behind Alabama’s poor outcomes for its babies are myriad, and include Alabama’s high rates of obesity and diabetes, overall poor health, and availability of medical care, particularly in poor and underserved areas.

But it’s also worth noting that if you’re a pregnant woman in Alabama, you don’t have the same birthing options that mothers in other states have.

When Christi Britten, originally from Adamsville, Ala., moved back to her home state from Seattle with her young family, she learned she couldn’t have a Certified Nurse-Midwife attend her deliveries in a hospital, like she’d had in Washington with the births of her two older daughters.

Very few Certified Nurse-Midwives – which can legally practice in Alabama and are credentialed similarly to Registered Nurses – work in Alabama, and it’s illegal for any other kind of midwife to assist births unattended by an obstetrician.

Britten eventually found an OB-GYN who she felt respected her desire to try for a natural birth with minimal medical intervention. She hired a doula – a trained childbirth assistant who advocates for the mother – and labored in a tub at a nearby hospital.

She gave birth to her son in the water with just her husband and doula present. It was the kind of birth she’d wanted, but required some subterfuge on her part. Water birth was against hospital rules.

Three years later Britten delivered her youngest, a girl, at the same hospital. That time the staff was more diligent about making her get out of the tub before pushing.

“Everything ended up being OK, but it was the most traumatic labor for me,” said Britten, “because there were a lot of things I couldn’t control.”

Her water was broken by the doctor so the doctor could deliver the baby before going into another surgery, and she had to have an episiotomy, which is an intentional incision made to prevent additional vaginal tearing during childbirth.

“I was angry at first, but I’ve come to terms with it,” said Britten. “I think that’s why it’s super important to have a Certified Nurse-Midwife in the hospital, so women can do this on their own timeline. Labor is a long process – that’s why it’s called labor. The model that hospitals offer now, it doesn’t allow women to labor as long as they need or want to.”

While there’s no clear consensus on what birth options should be legally available to Alabama’s pregnant women – some in the medical community point to the potentially dangerous consequences of women delivering outside of a hospital setting – there’s no disputing that Alabama is one of the worst states for birth outcomes.

Alabama has the third-highest rates of preterm birth and low birth weight in the nation, according to 2012 CDC data. Preterm birth – a baby born before 37 weeks gestation – is the greatest cause of infant death in America.

The WalletHub ranking not only listed Alabama as the worst place in the United States to have a baby – ranking it 51 out of 50 states and the District of Columbia – but also revealed Alabama has the lowest number of midwives and OB-GYNs per capita.

“In Seattle, midwives are part of the medical practice,” said Britten, who has been active in advocating for more birth options for Alabama mothers. “If you’re low risk, they don’t send you to an obstetrician, they send you to a midwife. You’re paired with an OB in case anything goes wrong, but in Washington, midwives often deliver babies.”

In Alabama, women can’t choose a home birth or delivery at a birth center because it’s illegal for an unlicensed midwife to attend births, or for a licensed provider to do anything against regulations for his or her profession.

Legislation to allow Certified Professional Midwives (CPMs) to practice in Alabama is presented during the state legislative session every year for the past several years and has always failed.

Certified Nurse-Midwives (CNMs) can legally practice, but a host of disputed reasons – from lack of general education about midwifery to insurance payment – have led to a dearth of CNMs practicing in the state, although many work in nearby states like Tennessee and Georgia.

It would be naïve to argue that access to midwives or birth centers is the only way – or even necessarily the best way – to improve birth outcomes for mothers and babies in Alabama. It’s a complicated problem that will likely require a many-pronged approach to solve.

But as more women look at the birth options available elsewhere around the country, and as the medical community seeks ways to improve the health of mothers and babies across the state, alternative options like midwives, birth centers and natural birth healthcare models have come under increased scrutiny.

Asking for choices

After the Brittens moved to Florence and Christi learned she was pregnant, “I cried because I didn’t know what to do,” she said.

“I had had my other children in a Seattle hospital (attended by the midwife), but now I was faced with a big decision: do I want to birth in the hospital down the street from my house (without a midwife), drive to Tennessee to have my son (in a birth center with a midwife) or have a home birth? The home birth option scared me because I knew I wouldn’t be able to have a midwife at home with me legally.

“So it was either have a hospital birth down the road, or risk it and travel to Tennessee.”

Her insurance wouldn’t cover a birth at the birth center. “I could pay $800 at the birth center in Tennessee, or have the birth cost $3,000 at the hospital but only pay a $350 deductible. Do I pay the deductible and know the insurance company is paying this astronomical price?”

Coming soon

Birth in Alabama – with special attention on who exactly is allowed to assist a birth and where – is a complicated, tangled subject, and one that continues to draw attention from state legislators, the medical profession, birth advocates and mothers themselves.

This article is the first in a series examining birth in Alabama. Over the next few weeks, we will be presenting various viewpoints and talking to key players involved in the effort to offer more birthing options and to improve outcomes for Alabama mothers and babies.

If you have questions you’d like answered or would like to share your thoughts, contact Anna Claire Vollers at avollers@al.com.

By: Anna Claire Vollers Source

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