A landmark legal battle is unfolding across the South as maternal health advocates challenge hospital and state birthing regulations.
Midwives in Georgia, Alabama and Mississippi have sued state health departments over regulations they say limit birthing options and worsen gaps in maternal care. They are challenging laws that prevent direct-entry midwives from attending births and rules that require costly physician supervision agreements.
The cases come amid a deepening maternal health crisis, where the rates of maternal mortality are getting higher. In the United States, the maternal mortality rate is the highest among high-income nations.
Many of the states with the nation’s most restrictive birthing laws also report some of its worst maternal health outcomes. Alabama, Georgia, Arkansas, Louisiana and Mississippi have pregnancy-related mortality rates roughly twice as high as those in the best-performing states, according to The Commonwealth Fund.
The crisis becomes even more acute when viewed through the lens of race. Black women face some of the nation’s highest rates of pregnancy-related deaths. The disparities persist even after accounting for income and education, pointing to structural factors that extend beyond socioeconomic status.
Advocates note that the lawsuits are about more than professional licensing and access to opportunities. They are challenging whether states can continue restricting access to expectant mothers as maternal deaths persist. Hospital obstetric unit closures, health provider shortages and limited access to community-based maternity care have left women with few options.
Reproductive rights activists claim the solution lies in a profession that predates modern medicine: community-based midwifery. In states, like California, New York, Virginia, Oregon and Florida, non-nurse direct entry midwives are allowed to practice with varying state regulations. These states license or legally regulate the practice and have among the lowest maternal deaths.
However, in some southern states, the legal fight for safer regulations with access to less restricted midwifery care is still ongoing. This puts them among the highest ranked in maternal deaths.
The Legal Fight To Define Safe Reproductive Care
Southern State medical boards and conservative lawmakers defend the strict rules as vital protection measures.
Officials claim that birthing carries inherent, unpredictable risks that require rapid medical intervention within a clinical setting. As a result, they prevent direct-entry midwives, who are not trained as nurses, from attending births.
With the barring of direct entry midwives, only nurses specialized in midwifery are allowed to give birth in the states. However, to facilitate birth, nurse-midwives must enter an agreement with a state-licensed physician. These agreements can come with strict requirements, including geographic proximity rules, specialty restrictions, and thousands of dollars per month in filing and physician fees.
On the contrary, midwives, whose lawsuits are backed by the Center for Reproductive Rights and the National Black Midwives Alliance, are arguing that the rules are anti-competitive rather than safety-driven. Their reasoning is because a third of the state lives in areas without labor and delivery services.
Challenging Midwifery Restrictions in Southern States
In Amani et al. v. The State of Georgia, the Center for Reproductive Rights argued that the restrictions placed on midwives worsen maternal health outcomes. The organization explains that’s because the state is creating barriers that prevent skilled midwives from practicing.
“Restricting access to maternity care providers doesn’t make pregnant people safer,” read a statement on the organization’s official website. “Instead, it leads to more deaths. To meaningfully improve maternal health, pregnant people need more support–including access to midwives.”
The group also argued that midwifery is both an ancient and effective practice. They went on to explain the benefits of expectant mothers having a midwife.
“People cared for by midwives are less likely to have pregnancy interventions like C-sections, episiotomies, epidurals, and drug-induced labor–costly procedures that can lead to health complications,” the statement read.
Who Controls Access To Midwifery Care?
The American College of Obstetricians and Gynecologists has maintained strict clinical guidance regarding where and with whom birthing takes place. The group has not issued a direct statement on the lawsuits. However, its leaders have called for national uniformity in midwifery regulation.
“Birthing persons in every state should be guaranteed care that meets these important minimum standards,” the medical group wrote in a statement on their website.
The ACOG also emphasized patient autonomy in their stance on midwifery.
“ACOG respects a pregnant person’s right to make a medically informed decision about their birth attendant and place of delivery and believes hospitals and licensed, accredited birth centers are the safest setting for birth,” the statement read.
The group also expressed support for standards set by the International Confederation of Midwives, which accredits both certified nurse-midwives and direct-entry midwives.
Still, the relationship between midwives and physician organizations has long been complex, with medical boards historically advocating for tighter regulation of the profession.
Racial And Medical Discrimination In Midwifery
Until the early 20th century, midwifery was the primary form of childbirth care in the United States. Census records show the practice was widespread and often interracial. In many rural Southern communities, Black “granny midwives” served as the primary birth attendants for generations.
The rise of state licensing regulations systematically pushed both Black and white midwives out of formal practice. During this period, federal public health efforts gave states greater authority over maternal care regulation. In the South, where Black “granny midwives” attended the majority of rural births, state health boards and medical groups worked together to professionalize childbirth care.
Southern health officials and physician groups began campaigns to discredit traditional midwives. White male obstetricians often portrayed Black midwives as untrained and unsanitary, linking them to high maternal mortality rates.
In 1926, Dr. Felix J. Underwood, director of the Bureau of Child Hygiene for Mississippi wrote about the topic in the Southern Medical Journal.
“What could be a more pitiable picture than that of a prospective mother housed in an unsanitary home and attended in this most critical period by an accoucheur, filthy and ignorant, and not far removed from the jungles of Africa, laden with its atmosphere of weird superstition and voodooism,” he wrote.
Strict requirements for nurse-midwifery certifications was effective at dismantling traditional practices and banning direct entry midwives. The stringent requirements and high tuition excluded many older, poor, rural Black women who had been practicing as midwives for most of their lives.
The standards have had a lasting effect. Today, the number of Black midwives remains far below historical levels, even as Black maternal mortality rates remain disproportionately high.
Pressure Builds For Midwifery Reform
While midwifery remains largely regulated at the state level, legal action and policy pressure have begun to reshape access in several states. In Hawaii, a coalition of midwives and patients filed a federal lawsuit, challenging a state law that criminalized unlicensed midwifery. Advocates argued the law discriminated against traditionally trained and Indigenous birth workers.
The lawsuit, brought by the Center for Reproductive Rights, Native Hawaiian Legal Corporation and Perkins Coie in 2024, ultimately expanded access to midwifery care.
Other states have pursued reform through legislation rather than litigation. Oregon recently passed Senate Bill 692, requiring insurers to cover community-based perinatal services, including care provided by midwives and doulas. New Mexico has also expanded pathways for direct-entry midwives through regulatory changes aimed at increasing access to maternal care.
In North Carolina, lawmakers recently ended the state’s longstanding requirement that certified nurse-midwives maintain physician supervision agreements. Under the new law, only midwives with fewer than 24 months and 4,000 hours of clinical experience must practice under a collaborative agreement with a physician or experienced certified nurse-midwife. Once those requirements are met, they can practice independently.
While there has been some legal success across the country, there’s still some work to be done for complete reform. In Alabama, midwives and birth centers challenged state rules requiring freestanding birth centers to obtain hospital-style licenses. After an appellate court sided with the state health department, advocates asked the Alabama Supreme Court to review the case. The court declined to hear the appeal in May, leaving the regulations in place.
The Broader Debate in Midwifery Care
Taken together, these cases reflect a broader shift in the debate over maternity care. The question is no longer if midwives should participate in the health care system. Increasingly, policymakers are debating how to integrate midwives into the process.
For clinicians, the stakes extend beyond licensing. Expanding the role of direct-entry midwives could reshape maternity care delivery, particularly for low-risk pregnancies traditionally managed within physician-led systems.
The outcome of these legal and legislative battles may help determine who provides care, where that care is delivered and how states respond to persistent shortages in maternal health services.
