Georgia bans many midwives from practicing. Several are suing the state.

Twice a month, Sarah Stokely travels 4.5 hours from her home in Rome, Georgia, to work for a week at a birthing center in Blountville, Tennessee.

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Stokely is a certified nurse midwife – the title given to registered nurses specializing in midwifery. But Georgia’s laws make it difficult for her to practice there.

The state requires all nurse midwives to have formal, written agreements with physicians describing when physicians should intervene in the evaluation or treatment of patients. Stokely said the agreement, which often requires midwives to pay doctors for their time and liability insurance, was too costly. She was offered about $500 a month, she said.

Midwives who do not have a nursing degree are not authorized to practice in Georgia. These laws make Georgia one of the most restrictive states in the country for midwives.

Stokely and two other midwives sued the state Thursday, alleging Georgia’s policies violate the state constitution and fail to ensure patient safety.

In the lawsuit, a preliminary version of which was shared exclusively with NBC News, the plaintiffs claim their midwifery services are essential in Georgia. More than a third of the state’s counties are considered maternity care deserts, meaning there are no obstetrics providers or birthing centers, according to the nonprofit March of Dimes. The plaintiffs also claim that making it easier for midwives to practice could reduce Georgia’s high maternal mortality rate. For every 100,000 births in the state, 30 mothers die from complications during pregnancy or within six weeks, according to March of Dimes.

“There are places in the state where there is nowhere to deliver babies or access pregnancy care nearby. We have midwives, including our clients, who are ready and willing to fill that gap to serve these families, and the state is treating them like criminals,” said lead plaintiffs’ attorney Hillary Schneller, senior attorney at the Center for Reproductive Rights.

A spokesperson for the Georgia attorney general’s office said it was “unable to comment due to pending litigation.”

This lawsuit is one of several filed in recent years challenging state restrictions on the practice of midwifery. The cases argue that midwives play an important role in combating the provider shortage, which has worsened as hospitals close obstetrics units.

In January, the American College of Nurse-Midwives sued Mississippi’s medical licensing board, where midwives are also required to enter into collaborative agreements with doctors to practice. The lawsuit claims the rule poses “a major obstacle to closing Mississippi’s gaps in prenatal and postpartum care.” In a court filing, the state disputed that claim and said the regulations “speak for themselves.”

Meanwhile, in Alabama, a lawsuit pending since 2023 challenges a regulation requiring birth centers — facilities where midwives supervise deliveries and administer pre- and postnatal care — to be licensed as hospitals. The lawsuit argues that the restriction (which is not enforced while the lawsuit proceeds) would make it difficult, if not impossible, for birth centers to operate. An Alabama court sided with the birthing centers last year, but an appeals court overturned the decision in January. The American Civil Liberties Union, which represents the birthing centers, asked the state Supreme Court to review the case.

“Georgia is not the only country experiencing a shortage of maternity care and restrictions on midwives,” Schneller said. “We’ve been in this broken system for a long time, and it’s not like we don’t know how to get out of it.”

Midwives say agreements with doctors create obstacles

Sixteen states require some form of collaborative agreement with a physician for a nurse midwife to practice.

Supporters of these agreements say they are necessary for patient safety. Since midwives are trained to supervise low-risk pregnancies and typically send patients to the hospital if complications arise, agreements with doctors should in theory give midwives someone to consult with or transfer patients to in such scenarios. But in practice, it is not guaranteed that doctors will be on call when midwives need them, and many midwives say the agreement implies they are incapable of making informed decisions for themselves.

“There’s a little bit of distrust about our ability to do things independently,” Stokely said.

The plaintiffs in the new lawsuit also allege that it may be difficult to find doctors in Georgia willing to make the deal.

“I don’t think I’ve yet met a midwife who is opposed to working with obstetricians, but I have met many obstetricians who are opposed to working with midwives,” said Jamarah Amani, another plaintiff.

A patchwork of national regulations for midwives

Georgia is one of 38 states that does not allow licensing for certified midwives with a master’s degree in midwifery. It is also one of 13 states that does not offer licensure pathways for certified professional midwives, who train and take exams but do not have a degree. All 50 states recognize nurse midwives.

Tamara Taitt, the third plaintiff in the Georgia lawsuit, said the restriction led to staffing problems at the birth center she runs in Atlanta.

Because she can’t hire midwives who aren’t nurses, Taitt said, her candidate pool is limited. As a result, she said, the practice is sometimes unable to accept new patients, and midwives are sometimes overstretched to accompany their patients to the hospital when they need transfers.

“If you want to solve the problem of maternal and infant mortality, it makes no sense not to reach out to every provider possible,” Taitt said.

Some states have also imposed regulations on home births, which have become increasingly popular in the United States. In Nebraska, for example, it is a crime for a nurse-midwife to attend a home birth. A pregnant mother filed a lawsuit against the state in January challenging the law; the case was settled last month, with the state granting a religious exemption to the ban.

Taitt and her fellow plaintiffs argue in their lawsuit that Georgia regulations limit pregnant women’s options for giving birth.

“The state needs to listen to its own citizens who are saying, ‘We demand access to midwifery care. We want to have our home births. We want to have our births in birthing centers,'” said Amani, who previously owned a home in Georgia.

She moved to Florida more than a decade ago and planned to eventually return to her family in Georgia. But she never did because of Georgia’s restrictions on midwives.

Years ago, Amani said, she and her family temporarily evacuated Florida because of Hurricane Irma and stayed briefly in Georgia. One of her patients also fled there, then called Amani after having contractions. Amani was forced to tell the woman that she would not be able to supervise the delivery if it took place in Georgia.

“I remember her being so shocked and appalled,” Amani said. “Her trusted care provider is on the street, but he cannot legally care for her. »