AL.com: Alabama wants to license birth centers as hospitals. That’s absurd.
Here’s a bureaucratic puzzle: What do you call a small, home-like birth setting staffed bymidwives, designed specifically to offer low-intervention, low-cost maternity care to healthy mothers with low-risk pregnancies? If you’re the Alabama Department of Public Health, apparently the answer is: a hospital.
That’s the absurd regulatory position at the heart of Oasis Family Birthing Center v. Alabama Department of Public Health, a case recently before the Alabama Supreme Court. The court denied the center’s request to review its appeal earlier this month. The midwives and birth centers asking the court for relief had a simple, compelling argument: birth centers are not hospitals, have never been hospitals, and forcing them to obtain hospital licenses is effectively a death sentence for an entire model of care that Alabama women desperately need.
Alabama’s maternal health situation makes this especially urgent. The state is facing a genuine crisis. Maternity care deserts — defined by the March of Dimes as geographic areas with no obstetricians, nurse-midwives, or birth facilities— are a real and growing problem across the country. Alabama is no exception, where 37.3% of its counties are classified as maternity care deserts and another 31.3% offer only low- or moderate-access to maternity care.
A Pacific Legal Foundation survey of birth center regulations across all 50 states found a direct correlation between regulatory burden and birth center availability: states that pile on the requirements tend to have fewer birth centers or none at all. For example, among states that require a certificate of need before a birth center can open, 60 percent have only one birth center or none. For states without those requirements, that figure drops to 20 percent. In other words, certain regulatory burdens don’t just add paperwork, they eliminate options.
Freestanding birth centers are midwife-led facilities that offer prenatal, labor, and postpartum care to women with low-risk pregnancies. They’re cozy and community-based by design, just like a home-birth setting— the antithesis of a sterile hospital wing. As of 2022, there were about 400 freestanding birth centers scattered across 40 states, and the evidence supporting their safety and effectiveness is substantial. A major federally funded study, the Strong Start for Mothers and Newborns Initiative, found that the birth center model produced the most consistently favorable outcomes of any model studied, including lower rates of cesarean birth, lower rates of preterm birth, and higher breastfeeding rates. The National Birth Center Study II, which tracked outcomes for more than 15,000 women, reported high rates of natural birth and no maternal deaths. Study after study, domestic and international, has reached similar conclusions: for low-risk pregnancies, birth centers work.
None of that evidence has apparently moved the Alabama Department of Public Health, which in 2023 forced one birth center to shut down despite a perfect safety record, then pushed regulations requiring birth centers to be licensed as hospitals. That requirement isn’t a safety upgrade — it’s a regulatory sledgehammer. Hospital licensing involves construction standards, staffing mandates, and infrastructure requirements that are simply incompatible with the birth center model.
Requiring a birth center to comply with hospital regulations is a bit like requiring a family doctor’s office to meet the standards of an emergency trauma center. The requirements don’t fit the facility, and the cost and compliance burden would make operation impossible.
A state trial court blocked this approach in May 2025, ruling in favor of the Alabama plaintiffs.An appeals court reversed that decision in January 2026, and then the midwives, represented by the American Civil Liberties Union (ACLU), and others asked the Supreme Court to step in. They were right to keep fighting.
Alabama’s residents have almost no options to lose. Birth centers play an especially critical role in underserved communities, including rural areas where hospital labor and delivery units have been closing for years. Birth centers can fill the gap in these maternity care deserts and other underserved areas— but only if they’re allowed to exist.
Notably, science supports midwife-led care. Studies find that certified nurse midwives achieve similar or better outcomes for low-risk pregnancies compared to physician-led care, including lower rates of pre-term birth and fewer costly interventions like epidurals and cesarean sections. Thirty-five states have already recognized this by allowing certified nurse midwives to practice independently. Alabama’s regulatory approach bucks that national trend for no evident clinical reason.
This isn’t a close call. The Alabama Department of Public Health has essentially decided to try to regulate freestanding birth centers to death by reclassifying them as something they plainly are not. But applying hospital licensing requirements to birth centers isn’t about patient protection; it’s a regulatory fiction in the service of shutting down a competitor to traditional hospital-based maternity care.
The Alabama Supreme Court should have seen this for what it is, restore the lower court’s ruling, and let Alabama’s birth centers get back to doing what the evidence shows they do quite well: helping mothers have healthy babies.
This op-ed was originally published on AL.com on May 24, 2026.
