Against some of the state’s biggest medical associations, a grassroots coalition of mothers and advocates successfully overturned a 40-year prohibition of midwifery in Alabama, but for certified working midwives and those who wish to become one, there’s still work to be done.

Last week, Gov. Kay Ivey signed House Bill 315 into law, calling it “a perfect example of the people of Alabama playing an active and effective role in lobbying their government.”

“I signed the midwifery bill because it gives mothers more options to choose how to deliver their baby, while simultaneously ensuring that those midwives who practice in Alabama are qualified to do so,” Ivey said. “[It] strikes the appropriate balance of removing regulations to allow midwives to practice, while also making sure offered services are safe for and in the best interests of mothers and children.”

For Courtney Gordon, a certified doula in Mobile who is training to become a midwife, the signing of the law was welcome news — not only for herself, but for mothers across the state.

“I’ve been working as doula for a little more than three years now, and it’s been such a hassle for moms and families who want to have a home birth,” Gordon said. “Some do, but they have had to cross the Mississippi border.”

While most women choose midwifery to give birth at home or to receive consistent care from the same person throughout their pregnancy, some do so out of necessity as hospitals in rural areas continue to go out of business or close their labor and delivery units to cut costs.

In 2014, only 29 of Alabama’s 67 counties had hospitals offering obstetrical services, and Gordon said extending service to mothers in those areas is big plus of HB 315’s passage.

“There are also a lot of rural counties where mothers have to drive two and three hours every time they have a prenatal appointment and when they finally do go into labor,” she said. “We’re hoping those areas will be able to benefit from this.”

According to those who followed it, though, House Bill 315 was a bit of a dark horse.

Colleen Tullis, a Mobile resident, has been a certified midwife for more than a decade. Certified in Louisiana and practicing in Mississippi, she’s provided out-of-hospital care for hundreds of mothers even as her profession remained a crime at home.

After 13 years of striking out in Montgomery with legislation that hasn’t been able to make it out of committee, Tullis said there was no indication the 2017 regular session would be different.

“We’ve presented this bill or some form of it for years, and we’d always get shot down,” Tullis said. “This year, it just started flying though, especially compared to our previous experiences.”

While the bill cleared the House with few issues, it moved more slowly through the Senate, where, despite passing 30-0, supporters had to make some concessions to keep it alive.

Provisions requiring midwives to carry liability insurance were added along with controversial prohibitions on certain “high-risk” pregnancies, such as those with multiple children and mothers who have previously had a cesarean section. Another requires midwives to collect and record the number of births, deaths and transfers to hospitals that occur in their work.

In the waning hours of the session, a regulatory board was also established to “approve, renew, suspend or revoke” midwifery licenses. Its seven members will be appointed by the governor, affirmed by the senate and comprise four certified midwives, a nurse midwife [or registered nurse], a nurse practitioner and a consumer who’s used the services of a midwife.

Initial nominees will be submitted to the governor’s office by a consensus between the Alabama Birth Coalition, which helped push HB 315, and the Alabama Midwives Alliance, of which Tullis is a member.

Tullis said she’s actually pleased with the board’s format, though. With a majority of midwives, she called the setup “excellent,” adding that “many states would like [Alabama’s] arrangement.”

One of the last hurdles for HB 315 was Sen. Slade Blackwell, R-Montevallo, who turned a 10-minute discussion on the final day of the session into something resembling a filibuster.

However, Sen. Vivian Davis Figures, D-Mobile, became somewhat of a last-minute champion for advocates in her defense of the bill on the Senate floor — at one point openly asking Blackwell, “Who are you working for? Who has you at the mic trying to kill this bill?”

Tullis seemed agreed with Figures, telling Lagniappe she believes the bill’s opposition “pulled out all the stops” on the session’s final day when they realized it might actually pass.

“It was very frustrating,” she added. “So much of what they started trying to tack on, we’d been asking for for years.”

A key opponent of HB 315 and similar legislation has been the Medical Association of the State of Alabama, which offered the following statement: “While the Medical Association remains concerned about the safety of at-home births, we are satisfied that the amendments added to the legislation will provide an added level of protection for mothers and infants that was not contained in the original bill. The final version of the bill that passed also included some language to provide liability protection to physicians and hospitals that may have to assume care of the patient of a midwife who experiences complications.”

Despite that pushback, though, Gordon said she’d like to see a community of OB-GYNs and midwives working together to achieve better outcomes for mothers and babies.

“Other places around the country have that, and we’d like to see that model of care that supports families and women by giving them the choices they desire,” she said. “When we do that, there are better maternal and fetal outcomes and lower rates of postpartum depression.”

With a board to be seated, regulations to be written and a shortage of midwives to make it all happen, Tullis said it could be a year before anyone is legally practicing in Alabama. Yet, with the door open for the first time in four decades, she is hopeful others like Gordon can ultimately meet the demand that already exists for a service that was a crime last month.

“We will put a board together and have all these rules and regulations in place. This will all come to fruition,” she said. “After 13 years, we’ve proven that perseverance pays off. If people speak loud enough, you can make the government listen. It’s not easy, but you can do it.”

This article was edited on June 1 to add a statement from the Medical Association of Alabama.