Twice a month, Sarah Stokely travels 4½ hours from her home in Rome, Georgia, to work for a week at a birth center in Blountville, Tennessee.
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Stokely is a certified nurse-midwife — the title for registered nurses who specialize in midwifery. But Georgia laws make it difficult for her to practice there.
The state requires all nurse-midwives to have formal, written agreements with physicians that describe when physicians must intervene in evaluating or treating patients. Stokely said the agreement, which often requires midwives to pay physicians for their time and liability insurance, was too expensive. She was quoted around $500 per month, she said.
Midwives who don’t have nursing degrees, meanwhile, aren’t allowed to practice in Georgia at all. The laws make Georgia one of the country’s most restrictive states for midwives.
Stokely and two other midwives sued the state Thursday, alleging that Georgia’s policies violate the state constitution and don’t ensure patients’ safety.
In the suit, a draft version of which was shared exclusively with NBC News, the plaintiffs argue that their midwifery services are essential in Georgia. More than one‑third of the state’s counties are considered maternity care deserts, meaning there are no obstetric providers or birthing facilities, according to the nonprofit group March of Dimes. The plaintiffs also say making it easier for midwives to practice could lower 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 afterward, according to March of Dimes.
“There are some places in the state where there’s nowhere to give birth or access pregnancy care nearby. We have midwives, including our clients, who are ready and willing to fill that gap to serve those families, and the state is treating them like criminals,” said the lead attorney for the plaintiffs, Hillary Schneller, senior counsel at the Center for Reproductive Rights.
Representatives for the state didn’t immediately respond to a request for comment.
The lawsuit is one of several filed in recent years to challenge state restrictions on the practice of midwifery. The cases argue that midwives play an important role in addressing provider shortages, which have become more acute as hospitals close obstetric units.
In January, the American College of Nurse-Midwives sued the medical licensure board of Mississippi, where midwives are also required to have collaborative agreements with physicians to practice. The lawsuit says the rule is “a major barrier to closing Mississippi’s gaps in prenatal and postpartum care.” In a court filing, the state disputed that assertion and said the regulations “speak for themselves.”
In Alabama, meanwhile, a lawsuit that has been ongoing since 2023 challenges a regulation requiring birth centers — facilities where midwives oversee deliveries and administer pre- and postnatal care — to be licensed as hospitals. The lawsuit argues that the restriction (which isn’t being enforced while the suit plays out) would make it difficult, if not impossible, for birth centers to operate. An Alabama court sided with the birth centers last year, but an appeals court reversed the decision in January. The American Civil Liberties Union, which is representing the birth centers, has asked the state Supreme Court to review the case.
“Georgia is not unique in the maternity care shortage it is facing 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 physician agreements create barriers
Sixteen states require some form of collaborative agreement with a physician for a nurse-midwife to practice.
Proponents of the agreements argue that they’re necessary for patient safety. Because midwives are trained to oversee low-risk pregnancies and usually send patients to hospitals if complications arise, agreements with physicians in theory should give midwives someone to consult or transfer patients to in such scenarios. But in practice, it’s not guaranteed that physicians will be on call when midwives need them, and many midwives say the agreement implies they’re incapable of making sound decisions on their own.
“There is a bit of mistrust that we can do things independently,” Stokely said.
The plaintiffs in the new lawsuit also allege that it can be difficult to find doctors in Georgia willing to enter into the agreement.
“I don’t think I’ve met a midwife yet that is opposed to working collaboratively with obstetricians, but I have met many OBs that are opposed to working with midwives,” said Jamarah Amani, another plaintiff.
A patchwork of state regulations for midwives
Georgia is one of 38 states that don’t allow licenses for certified midwives, who have master’s degrees in midwifery. It’s also one of 13 states that don’t offer paths to licensure for certified professional midwives, who complete training and exams but don’t have degrees. All 50 states recognize nurse-midwives.
Tamara Taitt, the third plaintiff in the Georgia lawsuit, said the restriction has led to staffing issues at the birth center she runs in Atlanta.
Because she can’t hire midwives who aren’t nurses, Taitt said, her pool of applicants is limited. As a result, she said, the practice is sometimes unable to take new patients, and midwives are sometimes stretched too thin to accompany their patients to the hospital when they need transfers.
“If you are invested in solving the problem of maternal mortality and infant mortality, it doesn’t really make any sense that you’re not leveraging all of the providers that you can,” Taitt said.
Some states have also imposed regulations on home births, which have become increasingly popular in the U.S. In Nebraska, for instance, it’s a felony for nurse-midwives to attend home births. A pregnant mother sued the state in January to challenge the law; the case was settled last month, with the state carving out a religious exemption to the ban.
Taitt and her fellow plaintiffs argue in their suit that Georgia’s regulations limit pregnant women’s options for their deliveries.
“The state needs to listen to its own citizens that are saying: ‘We demand access to midwife care. We want to have our home births. We want to birth in birth centers,’” said Amani, who previously owned a home in Georgia.
She moved to Florida more than a decade ago and had planned to move her family back to Georgia eventually. 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 fled there, as well, then called Amani after she experienced contractions. Amani was forced to tell the woman that she couldn’t oversee the birth if it happened in Georgia.
“I remember her being so shocked and appalled,” Amani said. “Her trusted care provider is down the street but can’t legally attend her.”