Alabama was Already in a Reproductive Health Care Crisis

In a state with just four female senators, advocates are pushing against some of the steepest barriers to access in the nation.

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Emma Bertolaet gets right to the point: “We have shit access to reproductive maternal health care.”

She is a practicing doula and Ph.D based in Tuscaloosa who has studied the impacts of birthing and health care on Alabama women for the better part of six years. It’s work that has intensified since the state passed one of the most restrictive abortion bans in U.S. history.

The bill’s sponsor, Republican Representative Clyde Chambliss, claimed the legislation was essential because life was endangered. “Human life has rights,” he said, “and when someone takes those rights, that’s when we as government have to step in.”

And yet, Bertolaet points out, women of color living in Alabama’s rural “Black Belt” region—so called first for its rich soil and later for its plantation slavery and sharecropping—have to drive up to three hours to receive any reproductive or maternal care beyond basic family practice care.

“If [Alabama was] pro-life,” she says, “we’d invest in health care and improve access so infants could live.”

It’s no secret that the nine states to date that have passed bills set to restrict abortions are setting up a clear challenge to Roe v. Wade. These pro-life-backed so-called “heartbeat bills” are designed to restrict abortions as early as week six, before most women even know they are pregnant. But underlying this national story is a local one that’s just as troubling: prior to its abortion ban, Alabamians were already in a reproductive and maternal health care crisis.

Alabama has one of the highest infant mortality rates in the country: 9.6 deaths per 1000 births. Of the fifty-four rural counties in the state, only seventeen have access to an obstetrician. Furthermore, the state has no laws protecting jobs for pregnant women or new parents. State residents must rely on the federal Family Medical Leave Act, but restrictions apply.

“If Alabama was pro-life, we’d invest in health care and improve access so infants could live.”

Alabama is the sixth poorest state in the United States, with fifteen counties having poverty rates higher than 25 percent. In 2018, 250,000 children in the state were living below the poverty line, and the poverty rates for white, black and Latinx residents were all above the national averages.

“Women are still treated like chattel here,” says Carin Mayo, who lost a bid last November for Alabama’s House of Representatives. “Women making $10 an hour can’t afford child care or affordable housing. How can families afford a child when they can’t even get access to, or afford, birth control and reproductive health care?”

In her role as a doula, Bertolaet educates women about their pregnancies while providing support to nurse midwives. But access to nurse midwives is difficult in Alabama.

Most of Alabama’s hospitals are localized in the state’s larger cities and communities such as Huntsville, Montgomery, Birmingham, Tuscaloosa, and Dothan. And while the Affordable Care Act added midwifery as a mandatory coverage under Medicaid, it only covers certified nurse midwives with an R.N. or B.S.N. in addition to a masters of science in midwifery.

Alabama complicates this rule by requiring an obstetrician be present at all hospital births, again making access even more difficult for poor, rural women. A certified professional midwife can do home deliveries, but they are much harder to access, have no consistent medical staff backup, and are not covered on most insurance plans.

The access problem is intensified by the closing of rural hospitals—six in the last eight years— and what Bertolaet sees as a monopoly of insurance options. Blue Cross/Blue Shield, Tricare (for military personnel and families), and Medicaid are the only options for most people, she says.

As Mayo sees it, Alabama’s abortion ban was just “another move to keep people in poverty and put a foot on the necks of people of color.”

She ran for office in part because she wanted more women represented in the lawmaking process. Though women make up 51.5 percent of the state’s population, there are currently only four women in the Alabama state senate. All of them are Democrats in the eight-person minority party. Alabama’s abortion bill was passed by twenty-five white male Republicans in the state senate without any debate allowed by those in opposition.

A higher education administrator, Mayo cites the lack of affordable health care, substandard education, and poor economic decisions that maintain systemic poverty, as evidence that Alabama is not, in fact, pro-life.

“We have one of the highest infant mortality rates in the nation (higher than some third-world countries),” she wrote in a recent op-ed, “all because we are ‘pro-life.’ ”

“Talking about abortion takes away from talking about birth,” Bertolaet, the doula, asserts. This focus on abortion creates fear, undermines female empowerment, and distorts the realities and health risks associated with birth.

Bertolaet’s research suggests that women and children would be better served by changes to four key areas, rather than anti-abortion laws. She argues Alabama should focus on sex and reproductive education, improved care provider options, increased access to facilities, and changes to how we view birth.

Perhaps most important among these changes is providing women in Alabama access to facilities and providers where they live, and shifting how we see birth and pregnancy. Shortages due to a lack of access, she says, can lead to long waiting lists, which disportionately impacts women of color, regardless of social class.

This focus on abortion creates fear, undermines female empowerment, and distorts the realities and health risks associated with birth.

Mayo advocates for increasing the minimum wage, instituting equal funding of education, dismantling predatory lending, and addressing the state’s food insecurity problem—Alabama’s childhood food insecurity rate is 22.5 percent, five points above the national average—as better ways to serve the lives of state residents. Anti-abortion bills, she argues, ignore the poverty women and children experience in Alabama.

Despite her frustration, Mayo has hope. She keeps a Ruth Bader Ginsburg action figure close at hand to embolden her to speak up for women and all those experiencing injustice.

“We are not done fighting,” Mayo says. “And we are not going away.”