To the casual observer, opening Birth Sanctuary Gainesville might not make a lot of sense. First, Gainesville is a rural town in Alabama with a population of less than 200. Second, because of state regulations that severely restrict the scope of care nurse-midwives can provide, there are no birth centers in the entire state. That is about to change because FNU alumni Dr. Stephanie Mitchell, DNP, CNM, CPM, plans to open Birth Sanctuary Gainesville later this year. While the uncertainties are many, Mitchell insists, “It will get done.”
Mitchell is the sort of person who finds ways to get things done. Barriers represent an opportunity rather than a permanent roadblock. Even her road to becoming a nurse-midwife was a circuitous one. Where others might have given up and changed course, Mitchell never wavered from her plan.
Growing up in urban Boston, Massachusetts, in the 1980s, Mitchell’s first thoughts of pursuing a medical career began by watching The Cosby Show.
“My very first exposure to childbirth was on television,” Mitchell said of The Cosby Show. “It was very shocking to me because the family would have mirrored my family, except that they were completely different echelons of human society. We were struggling along in the hood, the ghetto, dealing with all the things that 1980s Boston brought for a low-income black family. It was the opposite on TV. The father was an obstetrician, and the mother was a lawyer. That was my first exposure to pregnancy, and the healthy dynamic of that family really appealed to me and stuck with me.”
Her second exposure to pregnancy and her first to obstetrics came a few years later when she was 16 and pregnant. She had collaborative care with an obstetrician and a midwife.
“The way my body was honored during that process of pregnancy is really cemented into my mind,” she said. “I figured out that the word wasn’t ‘obstetrician’ or ‘obstetrics’ – it was ‘midwife’. I thought, ‘How do I do that?’”
She did that by having her baby, finishing high school, attending community college, and going on to earn her BSN from Curry College. She knew she wanted to be a midwife and wanted to attend Frontier Nursing University. She also knew that she needed to gain experience, preferably in labor and delivery. She worked in pediatrics for about six years before getting into a labor and delivery unit, where she worked for six years before applying to Frontier. She continued working in labor and delivery while she earned her MSN and DNP from FNU, the latter in 2019.
“The hospital I worked at was a lovely place in the backdrop of my neighborhood in Boston. I learned so much and have deep respect for my colleagues there,” Mitchell said. “But it was shocking to me to get to the labor and delivery unit and realize that the medical staff was not reflective of the community. I had come from the Boston Children’s Hospital, and we had a very diverse staff. I got to the labor and delivery unit, and it was shocking to be one of three black nurses on a staff of 120 in that unit. That was difficult because there are so many stark cultural differences between the care providers and those that they are caring for.”
Mitchell had learned the importance of diversity at an early age when she was part of a busing program aimed at addressing segregation in the city. She attended school in a predominantly white school system.
“You learn to interact with people who are definitely not from your community,” she said. “To have experience with individuals that don’t look like you, don’t talk like you, don’t have the same cultural norms as you, provides exposure that’s valuable in life. Midwives and advanced nurse practitioners are not always going to be black or people of color or LGBTQ, but you have to have people in place who are truly antiracist and empathetic.”
Mitchell was also concerned about what she termed “the conveyor belt of care” that sometimes persists in hospitals with high volumes of patients. She wanted to practice in a different setting, where more time could be spent with the patients in a less frantic environment. She wanted to open a birth center and started looking into the prospects in Boston. She soon realized that funding would be a problem, as would the significant amount of competition. She shelved the idea temporarily until she and her husband Jamie moved to Gainesville, Alabama, where Jamie had family.
Jamie is a successful pitmaster who got into the catering business. When the catering business became overwhelming, the Mitchells realized that a restaurant would be the better option. Starting a restaurant in Boston would not only be expensive but also involve a great deal of competition.
“He wanted to get rid of the landlord and the competition, so we came down here to Gainesville and built a restaurant,” Mitchell said. The Alabama Rib Shack is open Friday through Sunday, with the capacity to cater as needed.
As they prepared to move, Mitchell began researching places where she might be able to work. She soon found that there are no birth centers in the state. Further, in Gainesville and the surrounding area, there is no access to family planning services, midwifery care, or obstetric care.
“If you’re pregnant, it’s a desert,” Mitchell said. The nearest options are approximately 45 miles away in Tuscaloosa or across the state line into Mississippi.
It didn’t take long for Mitchell to think about opening her own birth center in Alabama. Not only did she need it as a source of income, but the community needed it as well.
“I’ve always valued the low volume, slower-paced care that can be offered through midwifery,” Mitchell said. “I had a good amount of surface information to build on what it would mean to build a birth center in Alabama. It was important to me to work in the black and not be in a situation where I am over my head and sink myself before I get started. Kitty Ernst wisely once reminded me to follow the money. I followed the business model that my husband has followed for years – eliminate the competition and eliminate the landlord. There is no competition in Alabama, and people deserve to have options. To not have it as an option is unconscionable.”
While many would agree with that, few have been as determined as Mitchell to bring about the necessary changes. One of the primary barriers created by the state’s legislation and regulation of midwives is the prevention of independent practice. Mitchell sought out physicians with whom she could partner to provide collaborative care but found none.
Midwives who attended out-of-hospital births in Alabama were jailed until 2019 when the state began issuing midwifery licenses for Certified Professional Midwives (CPM) for the first time since 1976. Contrary to Certified Nurse-Midwives (CNM), who have nursing degrees, CPMs are not required to have a nursing degree. Despite being a CNM, Mitchell had to get a CPM license so she could practice in Alabama.
“I was annoyed that I had to be a CPM because it prevents me from offering those full range of comprehensive health services,” Mitchell said. “ I see the value in being a Certified Nurse-Midwife. I see the value of being able to provide that umbrella of comprehensive care. Why would anyone ever specifically go the path of CNM only to be boxed in a corner to be a CPM? Prescriptive authority, billing insurance, access medications, full-scope care – it’s all gone. Especially in a healthcare desert like Alabama, it doesn’t make any sense. I’m still fighting that battle. It will take a while. But it’s not, ‘we can’t do it,’ it’s ‘we haven’t done it yet.’”
Mitchell says that the Alabama Birth Center Coalition, Alabama Midwife’s Association, the Alabama Board of Midwifery, and the Alabama chapter of the American College of Nurse-Midwives are all lobbying for change. In the meantime, she is pressing forward with Birth Sanctuary Gainesville. For years on their visits to Alabama, Mitchell had admired an old two-story home in Gainesville. Built in 1835, it is a registered historic landmark. It sat empty for years until, shortly after they moved, Mitchell saw that it was for sale. The Mitchells bought it and began renovation and construction to convert it into a birth center.
The roof, soffits, plumbing, electrical, and HVAC all had to be replaced or updated, but the structure was good, and the price and location were right. An exam room and a bathroom have been added, and the work continues with hopes of opening later this year.
“My first goal is to get this birth center opened this year and have our first birth here this year,” Mitchell said.
Grassroots efforts have provided the majority of the funding for the construction of the birth center. One fundraiser is a legacy walkway campaign in which people can purchase bricks and inscribe their own messages. Another fundraiser included the creation of three $5,000 scholarships that will go to BIPOC (Black, Indigenous, and people of color) midwifery students.
“This grassroots effort is a constant return back into the systems we’re working in,” Mitchell said. “It’s been overwhelming. I’ve been filled with gratitude, and I remain so humble about this project, reminding myself that this isn’t a ‘me project.’ This is a project that will impact so many families just to be able to have that access to care.”
Mitchell hopes to continue to give back to the nurse-midwifery profession by precepting students. She knows drawing them to rural Alabama might be difficult so that the birth center will include a special space for students. Mitchell describes it as a calm room where students will be able to rest or sleep in their own private space.
Until the birth center is ready to open, Mitchell is operating as an LLC and providing home birth services as a CPM. She plans to continue to offer home births even after Birth Sanctuary Gainesville is fully operational. She is also working with the University of Alabama-Birmingham’s midwifery program, assisting with course development and serving as an adjunct professor.
“I have been delighted to take part in that program,” she said. “I believe that’s the solution. UAB is a stronghold for the state. They are highly influential, and what better investment into the future of maternal healthcare and pregnancy healthcare than having a school that is going to be educating the midwives? That will lay the groundwork for accessibility in ways that we haven’t even thought about in this state.”
Mitchell has successfully managed to fund the birth center to this point and continues to advocate for more access to nurse-midwifery care in the state. She has overcome many obstacles and knows many more loom ahead, not the least of which is the potential patient population.
“It doesn’t make any sense to build a birth center here,” she said. “The same thing about my husband having a restaurant here. It seems highly unlikely and improbable. But what he has learned is that people will travel for quality. They will do it in Alabama for barbecue in a minute. There is the same sort of model in terms of accessibility. We’re talking zero freestanding birth centers in the state. It becomes a question of, ‘Do you want to travel to get care?’”
Mitchell said that, in order to help with that, they are even considering providing space for families who make the journey with their loved ones. It’s true that travel is a potential hurdle, but true to her nature, Mitchell sees not only the barrier but also the potential solution. In the end, it all makes perfect sense.
Dr. Mitchell wishes to acknowledge her husband, Jamie. “Making the journey into midwifery with a family could have been my insurmountable obstacle. He’s been my stronghold for the last 20-plus years.” She also expressed her gratitude for the support of her children, Jasmyn, Jaymie, Jayar, and Jesse, and wished to acknowledge former FNU Academic Advisor and current Clinical Advisor Carisa Lipp. “I loved so many of the faculty, but none so much as Carisa. She was the constant person of contact at FNU as I made my way through each term. I can’t say how much her guidance meant. Funny that it wasn’t a midwife who I’d describe as most impactful, but that just goes to show that one’s biggest support can come from unexpected places if you keep your eyes peeled and your heart open!”