Since 2023, the Alabama Department of Public Health has been involved in litigation over its attempts to regulate freestanding birth centers in the state as hospitals, effectively preventing such facilities from operating in Alabama.
The plaintiffs initially won a favorable judgment in 2025, when the Fifteenth Judicial Circuit Court ruled that birth centers—which provide midwifery care to low-risk pregnant patients—should not be considered “hospitals” under Alabama law and cannot be regulated as such. However, the Alabama Court of Civil Appeals reversed the decision on appeal, and in May 2026, the Alabama Supreme Court declined the plaintiffs’ request for further review.
Now, the case is back before the Circuit Court of Montgomery County, where the plaintiffs are arguing that even if ADPH has the authority to regulate birth centers, the specific licensing rules currently in place unlawfully restrict Alabamians’ access to birth center care.
To learn more about the ongoing litigation and its relationship to maternal care access in the state, APR spoke with Donna Matias, an attorney with the Pacific Legal Foundation who recently published an op-ed on the issue.
“The argument that the plaintiffs made in the Oasis Family case is that you can’t regulate birth centers as hospitals because they’re not hospitals. They’re very different from hospitals—I mean, it’s a completely different setting, right?” Matias said. “And obviously, what it takes to open and operate a hospital is much, much more than the plaintiffs believe was intended by the rule. And so it’s not to say that birth centers should not be regulated at all, it’s just to say that they shouldn’t be required to meet all of the requirements for a hospital.”
Matias also provided insight into the plaintiffs’ current arguments before the Circuit Court of Montgomery County.
“They’re arguing a right to procreate under both the Alabama and U.S. Constitutions, and those fall under the right to privacy,” Matias said. “They have, I believe, substantive due process claims, which is to say that the burden that these regulations put on the birth centers violates Alabamians’ right to pursue happiness and violates their right under the Alabama Constitution—I’m not as familiar with the Alabama Constitution—but it’s something like the right to pursue useful activities, sort of the right to pursue happiness. I believe there were several Alabama Administrative Procedure Act claims, and those deal with whether the agency is acting within its authority or not.”
While the Alabama Constitution does not specify a right to pursue useful activities, it does establish that the sole objective of government is to protect citizens in their “enjoyment of life, liberty, and property.”
In Matias’ view, ADPH’s attempt to saddle birth centers with hospital-like regulations is only exacerbating a maternal health care crisis already plaguing the state.
“I think it’s pretty clear that the more you regulate, and I would say overregulate, the more likely it is that you’re going to have birth centers just not come into existence. And if they’re not coming into existence, then you’ve got a whole lot of women who are being denied access to care,” Matias said. “I believe 34 percent of the counties in Alabama are maternity deserts. So that means there is no access to care. I think there’s another 30 percent that are restricted access, very limited access. So what it means is if you’re the state or you’re ADPH and you’re not allowing these birth centers to come into existence, you’re continuing the crisis and you’re probably worsening the crisis.”
“You know, one of the interesting things about regulatory burdens is that we very rarely count what doesn’t come into existence, what’s kept out, right?” she added. “There’s no way of counting it, we don’t know who’s disincentivized by it, we don’t know how many birth centers in this case try to open but can’t. We don’t know, we don’t measure it, and so we tend to not really understand, I think, how impactful regulation and regulatory burdens can be, not just on the providers, but even worse, on the patients.”
As for why ADPH is intent on preserving these regulatory burdens, Matias speculated that the state may be seeking to limit competition for other maternity care providers.
“I can only speculate, and obviously I’m not in their head and I probably have a bit of a cynical view given what I do for a living. We challenge these kinds of regulations all the time. I don’t think ADPH is scheming to say, ‘how can we deny access to care?’ I don’t think that’s the incentive, but I would not be surprised if there was some incentive that had to do with dampening competition with other providers of maternity care,” Matias said. “I don’t know if that’s what’s going on here, but I will say that I have seen that in other instances where anytime you’re challenging licensing schemes and things like that, which I do all the time, there is a protectionist element to it. How great it is in this particular case, I can’t say.”
Matias said birth centers have been shown to be a safe and effective method of providing maternal care to pregnant patients across the country and internationally, raising further questions about why ADPH appears intent on limiting access.
“The studies on the safety and effectiveness of this as an option, the birth center model as an option, it’s undeniable, right? So it’s not like there’s an argument that can be made that, ‘well, we’re not really sure if midwifery is better or not,’” Matias said. “There’s plenty of studies—like I say, nationally, internationally—that this particular model of care for low-risk pregnancies, the outcomes are at least as good as, if not better, than physician-led care. It’s really hard to ignore protectionism as at least some element here, because I don’t believe that they want to deny access to care. It’s just sort of the side effect of their main goal, whatever that may be.”
Indeed, a 2022 study published in the Journal of Prenatal Education found that pregnant patients who access birth center care typically experience better health outcomes than those with similar risk profiles who receive typical perinatal care, including lower rates of preterm birth, low birth weight births and cesarean birth, and higher rates of breastfeeding.
“The evidence really does support the existence of freestanding birth centers and the birth center and midwifery model of care is effective and very safe and I think it’s at least part of the solution to a very severe maternity care crisis,” Matias said. “I think that the state of Alabama should take note of that and act accordingly.”
