Jamarah Amani was living in Pennsylvania when she had her first child. She had the care of a midwife who made her experience so much easier. The midwife got on the floor to show Amani yoga poses for back pain, answered all of her questions and stayed by her side through the birth.
Then Amani moved from Pennsylvania to Georgia. Her experience with the birth of her second child couldn’t have been more different. Without access to midwifery care covered by Medicaid, she found herself fighting hospital staff over birth positions and unwanted medical interventions.
“We had to battle the hospital system and really just fight for basic dignity and freedom of movement and autonomy over my body,” she said. “When I had that experience with my second birth, I was like, I am definitely going to become a midwife.”
Knowing she wanted to provide care outside a hospital setting, Amani began apprenticing. But Georgia’s laws don’t allow direct-entry midwives — those without nursing degrees — to practice, so she moved to Florida to obtain her midwifery license. She held onto her Georgia house for a while in hopes she would be able to return. That was 18 years ago.
In April, Amani became one of three plaintiffs in Amani et al. v. State of Georgia, a lawsuit filed in Fulton County Superior Court. Backed by the Center for Reproductive Rights, the suit argues that Georgia’s ban on direct-entry midwives and its requirement that certified nurse-midwives maintain written agreements with physicians to practice independently violate the Georgia Constitution and limit maternity care in areas where families have no other options. Georgia has one of the highest maternal mortality rates in the country. The plaintiffs argue that these restrictions on midwifery care are adding to the harm.
Those who choose the direct-entry pathway often do so because they want to specialize in out-of-hospital births and practice in a community context. They receive specific training on home births and working in birth centers, which is different from the hospital training received by certified nurse midwives.
Birth centers offer home-like care for low-risk pregnancies. Georgia has just three, all in the Atlanta metro area. The state’s oldest, which operated in Savannah for nearly 40 years, closed in February. According to March of Dimes, more than one- third of Georgia counties qualify as maternity care deserts, meaning there are no obstetric providers, birth centers or hospitals providing obstetric care.The plaintiffs argue that the laws make it difficult for new centers to open and serve the areas that don’t have other options.
Tamara Taitt, another plaintiff and direct-entry midwife, spent nearly a decade directing a freestanding birth center in Florida and now lives in Georgia. She is the executive director of Atlanta Birth Center, but state restrictions mean, despite her experience, she cannot practice at the center she runs. The direct-entry midwives on her staff work as birth assistants to the nurses.
“Not having access to direct-entry midwives to hire means that there’s actually a lot of training time that goes into preparing a nurse midwife to adequately cover in a birth center,” Taitt said.
By limiting who can practice, she said, “Georgia is squandering a workforce that is ready and available to care for families.”
Though certified nurse-midwives — who have a nursing degree — are allowed to practice in both hospital and birth center settings, there are limits on independent practice. They are required to maintain written protocol agreements with physicians. But physicians have no obligation to accept them and they can be terminated at any time.The agreements can also be costly, with physicians asking for monthly fees ranging from hundreds of dollars to over a thousand.
The third plaintiff in the lawsuit, Sarah Stokely, holds an active Georgia nursing license and lives in Rome, a rural area with few maternity care providers. After nursing school, she began working at a small birth practice. However, the practice couldn’t afford to secure physician agreements for more than one nurse-midwife, so she was unable to practice to the full extent of her licensure.
She now drives more than four hours each way to work at a birth cottage in Tennessee.
“I refuse to pay a physician when I can travel to another state where I don’t have to,” she said.
She also prefers to work alongside direct-entry midwives rather than separate from them. Tennessee is one of 36 states that offers direct-entry midwives a path to licensure, something she hopes the lawsuit could help bring to Georgia.
“Their livelihood is threatened if they do practice within this state. They’re here. They live here. They want to work here,” she said.
Georgia has been central in the long history of midwifery restrictions in America. In the early 20th century, estimates suggest Georgia had between 5,000 and 9,000 working midwives, half of whom were Black women. These “granny midwives,” as they were often called, served rural communities where physicians were scarce.
In 1925, Georgia began to formally regulate midwives. An article written by a member of the Georgia State Board of Health describes the effort as a gradual process of “elimination” of the “old, the unclean and the unfit” and urged local physicians to “assist in this weeding out.” Requiring nursing credentials meant that racist admissions policies would lock many Black midwives out.
“The schools where you could go to study nursing, Black people couldn’t go to. It was intentionally done to decimate the workforce of Black midwives knowing that they would not be able to go to those schools decades before the Civil Rights Movement happened,” Amani said.
By 1963, the state had declared hospital delivery the ultimate goal, and in 1979 it stopped certifying new midwives altogether. Today only 6 percent of the U.S. midwifery workforce is Black.
The absence of Black midwives has removed a source of care that many Black families have historically trusted. Black Georgians are more than twice as likely to die from pregnancy-related causes as White Georgians, according to a report from the Georgia Department of Public Health.
Other Southern states, like Florida and Texas, created new direct-entry licensing frameworks starting in the 1980s. Georgia did not. Supporters of Georgia’s restrictive framework argue it is necessary to ensure patients’ safety. Some maintain that collaboration with physicians is a patient protection, particularly when something goes wrong during labor. However, a 2018 study found that states with the most midwife-friendly laws had significantly lower rates of preterm birth, low-birth-weight infants and neonatal death. In states like Washington, where midwives practice with greater autonomy and direct-entry midwives have paths to licensure, maternal and neonatal outcomes are better or comparable to Georgia’s.
The three midwives who are suing Georgia say the requirements are more about control than safety. Physicians’ control over protocol agreements, they say, effectively gives a competitor the power to stop a midwife’s ability to practice.
“If we are saying that keeping people healthy and well during pregnancy matters to us, then what are the pathways to do that? And to me, it certainly includes utilizing our whole work first to the fullest extent of our skill,” Taitt said.
The Georgia lawsuit is part of a broader legal push against midwifery restrictions nationwide. The Center for Reproductive Rights previously challenged a Hawaii law that criminalized Native Hawaiian cultural birth practitioners. The case was settled and Hawaii passed laws decriminalizing midwifery in the state. The American College of Nurse-Midwives recently filed suit in Mississippi over physician agreement requirements.
In Georgia, the legislative route has stalled. House Bill 520, introduced in the 2025 session, would have created a licensing pathway for direct-entry midwives and eliminated the physician agreement requirement, but it never made it out of committee.
“We’ve had some champions in the Georgia legislature who have really tried,” Amani said. “But overall, this issue has been ignored, and that’s just not acceptable anymore. We’re not asking. We’re demanding our rights, really on behalf of the mamas and families who need us.”