Dr. Heather Skanes’ team at the Oasis Family Birthing Center in Birmingham, Alabama, started turning away patients this spring as state officials cracked down on alternative childbirth options.

The center had offered patients with low-risk pregnancies a place to deliver their babies outside of a hospital, where cesarean sections weren’t performed, epidurals weren’t administered and midwives took the lead. Some women labored in an inflatable aqua birthing pool, in what Skanes saw as a more supportive environment in which Black women in particular would feel more comfortable and heard.

But in March, officials with the Alabama Department of Public Health told Skanes that they considered the previously unregulated facility to be a hospital that didn’t have proper permission to be open, according to her attorneys.

The American Civil Liberties Union is suing the state Public Health Department on behalf of Skanes over what it has called a “de facto ban” on freestanding birth centers. The court battle is unfolding as the agency is weeks away from implementing licensing regulations for the facilities.

Alabama has an alarming record on keeping expectant and new mothers alive, with a higher share of residents dying in pregnancy and during or shortly after childbirth than almost any other state. More than a third of counties in Alabama lack hospitals with labor and delivery units or practicing obstetric providers, according to a report last year from the March of Dimes.