With eight kids and another one on the way, Megan Alger can seem more like the CEO of a small company than a typical American mom. In their family's suburban home in Augusta, Ga., kids are taught to be self-sufficient from a young age.
Megan regularly deputizes her older children to care for the younger ones. "I just gave my 2-year-old to my 8-year-old and said, 'Go put him in his bed,'" she says around nap time, laughing. "We'll see if it works."
The 8-year-old obediently carried his brother to his crib and shut the door.
As Roman Catholics, Megan and her husband, Stephen Alger, believe strongly in the family unit. Megan doesn't engage in paid work in order to homeschool the younger kids and run the household. She has delivered most of her babies at home. That's the plan with this next one too.
In many ways, they appear to be exactly the kind of people whom President Trump has in mind in his call for large families — the movement known as pronatalism. The administration has floated ideas like baby bonuses, increased access to in vitro fertilization and tax breaks to encourage people to have more children.
At the same time, a growing number of Americans distrust medical institutions — where most babies are born. And families like the Algers, as well as advocates for maternal health, say the federal government could do a lot more to support parents, starting with birth.
" I feel that for a country that's taking on this almost pro-life stance and pro-baby, and you want to have the nuclear family, we're not really doing much to increase the safety of that," says Katie Chubb, a community organizer who has been trying for years to give families in Augusta more options when it comes to where they have their babies.
"We're not doing much for mothers and birth safety."
Growing medical distrust
The Algers say there was a time when they were willing to vaccinate their children. But they wanted to do it on a slower schedule, and the school that their son was attending wasn't cooperating. "We were constantly in the office with school administration," says Stephen, "because somebody else had found out that 'the Algers weren't vaccinated' and were throwing a fit."
Feeling ostracized, they left — and decided to forgo vaccines all together.
Though only Megan voted for Trump in 2024 — Stephen says he didn't like either candidate — they both felt hopeful when Robert F. Kennedy Jr. was appointed secretary of health and human services. His skepticism about vaccines and America's food system, they say, has offered some cultural legitimacy to their point of view.
" I'm not looked at as much like I'm crazy when I don't let the kids have red dye or high fructose corn syrup at the birthday party," says Megan.
Their skepticism has also led them to a deep distrust of hospitals. And they are not alone.
One study shows that trust in doctors and hospitals declined by 30 percentage points between 2020 and 2024. Megan, who grew up in a military family with five siblings, says she watched her own mother be mistreated at a hospital.
Stephen points to Georgia's high rate of maternal mortality as another reason he doesn't trust the system. For every 100,000 live births, 33.9 resulted in death in that state, according to a 2018-2021 report from the Centers for Disease Control and Prevention. That's well above the national maternal mortality rate of 23.5 deaths per 100,000, according to the same report.
"I'm a logical guy," says Stephen. "If you're telling me that hospital intervention is the thing that's supposed to decrease the maternal mortality rate, why is the maternal mortality rate increasing as women adopt more common medical practices to having children?"
The Algers have had most of their babies at home with a midwife who is licensed in another state, but not in Georgia. That's the plan with this next one as well.
"Something tragic could happen," says Stephen. " I acknowledge this is a risk we are accepting in order to get the benefits from having the baby at home."
The Algers fear that in a hospital they would be pushed into interventions they don't want, in the interest of speeding up labor or making things more convenient for doctors.
To be clear, data shows hospitals are safer than home birth — even in states with high rates of maternal and infant mortality — for both mothers and babies. The American College of Obstetricians and Gynecologists says the risk of a baby dying in a home birth is twice that of hospital birth.
"Momnibus" legislation
For years, advocates across the United States have been warning that the country is not doing enough to provide for America's moms and babies. They point to high rates of maternal and infant mortality despite high health care spending.
In 2023, Sen. Tammy Baldwin of Wisconsin was one of several legislators to introduce the Perinatal Workforce Act. She and other Democratic lawmakers aimed to improve the perinatal health workforce with diverse kinds of credentialing for health care workers involved in births. Her state has one of the highest rates of infant mortality, especially for Black women.
In addition, the Biden administration outlined an ambitious plan called the Maternal Health Blueprint in 2022. Its priorities included "ensuring women's voices are heard in the healthcare system" and "expanding the perinatal workforce" — birth workers including doulas, midwives and specialized nurses.
But advocates say that under the Trump administration, much of their advocacy for increased investment in maternal and child health outcomes is on hold. The Perinatal Workforce Act did not pass.
A gray market for home birth
It's not illegal to give birth at home in Georgia. But it's difficult. And advocates say it would be safer if there were more licensed midwives.
Unlike some other states, Georgia does not license midwives who haven't first been trained as nurses. Those who have been trained and licensed, called certified nurse midwives, can be difficult to find and hire, especially in rural areas.
The American College of Obstetricians and Gynecologists (ACOG) offers a cautious endorsement of other kinds of training for midwives. ACOG acknowledges that there are not enough qualified people to deliver babies but says that bringing a life into the world is dangerous and requires standards and training. It's a problem that's getting worse as rural hospitals close.
In Georgia, this legal landscape has given rise to a gray market for midwives.
Adjgiwa is a midwife who has never received formal training. She asked to be identified only by her middle name, for fear of drawing the attention of local health authorities. Sitting in a rocking chair on her front porch in the Georgia heat one afternoon, she says she no longer knows how many babies she has delivered in her 45 years as a midwife. "I stopped counting at 1,000," she says, chuckling.
Adjgiwa does not take insurance or partner with hospitals. Her clients find her by word of mouth and pay her in cash. She says she'd prefer to be licensed or work in a birth center. That would allow her to communicate with doctors about patients when she has to transfer them into their care.
Adjgiwa says when the COVID-19 pandemic hit, demand for her services increased. "All of the midwives that I knew, if they already had a busy practice, it just got busier," she says.
"Women started losing their faith in the medical system," she says, "when it comes to their own lives and the life inside of them."
Women are going to keep having babies at home, Adjgiwa argues, so it would be better to give families more options that are safe and legal.
The Algers' baby is due around Christmas. In the past, Stephen has delivered several of their babies himself when the midwife didn't get there in time.
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