Alabama currently prohibits certified professional midwives (CPMs) from practicing, despite evidence that midwifery care is as safe and often more cost-effective than hospital births. Many families prefer the personalized care of midwives and there is a significant lack of maternity care providers in numerous Alabama counties. Advocacy for the legalization of CPMs is essential to improve access to midwifery care and overall maternal and neonatal outcomes in the state.

1. Why Alabama Needs Certified Professional Midwives

2. What Is A Midwife? “ A midwife is a person who, having been regularly admitted to a midwifery educational program, duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. She may practice in any setting including in the home, the community, hospitals, clinics or health units.” Adopted by the International Confederation of Midwives 19 July 2005

3. Why Families Choose Out-of Hospital Birth Personal or religious reasons

4. Why Families Choose Out-of Hospital Birth Personal or religious reasons Concern about the medical model of care and/or hospitals

5. Why Families Choose Out-of Hospital Birth Personal or religious reasons Concern about the medical model of care and/or hospitals Geographic Issues

6. Why Families Choose Out-of Hospital Birth Financial Considerations

7. Who Uses Midwives? Low risk, healthy women who: Desire natural childbirth—the medicated rate in hospitals is 90% Dislike the institutional atmosphere and lack of autonomy in a hospital. Want individualized, family-centered care. Do not have health insurance and seek cost effective options. Must travel great distances, in labor, to give birth.

8. “ Those who do not understand history…” In the 1970’s, Alabama, like the rest of the nation, was experiencing a renaissance of out-of-hospital birth. Mothers were seeking health care alternatives. These mothers were largely Caucasian, middle class and educated. They wanted birth to be safer and more comfortable than what was being offered in hospitals at the time. As granny midwives like Onnie Lee Logan neared retirement, the clients they had lost to Medicaid-funded hospital births were largely replaced with these mothers.

9. Inspired by traditional midwives, some midwives chose to enter the field directly without first becoming nurses. They organized themselves into professional groups and formulated standards of practice. The Midwives Alliance of North America (MANA) was founded in 1982 and the North American Registry of Midwives (NARM) in 1987. Seeing the need for a national standard and a psychometrically sound testing process, NARM created the Certified Professional Midwife (CPM) credential in 1994 to aid midwives seeking licensing and regulation.

10. What Is A CPM? The Certified Professional Midwife (CPM) credential is accredited by the National Organization for Competency Assurance, which also accredits the Certified Nurse Midwife (CNM) credential. CPM credential is backed by nationally recognized and psychometrically sound assessment. The CPM credential is legally defensible. The only profession which specializes in out of hospital births. Promotes the Midwives Model of Care

11. How do Certified Professional Midwives Receive Their Credentials? The Certified Professional Midwife (CPM) credential is issued by the North American Registry of Midwives (NARM) and is recognized internationally. The CPM credential is accredited by the National Commission for Certifying Agencies (NCCA). This competency-based education is accomplished by the most efficient method of learning: a one-on-one tutor, or preceptor. This preceptor must be approved by NARM. The CPM must document competent performance of over 750 skills. The student attends a minimum of 40 births -- 20 as a student and 20 as the primary midwife while still under supervision.

12. All CPMs MUST have a minimum of: 40 out of hospital births 75 prenatal exams 20 initial exams 20 newborn exams 40 postpartum exams Current Adult CPR Infant CPR or Neonatal Resuscitation The student trains for a minimum of one year, and training is the equivalent of 1350 clinical hours . After completing the rigorous educational and training process, which usually takes 3 to 5 years , the student must pass a hands-on Skills Assessment exam that is administered by a NARM Qualified Evaluator. Upon passing the Skills Assessment, the student must pass an eight hour written exam .

13. Each CPM Must Develop: Informed Consent Document and Practice Guidelines An Emergency Care Plan NARM Requirements for Re-Certification, which occurs every 3 years Current CPR Certification for Adult & Infant CPR or Neonatal Resuscitation 5 hours of Peer Review 25 hours of Continuing Education or re-take NARM Exam Twenty-six states currently require passing the NARM exam for licensure as a direct-entry midwife. Alabama is one of only 10 states that actively prohibit CPMs from practicing.

14. What Does Midwifery Care Include? Prenatal care Continual risk assessment Nutritional counseling Community based resources Avoiding unneeded interventions Monitoring throughout labor Continuous on-site care Family-centered care Postpartum care for the mother and child The Midwives Model of Care is based on the fact that pregnancy and birth are normal life processes.

15. Midwives Model of Care The application of this woman-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean section.

16. Midwifery Care vs. Obstetrical Care Midwifery Care Unrestricted access to Care Provider. Continuity of care– Mother sees the same healthcare provider for every visit. Low stress delivery environment – mother chooses setting, pace, attendants, and circumstances. Technology used only when appropriate AND informed consent is given. Mothers choose the most comfortable, safe position for delivery. The average midwife spend 60-75 contact hours with clients during pregnancy and birth Obstetrical Care Access by appointment during business hours only. Mother sees whomever is on call for delivery. Mother forced to abide by hospital regulations, with nurses and doctors juggling multiple births. Technology used as matter of course, informed consent often IMPLIED. Mother’s delivery position limited by hospital protocol or doctor. The average physician spends less than 10 hours with patients during prenatals, labor and postpartum

17. Over 30% of babies born in the United States are surgically delivered from their mothers’ bodies. Cesarean section rates in the United States has more than quadrupled in the past 30 years, with no corresponding improvement in neonatal outcomes.

18. The Mehl Study A Comparison of Hospital and Home Births Lewis E. Mehl, M.D. conducted a study of hospital births and home births to determine the relative safety of each. 1,046 home births were randomly matched and compared with 1,046 hospital births. The women were matched for: Age Parity Socio-economic status Gestational length Education Individual risk factors Virtually all of the couples in both groups had taken childbirth education classes. The babies’ birth weights were not statistically significantly different, so this does not enter into the results.

19. The Mehl Study A Comparison of Hospital and Home Births Intrapartum Period “ Intrapartum” means “during the birth” The home births had 83% less fetal distress. The home births had 80% less elevated blood pressure and/or pre-eclampsia. The home births had 71% less meconium staining. The home births had 16% less stalled labor. The home births had 87% less shoulder dystocia. The hospital births had 73% less bleeding during labor. The hospital births had 66% less retained placental fragments.

20. The Mehl Study A Comparison of Hospital and Home Births Neonatal Outcomes The definition of “neonatal” used here is that period of time which begins at birth and ends on the 28 th day of life. The home births had 57% less neonatal asphyxia. The home births required 73% less neonatal resuscitations. The home births had NO birth injuries. In the hospital births, there were 30 birth injuries, including skull fractures, facial nerve palsies, brachial nerve injuries, and severe cephalohematomas. The home births had 83% fewer neurologically abnormal infants.

21. The Mehl Study A Comparison of Hospital and Home Births Apgar Scores Apgar scores are measurements of a baby’s physical well-being. A score of 0, 1, or 2 is given for each five areas; heart rate, respiration, muscle tone, reflex irritability, and color. A “perfect” score is 10. Below is a comparison of the Apgar scores of the home births and the hospital births. Apgar Score Home Hospital 1-minute score < 4 20 (1.91%) 36 (3.44%) 1-minute score < 7 56 (5.35%) 116 (11.09%) 5-minute score < 4 3 (0.29%) 8 (0.76%) 5-minute score < 7 11 (1.05%) 23 (2.20%)

22. The Mehl Study A Comparison of Hospital and Home Births Procedures Used The home births had 56% less Oxytocin used during first stage, 76% less during second stage, and 74% less during third stage. The home births had the SAME number of 1 st -degree lacerations as the hospital, the hospital had 58% fewer 2 nd -degree, home had 81% fewer 3 rd -degree, and home had 93% fewer 4 th -degree lacerations. The home births had 90% fewer cervical lacerations. The home births had 88% fewer episiotomies. The home births had 95% less anesthesia and 97% less analgesia The home births ended up in 67% fewer caesarean sections. Infant death rate low in both home and hospital, essentially the same.

23. The home births were found to have significantly better outcomes. “ Home Birth Versus Hospital Birth: Comparisons of Outcomes of Matched Populations.” By Dr. Lewis Mehl, Presented on October 20, 1976 before the 104th annual meeting of the American Public Health Association. For further information contact the Institute for Childbirth and Family Research, 2522 Dana St., Suite 201, Berkeley, CA 94704

24. Is this the ONLY Option? Most babies are born to mothers who are numb from the waist down and tangled in a web of tubes and wires.

25. 39 of 67 Alabama Counties Currently Have No Maternity Care Despite this birthing technology, the US maintains one of the highest rates of maternal and neonatal mortality among all developed nations. Alabama ranks 43 rd nationally in infant mortality

26. Why We Need Midwives In Alabama Scientific studies show midwifery care and out of hospital birth to be AS SAFE as physician assisted hospital births for most women. Many families prefer to receive the more personalized care of a midwife. Midwife-assisted births are significantly less expensive than hospital births. Midwives offer care in BOTH urban and rural areas, and to all socioeconomic groups. Many Alabama counties have no providers of maternity care. Many Alabama counties do not have hospitals equipped to offer maternity care.

27. What About Other States? Midwives are licensed or regulated in 26 states in the U.S. Integrate Licensed Midwives as part of Emergency Preparedness System NO state that has adopted the CPM has EVER rescinded it. Every state that allows CPMs has better neonatal/maternal outcomes than does Alabama

28. Licensing Trends of CPMs

35. Midwifery Makes Good Cents In 2007, the typical total cost for pregnancy through postpartum was approximately $3000.00 The cost for physician-supervised prenatal care and hospital care began around $12,000.00—the cost is higher for C-section

36. Some Celebrity Women Who Chose Homebirth in the U.S. Lisa Bonet Cindy Crawford Tyne Daley’s Daughter Tania Joy Gibson – Miss Illinois Woody Harrellson’s Wife Mrs. Val Kilmer Carol King Ricki Lake – in training to be a midwife Mrs. Michael Landon Pamela Anderson Lee – twice Mrs. Kenny Loggins Lindsey Wagner – The Bionic Woman Supermodel Stella Tenant Every US President until Jimmy Carter Demi Moore Singer Nellie Furtado Liberty Phoenix – River’s sister Kenny Preston – wife of John Travolta Tracy Reiner – Rob Reiner and Penny Marshall’s daughter Kenny Roger’s second wife John Schnieder’s wife, Ellie Mrs. David Soul Meryl Streep Mrs. Richard Thomas Kathleen Kennedy Townsend – Bobby Kennedy’s daughter 80% of the people currently on the planet

37. What We Must Do Alabama citizens should join the consumer grassroots organization, the Alabama Birth Coalition, to help increase access to midwifery care. Write, then call, your insurance provider and request coverage. Contact your Legislator to let him/her know that you want this option. Become involved in local effort to educate the public and encourage natural childbirth options in your community

38. Alabama Families Want Safe Homebirth