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Protect Mothers & Babies: Make Home Birth Safer

We are a citizen-led group seeking to make out-of-hospital birth safer through stronger, uniform regulations in the United States. Despite the increased risk of morbidity and mortality at out-of-hospital births (1,2,3), families have a legal right to choose their setting of birth and to expect that out-of-hospital midwives are regulated to meet a high standard of safety and accountability.

By signing this petition, we endorse the following regulations:

1. Require a License - Midwives attending out-of-hospital births should be required to have a license to practice, as is the case for any other profession. Practicing as a midwife without a license should carry penalties in every state.

2. AMCB Certification - Midwives should be certified through the American Midwifery Certification Board* (AMCB). The American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) support midwifery care by AMCB certified midwives and those who meet standards by International Confederation of Midwives (8). The AMCB is the Gold Standard of midwifery certifications and is recognized in all 50 states. For out-of-hospital births of low-risk pregnant women, AMCB certified midwives are associated with significantly lower mortality rates than midwives certified through NARM** (4,5,6).

3. Malpractice Insurance – Midwives attending out-of-hospital births should be required to carry medical malpractice insurance. Requiring insurance cuts out-of-hospital neonatal mortality in half, without reducing access to home birth providers (7). Insurance ensures that a midwife is individually liable for outcomes, gives families a means of recourse, and relieves state-funded programs of the financial burden associated with poor outcomes at out-of-hospital births, such as lengthy NICU stays.

4. Low-risk Scope and Newborn Care - Midwives' out-of-hospital scope should be limited to low-risk pregnancies and births, as outlined in the recommendations from the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists (ACOG), the College of Midwives of British Colombia (Canada) and the Royal Dutch Organisation of Midwives (Netherlands) (8,9,10,11).

At a minimum, the following conditions should be risked out of out-of-hospital birth: 
- Preexisting maternal disease
- Significant disease arising during the pregnancy, such as diabetes mellitus
- Prior uterine surgery
- Non-cephalic presentation
- Multiple gestation
- Gestational age less than 37 weeks or greater than 41 weeks 6 days
- Ruptured membranes for more than 24 hours
- Meconium-stained fluid

5. Report Outcomes to the Public - To bring greater transparency to risks of out-of-hospital birth, an independent state agency should collect and report data on birth and death (fetal, neonatal and maternal) outcomes of planned out-of-hospital births, including intrapartum and neonatal transfers to hospital care, type of attendant and planned setting of birth, similar to the law and reporting system in Oregon (12).

6. Integrated System of Care - Licensed, insured, AMCB-certified midwives should have access to labs and collaborative agreements with a currently-practicing physician and with a local hospital to ensure continuity of care.

Implementing these regulations throughout the country establishes uniformity, in stark contrast to the inconsistent and convoluted system that we currently have (13). More importantly, these regulations will improve out-of-hospital outcomes for mothers and babies, all the while supporting midwifery autonomy and respecting the midwife’s role as a primary care provider.

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* The American Midwifery Certification Board (AMCB) is the certifying agency for Certified Nurse Midwives and Certified Midwives
** The North American Registry of Midwives (NARM) is the certifying agency for Certified Professional Midwives and Licensed Midwives.

References
1. Grünebaum A, McCullough LB, Sapra KJ, et al. Apgar score of 0 at 5 minutes and neonatal seizures or serious neurologic dysfunction in relation to birth setting. Am J Obstet Gynecol 2013;209:323.e1-6

2. Cheng YW, Snowden JM, King TL, et al. Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol 2013;209:325.e1-8

3. Grunebaum A, et al. Term neonatal deaths resulting from home births: an increasing trend. Am J Obstet Gynecol 2014; Volume 210, Issue 1, S38.

4. Stapleton, S. R., Osborne, C. and Illuzzi, J. (2013), Outcomes of Care in Birth Centers: Demonstration of a Durable Model. Journal of Midwifery & Women’s Health, 58: 3–14.

5. Johnson Kenneth C, Daviss Betty-Anne. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ 2005; 330 :1416

6. Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D. and Vedam, S. (2014) Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery & Women’s Health, 59: 17–27.

7. Muniz, L. Do State Midwifery Laws Matter? Linked Birth / Infant Death Records on CDC WONDER On-line Database. Sept. 2014.

8. American Academy of Pediatrics Policy Statement on Planned Home Birth, Committee on Fetus and Newborn Pediatrics. Vol. 131 No. 5 May 1, 2013 pp. 1016 -1020

9. Planned home birth. Committee Opinion No. 476. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:425–8

10. Janssen PA, Saxell L, Page LA, Klein MC, Liston RM, Lee SK. Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician [published correction appears in CMAJ. 2009;181(9):617]. CMAJ. 2009;181(6–7):377–383

11. Midwifery in the Netherlands. The Royal Dutch Organisation of Midwives. First edition, KNOV, October 2012.

12. 687.495 Oregon Revised Statutes - Board of Direct Entry Midwifery

13. Midwifery Laws State by State - Safer Midwifery for Michigan

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    Coalition for Safer Home Birth started this petition with a single signature, and now has 615 supporters. Start a petition today to change something you care about.