Political Tactics Deprive “Home Birth Safety Act” of Promised Vote

Rep. Mike Ball from Madison
has sponsored HB 67.

by Anna Bertone, MPH  Guest Blogger

The Senate Judiciary Committee held a hearing yesterday for House Bill 67, and Senate Bill 99, "The Home Birth Safety Act." The bill, sponsored by Rep. Mike Ball, R-Madison, and Sen. Paul Bussman, R-Cullman would have decriminalized the practice of Certified Professional Midwives (CPMs) in an effort to improve out-of-hospital maternity care in Alabama.

Supporters from across the state filled the room and waited through hours of less popular bills to the last on the agenda – the midwifery bill. The committee allowed three testimonies from the opposition and two from the proponents. Legislators were preparing to vote as planned when Sen. Bryan Taylor, R-Prattville made a late arrival and halted the legislative process by calling for the bill to be tabled. The "no" votes on tabling the bill were Sen. Orr, Sen. Ward and Sen. Williams.

Sen. Bryan Taylor arrived late and
called for SB 99 to be tabled.

The disappointing end to the public hearing came after passionate testimony from both sides of the issue. The opposition cited a not yet published study on national birth certificate data  that found an elevated relative risk of neonatal death for home births. They gave no discussion of absolute risks or the limitations of using administrative records for research purposes. They recounted examples of tragic outcomes from Alabama home births in such detail that many in the audience could identify the cases being described.  

Supporters referenced favorable results from a recent observational study that used “intention to treat” methodology. This study design avoids many of the limitations in using birth records. It involves enrolling women who are planning a home birth early in prenatal care and then following them to document the outcome. They also explained to legislators that credentialed midwives should not be blamed for poor outcomes occurring at unattended home births or births attended by lay midwives (as were the anecdotal scare stories). On the contrary, this legislation seeks to address unsafe out-of-hospital birth practices.

 "Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery."      ACOG 2011 Statement

The Medical Association of the State of Alabama uses powerful political leverage to oppose home birth safety legislation year after year. They acknowledge that parents are choosing home birth in increasing numbers, that it is within their legal right to do so, and that birth carries risk of injury and death to mother and child. Nevertheless, they refuse to come to the table with parents and midwives to discuss safety measures. Medical opponents agree in principal but not practice with the official American College of Obstetricians and Gynecologists 2011 statement on planned home birth, to “respect the right of a woman to make a medically informed decision about delivery.”  We are not respecting women’s choices in childbirth if we strive for standards and quality improvement in the hospital setting but refuse to implement safety measures for alternative choices.

After studying the issue, Dr. Pippa Abston
supports the licensure of CPM's.

According to an Alabama pediatrician:

"I have studied this issue in detail and have learned that the CPM certification process  is rigorous and appropriate.  With well-trained attendants, planned home birth can be a safe option for low risk pregnancies.  Even for higher risk cases, women who decide to give birth at home have significantly better outcomes if they are able to have a well-trained midwife present than if they are not.  Home births without such help, happening now in our state, are dangerous to both mother and newborn.  I support the licensure or at least the decriminalization of CPM practice, to improve the safety of mothers and newborns." -- Pippa Abston, MD, PhD

Women choose to birth outside of the hospital for a variety of cultural, spiritual, economic and personal reasons. For some, a previous negative hospital experience has left them seeking alternative care in a state with no freestanding birth centers. Others hope to avoid the risks associated with routine hospital interventions or hospital-acquired infections. The rising cesarean rate (now 1 in 3 in AL) may be contributing to women choosing a setting more conducive to physiologic birth. Some women who have experienced sexual trauma or forms of discrimination prefer to birth in a familiar setting. There are individuals and communities (Amish, Mennonites) that hold pregnancy and birth to be normal but private life events belonging to the family. Costly hospital services are enough to deter some uninsured or underinsured individuals from utilization.

The 28 states already authorizing the practice of CPMs have come to the common sense

The Alabama Birth Coalition will
keep fighting for the birthing
rights of Alabama mothers.

conclusion that it’s absurd to allow home births but outlaw qualified care providers to attend them. The safest possible course is to license and regulate credentialed midwives while collecting publicly available data on maternal and child outcomes. 

Families choosing home birth are fed up with bullying tactics from powerful special interest groups and want to let the legislative process work to come up with real solutions to real problems. We at the Alabama Birth Coalition agree with the American Public Health Association’s resolution  to increase access to trained out-of-hospital maternity care providers as an important step in improving public health and safety. We support the safest possible care for all Alabama families, regardless of chosen birth setting. 

For more information, visit www.alabamabirthcoalition.org or find the organization on Facebook.

The Alabama Birth Coalition (ABC) is a 501c4 non-profit, grassroots organization.

Will Alabama Actually Make Home Birth Safer?

By Glenni Lorick, IBCLC

For the last several years, the Alabama Birth Coalition has worked tirelessly to pass legislation providing for the licensing and regulation of Certified Professional Midwives. Each year, their efforts have fallen short, as the bill has either not made it out of committee or been terribly altered by unfriendly ammendments. There is good reason to hope that this year will be different!

A New Committee

Instead of presenting a bill to the Health Committee like they have in past years, this year they have taken a different approach: they have provided a bill to the Judiciary committee! The focus of the bill is the decriminalization of home birth. House Bill 67 and Senate Bill 99, "The Home Birth Safety Act," would decriminalize the practice of Certified Professional Midwives (CPM's).  According to the Alabama Department of Public Health, 1,448 women gave birth outside of the hospital from 2005-2012. Many of those mothers had no medical assistance, increasing the risk dramatically. 

While it is not illegal for a mother to give birth in the comfort of her home, it IS illegal for anybody with any medical training to provide assistance to her. This bill provides immunity to midwives and certain healthcare providers who assist in "physiologic childbirth." In other words, specially trained professionals will not be prosecuted for helping a mother give birth at home.

The Debate

Opponents argue that home birth is inherently unsafe. They insist that a woman should only give birth in the safe confines of a hospital. In fact the president of the Medical Association of the State of Alabama weighed in heavily against this bill. Nevertheless, even Governor Bentley recognizes that Alabama mothers ARE having babies at home, and the wisest thing to do is make it as safe as possible for them by allowing trained professionals to attend those births. 

Proponents of the Home Birth Safety Act recognize that the bill on the table actually helps to ensure the safety of mothers by authorizing only "midwives who hold a current midwifery certification from an organization accredited by the Institute for Credentialing Excellence." Certified Professional Midwives are specifically trained in dealing with out-of-hospital births. They are experienced professionals who have undergone thorough testing of their knowledge base.

You Can Help

Tomorrow at 1:00 pm a public hearing is scheduled before the Senate Judiciary Committee followed by a committee vote. Many members of the Alabama Birth Coalition will travel to Montgomery to show their support. Assuming this bill passes the committee tomorrow, you need to contact your state senator, asking him or her to vote in favor of this bill when it comes to a full vote of the senate. Hopefully, the same process will take place in the House.

Eventually the Alabama Birth Coalition would like to see the practice of midwifery licensed and regulated by the state. This would confer even greater protection on childbearing families. Nevertheless, decriminalization is a very important first step!

Whether you personally would be comfortable with a home birth or not, it is time to recognize that every mother has the right to choose how she wants to give birth. Some women just want their epidural in the hospital, and that is their right. Others want a natural birth in a hospital setting. Some even want a Certified Nurse Midwife.  If a woman has the right to choose to end the life of her child, then she should certainly have the right to choose where and under what birthing circumstances her child's life outside of the womb will begin.

Donate to ABC and Receive Birth Photography!!

Recently photographer Jessica Molepske moved from Texas to Huntsville because of her husband's job. Jessica's work has been featured in the online Newborn Magazine. Before moving here, Jessica contacted me a couple of months before the move to let me know she would like to meet me and to offer a promotion for our customers in order to begin meeting people here.

A couple of weeks ago, I actually met Jessica in person when she came by the store to introduce herself.  We talked about what kind of promotion she wanted to run. Today Jessica came in with information to begin the promotion!

Win a Free Newborn Photo Session

For every $50 you spend in the store between now and July 20, you will receive one entry for a free newborn photo session and photo package. It is a $300 value! The more you spend at A Nurturing Moment, the more chances you have to win.  Jessica likes to do the Newborn Session within 12 days of baby's coming home from the hospital because babies are so sleepy and do very well in a variety of precious poses.

Donate $100 to ABC and Have Your Birth Photographed!

About a week ago, I received this message from Jessica via Facebook:   

Hi Glenni, 

I just recently realized that it's illegal for a midwife to attend a

 homebirth here in AL?? I am so heartbroken over this! I read that article you posted the other day..and I'm wondering is there anything I can do? I wouldn't really know where to start..but this is a change I would like to see! 

Jessica

I suggested that the most important thing she could do is get in touch with the Alabama Birth Coalition. She did just that, and has agreed to photograph the Walk for Midwives this fall. Today Jessica announced that she is offering something VERY special to help raise money for ABC.  Between now and the date of the walk in November, Jessica is offering to photograph your birth in return for a minimum donation of $100 to ABC!! Of course, if you feel led to donate more, that is wonderful. But Jessica is offering her services as a way to support this cause.

We have many amazing photographers here, and Jessica is excited about meeting and working with them. Take just a minute to friend her on Facebook, then come on by and enter to win your newborn session. If YOU aren't pregnant, you can give the session to a friend. What an amazing gift that would be!!

Women's Rights, Alabama Law and Midwives

For the last several years, an amazing group called the Alabama Birth Coalition has been working

Photo from SoulVegMama

tirelessly to bring about legislative change which will allow Certified Professional Midwives (CPM's) to practice in Alabama. This legislation is important because in many rural counties, women have to drive an hour or more to the nearest hospital with a maternity unit. Families who don't want medical community involvement may end up giving birth at home without any attendant at all. Legalizing CPM's and home birth would offer these women another option. Furthermore, creating legislation that sets forth licensing requirements and regulates the practice of CPM's actually helps to ensure that women choosing home birth receive a high standard of care.

The Opposition 

Opponents of the bill, however, are many and powerful. Unfortunately even within the midwife community, there is sharp disagreement about this legislation. Certified Nurse Midwives (CNM's) sometimes cite the lack of medical training received by CPM's as a reason not to support the bill. Are their concerns legitimate? Certainly the kind of training that CPM's receive is different in nature than that received by CNM's. It is definitely more focused on out-of-the-hospital births. In fact, a candidate cannot even become a CPM without experience in at least 10 births in a non-hospital setting.

While it is true that we do currently have 17 CNM's in the state of Alabama, only a very small handful of them are actually catching babies! Some work in doctor's offices, others teach, but only 3 or 4 hospitals in the state have a CNM delivering babies. Why is that?  Why isn't there a single freestanding birth center in this state? In one word, the answer is MONEY.  Blue Cross, Blue Shield of Alabama, the largest insurance provider in the state, doesn't reimburse for midwife delivery the way they do for a physician delivery...not even close! Plus, the Alabama law is written in such a way that a midwife may only practice under direct supervision of a physician. Essentially, her supervising doctor is supposed to be on the premises when a midwife is delivering. Few doctors are willing to have midwives deliver under those conditions.

The Reality

Dr. Pippa Abston 

Within the medical community here in Alabama, it is common to hear how unsafe home birth is. But is it really? Dr. Pippa Abston, a pediatrician and instructor in the UAB family residency program used to agree with those who opposed home birth. In fact, she was a rather outspoken opponent. However, she began to thoroughly examine this issue, to actually see what a CPM does, and to understand just how badly we need the quality of care in many Alabama communities that a CPM would provide. In fact, Dr. Abston wrote a 5 part series about the importance of CPM's for Alabama women. It will take some time, but if you really care about this issue, you need to read Dr. Abston's excellent series. She has covered everything from the training of  a CPM to the safety issue to the desperate need in our rural counties.

The Root Issue

This is, at it's most fundamental point, a human rights issue. Last Friday evening The Alabama Birth Coalition sponsored a presentation of the film, Freedom For Birth. Take 15 minutes to watch the abbreviated web-version of this film. It details the cases of Hungarian midwife, Agnes Gereb and Hungarian mother, Anna Ternovsky. In 2010, The European Court of Human Rights affirmed that a woman has the right to give birth in the place and manner of her choosing.

Hungarian midwife Agnes Gereb

The United States Supreme Court in the infamous Roe v. Wade decision in 1973 stated that a woman has the right to abort her unborn baby - a decision I don't personally support. However, based on that precedent, it is utterly illogical to say that she doesn't have the right to choose how and where her baby (whom she has chosen not to kill) can be born.  Even in the highly unlikely event that Roe v. Wade were ever reversed, it should be a common-sense decision to view a woman's right to give birth as she pleases as her decision to make. Whether a physician or a competent midwife  performs her prenatal care should be up to her. If a mother has chosen the midwifery model of care, and her midwife realizes that something is amiss, then her midwife should be able to have a collaborative professional relationship with a physician and should be able to stay with the mother throughout  whatever kind of birth the mother needs at that point. Opponents may say that this endangers mothers and babies. However, in the Netherlands where this is the model, the maternal and infant death rate is lower than that of the United States.

A Call to Action

There are many states in this country where women have absolute freedom to give birth in the manner that is most comfortable for them.  Alabama, however, is definitely not one of those states. We would do well to look at the maternity care models in states like Texas, Tennessee,  and New York. Two separate and very important things need to happen legislatively in Alabama:

Hungarian mother Anna Ternovsky

1. CNM's need to be authorized by law to work without direct physician supervision in any birth setting, and insurance reimbursement for their services needs to be mandated.
2. CPM's need to licensed and regulated by the state to ensure that mothers desiring their services are getting the highest possible standard of care. This will stop the mass exodus of birthing mothers to surrounding friendlier states, and allow mothers in the poorest Alabama counties access to local well-trained professional birth support.

Anna Ternovsky was willing to take her fight to the highest court that held jurisdiction over her country.  Will it actually take a mother here beginning that judicial fight to create the changes that must occur? I would hope that our legislators, midwives and physicians will find a way to come together in respectful support of mothers and babies before that happens. However, the Alabama Birth Coalition has been struggling for twelve years to bring about legislative change. Maybe now is the time to seek the kind of judicial ruling that will ensure all mothers have their basic right to give birth as they choose protected.

Someday I would love to see a Free-standing birthing center here in Huntsville where both CNM's and CPM's work together and have healthy collaborative relationships with local physicians. There is absolutely no valid reason why this can't happen. And I believe it will. If all those who are concerned about birth in this state would simply work together, we could lower our infant mortality rate, provide high-quality care to the poorest among us, and make certain that every Alabama mother receives her basic human right to the birth of her choosing.

Huntsville Walk for Midwives

Yesterday morning more than 100 proponents of a woman's right to choose how and where she gives birth gathered at Big Spring Park for the Walk for Midwives. They raised money for the Alabama Birth Coalition, but more importantly, they were hoping to raise awareness about the importance of changing the Alabama law.

The majority of states allow women to give birth as they choose. Alabama, however, does not. In Alabama, women who would prefer to give birth in the comfort of their own home with a trained professional midwife are denied that option. There is much debate about the safety of women giving birth at home, and this isn't the forum to debate that.

However, if we had greater availability of midwives routinely offering services in Alabama hospitals and birth centers, perhaps fewer mothers would opt for home birth. Women who want to avoid interventions, who want to labor in the water and who want to give birth in non-traditional positions often feel they don't have those options with an Ob/Gyn in a traditional hospital setting. Although we do have some doctors in our area who are very open to a woman's preferences, the presence of midwives working alongside them would go a long way toward helping this group of mothers feel comfortable.

The Alabama Birth Coalition is working to change the law in Alabama. If Blue Cross Blue Shield would change the way they cover midwife deliveries in the hospital setting, that would be a terrific first step. Another important step is the legalization and regulation of Certified Professional Midwives. Many rural Alabama counties have no prenatal care or hospital at all. That's one of the primary reasons that Alabama has such a high infant mortality rate. Women in these rural counties would be well-served by the changes in legislation that the Alabama Birth Coalition is seeking.