Thursday, April 2, 2015

Sample Email Against NC "Home Birth Freedom Act"

If you are in North Carolina, please make your voice heard and speak out against Senate Bills 542 and 543! To find out who your senator is, go to this page and click on your county on the "North Carolina Senate" map: Who Represents Me? Your senator's page will have their office's phone and email information. This is a slightly modified version of the email I sent to my senator's office. Feel free to use it and modify it how you want to email your own legislators.

Hi! My name is ______ and I live in _____, NC.

I am against Senate Bills 542 and 543.

The bills require CPMs to have an active license to practice, but they do not require them to carry malpractice insurance, report their birth outcomes to the public, limit their scope of practice by excluding things like VBAC, breech, or multiple births, or have written collaborative agreements with hospital-based CNMs or physicians that would provide oversight.

These midwifery licensing bills do not benefit women. They benefit midwives by allowing them to charge money to attend homebirths without the regulations in place to protect women and babies.

There are already midwives that can legally practice in North Carolina. These midwives - Certified Nurse Midwives - are some of the most educated midwives in the world. They must have a nursing degree and a master's degree. Their education meets the International Confederation of Midwives (ICM) standards and they would be qualified to practice in any other developed country. Again, those midwives are already allowed to practice in NC. The bills would legalize Certified Professional Midwives - and these midwives are so poorly educated that they would not be allowed to practice in any other developed country in the world. They do not have any degree requirements. Their only educational requirement is to have a high school diploma, and if they became a CPM before September 2012, they don't even need that. They don't need to take even basic college biology. They don't need to take anatomy, or physiology, or microbiology, or immunology.

So if the NC "Home Birth Freedom Act" passes, CPMs, who would not be qualified to practice in any other developed country in the world, will be able to legally practice midwifery in North Carolina. I can't call what they're doing practicing medicine, because they don't consider what they're doing practicing medicine. In Bill 543 they claim "Midwifery is a profession in its own right, and it is not the practice of medicine." That's right - determining the medical condition of a woman and child, ordering labs, giving medicine, and dispensing medical advice, is not, according to these bills, "practicing medicine."

It's logical to think that with their almost non-existent education, CPMs would have poor outcomes for the women and babies they care for, and that has been backed up by every major study done on home birth in the USA.

Important - these studies are all on planned, midwife-attended home births.

- This 2012 study ( on direct-entry midwives in Oregon found that they had 9 times as many newborns die under their care than died at the hospital
- This study released last year ( found that babies born to direct-entry midwives at home births died 4 times more often than those born at the hospital
- This meta-analysis from Arizona in 2013 ( found that babies died 3 times more often at home birth
- These 2008 statistics from the CDC Wonder Database ( found a death rate 3.5 times higher at home birth
- This study (, released last year by the Midwives Alliance of North America, found a death rate 5.5 times higher at home birth (for low risk pregnancies; for breech babies the death rate was 28 times higher)
- This study ( found that babies born at home suffer 17 times as many brain injuries as those born in the hospital
- This study ( found that 3 times as many babies born at home have seizures
- This study ( found that 10 times as many babies born at home have an Apgar score of 0

And I'm not cherry-picking the data by only showing the studies that prove my point - these are all of the major studies on home birth in the US. Not a single study has shown direct-entry midwifery in the US to be a safe care option. When confronted with this data, many midwife advocates will say that the MANA study that came out in 2014 shows that home birth is safe - but that is the study that showed a death rate 5.5 times higher for newborns born at home.

If the NC legislators are determined to pass these bills despite the increased risk of newborn death, maternal death, brain damage, and seizures, there are several different ways they could improve them.

1. Require malpractice insurance

First of all, the bills should require midwives to have mandatory malpractice insurance. In a report comparing different state midwifery laws, "Do State Midwifery Laws Matter?" (found here: , the data shows that requiring midwives to carry malpractice insurance cut the rate of newborn deaths in half. Additionally, it does not restrict access to CPM care.

This simple and effective way to protect women and children - requiring midwives to carry malpractice insurance - is not currently a requirement in Senate Bills 542 and 543, despite data showing that it halves newborn death rates without decreasing access to care.

The first section of Bill 543 claims "Access to prenatal care and delivery services is limited by the inadequate number of providers of midwifery services, and the practice of midwifery may help to reduce this shortage." It also claims "In the interest of public health, the State should promote the regulation of the practice of midwifery for the purpose of protecting the health and welfare of women and infants." If this is true - that the bills are being passed in the interest of women and infants - then they will require mandatory malpractice insurance. Women and children are the ones who benefit from the mandatory malpractice insurance requirement - and they benefit a lot. If the bills are truly being passed in their interest, that requirement will be included.

If, however, the bills are being passed in the interest of midwives, they will not - as they currently do not - require midwives to carry malpractice insurance.

If the authors of the bill continue to leave out this simple, effective protective measure, it will be clear that these bills are for the benefit of midwives, not for the benefit of women and children.

2. Require collection and publication of birth outcomes

As it currently stands, midwives do not have to report the outcomes of births under their care to any governing body. If the authors of bills 542 and 543 are determined to pass them despite studies showing increased risks to women and children, they should at least include a requirement that birth outcomes of CPMs must be collected and publicly reported. 

The state of Oregon has this requirement. "In 2011 the Oregon House Health Care Committee amended the direct-entry midwifery—'DEM'—law to require collection of information on planned place of birth and planned birth attendant on fetal-death and live-birth certificates starting in 2012."

"Oregon now has the most complete, accurate data of any US state on outcomes of births planned to occur in the mother’s home or an out-of-hospital birth center."

What did they find? That out-of-hospital birth with a non-nurse midwife had a death rate 9 times higher than hospital birth. (Report here.) This is the type of birth that North Carolina Senate bills 542 and 543 are promoting - out-of-hospital births with non-nurse midwives.

If the authors of these bills still want to pass them despite knowing of the greatly increased risks of non-nurse midwife care to mothers and children, they should at least require collection and publication of birth outcomes. This will help identify problems in the system and provide more information to mothers deciding on care providers.

3. Define "normal" pregnancy and care transfer guidelines

As the bills are currently written, CPMs are allowed to "provide care for the healthy woman who is expected to have a normal pregnancy, labor, birth, and postpartal phase." The problem is that the bill provides no definition of "normal." So the decision of what constitutes a "normal" pregnancy is left up to the midwives themselves, and that is a loophole that will be taken advantage of.

Other countries that have well integrated home and hospital birth systems, like the UK and the Netherlands, have strict "risking out" criteria for who is a good candidate for home birth and is "expected to have a normal pregnancy, labor, birth, and postpartal phase." These criteria are standardized and plainly written out, and if a woman develops any of the risk factors  listed she is transferred from a midwife to a higher level of care.

Common risking out criteria include breech births, multiples, previous cesarean sections, and much more. Consider the differences between the transfer care guidelines of the Netherlands vs. the state of Oregon: Dutch Homebirth Standards vs. Oregon Homebirth Standards. Now think about two things: the Netherlands standards for what constitutes a "normal" pregnancy are much, much higher. And even though they do have some pregnancies that direct-entry midwives are not allowed to care for, Oregon non-nurse midwives still have a newborn death rate 9 times higher than hospitals.

The North Carolina "Home Birth Freedom Act" defines no risking out criteria at all. How high will our death rates be? If the NC legislators wants to protect women and babies, they will make sure the bills define what constitutes a "normal" pregnancy and what risk factors will necessitate a transfer of care.

4. Require written collaborative agreements with a hospital-based CNM or physician

As it is currently written, the NC "Home Birth Freedom Act" grants direct-entry midwives the freedom to take on any clients whose pregnancy they themselves define as "normal," have multiple negative birth outcomes without reporting the results to anyone, and experience no financial or professional repercussions. The midwives are essentially free agents. They have no supervisors to ensure that they're working within their scope of practice and they report their results to no one.

In a word, there is no accountability.

If the authors of this bill want to protect women and children, they will make sure that the CPMs they legalize are working within their scope of practice. To do this, they need to require written collaborative agreements with hospital-based CNMs or physicians.

New Jersey's midwifery laws are a good example of this type of supervision. Found here ( they read:

"a) Prior to beginning practice as a midwife, a licensee shall enter into an affiliation with a physician who is licensed in New Jersey
b) The licensee shall establish written clinical guidelines with the affiliated physician which outlines the licensee's scope of practice.
c) The clinical guidelines shall set forth:
  1. An outline of routine care;
  2. Procedures the licensee will perform or provide;
  3. Procedures to follow if one of the risk factors from N.J.A.C. 13:35-2A.9 and 2A.11 is encountered;
  4. The circumstances under which consultation, collaborative management, referral and transfer of care of women between the licensee and the affiliated physician are to take place, and the manner by which each is to occur
d) A licensee shall provide clinical guidelines and the identity of his or her affiliated physician(s) to the Board upon request.
e) The clinical guidelines shall include provisions for periodic conferences with the affiliated physician for review of patient records and for quality improvements.
f) A licensee who practices without establishing clinical guidelines with an affiliated physician commits professional misconduct as proscribed by N.J.S.A. 45:1-21(e)"

Such standards ensure that all mothers and babies under the care of CPMs are protected by ensuring that CPMs are working within their scope of practice, care is transferred if a pregnancy becomes high-risk, and outcomes are known and documented by a supervisor.

The NC "Homebirth Freedom Act" currently grants too much freedom to poorly-educated midwives, without putting into place safety barriers that will protect mothers and children.

Certified Professional Midwives do not have enough education or oversight to safely care for mothers and babies. As the Senate Bills are currently written, there are no limitations on their scope of practice as long as they claim they believed the mother's pregnancy was going to be "normal." There is no oversight of their practice to ensure they are taking on only low-risk clients, and there are no governing bodies that they have to report their outcomes to. Basic protective measures such as mandatory malpractice insurance and written collaborative agreements are missing.

If the NC legislators still want to pass this bill despite knowing of the increased rates of neonatal death, maternal death, brain damage, and seizures that occur with non-nurse midwife care, if they want to show that they are truly thinking mothers and babies, and not just furthering midwives' interests, they will make sure the bills: 1. Require midwives to carry malpractice insurance 2. Require collection and publication of birth outcomes 3. Define "normal" pregnancy and care transfer guidelines 4. Require written collaborative agreements with hospital-based CNMs or physicians

If these provisions are included in the bills, it will show that they are being passed with mothers and babies in mind. If they are absent from the bills - as they currently are - it will show that the NC "Home Birth Freedom Act" is more concerned with benefiting midwives than providing safe care to mothers and babies.

Thank you for reading all of this - it's very important.

For other resources on why legalizing CPMs is unsafe, you can look at the information compiled in these sources:

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