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	INTRODUCTION

TOP INTRODUCTION 2001-1: Improving Early... References 2001-2: Reducing Maternal-Fetal... References  2001-3: Increasing Access to... References   2001-4: Hospital Emergency... References    2001-5: Health Status of... References     2001-6: Global Campaign to... References     2001-7: Research and... References     2001-8: Establishment of a... References     2001-9: Protection of Child... References     2001-10: Support for National... References     2001-11: Support of the... Footnotes  References     2001-12: Discontinuing the Use... References     2001-13: APHA Resolution on... Footnotes   References     2001-14: APHA Supports the... References     2001-15: Recognition and Support... References     2001-16: Recognizing the Role... References     2001-17: Support the Framework... References     2001-18: Support for Curricula... References     2001-19: Opposition to National... References     Public Health Impact Statement 2001-20: Support for Culturally... References     2001-21: Threats to Global... References     2001-22: Opposition to Coercion... References     2001-23: Protection of the... References     2001-24: Trust Fund for... References     2001-25: Participation of Health... References     2001-26: Condemnation of... References     INTERIM POLICY STATEMENTS LB01-1: Improving the Nutrition... References     LB01-2: Alert on the... References     LB01-3: Occupational Safety and... LB01-4: Resolution Supporting... References     LB01-5: Preserving Worker and... References     LB01-6: Opposing War in... References     LB01-7: Call for United... References     Public Health Impact Statement

	2001-1: Improving Early Childhood Eyecare

TOP INTRODUCTION 2001-1: Improving Early... References 2001-2: Reducing Maternal-Fetal... References  2001-3: Increasing Access to... References   2001-4: Hospital Emergency... References    2001-5: Health Status of... References     2001-6: Global Campaign to... References     2001-7: Research and... References     2001-8: Establishment of a... References     2001-9: Protection of Child... References     2001-10: Support for National... References     2001-11: Support of the... Footnotes  References     2001-12: Discontinuing the Use... References     2001-13: APHA Resolution on... Footnotes   References     2001-14: APHA Supports the... References     2001-15: Recognition and Support... References     2001-16: Recognizing the Role... References     2001-17: Support the Framework... References     2001-18: Support for Curricula... References     2001-19: Opposition to National... References     Public Health Impact Statement 2001-20: Support for Culturally... References     2001-21: Threats to Global... References     2001-22: Opposition to Coercion... References     2001-23: Protection of the... References     2001-24: Trust Fund for... References     2001-25: Participation of Health... References     2001-26: Condemnation of... References     INTERIM POLICY STATEMENTS LB01-1: Improving the Nutrition... References     LB01-2: Alert on the... References     LB01-3: Occupational Safety and... LB01-4: Resolution Supporting... References     LB01-5: Preserving Worker and... References     LB01-6: Opposing War in... References     LB01-7: Call for United... References     Public Health Impact Statement

Recognizing that visual development from birth through school age has sensitive and critical periods where abnormalities can lead to permanent impairments, especially in the development of binocular vision, an important part of human vision; and

Realizing that conditions such as strabismus (ocular misalignment) including esotropia (crossed eyes) and exotropia (outward turned eyes) occur in up to 6.7% of children prior to age 5^1–5 and anisometropia (significant difference in refractive prescription between the eyes) has a 1% prevalence^3–6 and clinically significant hyperopia (farsightedness) a prevalence of 3-6%^6,7; and

Noting that clinically significant hyperopia causes almost half of all cases of esotropia and over 90% of cases of anisometropia, and that these and strabismus are responsible for nearly all amblyopia, the leading visual impairment in children, with a prevalence of up to 4.5%^2–9; and

Noting that the majority of eye and vision conditions in infancy and preschool ages are not obvious on gross examination and go undetected until children can read standard letter acuity charts around age 5 years^2,4,5,10; and

Noting that decreased binocular vision and depth perception can lead to problems in gross motor and fine motor development, and that uncorrected hyperopia is associated with deficits in visual perceptual skills, reading readiness, intelligence quotient, and reading achievement,^11–19 and correction of hyperopia by age 4 improves the expected reading achievement later in school²⁰; and

Realizing that infant and early comprehensive childhood eyecare is a neglected area, that less than half of pediatricians perform even limited vision screenings,²¹ and pediatric screening when performed is usually limited to a light reflex test which will not detect most strabismus, hyperopia or anisometropia; and

Noting that despite previous APHA resolutions^22,23 and United States Public Health Service Preventive Services Task Force Guidelines,²⁴ there is a paucity of public health preschool vision screening programs and those programs that exist have low sensitivity and specificity for the above conditions²⁵; and

Recognizing that the American Academy of Pediatrics,²⁶ the American Academy of Ophthalmology,²⁷ The American Association for Pediatric Ophthalmology and Strabismus,²⁸ the American Optometric Association,²⁹ the U.S. Public Health Service³⁰ and Prevent Blindness America³¹ agree that screening under age 3 is not successful but there is ample evidence that amblyogenic conditions should be detected and treated as early as possible; and;

Realizing that despite intensive efforts to develop eye screening devices such as photorefraction there is at this time no valid screening method for detecting most strabismus, amblyopia, and hyperopia prior to age 5^4,32,33; and

Noting that reducing blindness and vision impairment in children ages 17 years and under is an objective in Healthy People 2010³⁴; therefore

1. Encourages a regular comprehensive eye examination schedule as opposed to just screening based on the onset of strabismus and amblyopia should be set, so that all children have exams performed at approximately age 6 months, 2 years, and 4 years;
   
2. Encourages all children's health insurance programs to provide vision care benefits.
   
3. Encourages health insurers to educate parents on the value of adhering to the comprehensive eye exam schedule through the use of health care providers, health education and health promotion professionals as an important part of preventive health care just as vaccination, physical exam, hearing, and dental exams are;
   
4. Encourages pediatricians to recommend all children receive exams which have the ability to detect all cases of strabismus, amblyopia, and refractive errors, and refer children at high risk including but not limited to children born prematurely, children with developmental deficits, and children with family histories of strabismus and amblyopia;
   
5. Requests all children's health programs require monitoring in their quality assurance programs to insure that young children's eye and vision needs are met.
   

	References

TOP INTRODUCTION 2001-1: Improving Early... References 2001-2: Reducing Maternal-Fetal... References  2001-3: Increasing Access to... References   2001-4: Hospital Emergency... References    2001-5: Health Status of... References     2001-6: Global Campaign to... References     2001-7: Research and... References     2001-8: Establishment of a... References     2001-9: Protection of Child... References     2001-10: Support for National... References     2001-11: Support of the... Footnotes  References     2001-12: Discontinuing the Use... References     2001-13: APHA Resolution on... Footnotes   References     2001-14: APHA Supports the... References     2001-15: Recognition and Support... References     2001-16: Recognizing the Role... References     2001-17: Support the Framework... References     2001-18: Support for Curricula... References     2001-19: Opposition to National... References     Public Health Impact Statement 2001-20: Support for Culturally... References     2001-21: Threats to Global... References     2001-22: Opposition to Coercion... References     2001-23: Protection of the... References     2001-24: Trust Fund for... References     2001-25: Participation of Health... References     2001-26: Condemnation of... References     INTERIM POLICY STATEMENTS LB01-1: Improving the Nutrition... References     LB01-2: Alert on the... References     LB01-3: Occupational Safety and... LB01-4: Resolution Supporting... References     LB01-5: Preserving Worker and... References     LB01-6: Opposing War in... References     LB01-7: Call for United... References     Public Health Impact Statement

 
1. Stidwill D. Epidemiology of strabismus. Ophthalmic Physiol Opt 1997;17:536–9.[Medline]

2. Moore BD. The epidemiology of ocular disorders in young children. In: Eye care for infants and young children. Boston: Butterworth-Heinemann, 1996:21-30.

3. Lennerstrand G, Jakobsson P, Kvarnstrom G. Screening for ocular dysfunction in children: approaching a common program. Acta Ophthalmol Scand 1995; 77: 26–38.

4. Hatch SW. Ophthalmic research and epidemiology. Boston: Butterworth-Heinemann, 1998:265-268, 193-228.

5. Blohme J, Tornqvist K. Visual impairment in Swedish children. III. Diagnoses. Acta Ophthalmol Scand 1997;75:681–7.[Medline]

6. Kleinstein RN. Vision disorders in public health. In: Newcomb RD, Marshall EC. Public health and community optometry, 2nd Ed. Boston: Butterworth-Heinemann 1990:109-125.

7. Moore B, Lyons SA, Walline J, et al. A clinical review of hyperopia in young children. J Am Optom Assoc 1999;70:215–24.[Medline]

8. Newman DK, East MM. Prevalence of amblyopia among defaulters of preschool vision screening. Ophthalmic Epidemiol 2000;7:67–71.[Medline]

9. Dell W. The epidemiology of amblyopia. Problems in Optom 1991;3(2):195–207.

10. Arnaud C, Baille MF, Grandjean H, et al. Visual impairment in children: prevalence, aetiology and care, 1976-85. Paediatr Perinat Epidemiol 1998;12:228–39.[Medline]

11. Grisham JD, Simons HD. Refractive error and the reading process: A literature analysis. J Am Optom Assoc 1986;57:44–55.[Medline]

12. Grosvenor T. Refractive status, intelligence test scores, and academic ability. Am J Optom Physiol Opt 1970;47:355–61.

13. Hoffman LG. The relationship of basic visual skills to school readiness at the kindergarten level. J Am Optom Assoc 1974;45:608–13.

14. Williams SM, Sanderson GF, Share DL, Silva PA. Refractive error, IQ, and reading ability: A longitudinal study from age seven to 11. Devel Med Child Neurol 1988;30:735–42.[Medline]

15. Solan HA, Mozlin R, Rumpf DA. Selected perceptual norms and their relationship to reading in kindergarten and the primary grades. J Am Optom Assoc 1985;56:458–66.[Medline]

16. Scheiman MM, Rouse MW. Optometric management of learning-related vision problems. St. Louis: Mosby Year-Book, 1994.

17. Rosner J, Gruber J. Differences in the perceptual skills development of young myopes and hyperopes. Am J Optom Physiol Opt 1985;62:501–04.[Medline]

18. Rosner J, Rosner J. The relationship between moderate hyperopia and academic achievement: how much plus is enough? J Am Optom Assoc 1997;68:648–50.[Medline]

19. Rosner J, Rosner J. Some observations of the relationship between visual perceptual skills development of young hyperopes and age of first lens correction. Clin Exper Optom 1986;69:166–68.

20. Committee on Practice and Ambulatory Medicine. Vision screening and eye examination in children. Pediatrics 1986;77:918–19.[Abstract/Free Full Text]

21. Wasserman RC, Croft CA, Brotherton SE. Preschool vision screenings in pediatric practice: a study from the pediatric research in office settings (PROS) network. Pediatrics 1992;89:834–38.[Abstract/Free Full Text]

22. APHA Resolution 8203: Children's Vision Screening. APHA Public Policy Statements, 1948 to present, cumulative. Washington, DC: APHA, current volume.

23. APHA Resolution 8905: Children's Preschool Vision and Hearing Screening and Follow-Up. APHA Public Policy Statements, 1948 to present, cumulative. Washington, DC: APHA, current volume.

24. United States Public Health Service. Vision screening in children. Am Fam Physician 1994;50:587–90.[Medline]

25. Preschool Vision Screening: Maternal and Child Health Bureau and National Eye Institute Task Force on Vision Screening in the Preschool Child. Pediatrics 2000;106:1105–16.[Free Full Text]

26. American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Ophthalmology. Eye examination and vision screening in infants, children, and young adults. Pediatrics 1996; 98:153–7.[Abstract/Free Full Text]

27. American Academy of Ophthalmology. Pediatric Eye Evaluations. Preferred Practice Pattern. San Francisco: American Academy of Ophthalmology, 1997.

28. The American Association for Pediatric Ophthalmology and Strabismus. Eye care for the children of America. J Pediatr Ophthalmol Strabismus 1991;28:64–7[Medline]

29. American Optometric Association Consensus Panel on Pediatric Eye and Vision Examination. Optometric clinical practice guidelines: pediatric eye and vision examination. St. Louis: American Optometric Association, 1994.

30. U.S. Public Health Services Task Force. Guide to clinical pre—ventive services, Second Edition. Washington, DC: U.S. Department of Health and Human Services, 1996.

31. Gerali P, Flom MC, Raab EL. Report of Children's Vision Screening Task Force. Schaumburg, IL: National Society to Prevent Blindness, 1990.

32. Cooper CD, Gole GA, Hall JE, et al. Evaluating photoscreeners II: MTI and Fortune videorefractor. Austral N Zealand J Ophthalmol 1999;27:387–98.[Medline]

33. Mohan KM, Miller JM, Dobson V, et al. Inter-rater and intra-rater reliability in the interpretation of MTI photoscreener photographs of Native American preschool children. Optom Vis Sci 2000;77:473–82.[Medline]

34. Bowyer NK, Kleinstein RN. Health People 2010—Vision objectives for the nation. Optometry 71:569–78.

	2001-2: Reducing Maternal-Fetal HIV Transmission with Rapid HIV Tests

TOP INTRODUCTION 2001-1: Improving Early... References 2001-2: Reducing Maternal-Fetal... References  2001-3: Increasing Access to... References   2001-4: Hospital Emergency... References    2001-5: Health Status of... References     2001-6: Global Campaign to... References     2001-7: Research and... References     2001-8: Establishment of a... References     2001-9: Protection of Child... References     2001-10: Support for National... References     2001-11: Support of the... Footnotes  References     2001-12: Discontinuing the Use... References     2001-13: APHA Resolution on... Footnotes   References     2001-14: APHA Supports the... References     2001-15: Recognition and Support... References     2001-16: Recognizing the Role... References     2001-17: Support the Framework... References     2001-18: Support for Curricula... References     2001-19: Opposition to National... References     Public Health Impact Statement 2001-20: Support for Culturally... References     2001-21: Threats to Global... References     2001-22: Opposition to Coercion... References     2001-23: Protection of the... References     2001-24: Trust Fund for... References     2001-25: Participation of Health... References     2001-26: Condemnation of... References     INTERIM POLICY STATEMENTS LB01-1: Improving the Nutrition... References     LB01-2: Alert on the... References     LB01-3: Occupational Safety and... LB01-4: Resolution Supporting... References     LB01-5: Preserving Worker and... References     LB01-6: Opposing War in... References     LB01-7: Call for United... References     Public Health Impact Statement

Knowing that previous APHA policy recognizes the importance of international prevention of perinatal HIV transmission,¹ supports testing under prevailing guidelines for confidentiality and counseling, and is opposed to mandatory HIV testing of pregnant women²; and

Noting that APHA has no formal policy on rapid HIV testing in labor and delivery; and

Realizing that the APHA Task Force on Rapid HIV Testing in Labor and Delivery recently provided to HRSA its recommendations supporting the availability of rapid HIV tests in labor and delivery for women in labor of unknown HIV status whose fetus may be at risk for maternal-fetal HIV transmission³; and

Understanding that those recommendations were based on the availability of the FDA-approved SUDS HIV test, which has since been withdrawn from the US market in October 2000 and returned in April 2001, a test that must be run in a CLIA-certified lab making it logistically difficult to provide timely results in a labor and delivery setting; and

Being aware that other rapid HIV tests that are being manufactured, some that have been approved in other countries, have been evaluated and found by the CDC and others to be more accurate than the SUDS test, roughly equivalent to standard EIA tests, and deliver results in less than 10 minutes without laboratory equipment, potentially at the bedside,^4,5 and are not yet approved by the FDA, effectively leaving no available FDA-approved rapid HIV test delivering timely results in labor and deliver; and

Recognizing that approximately 5% to 10% of the 4 million annual births in the US are to mothers with inadequate or no prenatal care⁶ and that approximately 6000 HIV-infected women give birth in the US every year and an estimated 500,000 infants become infected each year worldwide⁷; and

Realizing that the nation, as well as other countries, needs rapid HIV testing with informed consent in labor and delivery to cost-effectively prevent hundreds, and potentially thousands worldwide, of lethal maternal-fetal HIV transmissions to newborns⁸; and

Understanding that rapid HIV testing during labor and delivery in mothers with unknown HIV status has been very well received, with over 85% consenting⁹; and

Sensing that, in the United States and Europe, the possibility of preventing almost all new cases of pediatric HIV infection is within reach¹⁰; and

Observing that the CDC¹¹ and others¹² recognize the urgent need for rapid HIV tests and that ‘Fast track’ approval of the HIV rapid tests through the FDA has been encouraged by other groups including the National Alliance of State and Territorial AIDS Directors (NASTAD)¹³; therefore, APHA

1. Supports the development of rapid HIV test kits of appropriately high sensitivity and specificity to properly meet the needs of primary prevention;
   
2. Encourages the expedited and early FDA approval of rapid HIV test kits; and
   
3. Strongly urges public funding for distribution of rapid HIV test kits to hospitals and birthing centers in developed and developing countries to prevent maternal-fetal HIV transmission in labor and delivery of women in labor with an unknown HIV status; and
   
4. Urges the rapid widespread dissemination by government agencies of the APHA Working Group guidelines for ethical and effective use of rapid HIV tests in labor and delivery; and
   
5. Seeks the rapid universal adoption of this policy by local, state and federal authorities, professional societies and hospital associations.
   

	References

TOP INTRODUCTION 2001-1: Improving Early... References 2001-2: Reducing Maternal-Fetal... References  2001-3: Increasing Access to... References   2001-4: Hospital Emergency... References    2001-5: Health Status of... References     2001-6: Global Campaign to... References     2001-7: Research and... References     2001-8: Establishment of a... References     2001-9: Protection of Child... References     2001-10: Support for National... References     2001-11: Support of the... Footnotes  References     2001-12: Discontinuing the Use... References     2001-13: APHA Resolution on... Footnotes   References     2001-14: APHA Supports the... References     2001-15: Recognition and Support... References     2001-16: Recognizing the Role... References     2001-17: Support the Framework... References     2001-18: Support for Curricula... References     2001-19: Opposition to National... References     Public Health Impact Statement 2001-20: Support for Culturally... References     2001-21: Threats to Global... References     2001-22: Opposition to Coercion... References     2001-23: Protection of the... References     2001-24: Trust Fund for... References     2001-25: Participation of Health... References     2001-26: Condemnation of... References     INTERIM POLICY STATEMENTS LB01-1: Improving the Nutrition... References     LB01-2: Alert on the... References     LB01-3: Occupational Safety and... LB01-4: Resolution Supporting... References     LB01-5: Preserving Worker and... References     LB01-6: Opposing War in... References     LB01-7: Call for United... References     Public Health Impact Statement

 
1. APHA Policy Statement 9919: International Prevention of Perinatal HIV Transmission. APHA Policy Statements; 1948—present, cumulative. Washington, D.C.: American Public Health Association; current volume. Available online: http://www.apha.org/legislative/policy/policysearch/index.cfm?fuseaction=view&id=190

2. APHA Policy Statement 9520: Opposition to Mandatory HIV Testing of Pregnant Women. APHA Policy Statements; 1948—present, cumulative. Washington, D.C.: American Public Health Association; current volume. Available online: http://www.apha.org/legislative/policy/policysearch/index.cfm?fuseaction= view&id=115

3. American Public Health Association HIV Rapid Test Working Group, "The Use of Rapid HIV Tests During Labor and Delivery: Recommendations for Best Practices", Nov. 2000. Available online: http://www.apha-hivaids.org/

4. Giles RE, Perry KR, Parry JV. Simple/rapid test devices for anti-HIV screening: do they come up to the mark? J Med Virol. 1999 Sep;59(1):104–9.[Medline]

5. Webber LM, Swanevelder C, Grabow WO, Fourie PB. Evaluation of a rapid test for HIV antibodies in saliva and blood. S Afr Med J. 2000 Oct;90(10):1004–7.[Medline]

6. Kogan, MD, JA Martin, et al. The changing pattern of prenatal care utilization in the United States, 1981-1995, using different prenatal care indices. JAMA. 1998;279(20):1623–8.[Abstract/Free Full Text]

7. Fowler, MG, RJ Simonds, et al. Update on perinatal HIV transmission. Pediatr Clin North Am. 2000; 47(1):21–38.[Medline]

8. Grobman WA, Garcia PM. The cost-effectiveness of voluntary intrapartum rapid human immunodeficiency virus testing for women without adequate prenatal care. Am J Obstet Gynecol. 1999;181:1062–71[Medline]

9. Rajegowda BK, Das BB, Lala R, Rao S, Mc Neeley DF. Expedited human immunodeficiency virus testing of mothers and newborns with unknown HIV status at time of labor and delivery. J Perinat Med. 2000;28(6): 458–63.[Medline]

10. Fowler MG. Prevention of perinatal HIV infection. What do we know? Where should future research go? Ann N Y Acad Sci. 2000 Nov;918:45–52.[Abstract/Free Full Text]

11. Tao G, Branson BM, Kassler WJ, Cohen RA. Rates of receiving HIV test results: data from the U.S. National Health Interview Survey for 1994 and 1995. J Acquir Immune Defic Syndr. 1999 Dec 1;22(4):395–400.

12. Minkoff, H. and M. J. O'sullivan. The case for rapid HIV testing during labor. JAMA. 1998;279(21): 1743–4.[Free Full Text]

13. National Alliance of State and Territorial AIDS Directors (NASTAD) Letter to the FDA Urging Expedited Approval of Rapid HIV Tests. May 18, 2000. Available online: http://www.nstad.org/fda_rapidtest.htm.

	2001-3: Increasing Access to Out-of-Hospital Maternity Care Services through State-Regulated and Nationally-Certified Direct-Entry Midwives

TOP INTRODUCTION 2001-1: Improving Early... References 2001-2: Reducing Maternal-Fetal... References  2001-3: Increasing Access to... References   2001-4: Hospital Emergency... References    2001-5: Health Status of... References     2001-6: Global Campaign to... References     2001-7: Research and... References     2001-8: Establishment of a... References     2001-9: Protection of Child... References     2001-10: Support for National... References     2001-11: Support of the... Footnotes  References     2001-12: Discontinuing the Use... References     2001-13: APHA Resolution on... Footnotes   References     2001-14: APHA Supports the... References     2001-15: Recognition and Support... References     2001-16: Recognizing the Role... References     2001-17: Support the Framework... References     2001-18: Support for Curricula... References     2001-19: Opposition to National... References     Public Health Impact Statement 2001-20: Support for Culturally... References     2001-21: Threats to Global... References     2001-22: Opposition to Coercion... References     2001-23: Protection of the... References     2001-24: Trust Fund for... References     2001-25: Participation of Health... References     2001-26: Condemnation of... References     INTERIM POLICY STATEMENTS LB01-1: Improving the Nutrition... References     LB01-2: Alert on the... References     LB01-3: Occupational Safety and... LB01-4: Resolution Supporting... References     LB01-5: Preserving Worker and... References     LB01-6: Opposing War in... References     LB01-7: Call for United... References     Public Health Impact Statement

Reaffirming its position on credentials for health occupations, that there should be alternative routes involving educational systems of selection and preparation, and legal systems of licensing by which people can prepare and qualify for health occupations¹; and

Reaffirming its recognition that many women seek birthing alternatives²; and

Recognizing that pregnancy and birth are normal life events for a majority of women^3,4,5; and

Reaffirming its endorsement of the philosophy of family-centered maternity care, the importance of continuity of care, and the use of a variety of licensed care-givers⁶; and

Recognizing that Direct-entry Midwives encompass a diverse group of midwives that have entered the profession directly through midwifery education and training, and not through a prerequisite program such as nursing⁷; and

Recognizing that there are alternative educational systems of selection and preparation for national certification of Direct-entry Midwives that include either the Certified Professional Midwife (CPM) credential and the Certified Midwife (CM) credential; and that both require didactic programs, written examinations and clinical experience.^8,9 In the case of the Certified Professional Midwives the didactic component consists of education in a program accredited by an agency that is recognized by the US Department of Education or the Portfolio Evaluation Process program, the North American Registry of Midwives competency-based, educational portfolio evaluation, and the clinical component is equivalent to one year of experience which includes more than a thousand contact hours under the supervision of one or more preceptors, some of which must be in out-of-hospital settings, but none of which need to be in hospital settings⁸; and in the case of the CM credential requires education in institutions of higher learning accredited by an agency that is recognized by the US Department of Education to meet the same standards that Certified Nurse Midwives must meet, completing core science requirements similar to those required for a nurse, and fulfilling core midwifery requirements that are a part of all accredited nurse-midwifery education programs, and clinical experience that must include hospital experience, but is not required to include out-of-hospital experience.⁹

Recognizing that individual states interested in incorporating direct-entry midwives into their health care systems are moving toward regulatory models based on national certification⁵; and

Recognizing evidence that many women seek alternatives to hospital care for normal pregnancy and birth, and

Recognizing the evidence that births to healthy mothers, who are not considered at medical risk after comprehensive screening by trained professionals, can occur safely in various settings, including out-of-hospital birth centers and homes^10–14; and

Noting that an epidemiological study of Certified Professional Midwives (CPMs) is ongoing in order to investigate and evaluate practice outcomes, safety, client satisfaction, and practitioner competency¹⁵; and

Recognizing that out-of-hospital settings have the potential for reducing the costs of maternity care^7,12,16; and

Recognizing evidence that access to quality maternity caregivers remains an important issue, particularly for underserved urban and rural communities¹⁷; which may be addressed through out-of-hospital maternity services in some communities; and

Reaffirming that the APHA currently recognizes the value of and promotes educational opportunities for nurse-midwifery,¹⁸ and that many professionals recognize the contributions of direct-entry midwifery; and

Reaffirming that APHA has been an innovator in public health care by supporting research on alternative and complementary medicine^1,19 and increased access to midwifery services in the United States,²⁰

Recognizing that there should be alternative routes involving educational systems of selection and preparation, and legal systems of licensing by which people can prepare and qualify for health occupations, including those direct-entry midwives who are nationally-certified and who have successfully completed "a recognized midwifery education process"^21–23,25; and

Recognizing evidence that direct-entry midwives have multiple educational routes^22,24 available to them in order to meet the entry-level requirements of knowledge, skills and experience^22,24,25;

Recognizing evidence that individual states interested in incorporating direct-entry midwives into the health care system are moving toward regulatory models based on national certifications²²;

Therefore, APHA

1. Supports efforts to increase access to out-of-hospital maternity care services and increase the range of quality maternity care choices available to consumers, through recognition that legally-regulated and nationally certified direct-entry midwives can serve clients desiring safe, planned, out-of-hospital maternity care services, and further:
   
2. Encourages the development and implementation of guidelines for the licensing, certification and practice for direct-entry midwifery practitioners for use by state and local health agencies, health planners, maternity care providers, and professional organizations;
   
3. Urges that there be increased opportunities for supervised clinical learning experiences, in a variety of settings, including both high-risk and low-risk, incorporated into direct-entry midwifery education programs;
   
4. Encourages an increase in cost effective maternal care services for rural and underserved urban populations by advocating for increases in funding of scholarships and loan repayment programs targeted at members of these communities;
   
5. Urges public and private insurance plans to eliminate barriers to the reimbursement and equitable payment of direct-entry midwifery services in both public and private payment systems;
   
6. Encourages the National Center for Health Statistics, the US Department of Health and Human Services and State Vital Records Offices to add the CPM as a separate certifier category on birth certificates to enable routine collection of systematic data;
   
7. Urges HRSA, CDC and state health departments to improve the collection and quality of vital statistics and other data to enhance the monitoring of birth outcomes (e.g., infant and perinatal mortality rates, maternal mortality rates, etc.) resulting from services provided by all practitioners including specific types of midwife practitioners;
   
8. Urges Congress and appropriate Department of Health and Human Services agencies to increase funding and other support for ongoing research and evaluation of maternal health and birth outcomes, practice outcomes, quality of care outcomes, and safety related to the services provided by direct-entry midwives.
   

	References

TOP INTRODUCTION 2001-1: Improving Early... References 2001-2: Reducing Maternal-Fetal... References  2001-3: Increasing Access to... References   2001-4: Hospital Emergency... References    2001-5: Health Status of... References     2001-6: Global Campaign to... References     2001-7: Research and... References     2001-8: Establishment of a... References     2001-9: Protection of Child... References     2001-10: Support for National... References     2001-11: Support of the... Footnotes  References     2001-12: Discontinuing the Use... References     2001-13: APHA Resolution on... Footnotes   References     2001-14: APHA Supports the... References     2001-15: Recognition and Support... References     2001-16: Recognizing the Role... References     2001-17: Support the Framework... References     2001-18: Support for Curricula... References     2001-19: Opposition to National... References     Public Health Impact Statement 2001-20: Support for Culturally... References     2001-21: Threats to Global... References     2001-22: Opposition to Coercion... References     2001-23: Protection of the... References     2001-24: Trust Fund for... References     2001-25: Participation of Health... References     2001-26: Condemnation of... References     INTERIM POLICY STATEMENTS LB01-1: Improving the Nutrition... References     LB01-2: Alert on the... References     LB01-3: Occupational Safety and... LB01-4: Resolution Supporting... References     LB01-5: Preserving Worker and... References     LB01-6: Opposing War in... References     LB01-7: Call for United... References     Public Health Impact Statement

 
1. American Public Health Association Policy Statement 6805: Credentials for Health Occupations. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.

2. American Public Health Association Position Paper 8209: Guidelines for Licensing and regulating Birth Centers. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.

3. Stewart, David: The Five Standards of Safe Childbearing, NAPSAC International, 4th Edition, 1997.

4. Care in Normal Birth: a practical guide, Technical Working Group, World Health Organization. Department of Reproductive Health and Research, Section 1.1-1.6, 1999.

5. Rooks, JR: Midwifery and Childbirth in America. Temple University Press, Philadelphia, 1997.

6.