This is a homebirth contract for Birth With Hope Midwifery Services.  Each mother has a unique set of circumstances and each contract may vary depending upon those circumstances.

Client-Midwife Contract

Birth With Hope Midwifery Services (also referred to as Tori Hope Dennis, CPM, in this contract) and______________________ and ________________________

agree to the following terms and conditions for the provision of out of hospital midwifery services.

Informed Disclosure of Practice

I believe that birth is a safe, normal, physiological event. I believe that it is also sacred and spiritual in nature. I believe that women are strong human beings who are designed to experience birth and are fully capable of birthing naturally. I believe that babies were also designed to emerge from the experience safely and unharmed. I believe that good nutrition is an essential component of safe birthing. I believe that a well-trained and well-equipped home birth midwifery team offers healthy women and their families a safe opportunity to give birth in an environment of confidence, relaxation, trust, and security. I believe that beginnings are important, and that a natural birth is best for mother, and the best way for a baby to enter the world. I believe babies and mothers should not be separated at birth.

Midwife: Tori Dennis, CPM-TN: 

I have three children; all born with midwives.  I breastfed all my children.  I have been married for eighteen years.  I have a Bachelor’s degree in Science.  I am a Registered Nurse.  I certified with CAPPA as a doula, childbirth educator, and lactation educator.  I worked at a birth center for three years as a RN.  I am a CPM (Certified Professional Midwife), certified and regulated through NARM (North American Registry of Midwives).  I am licensed in TN as a midwife through the Tennessee Department of Public Health.  I provide home birth midwifery services in TN.  My official title is CPM-TN. 

As a midwife, I accompany you throughout your pregnancy journey, and during labor and birth. I believe that birth is an empowering  life-changing experience.  I offer a complete understanding of the birth process but more importantly I offer patience and reverence to your birth process. I will provide information to enable you to make informed choices. 

I recommend that you carefully consider all your options, do research, and ask questions.  In choosing a homebirth, you assume a higher level of responsibility and control of your care.  Throughout your pregnancy and birth, I keep you fully informed with your status and options, discuss pros and cons of each option and make a unique care plan for you.  I will maintain complete confidentiality of all details relating to your pregnancy and birth.  As I am independent and self-employed, I will be working for you.  I will accompany you through labor.  I am there to provide on-going physical assessment of you during your birth experience.  I will monitor the progress of your labor; provide support, reassurance and perspective to you;  offer suggestions for relaxation, massage, distraction, position or other techniques for comfort;  and I will monitor you and your baby for any indications of complications.  The care is unique to each woman/family.  It is my wish to allow you to birth in accordance with your own birth plan. 

What is a CPM?

A CPM is a Certified Professional Midwife.  She is a direct entry midwife who has met all the certification standards set by the North American Registry of Midwives (NARM).  What distinguishes a CPM from other nationally certified midwives is that CPMs primarily attend low-risk pregnant women in an out-of-hospital setting.  CPMs are trained via a competency-based model of education which requires them to gain direct hands-on experience in an out-of-hospital setting.

The legal status of Midwifery and Homebirth in Tennessee and Alabama:

In Tennessee, direct entry midwifery is legal.  In Alabama, direct entry midwives are prohibited from assisting mothers in the birth process/homebirths.  Two midwives have been arrested and prosecuted in Alabama within the past ten years.  I practice legally in Tennessee as a midwife who provides out of hospital birthing options.  Tennessee provides a licensure process, and I am licensed as CPM-TN through the TN Department of Health.  The Osteopathic Board governs direct entry midwives in Tennessee.  Midwives can file birth certificates legally in TN, but midwives may not file a birth certificate in AL.

Transfer

While we never anticipate transferring care to another care provider, there are conditions when a transfer may occur (i.e. fever during labor, thick meconium in early labor, fetal heart rate issues, etc.)  We will discuss each of these issues during the course of your pregnancy.  We will discuss a transport plan, and have the plan part of your chart.   

Informed Choice:

There are many symptoms, observations, treatments and procedures that you may be exposed to during the course of your pregnancy.  You have the right to know each and every treatment and procedure during the course of your pregnancy as well as the risks, benefits, alternative treatments and their risks and benefits.  You have a right to have all of your questions answered and have as much information as you need or want.  You also have a right to decline or refuse any treatment.  I will be providing you with a list of prenatal/postpartum treatments and procedures including a full explanation of the treatment, its risks and benefits. 

The client has the right to terminate this contract at any time, for any reason and receive a refund as outlined in this contract. The client agrees in the event that they chose to terminate this contract for any reason, that they will notify Tori Dennis, by phone, by email, or by regular postal service. If you are not satisfied with my care at anytime I would appreciate the opportunity to resolve any matters before formal complaints are made. However, the client understands they have the right to lodge formal complaints with NARM www.narm.org within 18 months of my care. 

Tori Dennis, CPM, reserves the right to decline further midwifery care of client: 1) in the event of non-payment within agreed upon terms.  2) assessment of client medical or psychological condition(s).  3) Due to noncompliant/uncooperative actions on the part of one parent or both, or on the part of family members.

Use of Medical Records

As a midwife, I respect your rights to privacy.  Your prenatal, birth and postpartum records are considered private.  I will not share any of your medical records with anyone you have not given permission to unless there is an emergent situation.  Only midwives in our practice will have working knowledge of your case.  The client authorizes Tori Dennis, CPM, to have full access to medical records for clinical management provided her privacy is reasonably protected in accordance with HIPPA laws and regulations. She also understands that birth attendants may have access to records when charting; and back-up midwives will have access to charts for consulting and/or co-care. 

Consent to Treatment

The client gives her consent to Birth With Hope Midwifery Services, Tori Hope Dennis, CPM, and all other employees of Birth With Hope Midwifery Services to care for and treat her during the course of her pregnancy, birth until conclusion of care at 6 weeks postpartum. This contract will remain in force until the conclusion of care; the client informs of her intentions to seek care elsewhere, or it is in the clients’ best interest medically to be referred for care due to unforeseen complications. The client agrees to assume full personal and legal responsibility for her decision to have an out-of-hospital birth and to prepare for the same.

Midwifery Services Provided/Scope of Practice

As your midwife, I provide: 

• An initial consultation (free)
• Informed choice, scope of practice, and financial agreement forms. 
• Regular prenatal visits and exams available every 4 weeks until the 28^th week, bi-weekly from week 28 through week 36 and weekly until your birth.
• Referrals to physicians/OB-GYN for consultation or further testing if the need arises during your prenatal period.
• Glucose and hemoglobin testing
• GBS testing
• A second midwife and possibly a third midwife to assist at your home birth.
• Assistance at your birth.  I will monitor the progress of your labor, provide support, offer suggestions for relaxation techniques or birth positions and I will monitor you and your baby for any indications of complications.  
• Optional use of birth tub for water labor or water birth
• Provide equipment: oxygen, suturing instruments, suction tubing, clamps & scissors
• Immediate post partum care for you and your baby.  I will remain after your birth for a minimum of 2 hours to monitor and assist with breastfeeding; perform newborn exam, weight and measurements;  clamp cord;  examine placenta. 
• Vitamin K shot and eye ointment available
• Post partum follow up visit.: within 24- 48 hours after birth at your home. If you need extra postpartum visits, you may come to see me in office. 
• Referral to lactation consultants in your area
• Referral for pediatrician visit for newborn assessment and PKU testing. Newborn hearing screens are encouraged by pediatricians.  Circumcisions are optional.   
• Filing of birth certificate and social security number 
• Telephone/email/text availability during your pregnancy- I return calls by the end of the business day; email within 24 hours; and text return by the end of the business day.
• 24/7 oncall availability after 36 weeks pregnancy. 
• Any necessary billing/paperwork that may be needed for your insurance company will be filled out and returned to you for filing. 
• Labor support in the hospital if a transport occurs.  In the event of a hospital transport, I have no official status in the hospital.  Your care would be transferred to the OB/GYN who is on call at the time of transfer.  I would remain with you as a labor support advocate until the birth is complete.
• I cannot guarantee a non-interventive or non-surgical birth.

Requirements of the family

As a homebirth family, I require:

• Honesty regarding all issues
• A signed contract.
• Notify midwife in a timely manner (via phone call) when active labor commences.  Do not text if you are in labor.  Call Tori first: 256.412.3633.  Call Brandice second: 256.394.6438
• Parents to take an active role in their care and well being through nutrition, exercise, attendance at prenatal visits and healthy lifestyle. 
• Attend all prenatal visits/ do not request to skimp on your midwifery care
• Client to understand the importance of seeing midwife for prenatal care; understand that the midwife is the primary care giver.
• No smoking
• No consumption of alcohol
• No use of recreational drugs
• Minimum of one ultrasound (to rule out congenital problems, and determine position of placenta).
• Provide copies of ultrasound reports to midwife
• Preparation for the birth/birth supplies accumulated by 36^th week of pregnancy.
• Willingness to transport to the hospital at the request of the midwife in the event a complication arises with mother or baby.
• Agreement to use the physician on call during a transport.
• Provide midwife a copy of pregnancy blood work
• Provide copies of prior childbirth records by second prenatal with Tori; this is imperative as we glean information from past birth experiences
• Arrangements established for care of newborn with family physician or pediatrician.  This is for a regular well-baby visit, and /PKU screening
• Honor our financial agreement.  This financial agreement is with Tori Dennis, CPM-TN, (director of Hope House, and owner of Birth With Hope Midwifery Services). The financial agreement is not with any other party, including apprentices.  More specifically, all payments will be directed to Tori Dennis. 

Financial Agreement:

• I/We/clients agree to pay Tori Dennis, Birth With Hope Midwifery Services, the sum of $3,500 for the birth fee by the 35-week visit.  This $3500.00 fee includes payment for: the primary midwife, Tori Dennis, and the possibility of a second midwife if Tori deems it necessary, and the midwifery assistant (Brandice Senecal). 
• Tori will compensate all midwives from the global fee of $3500.00.
• This fee does not cover lab work/prenatal panel (usually covered by any insurance)
• This fee does cover glucose testing and hemoglobin testing (finger sticks)
• This fee does not cover Rhogam if needed by Rh- mothers
• This fee does not cover ultrasound (usually covered by insurance)
• I/We/clients agree to pay Tori Dennis $100 for each prenatal visit. Typically, there are around 8-12 prenatal visits.  This fee will be deducted from the total birth fee.  $100 is expected at each prenatal. 
• There is not a discount for those who transfer late in pregnancy.  The full fee is required
• If your birth plan requires specialized care:  a planned breech add $1000 to birth price; planned twins add $1000 to birth price; a VBAC birth add $500.00 to birth price.
• If you choose to use our large birth tub, then a $50 liner fee will be required.
• An initial non-refundable deposit/retainer fee of $500 is required at the time you select Tori as your midwife and return a signed contract.  This $500 retainer reserves Tori as your midwife and covers administrative costs.  Midwifery care will not be provided prior to paying the nonrefundable $500 deposit.  This deposit is deducted from the total birth fee. 
• A second deposit of $500 is required at 20 weeks.  This deposit is deducted from the total birth fee.   
• If during labor, the client is transported to the hospital for any reason, I/we agree that Tori Dennis has been paid in full and there is no refund of monies.  
• In regard to insurance company correspondence, Tori's services are listed as out of network provider.   Your refund amount may be affected by deductibles.  Homebirth may not be paid for by your insurance company.  There is a $50 fee to fill out paperwork for insurance companies. 
• If labor commences before 36 weeks, or a homebirth is not recommended by midwife, or if the client/couple is referred to the hospital prior to the onset of labor, Tori agrees to refund the birth fee minus the $500 nonrefundable deposit, and minus the $100 per prenatal fee, and minus $500 consulting fee. 
• If I am not present at the birth due to circumstances beyond anyone’s control, such as rapid labor; but the second midwife or third midwife arrives in time for the birth, no portion of the fee will be refunded by Tori. 
• Tori Dennis reserves the right to terminate services and not attend the birth if full payment is not received as agreed above by the 35 week of pregnancy.  In the event payment is not made and Tori withdraws from providing care, she will immediately inform the client/couple in writing, in person and/or by phone.  Tori will also return any portion of the birth fee which has been paid except the non-refundable deposit of $500,  a $100 per prenatal charge for each prenatal visit thus far, a $250.00 cancellation fee, and a $500 consulting fee.
• If the full payment is not received as agreed above, due to situations of extreme hardship, Tori reserves the right to either terminate services or discuss payment plan options.  If a payment plan is acceptable to Tori, then a late fee of $100 will be added to each month of extended payment.  Tori reserves the right to NOT agree to a payment plan option. 
• If the client chooses to cancel this contract, the client is responsible to pay: $500 non-refundable deposit, $100 per prenatal fee, $500 consulting fee, and $250 cancellation fee. If you cancel after 36 weeks of pregnancy, then there will be an additional fee of $25 per day on call fee, for each day past 36 weeks. 
• If suturing requires the assistance of a midwife other than myself, it will be an additional $300 fee due the day of birth.  Please bring means of payment to the birth. 
• A client has the right to transfer to the hospital for suturing, if preferred. 

Affirmation of Informed Choice

The expectant parents affirm the following:

In choosing home birth I/we/clients understand that I/we/clients am/are taking primary responsibility for all decisions, procedures and outcomes regarding my prenatal, birth and postpartum care. I /we/clients acknowledge that I/we/clients am/are contracting for the services of Tori Dennis.  I/we/clients have chosen to have a home birth, based upon what I/we believe to be a thorough examination of the alternatives. I/We have discussed my/our prenatal care and birth options with physicians and other knowledgeable people to the extent I/we think is necessary. After considering these options, I/we have asked Tori Dennis of Birth With Hope Midwifery Services to assist me/us in my/our home birth/out of hospital birth. Tori Dennis has gone over the information on the previous pages and has discussed her philosophy and experience with me/us. Before signing this agreement I/we have had the opportunity to talk with (each other and) Tori Dennis and to ask her any questions I/we/clients wish. In addition to the other agreements above, I/we/clients also fully understand and agree as follows:

• Tori Dennis is a home birth midwife. Tori is not a medical doctor.  Tori will provide care for women who have normal, low risk, uncomplicated pregnancies and who expect a normal delivery of a healthy child.
• While there are many advantages to a home birth, it is impossible at a home birth to provide the medical type of care that is available in a hospital. For example, in a hospital there is more equipment, such as surgery scalpels, operating room, various medications (including anesthetics and analgesics), blood plasma and blood transfusions, epidurals, and induction medications/pitocin/cytotec. I/We/clients am/are fully aware that in the event of a catastrophic emergency there are fewer alternatives available at a home birth than there would be in a hospital setting. 
• It may become necessary during the birth to transfer the mother and/or child to the hospital, before, during, or after the birth. I/We agree to go to the hospital upon the midwife’s recommendation. Tori Dennis has recommended and I/we agree that we will be transported to the closest hospital, should this be necessary. We understand that in most circumstances, transport is by private car but can also be by ambulance if necessary.
• I understand that Tori Dennis does not practice medicine, therefore she DOES NOT carry medical malpractice insurance. 
• I understand that even with the most attentive care during the prenatal period, unpredictable medical problems may arise during pregnancy or childbirth. The following problems are considered high risk: insulin dependent diabetes; extremely high blood pressure; preterm labor-before 36 weeks; or active genital herpes.  Tori will transfer your care to a medical doctor if you become high risk during your pregnancy. 
• The following complications are very very rare, but may occur during the labor and birth process. I/We/clients understand that any of these situations could lead to permanent injury and/or death to my child or me.  They include but are not limited to:
  • Fetal distress (heart tone that goes too high or too low)
  • Meconium aspiration
  • Excessive blood loss during birth due to placental previa or abruption
  • Shoulder dystocia
  • Excessive blood loss after birth
  • Severe lacerations, 4^th degree
  • Retained placenta
  • Congenital defects
  • Prolapsed cord
  • Uterine rupture
  • Stillbirth
• I/We understand that Tori Dennis carries the following equipment, supplies, and medication during a homebirth:
  • Oxygen with Bag and Mask for Neonatal Resuscitation
  • Anti-Hemorrhagic Agents (to stop bleeding)
  • Fetoscope and hand-held Doppler (to listen to baby's heart tones)
  • Bags of  intravenous fluids (to rehydrate mother)
  • Urinary Catheters
  • Suturing Materials 
  • DeLee catheter for deeper suction than a bulb syringe of the newborn
• I/We understand that Tori Dennis does NOT have the following equipment, supplies and medication at a homebirth:
  • Pain Medication, including epidurals or narcotics
  • Surgical equipment for a c-section 
  • Forceps or Vacuum
  • Continuous Fetal Monitoring Equipment
  • Blood for transfusions

Release of Liability:

Before signing this agreement, we (hereby known as “clients”) have had an opportunity to talk with each other, with a medical care provider, an attorney, or other knowledgeable person, if needed, and with Tori and asked her questions. Tori has discussed her philosophy and midwifery model of care with us.  We have chosen to have a home birth.  We have asked Tori Dennis to assist us in our home birth.  Tori  has not represented to the clients that agreeing to her services guaranteed in any way a risk free or emergency free labor and birth experience.  The clients (both jointly and separately), the clients’ heirs, administrators, personal representatives, executors, and assigns, and the clients; family members, release and forever discharge Tori from all damages or causes of action, either at law or in equity, which the clients may have or acquire or which may accrue to the clients or the clients heirs, administrators, personal representatives, executors or assigns as a result of using the midwifery services of Tori. The clients intend this to be a complete release and discharge from all liability whatsoever.  The clients have read all statements contained herein and the clients fully realize that the clients are signing a complete release and bar to any claims which the clients have or believe the clients may have resulting from our agreement for midwifery services.  I/We/clients hereby release Tori Dennis and her assistants from all liability for complications which may arise during the course of my pregnancy, birth, or postpartum as a result of my decisions and my choice to birth my child at home and/or out of hospital.  I acknowledge that we believe in our right to birth where we choose.  I/We acknowledge that I/We have thoroughly read and understood this document. I/We further acknowledge that I/We have had an opportunity to have any questions answered regarding the benefits and risks specific to homebirth.

I HAVE READ, AGREE TO, AND UNDERSTAND THE ABOVE STATED MATERIAL.