This week there were about 120 home-birth enthusiasts demonstrating in front of our building for about 3 hours. The crowd was expressing their unhappiness about our draft regulations for Licensed Midwives. You might have also seen the Arizona Republic article on the demonstration.
As I’ve written before, we started the process of revising the rules for Licensed Midwives about a year ago and we’re coming near the end of the process. My main goal has been to improve the entire system- including coordination with EMS and hospitals as well as data collection and analysis, oversight, and emergency planning… with the goal of ensuring (to the extent we can) the health and safety of moms and newborns.
Anyway- one of the issues the demonstrators were discussing is the administration of medications like oxygen and Pitocin by Licensed Midwives. The current rules outline several emergency measures to be performed before emergency personnel arrive in cases where the health of the mother or newborn is at risk. These rules outline guides for the administration of some medication (oxygen, Pitocin). The rules currently in effect require a Licensed Midwife to identify a physician that has agreed to provide back up, consultation, and a prescription for these medications.
Some in the midwifery community would like the ADHS to grant the authority for midwives to obtain and administer medications on their own (without consulting a physician)… however that would require a change in state law that I have no authority to make because it requires a statutory change. When I explained that I don’t have the authority to permit midwives to obtain and administer medications without consulting a physician, a member of the committee (a midwife) asked us to remove all references to medications. I’m inclined to keep the current medication rule language so at least these meds will be in scope (in consultation a physician).
Another provision that’s controversial in the current and proposed new rule asks women to take certain blood and urine tests as a condition of having a licensed midwife attend their homebirth. In the draft rules, there are a handful of tests that women need to take if she wants to have Licensed Midwifery services. These tests (HIV, Hepatitis B, blood glucose, and blood Rh factor) are the only way for the midwife to establish that the birth will be low risk and safe for the health of the newborn and mom. The mom-to-be can still refuse the tests, but that means she wouldn’t be able to have a Licensed Midwife present during the home-birth because it wouldn’t be possible to determine if the birth is low-risk and suitable for a home delivery.
The parties on the Advisory Committee still don’t agree on several points. Hopefully, the draft final rules for public comment that we publish next week will get the parties closer to at least grudging consensus. If there’s still gross disagreement about the final regulations, we could always just scrap the entire effort and keep using the existing scope of practice.
I have been a client of midwives in the past; what I am having a difficult time understanding is what seems to be an infringement on my patient rights. I have the right to refuse any procedures or care from any doctor, why not a midwife? As I understand it, it isn’t just the refusal of blood work, but having to have a vaginal exam every hour while in labor. Too many vaginal exams can cause infection, especially after the water has broken (and this is not because midwives are not clean, it is the constant introduction of something into a sterile environment). Although I have no issue with a hospital being informed that a patient is in labor… what exactly does that do for safety? Are the hospitals to hold a bed for a possible patient? And what is the hospital’s responsibility, are they to call and check up if they don’t get a return call that the baby is born in a certain amount of time?
Although most home births have no problems what so ever (like birth in general), a midwife being able to carry life saving medications like O2 and Pitocin could really make a huge difference; a life or death difference. Yes, EMS would be contacted, but those precious moments could mean a dead baby or mother, and that is just foolish to take that risk.
Are you thinking of just leaving the rules as the currently are?
You have a point… at least for some of the tests. For HIV for example, perhaps we could include a provision that a record of a previous negative HIV test in the last few years perhaps we could waive that test requirement with a Midwife attestation.
Other tests are more problematic to waive. For example, monitoring for gestational diabetes with a blood glucose is important to do in every pregnancy. By knowing a patient has gestational diabetes there are things that can be done to prevent problems with both mother and baby from developing. Babies of these mothers can be born too big, have glucose problems after birth, and can end up with defects that can cause heart problems.
And yes… I’m thinking of leaving the existing rules just as they are and not filing any new rules at all. In other words, the scope of practice, standards, and adminstrative requirements would not change from what they are today.
Director, would the state be willing to cover the cost these tests should they become mandatory? Many who choose to birth at home will have limited financial resources and no insurance. They are payimg out of pocket.
It is sad the homebirth is looked through the lens of hospital birth. They are two different experiences and I know because I have had both. It is not unsafe to skip a glucose. My LM monitored my health through me far better than the other care providers I had who delivered in a hospital. I skipped the glucose test because we had been monitoring my blood sugar levels together. If there was a problem she would have spotted it long before the scheduled time for a standard glucose test and we would have talked about changing my diet so that my health and baby would be fine. Homebirth is filled with prevention versus fixing problems. I truly wish that the rules came from a place of understand instead of looked at homebirth through a physicians eyes.
I turned down the blood glucose test with my last 2 pregnancies. I would turn it down again in the future…. There are other ways to monitor this. I turned it down for that very reason.
I do not think you realize that there is much controversy on the diagnosis of “gestational diabetes” in the medical community. There does not seem to be a consensus on the fact that this is something that actually exists as well as a consensus on how to diagnose it. There has never been a comprehensive study done on a woman’s blood glucose levels in pregnancy that a doctor or midwife could reference to know if a pregnant woman’s glucose levels are high or not. This testing requirement needs another look at. More research needs to be done. Numbers that are being compared need to be equal, you would never compare the sugar levels of an apple to an orange as if they are the same. Why would you compare the glucose levels of a pregnant woman to other humans that may or may not be women but are definitely not pregnant, not even for the same length of gestation? Please check the facts on this, find out who they are comparing the glucose levels too. There are some huge discrepancies here. You said yourself that from the past records of homebirth in this state it looks like it is safe, why suddenly treat it like it is not?
After five all-natural (no meds, no interventions) hospital births, I decided that for this, my 6th pregnancy, to birth at home. In the highly-medicalized birth environment of a hospital, it has become increasingly difficult to have a natural birth, even if one chooses a great OB or CNM — hospital policy and crabby, unsupportive L&D nurses can make laboring naturally difficult.
I checked into a number of LMs and chose one with whom I felt very compatible.
On the issue of glucose — we did a post-prandial test. Would this be allowed under the new statutes? I have big babies (8 lbs 13 oz to 10 lbs, so far), I am 39, and, of course, I’m a grand multipara. However, even though I have large babies, I have NEVER had gestational diabetes; we did the post-prandial test as a safeguard, and it showed that I’m actually a bit hypoglycemic.
I’m wondering if I wouldn’t have been allowed to birth at home under the new guidelines. I declined all the STD tests — as my husband and I have been 100% faithful in our 18 years of marriage — as I declined them with my last births, all with OBs and a CNM.
And, for the record, with birth #5, I was technically Failure to Progress for more than 6 hours, “stuck” at 7 cm. However, my naturally-minded OB (now retired) said, “Your heart rate is fine, baby’s heart rate is fine, your blood pressure is fine, you’re not exhausted, if you’re OK, I’m OK.” He didn’t even pressure me for an AROM, as he thought (as I did) that baby probably just needed to get properly positioned to place equal and proper pressure on the baby-side of my cervix. When I finally went into transition, I went from 7 cm to having a baby in my arms in 10 minutes.
If midwives are forced to consult with MD OB/GYNs over every tiny bit of difficulty in labor — if their autonomy and freedom to function as MIDWIVES is removed, if their judgement is continually questioned (without cause, but just as a matter of course) — then will ANY woman really be able to have a home birth???? I think we’d see more “emergency” transfers that aren’t even emergencies, or at least WOULDN’T be emergent, if a midwife was allowed to administer pitocin, oxygen, and otherwise make the judgement calls that she is now able to make.
When the discussion of changing the statutes started, I was hoping we could get VBACs and multiples “legally” covered by Licensed Midwives, but now I’m just left hoping that midwives will be able to practice — the way they need to — at ALL! I’m sorry to say it, but I hope no changes go into effect. I hope the whole thing gets trashed. If it’s a choice between having limited freedoms to birth at home and having even many of those few freedoms removed??? I’ll take the first. It’s the lesser of two evils, in my opinion as a homebirth consumer.
I am happy to hear that revisions are being considered.
I am a little troubled, however, by “The mom-to-be can still refuse the tests, but that means she wouldn’t be able to have a Licensed Midwife present during the home-birth because it wouldn’t be possible to determine if the birth is low-risk and suitable for a home delivery.”
Who determines whether or not a birth is “suitable” for home delivery?
Is that not the right of the mother (any patient)?
And as long as the mother is properly informed of risks she assumes by refusing a test or procedure, should it not be up to that mother, in consultation with her chosen health care provider, to determine her preferred course of action?
Midwives go through rigorous education and training. It is my understanding that if they, or any other health care providers for that matter, feel that a transfer of care IS necessary, they advise their clients/patients appropriately.
The way the current regulations are written, the rights of the patient (mother) to self-determined health care are essentially ceded to the state. I am not certain that this is acceptable policy-making.
I do hope that the pending revision addresses both this highly critical issue, as well as the other ones.
Our statutory mandate and our mission as a health department is to protect th health of both the mother and baby.
Regarding tests… monitoring for things like gestational diabetes and Rh incompatibility important to do in every pregnancy. By knowing a patient has gestational diabetes or that the Rh factor is incompatable- one can implement clinical interventions to avoid downstream medical problems for the baby. In the absence of that information- it’s much more difficult to identify problems and implement interventions.
Mr Humble, thank you for your reply.
It does not address, however, my primary concern. The question is not whether or not certain tests are advisable or “better to have than not”.
The issue is that a person (mother) has the right to self-determined health care – and should not be forced to give up her choice of care practitioner, just because she refuses a form of testing or treatment that is “statistically preferable” – or even “standard medical practice”.
The language of these proposed new regulations CLEARLY obliterates that right. Many fine proposals have been put forth as to how to address this matter.
I urge you to consider revising the MSP to include language that states, _unequivocally_, that mothers have an absolute right to informed consent. Period. No strings. No caveats. No “then you must go elsewhere”. No “then you put your midwife’s license at risk because she’s no longer allowed to care for you legally”.
Informed, self-determined care must be paramount. It is a human right.
I also urge you to meet with midwives (which I understand has not yet happened, despite repeated attempts) over this, prior to the publication/revision of these regulations. It is my impression that the current draft will make it virtually impossible to implement current best practices “legally”.
Thank you for your consideration.
Questions, while I understand your rationale with knowing if something exists it allows for a plan to be made for the what ifs. Have you considered that many women want the autonomy of there bodies and will forgo these tests, even if it means that they can not have a provider attend there birth? Do you realize how many women feel this way? How many babies do you anticipate “saving” with the current revision? Homebirth neonatal mortality rates are significantly lower than hospital birth. Are you planning an over haul of the hospital system to at least get there numbers closer to what the midwives numbers are? Why are you coming from the point of view that homebirth has been proven to be dangerous? Will Humble, you have said yourself that from the data that anyone cared to collect that it did seem that homebirth midwives are safe in Arizona. Why are you now treating the midwives as well as those that want to birth at home as if they are criminals and need strict guidelines? What have “we” done to prove too you that more needs to be done and not less?
Dir. Humble,
Respectfully, it is vitally important that you understand women who choose homebirth are extremely interested in doing what is best for their baby.
In that vain, I can’t think of one mother who would not be concerned about Rh issues, for example. And as another, I was GBS positive and went to great lengths to ensure my newborns health and safety.
As far as STD screening is concerned, many of us whom are married and have been so for years and tested during our pap or other exam feel it is unnecessary while we are pregnant. Please know that in most of my appointments with my midwife, she went over the same exact explanations an OB would regarding the reasons for tests, the risk associated with certain conditions, and educated me on all the available and evidenced based research. There were many tests I took, and others I refused. Only after careful consideration. I did the same when I was under the care of an OB.
What is missing from this dialogue, in my opinion, is a statement that women are and have always been capable of making decisions for ourselves regarding medical treatment. What many of us are desperately trying to convey is that we are not being given the RIGHT to refuse a test. And quite frankly, it is seen by the over 700 people who are part of an online group, as degrading.
That being said, and at the risk of being redundant, the typical midwife and the typical homebirth family are scrupulous in their efforts to have the safest and healthiest outcome.
Midwives and homebirth mothers are not being cavalier, which many of us feel is implied in the way some of the rules on this issue are written. I know that was not the intent. But you must understand, please understand, that it can be easily left open to that interpretation.
Many of us in this community came to midwifery care after trauma in a hospital setting. Please, try and understand that this is ABSOLUTELY an issue of women’s rights and our ability to be treated the way we deserve. Many of the women who are so vehemently defending their rights have suffered post traumatic stress, severe post partum depression, humiliation, pain, and extreme suffering due to hospital births that went horribly wrong. We, the women who carry these babies under our hearts, we deserve to the right to refuse tests, refuse drugs, refuse invasive touch, and to refuse dismissive treatment.
Director Humble, I urge you to meet with the midwives and to hear them out on these specific issues to better serve the women of Arizona. I promise that you will instantly have a group of allies that will work tirelessly to reach the goals of the department.
I truly believe this work you are doing goes beyond a simple review of rules and regulations. You have an opportunity to create a watershed moment for women’s rights in Arizona and beyond.
Thank you for your consideration.
Lesley McKinley
Throughout this process, we have tried to maintain transparency by keeping all meetings with the committee appointed by the statute. If I were to meet privately with any of the parties there would be a perception that some of the Stakeholders are getting preferential treatment and we would lose the transparency we’ve been trying so hard to maintain. I don’t want that perception after all of this collaboration.
Are you listening to what they are saying or giving a blanket statement to cover tracks. I have a hard time believeing that the priority is the mom and baby when what seems to be the priority is that women are taken care of under a OB and in the hospital. This is the problem we are more worried about tests and cover our butts for money and liability than we are with takeing care of mom and baby and educating them on how to care for themselves and being more involved with their care. Womens bodies are designed to give birth you can not argue with evolution, if not we would not be having this conversation if instead of trying to prevent every last thing that COULD MAYBE go wrong and empower women to take care of themselves and educate themselves than maybe as generations come along we will teach them that pregnancy is safe and how to take care of thesmselves. Get out of the box and think long term not short term and how do I cover myself from liability. Just my opinion, I don’t have to wake up in the morning questioning my integrity and look myself in the mirror knowing I may actually be causing bigger problems on a larger scale for a longer period for our future.
And that is why, Mr. Humble, I will birth unassisted! I do not need an HIV screen, I do not need Rh factor test, I do not need a glucose screen, etc… There are alternatives to the glucose screen that will not harm me or my baby… This is getting dangerously close to affecting my constitutional right of liberty…. Just change it…. Why fight about it, you’re not birthing at home, so it’s not up to you to decide where I birth…. I go out to the damn woods and birth…. Putting those revisions in is only going to get like minded moms to stop care completely and do things their own way…. They will NOT got to an OB like you think. I hope you are thinking about these things, Mr. Humble… Leave the 1% of us alone… We don’t need a man to tell us what we can do with our bodies. It’s my body, my baby, my birth!!!!!
Tamra
Mom to 4, 3 born at home.
P.S. My one born at the hospital required a nicu stay because I was coerced to induce at 37 weeks for the only reason being she was “little”.. To this day we battle with illness and other things and I blame a fail maternity care system!
Our job is to set the practice standards for Licensed Professional Midwives. That’s it. How and where you choose to give birth is now and will always be up to you.
Yeah, I get that, but I want my midwife! I do not want testing I do not need. It is a waste of my money! I tested neg for HIV several years ago with a previouse pregnancy so I do not need to do it again… I am not at risk for Rh either as my husband and I are both +…. What my point is Mr. Humble is that I am my own book. I am different from the next woman. It is not a one size fits all… It can’t be. As for glucose testing…. A mom should be able to opt out and take other measures to ensure health like it should be anyways…. Those glucose drinks are toxic…. Want to know why adolescent diabetes is rising so much? Maybe their pancreases were taxed in the womb…. Makes you think, huh? I will not tax my body with that much sugar…. I don’t eat like that. My body does not get that much sugar….. Once again, one size does not fit all… A more accurate way to check sugar levels is to have the mom eat a normal meal…. One she would eat any other day of the week and then test…. I’m less than 100lbs Mr. Humble…. Do you know what that much sugar does to someone like me…. One size does not fit all. One more example just to be clear… I’ve given birth 4 times. My body knows how to do it. I do not need vaginal exams to see if I’m dilating. My body isn’t going to magically shut off and refuse… That’s crock… It’s not failure to progress it’s failure to wait… A first time mom…. MAYBE…. But since ive done it 4 times already…. I think my body knows what it is doing…. ONE SIZE DOES NOT FIT ALL!!!! I want my midwife Mr. Humble!
Yes. Ditto everything that Tamara just said.
How is it irresponsible to allow a midwife to attend a birth that she is comfortable with if the mom has refused testing? While these are good generalizations they do not apply to everyone. A midwife should be allowed to use her better judgement in the moment and on a client to client basis to decide if there is reason to be concerned.
It is every persons RIGHT to refuse medical tests and treatment. To require a mother to consent to tests in order to recieve the care of a qualified midwife is absurd. If the mother refused those tests while under the care of an OB, or while in the hospital, would she be refused care? If not, then why is refusing them when a midwife recommends them any different? Coerced consent is not informed consent. It’s about my right to choose the care that’s right for me.
If these tests are declined in a hospital environment there are immediate resources available that assist in emergency delivery and resuscitation for the mother and the baby.
It is acceptable to the state for these tests to be declined in a Freestanding Birth Center setting where no immediate hospital resources are available. Why would consumers being denied the same rights as those who choose to birth in a freestanding birth center?
How often are those measures needed? Why are you taking the decision out of my hands? Do you really think you care more about my baby than I do? If you do, you are sadly mistaken.
There are immediate resources for resuscitation with a Licensed Midwife *IF* she is allowed to carry oxygen. Midwives currently ARE allowed to carry oxygen. There are other reasons than “big babies” for which a newborn would need oxygen. You’re proposing to remove the midwives’ abilities to carry oxygen with them. That is incomprehensible to me.
Your response makes no sense she is asking about refusal of test and you are talking about emergencies, more blanket statements right Will.
All this work, made pointless because one man doesn’t get it. Is it too much to ask for you to follow the bill appropriately, evaluate important emergency measures that a midwife should have available and not expand the scope in reality without limiting it so severely that it’s really just for show? Stop wasting time on frivolous measures that cause more problems because you are missing the real issues and don’t understand. The right to refuse goes way beyond what you’ve listed. I am so didappointed in the perspective. All of this should have opened your eyes to the way midwives and their clients are treated and oppressed and how we are held back from being respected in our own autonomy and choices and refused best practices that bring even better outcomes. You need to listen to those who practice midwifery, those who pour their heart out into the care of these women. They understand us and know what we need.
I support “scraping the entire effort” and using the existing scope of practice.
Carol Denny LM CPM
This is a real possibility. The authorizing statute just requires us to consider changes to the regulations including the scope of practice. We could pass on the entire package- in which the regulations would stay exactly as they are today. Also, VBAC would remain out of of scope.
So either all the proposed changes are agreed to or none of them pass?
I am fine with VBAC and Breech remaining out of scope. I think VBAC is well supported in the literature but I don’t think the addition of VBAC is worth the changes. The restrictions for VBAC make it so that most VBACs still won’t be in our scope. I have a feeling that VBAC clients will not want to comply with the new rules. I don’t want to do breech births on purpose at home.
Without the current meds we are allowed in the rules to administer with standing orders, so many things could go wrong. I think it would create a terrible situation.
Women have to have the right to choose to refuse anything they don’t want no matter where they are. If that choice is taken away from midwifery clients, many of them will birth unattended.
I appreciate all of your hard work. I know the committee has worked hard also. But the loss of safety and patient rights is too extreme to make the proposed rules desirable.
I absolutely agree. The “progress” made in the few women who *might* be allowed to birth at home as a vbac and the chance that they will be ok with *ALL* the testing is not worth the MANY who will now be thrown out due to the new rules. PLEASE scrap it all if you can’t give women the right to refuse testing that may be harmful for them and still be seen by their midwife!!!
VBAC would not be out of scope for a homebirth for all care providers. We were just asking that midwives be added to the allowable list. There are care providers that can currently attend an out of hospital birth without all of the restriciotns that you are trying to put on VBAC as well as other homebirth families. Do not try to use this as leverage. That is wrong.
This community will not “sacrifice” one for the other. One woman’s autonomy for another woman’s VBAC, not acceptable!!!!
The entire purpose behind a self-determinatory refusal by women is the acceptance of their risk status, whatever it may be, just as for any mother birthing in a hospital setting. The mother deserves the right to self-determination and personal accountability. I wonder if AZ has yet to realize that 1/3 of US women who walk into a hospital come out with major morbidity and/or lifelong risk due to the treatment they receive. Low-risk is an illusory thing and mothers treated as low-risk have a tendency to STAY low-risk at home which they do not in hospital settings. The entire purpose of using a midwife is to have someone trained to identify when and if a birth needs appropriate transfer. You cannot determine ahead of time, no matter how much testing you might do, which mothers, at home or in the hospital, will need that other level of care. Which is why the mother deserves self-determination, an examination of possible risks and then given the right of refusal without abandoment by her midwife by virtue of state law.
Coerced consent is not informed consent. This will force more and more women to give birth on their own because they are being told by the state that they have to submit to specific types of care. This will result in state-enforced cesareans (due to providers who refuse to attend vaginal births after cesareans), more cesareans and more morbidity/mortality. Does Arizona really want to force women into the position of birthing alone because it refuses to recognize adult women have the right to make their own medical decisions?
I am concerned by the statement that the tests are “the only way for the midwife to establish that the birth will be low risk and safe”. This statement is problematic for several reasons. First, there are often other indicators of these conditions which are being tested for or the knowledge of the results may already be known. If a woman tested HIV or Hep B negative 10 years ago and has been in a monogamous sexual relationship since with no exposure to bodily fluid of strangers, she should be able to refuse an HIV test without it making her “high risk”. If a woman is not gaining excessive amounts of weight and her baby appears to be growing at an average rate and she is not showing any other signs of gestational diabetes, refusing a blood glucose test should not make her “high risk”, etc. Second, this is predicated on the idea that birth is inherently dangerous and the average woman cannot give adequately give birth, with is ridiculous and factually incorrect. These conditions are not common and are exceptions from the norm. These proposed restrictions will likely complicate UNcomplicated pregnancies far more often than they will improve “high risk” ones. Third, and most importantly, these restrictions completely destroy the notion of informed consent by removing the decision making processes from a trained and licensed healthcare professional and an autonomous individual and putting it in the hands of a third party with no familiarity of or relationship to the situation. Decisions about testing and all other aspects of birth belong to the woman who is actually giving birth and no one else. The role of the care provider is to provide all available information so that the birthing mother can make an informed decision. If that decision is refusal of certain procedures, that is her right and should not affect the quality of care she receives, just as it is the care provider’s right to make his/her own decisions about what types of circumstances s/he is comfortable attending. A woman should not be considered “high risk” until proven otherwise. I am a perfectly healthy first time mother currently 36 weeks pregnant. After consideration of the risks, benefits, and costs I chose to forgo any ultrasound scans, STI testing, and vaginal exams. God willing I will have this baby before these restrictions go into affect. Did you know the c-section rate in this state is around 30%? Twice what the WHO states is safe. As a first time low-risk mother, I have about a 28% of receiving major abdominal surgery and all the complications that go with it if I have this baby in a hospital. My homebirth midwife has a c-section rate of less than 2% (as do most). Exercising my right to informed consent should not increase my risk of unnecessary surgery by 14-fold. I’m not sure why you think women are incapable of making their own medical decisions when it comes to childbirth, but I suggest you reconsider this attitude.
You have a point… at least for some of the tests. For HIV for example, perhaps we could include a provision that a record of a previous negative HIV test in the last few years perhaps we could waive that test requirement with a Midwife attestation.
Other tests are more problematic to waive. For example, monitoring for gestational diabetes with a blood glucose is important to do in every pregnancy. By knowing a patient has gestational diabetes there are things that can be done to prevent problems with both mother and baby from developing. Babies of these mothers can be born too big, have glucose problems after birth, and can end up with defects that can cause heart problems.
Not true Mr. Humble… If weight gain and fundal growth are with in normal range then there would be no reason to suspect GD… Perhaps a waiver could be mom agreed to take a nutrition class about GD and taking a more reasonable and accurate test of consuming a standard meal. And at any time the midwife is concerned about the growth would then get a consult. There are alternatives. I would accept that. Taking a class does not stress my body out… At any rate it gives us a choice… A better choice than UC or hospital birth…. I do want to thank you for considering alternatives.
VBACs are currently out of scope for Licensed Professional Midwives. At the beginning of this process it seemed like bringing VBACs into scope was a priority. In order to do that safely, we wanted to include additional measures to balance the system- that’s where the emergency action plan etc. came into play.
If we were to drop VBACs we could potentially drop some of those measures. Maybe we will get some feedback at the next Advisory Committee meeting.
Director, I’ve seen you state a few times now that scrapping this attempt at rules revision is an option. While that may be so it is the Department’s obligation to the homebirth consumers and midwives to immediately begin the process to bring the laws that govern the practice of midwifery and the midwives ability to obtain and use the lifesaving drugs that it was previously assumed they had into law.
The Department should have identified and resolved this issue long before now. Since this attempt at rules revision has revealed an oversight by all on this issue it is imperative that no matter what happens with this rules revision that the process to rectify these problems in law be addressed as soon as possible.
Wouldn’t it be possible to keep the current scope of practice as is, but add all of these changes in for Breech and VBACs? In an already risky situation I could see how all of the tests and contacting the hospital could create less of a risk for mom and baby. Current wording will create a situation where many moms will choose to birth unattended and I don’t think anyone wants that.
I think that’s a GREAT idea: If there are to be more restrictions, place them on only the VBAC moms (I’m not so much in favor of doing the same for breech moms). That way, higher risk births would be subject to higher levels of testing and more careful protocol, but it would still allow many VBAC moms to birth at home, which they currently aren’t allowed to do, other than birthing unattended.
Then why not apply these increased “protections” specifically to VBAC moms?
Leave existing rules and regs as is, and only apply any additional restrictions to those seeking VBAC?
If the additional restrictions are truly only because of the addition of VBAC births, it seems only fair that those restrictions only apply to VBAC moms.
As the current draft is written, this additional burden is too great to the majority of healthy moms with normal births to make it worth it. I’d love to see home VBACs legalized, but not at the expense of additional regulatory burden for ALL home births. If that is going to be the case, the original rules were better than what we have now.
Would you please consider that the medication issue is one that needs to be taken up immediately by your department and brought to the governor and legislature? It has suddenly come to everyone’s attention that there is a situation that puts mothers, babies and even their midwives at risk because no one took the time to consider us while statutes moved along without us and the rules have not been looked at in a long time. Under ARS §36-104 it states this in your powers and duties:
4. Determine when a health care emergency or medical emergency situation exists or occurs within the state that cannot be satisfactorily controlled, corrected or treated by the health care delivery systems and facilities available. When such a situation is determined to exist, the director shall immediately report that situation to the legislature and the governor. The report shall include information on the scope of the emergency, recommendations for solution of the emergency and estimates of costs involved.
Thanks. I’ll look into this. It’s too late this legislative session but we can look into this for next session.
There have been many public comments suggesting a clause stating that the woman can refuse and continue care whilst acknowledging and taking responsibility for her own risk (by signing a release to that effect). Why is this not being considered? Here is an example that can be easily added to resolve this issue:
“In order to maintain patient autonomy, the state of Arizona recognizes that the patient may exercise their right to informed refusal for any of the above recommendations and guidelines – and, through written refusal, continue care with the midwife absolving her of legal responsibility/risk for the direct outcome as a result of that refusal. The pregnant patient has the legal right to self determination.”
I refused all tests and procedures in my healthy low-risk pregnancy. I knew my STD status, I knew my blood type, I was being responsible. That was MY responsibility. It would have been a significant financial hardship to pay for hundreds of dollars of unnecessary tests. Doing so for future pregnancies may force me into birthing unassisted. I assure you, if I had any shadow of a doubt, I would submit to any and all testing. But that is my business, just as my choice of care provider and birthplace are. I don’t want to have to birth alone and that is only viable choice left with these restrictions.
Please consider adding the statement above.
I think this is a great idea, too. It’s rather like signing an Against Medical Advice waiver in a hospital. If the state wants to be released from liability (and if the midwives are concerned about liability), having a legal statement signed by the mother acknowledging informed refusal and absolving the midwife and state of liability is a worthwhile option. I know if I had gestational diabetes or a breech baby (or whatever), I would SO MUCH RATHER sign such a statement and continue to birth at home with my chosen midwife than be an emergency transfer, or otherwise not be able to continue care with my Licensed Midwife.
Director Humble, I do appreciate everything you are doing in regards to expanding the Midwifery Scope of Practice.
The one thing I am concerned about is that a mother in the care of a LM does not have the right to refuse tests she does not deem necessary. In 1918 the organization formerly known as the Maternity Center Association (now known as Childbirth Connection) came together to protect and make known the rights for childbearing women. This organization is still in existence today to make those rights known. As listed on the Childbirth Connection website,http://www.childbirthconnection.org/article.asp?ck=10084, rights 9 and 10 state: **Every woman has the right to full and clear information about benefits, risks and costs of the procedures, drugs, tests and treatments offered to her, and of all other reasonable options, including no intervention.* She should receive this information about all interventions that are likely to be offered during labor and birth well before the onset of labor.
***Every woman has the right to accept or refuse procedures, drugs, tests and treatments, and to have her choices honored. She has the right to change her mind.
Please do not take these rights away from childbearing women in the state of AZ who wish to birth at home with licensed midwives.
I have many similar concerns to those voiced above. Therefore, as frustrating as it may be to those who have been working so hard, I find myself in support of the old rules.
I have had the sense, from the current rules draft, that midwives are seen as a detriment to maternal/child health, rather than seeing us as an asset to a Department who’s mission is to protect mothers and babies. We provide low cost, high quality, family centered care.
I remain interested in building bridges between Midwives, The Health Dept and Doctors/Hospitals. In the Blog Mr.Humble refers to “improving the entire system.” I deeply appreciate this sentiment. It seems that the tactic for doing this has been to undermine midwives and make us MORE dependent on a medical community that has no interest in doing business with us. I am midwife working in proximity to a hospital that is, at times unfriendly to midwives and home birth clients. I would love work with The Department on an outreach to foster respect between doctors and midwives. The current Midwifery Statute requires the Health Dept. to support Midwifery. Helping Midwives to be seen as the autonomous professionals we are is a very appropriate first step in improving the health and safety of moms and babies.
The currently existing rules already require all of the testing that is in the proposed new rules with the exception of Group B Strep. Group B Strep is the only new test.
From these posts, it appears that sme of our midwives may not have been following the curent regulations giving folks the false impression that the tests are not currently required (again, with the exception of Group B Strep).
By scrapping the entire package, we would go to the current status quo- which requires these limited tests to establish that the birth will be low risk.
Director Humble,
The foundation of good and respectful health care of any kind is respect for a client’s informed consent or informed refusal. It is a violation of client rights to insist that any test be mandatory. If a family wishes to accept or refuse any test or procedure, that is their prerogative and must be respected. To say “If you do not accept this test or procedure, your care will be discontinued” is not freedom of choice – it is coercive and abusive. That is not good-quality health care. It is the job of the midwife to provide the options and the information and then let the client make informed decisions. It is not her job to force her clients into certain actions by holding over their heads the threat of discontinued care.
Diana Johnston
Mr. Humble,
Acog doesn’t even suggest that OBs abandon their patients when they don’t comply with interventions or tests. Please see the opinion article that was released in Nov. of 2005 on the ACOG website entitled “Maternal decision making, Ethics, and the Law”. It says, “[Even if] a woman’s autonomous decision [seems] not to promote beneficence-based obligations (of the woman or the physician) to the fetus, the obstetrician must respect the patient’s autonomy, continue to care for the pregnant woman, and not intervene against the patient’s wishes, regardless of the consequences.”
What I’ve been wrestling with is that If a test is refused and the birth happens in a hospital environment there are readily available clinical interventions to improve the newborn’s outcome. There are very limited options at home.
Dir. Humble,
Some options are limited at home. (Such as no IV antibiotics) But, many of these tests have alternatives (alternative ways to determine risk and treat, as others have stated above… blood sugar monitoring without glucose stress, hibiclens for GBS, A+ blood for both parents so no need for Rh- testing, etc.) We home birth patients are more informed than the average hospital consumer. We cannot be lumped into this one size fits all package and we must maintain the right to determine our own level of risk. I live 5 minutes from a hospital should I need one… I am almost as close to the hospital as the birth center. I do not have the aversion to hospitals that many women do. I have not had a traumatic hospital birth. (Thankfully) But, neither, do I want to be in a hospital without just cause. These tests do not determine just cause by my definition of high risk. I ought to maintain the right to determine that level of risk.
So if I’m understanding correctly, Its MY choice and MY body to terminate and kill my baby during my pregnancy if I want to, but I’m not allowed to refuse testing that YOU deem necessary to ensure a safe DELIVERY of my baby?! I’m so confused. I’m choosing to give birth and give LIFE to my baby, obviously I care about doing that the best way for us. Please let us, along with a trained professional make the decision that is best for OUR body and OUR baby! How is THIS any less an issue of women’s rights and women’s choice than abortion.
Our statutory mandate for the regulations is to protect both the health of the mother and baby.
Director Humble, you continue to reply with concerns ‘for health of mom and baby’ …we are not wizards…we can not control the outcome of every birth….just as we can not control the outcome of every day waking up….we really don’t know if we are going to live or die…I could get hit by a bus walking across the street…while I understand your concern for safety life is a risk…trying to ‘control’ and ‘legislate’ every aspect of birth CONTROLS the individual family who wants to birth a certain way. We live in the United States, where our constitution was written based on liberty and freedom….we have become a sue-happy country where everyone wants someone else to take responsibility for their choices….what would happen if we wrote laws empowering individuals to take responsibility into their own hands? Instead of the ‘state’ feeling it is responsible for the health and safety of the mom and baby? I am well educated, informed, practice evidence based care and self care everyday of my life in regards to my health…I would do the same with my children when I have them…IF something was to go ‘wrong’ during birth for myself or my future child…I would not hold my midwife responsible. (Notice I have already made my decision to birth with a midwife and never be in a hospital for this sacred event) I am responsible for my choices, and I am responsible for the outcomes of my choices…not my midwife, the state I live in or the country…me. How would the state and countries financial burden be relieved if it asked each citizen to claim responsibility for their life and not EXPECT a saving grace for someone else to ‘save’ them? All we are asking as birth consumers is to have the ability to make choices based on personal decisions…by making those choices we accept responsibility for the outcomes…whatever they may be.
I am a mother that had a homebirth and I am very troubled by some of the restrictions I am reading about. I wouldn’t feel comfortable delivering at home if my midwife couldn’t carry oxygen or Pitocin without jumping through hoops, or if an emergency situation was occurring she was put in the position of calling first and treating second.
Not to mention having her call a hospital when I go into labor is just superfluous, it will burden the hospitals unnecessarily and involve them in a situation that they will statistically not be involved in at all.
I am a smart, college educated woman, trust that me and other women are intelligent enough to weigh the risks and benefits when it comes to deciding which tests we want and don’t want. As a whole I would say that most mothers who choose homebirth spend an incredible amount of time reading about birth and educating themselves.
If changes can’t be made then just please scrap the whole thing! I am planning on having more safe, peaceful homebirths with my wonderful midwife. Please don’t take that away or make it needlessly complicated and difficult.
You’ll see in the final draft rules for public comment that were posted yesterday at:
http://azdhs.gov/diro/admin_rules/documents/midwifery/licensing-of-midwifery-draft-rules-may24-2013.pdf
that the same medication administration language is in our final proposed draft when compared to the currently existing rules. This final draft proposes no chenges when it comes to medication administration.
I’m willing to scrap the entire effort… but realize that the existing regulations already require basic testing for things like HIV Rh etc. If we scrap the package these will still be required. Also, VBAC would remain out of scope.
Director Humble,
Thank you for taking the time to respond to me individually. I truly appreciate how seriously you are taking this issue. I apologize for some of the emotion with which some of us are posting, including myself.
Homebirthing is a hot button issue and in some states completely underground as I am sure you know. I think a lot of the more heated comments are coming from a place of fear that even though home births will be allowed it will be so regulated that most of us mothers will be “risked” out and forced to deliver with a typical OB in a system that many of us regard as broken. As an interesting aside the U.S. maternal mortality rate is so poor that it’s safer for women to deliver in Kuwait or Bulgaria. So it isn’t just a perception that something has gone truly awry with U.S. maternal care.
The GBS rule in the new draft is frightening me as a consumer, 30% of women will test positive and some will test positive one week and negative the next. I personally refused the testing because I knew that without cervical checks, allowing my water to break naturally and delivering into warm water my risks of transmitting to my daughter would be minimal. That was a decision I made after thorough research and discussion with my midwife about the risks and benefits. It’s obviously a decision that’s not right for everyone but it was right for us.
I know you have the best interests of us; the consumers and their children at heart and I appreciate that. I hope that some of the more controversial issues will be resolved.
Sincerely,
Becky
Thanks. Since the GBS test is a new addition, we’re honestly interested in the feedback. While I can’t guarantee we’ll change it… We’re listening to what you have to say and reviewing available guidelines and data.
Dear Dr. Humble,
Thank you for all of the hard work you are doing on this issue.
I have had three babies at home, all under the care of excellent licensed midwives in the state of Arizona. I would never voluntarily choose to birth any other way. The care I have received has been excellent.
One of the best things about care under licensed midwives has been those midwives’ respect for my informed decisions as a health care consumer. They present the benefits and risks of all tests and procedures, and then respect and honor the choices that I make.
I am extremely concerned about how the proposed guidelines violate my family’s right to informed consent and informed refusal of tests and procedures. Giving a woman the choices of (1) complete and unquestioning obedience to all tests and procedures, and (2) an unassisted birth, is not freedom of choice. It is coercion. The right of parents to choose or refuse tests and procedures must be respected, honored, and upheld. Anything else is a violation of parental rights.
I would suggest, as another commenter has, that women be given the option of signing releases so that families are able to make independent choices and midwives are protected liability-wise.
I am also deeply concerned about various other facets of the proposed guidelines – for example, the inability of midwives to carry lifesaving antihemorrhagics and the requirement midwives call 911 before beginning life-saving procedures. Both of those are asking for tragedy.
If all else fails, I would suggest keeping guidelines as they currently are, as the proposed updates are a definite step back.
Please feel free to email me personally with any questions.
Diana Johnston
Director Humble,
Can you speak to the addition of the advisory council some more? The proposed draft has the addition of the advisory council. My understanding of the purpose of the council is to assist the department in making recommendations to changes and provisions to the rules and regulations of licensed midwives on an annual basis. If so, is the scope of practice considered a fluid document that has the possibility to be open to improvement based off of the council’s recommendations?
Regarding some of the ‘hot topics’, is it fair to just tell both sides, ‘hey, if you don’t like this or that part; just wait till it comes up for review at the next annual council meeting and work on it some more.’ ?
I am a home birth consumer. I attended the rally this week and have been following the progress very closely. I am excited for the expanded scope of practice and am hopeful to see how these changes will bring more options to vbac clients. I would love to see this bring more collaboration within the medical community and I am very happy to see the state move to the CPM credentialing system. I am also very interested in becoming a member of future advisory councils. Can you provide more information as to how we can continue to work together to improve midwifery care in Arizona. Thank you for your efforts.
A statute was passed last year that gives the ADHS what’s called “exempt rulemaking authority” to revise the midwife licensing rules. It’s basically the “diamond lane” for developing regulations- much faster. That exempt authority expires on July 1, 2013. If we’re going to revise the current rules we need to be done before that date.
The current regulations don’t include an advisory committee. We developed that in the proposed rules so that there would be a formal input process over time to help the department and future directors make decisions about midwifery. If we don’t revise the rules, then the advisory committee wouldn’t exist- at least formally.
If we don’t revise the rules now, it’s still possible to revise them in the future at some point. However, this department has an enormous mission (a budget of about $2B and 2,000 employees) and there are alot of competing demands on agency resources…. and carving out resources to revise rules for midwifery (as controversial as this process has been) in the future will be difficult.
Let’s keep the good stuff that we have going. This is naturally going to be rocky as this is the first time anyone has even bothered to try. I don’t think anyone wants to waste the resources of the department and dropping the ball here is basically wasting time and money. But you have to be wary of overstepping basic human rights boundaries and respectful that these decisions impact people very deeply. We all have a responsibility to consider that and not put anything into rule that does not truly need to be there. All of the other things can be department recommendations for collaboration, but not rule. You can always send out something to midwives and hospitals asking them to implement some of these ideas of their own free will. You also can’t protect everyone from everything that might ever happen, or you will find yourself crossing that line. Remember who’s decision it is in the end to weigh any risks and there are risks on both sides of any choice, many of which are being taken way out of proportion. It’s the reason many of us choose midwifery and home birth in the first place, we don’t submit to fear based practices and believe it is better for our families. Part of protecting people is protecting their right to autonomy, freedom is a safeguard. Please don’t forget that, it is so important.
Thank you for looking into this and thank you for your responses.
I am happy to see this back and forth conversation. It has been frustrating to feel like our voices have not been heard. I have been involved in midwifery in Arizona since 1992 and each time rules and regulations have been opened to update it seems a fight ensues. It is difficult to work in a field that though regulated through and sanctioned by the state is not respected.
I cant understand why midwifery was ever taken out of the maternal and child health part of the health department to begin with. That is what we do, maternal and infant care..
Many times it seems that midwives are blamed for the bad relationship and feelings that is between our field and the “traditional” medical field. Many times over each of us has reached out to several doctors to establish a working relationship. We desire these relationships for the safety and continuation of care of our clients.
We are professionals. Midwives don’t abandon clients in need of medical care at the hospital door and wish them well. We call to inform the hospital we are coming in and our reasons for doing so. We remain with our clients during the transition and offer copies of records or at least complete information for the client’s chart. Including lab results. Many of us stay the entire length of the hospital stay, even when the situation ends in a c-section and we are sent to wait in the waiting room.
This rule change process has been stressful on many of us who are currently licensed. We have joined in to the discussion, maybe late to see that things we have always been granted and sanctioned to do are now felonies. The very essence of what we do being threatened and our choice to continue to work with women in the way we know to be the best and safest, and to chose this in light of possible prosecution , fines and jail time?? This is a hard option..
Many of us already work in a hostile area with doctors just waiting to catch us in something for which they may accuse us.
Director Humble,
I just wanted to thank you for your efforts on behalf of the homebirthing community. I have only recently become involved on this side of it. Up until a couple of weeks ago, I was simply a father of a home birthed daughter (and very soon a son, any day now!).
I can tell you that there is a lot of frustration out here, but as I parse through the mass amounts of information, I think there is a lot of common ground. It’s just that we’re a community that is sort of a moving target as to what each of knows and understands. We all continue to learn, and I think you’ve said as much yourself.
My plea is that you do not scrap all the hard work that has taken place thus far. There are good things in the new rules, such as the expanded scope of practice. We appreciate that.
I hope that you would consider tabling, by rule, some of the more controversial issues until a later date, and adopt those new rules that everyone can agree upon. Perhaps such a postponement will allow time for a new statute, or at least new consensus.
Thank you for taking the time to read and respond to all these comments. Such an effort does not all represent the act of an adversary, but an ally.
To Safe Homebirths,
Chris Dutkiewicz
I haven’t decided what to do yet. Thanks for this comment. It’s the kind of comment that I wish we had more of. I think it’s fine when people disagree… even good… but personal attacks don’t do much to move people closer to consensus.
Mr. Humble, I don’t believe you know anything about midwifery nor do you care to. Your office has the authority to license but, unfortunately, you do not have a clue about women or the birthing process. You do the State of AZ taxpayers a true injustice.
Thanks. Luckily we have a qualified and well-informed team of professionals to help with this and all of the other issues that we deal with in our complex mission.
I am not from AZ, but I am one of the thousands of women who have been following this issue from around the country. When you looked out to see those 120 demonstrators you may not have been able to see us, but we certainly were there. From my perspective, as a woman of childbearing age, neither of the options that you, Mr. Humble, have proposed is acceptable. Both scrapping the changes and keeping a vbac out of practice and adding all these tests and regulations are violations of a womans basic human right to determine the circumstances surrounding her birth…including who shall attend her, regardless of her risk factors. I have a right to refuse any procedure a doctor may suggest without his having to drop me as his patient, and the same should be true of midwives…without exception. There is no such thing as a RISK FREE childbirth; even the terms we use to catagorize pregnant women in general..low-risk and high-risk, have the common factor of risk. There are certainly risks that exist in a home birth that do not exist in a hospital birth…this is undeniable. However, there are also very real and very serious risks that exist in a hospital birth that do not exist in a home birth. The question before you is: WHO HAS THE RIGHT TO TELL A FULLY INFORMED MOTHER WHICH RISKS SHE IS REQUIRED TO ASSUME? And the answer, in a free country is, ONLY THE MOTHER. It does not matter what her risks factors are, you do not have the right to withhold midwifery care from her if she chooses to birth at home. In other countries they seem to understand this better than we do here. In 2010, the European Court of Human Rights, in the case of Ternovsky vs Hungary, decided that it is a basic human right of all women to determine the circumstances surrounding her own births, including who shall attend her. If you really believe that you have the job, or the RIGHT, to make these types of decisions for a woman, you are very much mistaken. This is outside YOUR scope of practice. If you listen carefully, you will hear the winds of change blowing. Woman all over the country, and indeed, the world, are undertaking to start a revolution in the world of birth. We are taking birth back. It has always belonged to us, we just lost sight of it for a while. It is only a matter of time before some pregnant mother here gets tired of this kind of unconstitutional treatment, and takes it to court in America. And there is an army of women who will stand with her. I am one of them. We are the only ones qualified to make the risk/benefit analysis for our own pregnancies and births. If you are not part of the solution, then you are part of the problem. PLEASE STOP TRYING TO PROTECT US FROM OURSELVES.
Our statutory mandate is to protect both the health of the mother and the baby… as it relates to the scope of practice of midwifery.
We will continue to look into the required test portion of the draft rules:
http://azdhs.gov/diro/admin_rules/documents/midwifery/licensing-of-midwifery-draft-rules-may24-2013.pdf
Perhaps we can move some from the requirement category to the physician consultation category. That would allow a licensed midwife to continue providing services even if the mom decides to decline the limited testing as long as there is consultation with a physician.
Dir. Humble,
I praise your efforts and I very much appreciate the consideration that you are giving to the health and safety of women and their babies. It has been clear in this process that you are reaching for the best possible outcome for everyone involved. Thank you for that.
I find it hard to believe that those who are leaving negative comments have seen this process from start to finish. A great deal of time and energy has gone into this process and the current attitude of dismissal seems to come from a place of frustration rather than commiseration. I was one of the “protesters” this week. Speaking for myself, I am protesting the absence of self determination. I value the role that you play in this and I am saddened by the air of animosity.
I would like to suggest a meeting with the midwives. No one knows home birth and their business better than they do. They have put a great deal of time and effort into compiling evidence-based research and thoughts toward the proposed changes. They truly value the safety of mother and baby above any business to be gained by broadening the scope of practice.
Many consumers have expressed a desire to be more involved in this process but most of us have careers and demands on our time which have not made it possible for us to “get up to speed” on all of the rules, statutes, research, etc. We are making efforts and attending meetings. We are asking for changes. But, we are also asking for our midwives to speak in our behalf. We want then to meet with you. We also want them to be our “consult.” Sometimes, we will seek the care of other physicians and specialists, but I reserve the right to determine with whom I consult.
Mr. Will Humble,
When I first read this blog post, I became concerned and annoyed with your statement that you want to “improve the safety for moms and newborns” and yet you would have the new scope of practice bar midwives from bringing lifesaving drugs and Oxygen to a homebirth. Does that mean that as long as moms and newborns are in a hospital and not in their home you want them safe and you would rather allow moms who choose to have a homebirth suffer be unsafe and possibly DIE because they have chosen to birth at home? I guess that could be a new spin on “Health and Wellness for all Arizonans” just allow those who don’t fit the criteria for being considered healthy die. I think that may be called a form of genocide though some may call it survival of the fittest. Of course, there are always the women who are very against having birth in a hospital where infections and diseases are commonly contracted there and decide that they will birth at home and alone. Are you really interested in “Health and Wellness for all Arizonans”? or just for those who are in the majority and trust in doctors and hospitals who treat birthing mothers like a table to wait on as quickly as is “polite” but moving them along and out the door nonetheless?
Let’s have a chat Mr. Humble, I am a mother who has a fused spine from S1 to T3. In other words, I have 7 lbs of rods in my back from the base of my spine to the bottom of my neck. Therefore I cannot have an epidural. I have had three children the first two in the hospital and the last at home with a LM. With my first child I was put on pitocin and had a Horrifying experience. I know that you are not a woman and that you have never experienced birth, but I ask will you sympathize for just a moment with me? It was incredibly painful and unlike in a “natural” birth the contractions were on top of each other and I felt like I was dying. Four years later I had my daughter in the hospital, in AZ. I had a 27 hour labor and a completely drug free birth. The only thing that hampered my experience was I felt pretty sorry for the Hospital that did not want my “special” case; in other words, a woman who has chosen an “alternate” birth plan. Throughout my long labor the nurse made it clear that I was not a “normal” case and that I was making people wait. Thankfully, the ultimate outcome was that I gave birth to a beautiful daughter who was amazingly alert and calm.
When I became pregnant with my third last Spring, we didn’t have insurance that covered a birth and I already knew that I could birth a healthy baby as I had done two times previously. I knew it may take longer to labor but I had learned how to cope with labor and I felt that birthing at home was the best option for both me and my baby (not to mention a hospital staff that would be frustrated with their inability to corral me through the system because I refuse to be induced ever again if possible). So, I saved every bit of my money and barely could cover the cost of my midwife’s services but birthing alone without someone trained in knowing when to make interventions was not an option. I want me and my baby to be healthy and I also feel it is ridiculous to make hospital personal wait for me to be stuck at 7 cm and contracting consistently for eleven hours.
During my appointments with my LM, I refused any testing besides basic blood tests to make sure I was healthy because A). I am healthy and I have been in a monogamous relationship for the last ten years and B). Why should I pay for taking a test that I already know what the results will be? When you said in your blog that they only way for a woman to know that she will have a healthy birth by taking tests, that is a pretty one dimensional statement when there are many people in who have never have lived a lifestyle that would create a need for such tests. It doesn’t seem fair does it that if I or anyone wants to refuse a test they will be refused care? Wow. That is a hindrance of the one’s rights to refusal that I have read multiple times….are you willing to pay for a test that you know that you do not need?
I am happy to report to you that I birthed a beautiful daughter on Human Rights Day, this January. I had what is called prodormal Labor, it was longer than my second birth but because of my amazing midwife, and her team, I had a transcending experience. I had my baby at home and I am proud of it. I was so grateful to finally experience a birth that I didn’t feel like a “broken” woman because I birth slow. I am grateful that my midwife had in her possession meds and oxygen available so that if there was a potential problem, I or my baby could have help before an ambulance could get there. Thankfully, my baby had an amazing high Apgar and is a sweet, bright, alert bundle of joy. Because that is what really matters isn’t it? That mom and baby are safe. I know that deep down inside, this is what you want.
If the scope of practice changes to these proposed changes, I ask you, what, in my situation should I do? Please let me know because my conclusion right now is that I would have to had birth at home ALONE. I and my baby may or may not have been safe without a midwife who could monitor my baby intermittently. Trying to Force women who would like to birth at home into hospitals by not allowing midwives to carry lifesaving drugs and oxygen is not an ethical way to make possible “Health and Wellness for all Arizonans”. Thank you so much for your time. I wish that you could witness the beauty of a home birth and the peace that a woman feels when her midwife is present and has those things that could be used in an emergency.
Sincerely, Heather Meyers
As you can see in the final proposed rules for public comment: http://azdhs.gov/diro/admin_rules/documents/midwifery/licensing-of-midwifery-draft-rules-may24-2013.pdf
we haven’t changed any of the language surrounding the administration of medications. The language in our proposed final rule is the same as the language in the currently existing regulations.
Thank you for the rules revision preview. I truly appreciate all the work that has gone into this.
For the positive group B strep, I might suggest including language about it being a consult with a physician. Also, there are physicians and other practitioners with prescriptive powers who have been willing to write scripts for women to have antibiotics to treat it at home so that it did not interfere with the homebirth plans. If we could get the flexibility to treat and/or retest to not have to b risked out on GBS status, that would be greatly appreciated.
Thank you again for all the work that has gone into this.
Good idea. I think we can do that.
I greatly appreciate your consideration in this matter. If there’s any way I can assist in helping make this a reality, I would be more than happy to do so.
The best thing you could do would be to get very familiar with the current rules and compare them to what we have proposed. If you think what we are proposing is better overall, then do what you can to let others that are home birth enthusiasts and licensed midwives to know what you think and why.
If things go poorly in the next couple of weeks I’m afraid we’ll just end up with the status quo- which would be OK with me… but it would waste a great opportunity to improve the system.
Regarding Type B Strep… we are looking at the data to see how many newborn Strep B reports we have gotten in the last few years and the demographics to see where to go from here. We have had newborn cases with very poor outcomes, but I want to see how we could best intervene. It could be that a declination in consultation with a physician would do it rather than making it a prohibited practice.
Director, in the new rules you are now requiring testing for Hepatitis B and C as well as GBS while still making it a termination of care for a parent to elect to not choose to test. Your purview is not to regulate the choices that parents make but to regulate the services that your Midwives *offer*. It should be a requirement that these tests are offered, their benefits and risks and what is to be done with the results and the parents decision documented by their midwife. Declining of these tests should not result in a termination of care. These tests are readily declined in the freestanding birth center setting without requiring a CNM to terminate care. The assertion that women under OB care will be birthing in hospitals with the necessary emergency equipment/measures at their fingertips is not a valid argument when freestanding birth centers offer the same right to decline and retain care.
Require documentation of these prenatal tests being offered and the parents consent or declination, do not require a termination of care. The current rebuttal as to why this is included in the rules does not work when other out of hospital options are supportive in the parent’s right to decline these tests.
I see that my comment regarding Mr. Humble’s knowledge of midwifery has been deleted. So let me say it in a better way. This is a war on women and men are making decisions that should not be making. A woman can abort but she cannot choose to have a birth anyway she wants. Something is very wrong with this picture. To the State of AZ…stay out of the birthing business. You have bigger problems.
We currently have a statutory mandate to set standards for and license professional midwives. Having said that… it is a legitimate matter of public policy as to whether professional midwives should be licensed at all.
Some states have no licensing standards and do not license professional midwives.
Repealing the AZ statute that madates us to license and regulate midwives would require a statutory repeal- which is possible.
I appreciate you trying to increase the options available to women who want to birth at home, especially in the case of VBACs. I see that you feel it is necessary then to bring in additional safety measures for these VBAC births. Can there please be a provision stating that the required testing, emergency action plans, and all other new safety measures only be applied to VBACs since those are the ones you are concerned about?
We’ll look at including all of the tests in the physician consultation section. I’m not saying we will do that, but that we will look into that during June.
Dear Mr Humble,
Thank you for the significant time and thought you have given.
As a licensed midwife for 3 years and ob nurse for 23, this body of rules concerns me deeply. Yet, I trust that the intent of the process is to create safety and wisdom for mother and baby.
If these issues cannot be resolved, I concur that the standing rules should be kept. It would be a loss to all of us who have invested time and thought into the process, but it is better than binding us to a set of rules that is potentially so controversial.
There is a new clause that deeply disturbs me. Mandatory testing for group B strep violates the CDC protocol which requires only that it be offered. If a woman is positive, under this draft she risks out of home birth. One third of women carry GBS as part of their normal flora, and thus 1/3 of women cannot have the choice of homebirth?
Underlying this is the bigger issue that a woman must have the right to research and choose or refuse any test, or vaginal exam. This philosophical premise is foundational to midwifery. Secondly, we must be permitted to practice as professionals, and treated with respect. I practice in a very collaborative manner, and freely refer clients to other health professionals. But I also expect that I can intervene immediately in an emergency situation with the appropriate reponse, such as 02 or a maneuver or intervention, and assess if the situation has resolved or requires immediate transport.
I do not want to pracice with less freedom than I had as a nurse in a birth center.
Feel free to contact me with any questions.
Joanna Wilder, RN, LM, CPM
Please take a close look at the current regulations alongside the new draft rules for public comment. Before you decide… consider the following:
We’d be moving to NARM to be consistent with the rest of the country
You’d have more in-scope manuvers
Reporting requirements would be electronic
The application process will be much easier
Medication scope would be just exactly as it is today
VBAC would be in scope under many circumstances
Full breech would be in scope
Midwives would have an official voice through the ongoing advisory committee
I am willing to not file any changes at all if that’s what the consensus is- but if you take a serious look, I think you’ll see the system will be better.
I’m also willing to look into moving at least some of the required testing into the consultation.
I would also like to Thank you for all the work that has been done on the rules thus far. I know that this is a very long and difficult process, and I do believe that you and the Department have the best interest of the midwives, moms and babies at heart. I would really not like to scrap everything that has been done. There are good things in the draft as you have stated above. I do still have concerns with the latest draft, mainly in regards to testing, refusal and termination of care. One of the biggest concerns is the termination of care for a GBS + mom. I see your responses in regards to possibly moving the testing into consultation which is certainly a better option; however I would ask that you actually do some more research on this topic. We are all about evidence based information and of course the moms ability to make choices and I don’t think that we have the latest evidence leading your decisions. The real issue that I am sure you are facing is that we do not have in our rules the ability to administer IV antibiotics which is the standard of care with a GBS + mom. It was originally my hope that the expanded scope of practice would actually be to resolve this issue. Instead we went in the opposite direction. I have read all your posts and letters and understand the place that you feel your hands are tied in relation to the medications. I do beleive that there are emergency measure that could be done to get this fixed quickly but do not have all the legal answers at this point. I do sincerely hope that the Department will work with the midwives in every way they can to resolve this issue with the statute so that all of these issues can be resolved. In the interim of fixing statute surrounding the medications, can you please consider that we have other options to handle a GBS + mom such as working with a physician or CNM to obtain the antibiotics prior to birth and the option to retest for a – negative result prior to birth. We should not have to terminate care. My concern is at this stage in their pregnancies if we have to terminate care they will birth at home unassisted with no one to watch a baby to see that they are in fact not sick. Instead of making it safer for them you are actually putting them at greater risks. Midwives are trained in what to look for and what to do for sick moms and babies. Parents do not have that training and can unknowingly put their babies at risks because they were forced to not have a trained professional with them before, during and after their birth. Mr. Humble as midwives we do a lot of postpartum care to ensure that moms and babies are healthy and safe and if they are not we make sure they get the appropriate care. Also the current standard of care states that a GBS test is only good for 5 weeks, therefor it is best to not test until 37 weeks so that you are covered through 42 weeks. You certainly can test at 35 weeks but if the mom has not birthed you would to follow the standard need to test again. These test are not cheap and many of our clients are self pay. We should minimize testing when possible. It is these little tidbits of information that should be known before rules are set.
I would like to say again that I appreciate all that you have done and all the time you have spent with others to attempt to educate yourself. I do wish that you trusted the midwives enough to actually meet with us and listen to us in regards to these issues, instead of simply looking to the in hospital professionals as if they know more than we do. Trust us to actually be the experts in out of hospital, natural and low risk birth. As much as you want to protect moms and babies, so do we. We wake up and take responsibility for these families everyday and we have no intentions to put them or ourselves at risk.
Regarding meeting with folks… the statute that asked us to look at the scope of practice and consider revisions formed a Scope of Practice Advisory Committee. The committee contains physicians, nurse midwives, CPMs, and consumers. I’ve stayed within the confines of the committee in terms of my personal meetings with Stakeholders during this process. If you’ve been coming to the meetings you know that the physicians and the CPMs and consumers don’t see eye to eye on some key issues. If I were to meet privately with any of the parties there would be a perception that some of the Stakeholders are getting preferential treatment. i don’t want that perception- which is why I have avoided sidebar meetings and have relied on the statutory committee for input.
What I have seen in this process is that you are an ally who is thinking creatively to try to find solutions. I would be sad to see the process come to naught.
So many things in this final draft have language that is cleaner. . Thank you.
A consultation would be a good compromise. As long as clients have the right to refuse I think consumers will be more receptive.
I am curious about the idea of going to MANA stats for data collection for midwives. This would fit the goal of collecting strong data on a national and state level, which is statistically appropriate to home birth, without using Arizona dollars.
Thank you again for your time.
I very much agree with the above comment. The new scope absolutely needs to include VBAC’s. Evidence fully supports that in a majority of cases having a VBAC at home is completely safe. Midwives are trained to recognize”red flags” and they are completely capable of recognizing if woman is low-risk without these proposed”required” tests. One in three women in the US ends up with a c-section, THAT is a failure of our modern maternity care system. Having a home birth greatly reduces that risk. There are so many things wrong with the current proposed revisions that it certainly would be easier just to scrap it but please consider keeping the real expansions. It is our right to have respectful maternity care, we are fully capable of making informed decisions when we ARE fully informed, a task that doctors today seem to overlook and we will keep demanding that ALL options be available to us.
I agree that there are way too many C Sections in AZ and in most of the country. A generation ago C sections were fairly rare. Now they are commonplace.
I am saddened that this is even an issue up for debate. I trust my midwives more than I have ever trusted the OB’s I have seen or anyone in the hospital. I trust my instinct to do what is right for my body and my baby. Please do NOT take away our rights.
Mr Humble,
As a practicing midwife since 1984, I believe with the rules revision we are losing much more than we are gaining and I would be in favor of retaining our current rules.
Please take a close look at the current regulations alongside the new draft rules for public comment. Before you decide… consider the following:
~We’d be moving to NARM to be consistent with the rest of the country
~You’d have more in-scope manuvers for both the baby and placenta
~Reporting requirements would be electronic
~The application process will be much easier
~Medication scope would be just exactly as it is today. This final draft doesn’t change the language surrounding the administration of medications from what exists in the current reg’s.
~VBAC would be in scope under many circumstances- it is out of scope now
~Full breech would be in scope
~Midwives would have an official voice through the ongoing advisory committee
~The required tests in this draft are the same as they are in the current reg’s (except for Group B Strep- which is new). I’m also willing to look into moving at least some of the required testing into the consultation.
If you take a serious look, I think you’ll see the system will be better. It will probably take about 4-8 hours.
I encourage you and everyone to invest time in really looking at the proposed rules side by side to the current rules. The stakes are high as is this process fails and we scrap the entire package I doubt this issue will be taken up again anytime soon.
Here are the final proposed rules for public comment:
http://azdhs.gov/diro/admin_rules/documents/midwifery/licensing-of-midwifery-draft-rules-may24-2013.pdf
I am willing to not file any changes at all if that’s what the consensus is- but if you take a serious look, I think you’ll see the system will be better.
First, I would like to thank you for taking the time to respond to my previous comment. I haven’t had time to read all of the comments to this blog post, so I don’t know if this has already been brought up, but I have been pondering the GBS problem that many women (homebirth or otherwise) will be facing. Many women in the homebirth community are very upset by the prospect of being unable to have a homebirth because of a test result. I was wondering, if it would be possible to put into the rules that if a woman is GBS+ she has the choice to see an OB/GYN or her PCP and take oral antibiotics to treat her GBS. She could obtain a written note for her records to give to her LM as proof of treatment. Is something like that possible?
Yes. Treatment is the key. As long as it’s treated it’s not usually an issue after birth. We’re trying to prevent bad outcomes for babies because of GBS that hasn’t been treated. The most effective treatment is IV antibiotics during labor. However, my team is exploring other options that might be available for preventing GBS transmission to babies.
Thank you for your civil and constuctive comment.
Can we ask where this suddenly came from? The reason I ask is because you’ve said you are not to be giving preference with a listening ear to any stakeholders. Yet this was not mentioned in any previous draft or public meeting and has been thrown in there without proper discourse or understanding of the consequences. It may have been given to you with an ulterior motive considering anyone who understands GBS and pregnancy will know that the way it is in the draft as a required transfer of care will throw out up to 30% of all women from midwifery care right at the end of pregnancy and will suddenly end a trusted relationship based on mutual respect that was meant to culminate in a specific birth plan without justification. And now the only choice this mother has is being forced into an entirely different care model, hospital or unassisted birth, and both are not supportive to that mother. This is important when you understand that the general risk you are saving us from is a .05% chance overall and a 0.5% for the mother who does test positive. This is one we are more than capable of weighing for ourselves and to put in perspective has less risk than many other things in the draft. There are also treatment options that should be presented and left up to the mother to choose that do not require IV antibiotics in a hospital, such an IM shot that will last 30 days (through birth) and has been proven effective for GBS. She has a right to be informed by her midwife and seek a consult for the treatment (until the med issue gets resolved), but this should always be her choice because there are risks/benefits to even this and if she refuses it, being at home or a hospital for birth will not improve the outcomes because in both scenarios the baby is monitored and informed. There is no preconception or early treatment that has been proven to reduce risk as you state. That was a red flag to me that this issue was not fully understood.
It really bothers me that this is suddenly restricting scope without proper evidence and reasonable perspectives on that evidence. I think you have a responsibility to divulge how and why you came to putting this into this nearly final draft. Nothing should be put in this draft without being presented to the entire committee and public first, for very good reason. You would already have all of this information if this was done properly instead of listening to unnamed stakeholders who do not necessarily care what happens to home birth clients or their midwives and most likely thinks they should not be at home at all, even though it has been proven to be very safe and with healthy overall outcomes. This is precisely what you are here for, to protect mothers and babies, even us the 1% who deserve to be informed and respected at the same time, not unreasonably forced into someone else’s model of care.
I hope you found this to be civil, even while addressing a concern in accountability. I would want the same if I were in your shoes. I would want evidenced based care first and foremost, making sure that gets into the hands of mothers with informed consent but at the same time with proper, not inflated, perspectives on risks while still respecting patient autonomy.
Thank you Director Humble for your attention to all the comments and for listening.
We will be discussing this (and the rest of the rules) with the committee at the next meeting on June 3rd. We’re looking at our data, reviewing the CDC’s guidelines for prevention, and our team will be discussing whether it needs to remain a prohibited practice or can be a consultation. I can’t guarantee it will change…but we’ll consider it.
Physicians, CNMs, and NDs who do home births don’t have to terminate care when patients refuse. This is unprecedented.
Director Humble,
As a two time hb consumer, I am excited and hopeful that the rules revision is going to lead to better midwifery care in Arizona. I can assure you that the consensus among consumers is to not scrap the revision. I am appreciative that public comment is still open and will continue to be reviewed through June. I urge other stakeholders to keep dialog open, respectful and evidenced-based. Thank you for considering the option for consult with required testing. I find it to be a realistic compromise for both the midwife, the client and the traditional medical community. Thank you for your stated support in working to change statute for the meds issue understanding that now is not the setting for that battle. I will continue to post recommendations via public comment and look forward to a successful collaborative effort.
Thank you. I urge you to mentor other consumers about how to most effectively impact decision-making… with civil and constructive comment.
Dir. Humble,
Thank you for your transparency in this process and for your willingness to respond to criticism and suggestions.
Safety is of course paramount for healthy moms and babies. But the fundamental rights of women to be in charge of their care is also paramount. I realize the extraordinary pressure this puts on your department. The push back from women and midwives, as I see it, is largely due to historic issues with women’s rights being sacrificed for the politics of others. I know that you respect women, respect mothers, and respect midwives. I ask that any rule changes keep this issue as high of a priority as safety.
The main reason women choose homebirth and the main reason I chose homebirth was safety. The second reason was personal autonomy. I’ve had a traumatic hospital birth and a gorgeous, healing homebirth. In the hospital, I was a number. In my home, I was attended with respect, dignity, expertise, and love.
I am not a midwife, but I am a woman who advocates for women’s rights and women’s autonomy. I urge you to read back any rule changes and ask yourself and your department if the rules reflect the very best that women deserve. Trust that women who choose homebirth do extensive research, are very well informed about risk, and base their decisions on what is right for them and for their family.
If statute is tying your hands in this regard, then please, let’s work together to change and improve this system legislatively and then come back to the drawing board. Birth is a rite of passage, and a singularly feminine endeavor. Our birth experience does matter. It is important. I’ve had it both ways and will forever be a convert to midwifery care. If we have to spend the next year getting this right, myself and scores of others will be there with you every step of the way. Please, call on us, trust us, and know that while we are sometimes angry, impatient, and frustrated, it’s because this is personal for each and every one of us.
Thank you for your continued passion, dedication, and humanity.
Lesley McKinley
thanks
Lesley McKinley, You summed up pretty much how I feel. Both about birthing and about Mr. Humble’s effort.
I will say that I’m glad the ADHS is being so open to have conversations about this with the public and with stakeholders! I think that Mr. Humble is doing a good job mitigating the issue and involving LM’s and other stakeholders in the process and listening!
Mr humble,
I know you are a busy man with many obligations and that other health issues are also demanding your attention simultaneously. So seeing that you are taking the time to even reply to this blog, really demonstrates your dedication and your commitment and passion to public health! I really admire you efforts also.
I too hope that a consensus is reached and that all the work being done does not goes to waste!
Thank you
Thanks. We appreciate our stakeholders and their feedback. We have received a lot of input from all sides, that hopefully will help make this a better system.
Director, I would like to offer the option of talking with the midwives to brainstorm about how we’ve met challenges in providing care to women while respecting their rights to autonomy. Clearly, this is a hot button issue for this crowd, and we have been in the trenches, so to speak, and have solutions that we can offer.
Mr. Humble
I am one of the very, very few home birth mother’s that needed to be transferred and have an emergency c-section. I had a completely normal and healthy pregnancy. No tests or monitoring you are suggesting would have changed my situation. I can tell you that it is only due to my midwife’s experience, knowledge and strength to advocate for me that both me and my baby are here today. Once I arrived at the hospital, they did nothing for almost 1.5 hours even though my baby was in distress. My baby was being monitored which clearly showed a problem. The nurse did nothing. It was due to my midwife’s endless pursuit to stand up for me and find someone in the maternity department that knew what they were doing that saved our lives. Until then no one treated the situation as an emergency. My point being that for you to say it is okay to refuse tests in a hospital because there is emergency equipment and staff to respond isn’t necessarily true. In my situation, the nurse would have let me and my baby die before she admitted she didn’t know what was happening. This type of thing happens all the time in the hospital. I am beyond grateful for the eventual medical care that I received. I always knew that I wanted to give birth at home and am so thankful that I was given that opportunity. I support everything that has been mentioned above by so many other midwives and home birthing mothers. I truly hope that you do not make changes to the existing rules that will violate a mother’s right to choose their health care provider and level of intervention.
Dear Mr. Humble….
What about IV antibiotic treatment for GBS with a written script for the patient who is positive. It is my understanding that oral antibiotics are not considered a valid treatment to treat GBS as stated by all OB’s. The standard of care in the US is IV antibiotic treatment. We are trying to avoid a transfer of care unless the situation is an emergency. Testing positive for GBS is not an emergency situation and only affects the baby postpartum.
Thanks. Its helpful when we get potential solutions in the comments that we can work with. I’ll take this back to my team.
This particular piece could very well make or break the entire effort. I thought June was too late to make changes which is why I fervently made this comment now. I hope I am wrong.
We’ll take that into consideration. Because this is a draft, we’ll be working on it until we file it. We appreciate comments and feedback…we review every one the Department receives.
I sincerely appreciate the work the department has put into this. As someone who has been invovled from the beginning, I know how hard you have and are continuing to work on this effort. In no way, do I believe you do not have the best interests of mothers and babies at the forefront of your mind. I recognize that you are receiving input from many people/organizations. I do not envy your job! There are many rules proposed that I am truly excited to see become a reality. I believe there are some major issues to work through in regards to the testing, but I am positive we can work together to come up with a solution that will work. It may not end up being the ideal resolution, but it can be better than what we currently have. The ideal resolution would be to give autonomy to all homebirth clients. Trust that they are being informed by the midwives you license and have their child’s best interest in the forefront of their mind. Several suggestions have been provided. The wording from the California Midwifery rules regarding informed refusal is fabulous. However, if that is not an option, I am believe consultation would be the next best option. GBS testing is the hottest issue right now. I would strongly suggest that the midwives are asked how this is currently handled in their practice. What do most clients due when they receive a positive result? Could clients get treatment and remain in their midwives care? How devistating would that be to a homebirh client to receive care for 36 weeks only to have to transfer to an undesired care provider! We must come up with a solution to this. I would suggest looking into treatment options that can be attained by the client. I would also suggest moving this to a consultation and not a transfer of care.
Thank you for of your dedication. I would absolutely NOT consider scraping this process! No one beneifits if that happens!
Thanks. I appreciate solution based comments, and we’ll continue to look at all of the options. I have my team looking through the guidelines and data.
Director Humble,
I want to thank you for the amount of time and effort you have put into this process. You are in an extremely difficult situation in the middle of very opposing ideas and beliefs. I appreciate that you are trying to understand all of the issues and make the right choices. Safety is of utmost concern to you and to the midwives. I appreciate that the language regarding medications was returned to the original language.
The other issue that is of extreme importance in this process is freedom. Parents must be able to exercise their rights to accept or refuse testing and/or treatment.
The Patients Bill of Rights says:
All patients should be guaranteed the following freedoms:
*To seek consultation with the physician(s) of their choice;
*To contract with their physician(s) on mutually agreeable terms;
*To be treated confidentially, with access to their records limited to those involved in their care or designated by the patient;
*To use their own resources to purchase the care of their choice;
*******To refuse medical treatment even if it is recommended by their physician(s);
*******To be informed about their medical condition, the risks and benefits of treatment and appropriate alternatives;
*******To refuse third-party interference in their medical care, and to be confident that their actions in seeking or declining medical care will not result in third-party-imposed penalties for patients or physicians;
*To receive full disclosure of their insurance plan in plain language
This has to be considered carefully. This freedom is extremely important. Could the new rules can reflect that clients have freedom to accept or decline recommendations, testing and/or treatment and not be denied care?
The new proposed GBS guidelines are a big problem, but I see from the above comments that others have explained it well, and you have said it can be changed. I recommend that it be the same as all the other testing/treatment recommendations with full informed consent and freedom to consent or decline.
These 2 things are deal breakers for me if they can’t be changed. I believe strongly in providing safe quality care with full informed consent that complies with the Patients Bill of Rights.
I understand that you are trying to show the hospitals that we provide good care and have mostly good outcomes. Are you sure they want the increased liability of midwives calling to say someone is in labor? It is unclear exactly what information will be required to give the hospital when we call. Doesn’t this violate HIPAA? Also, occasionally there are births that happen so fast after we arrive that we barely have time to get set up. In those rare instances, it needs to be recognized that there might not be time to call the hospital. I am concerned that instead of positive interactions with hospital staff that we would be greeted with animosity, which could discourage clients from wanting to transport should the need arise. I am very concerned that this rule will not have the results that you hope for.
Thank you for the positive changes you made…adding CNM, consultations can be verbal, fixing emergency measures, and definition improvements. Can we consult with other appropriate physicians? For example, if a woman has a history of seizures consulting with a neurologist, or if she has a history of thyroid disorder consulting with a endocrinologist?
Again, I want to thank you for your kind intentions in this process. I understand that you want to be fair to all of the parties involved, but I wish for your sake you that it was easier for you to hear from those who are actually in the field doing this work. We know the ins and outs of what it actually takes to provide safe and collaborative
care in a home birth setting.
Thanks. We’ll look into your questions. My main goal with these rules has been to use data to drive the decisions to create a safer system. Having a emergency action plan and making the hospital aware of patients laboring in the community provides a safety net, just in case it’s needed. And, when its not needed, the hospital knows that another successful delivery occurred in the community….hopefully, improving communication between the different groups of healthcare providers.
Thank you so much for helping us to see how our voices can effect this process. Being able to have an open dialogue with you is reassuring. It fosters trust in The Department and in the possibility for collaboration. My initial read of the draft was more positive than I had expected.
In my practice, which is small, I have had clients decide to birth in the hospital for a positive GBS, though most often they choose to birth at home. When my clients choose this option I expect them to take the risks seriously. We spend extra time with the parents teaching them about signs of infection and empower them with knowledge so they can help monitor babies for symptoms. I always stay with my clients longer during the immediate postpartum in GBS positive cases. Once I do leave the family, we discuss a specific plan of action should concern arise.
As I mentioned in my comment yesterday I am truly heartened by your interest in helping us improve communication with other healthcare providers. Once the storm of this draft process passes I would be curious to hear your suggestions about how we let our hospitals know that we will begin to inform them about births. I agree with you that this could, eventually educate the hospital team about how many positive outcomes we do have. I just can’t help feeling concerned about how this will be initially received.
Just as we license midwives, we also license healthcare institutions. We have a good working relationship with our hospitals, and can notify them of this new change. We can also work with the Arizona Perinatal Trust, that works with the labor and delivery units, to spread the word. I understand that this process will take time. But, eventually, it will result in an improved system for when transfers do occur.
I have been surprised with the intrepretations and emphasis put on to the testing. When coming into licensing we have to memorize the lists of required transfer of care and required consults for borth mother and baby. In the body of the rules it stated atleast in 3 places unless written refusal. Since a limited number of those things appear in the required consult area or transfer of care untill clear of the infection. It sort of outlined what could be refused and what had to have additional info behind it. Syphilis has a statute requiring everyone , including doctors to do the testing.. Eye ointment is to be offered but cn be refused, if mom is clear of a gonorrhea.
So i think that we are practicing to rule .
There are other examples like screening for diabetes…. Just didnt want to write up the whole list.
Thanks. You’re right. When you compare the new draft to the rules that are currently in place, besides the GBS, there is very little change. In fact, we removed the hepatitis A requirement. I encourage everyone to compare these new rules to the current ones.
Director Humble,
The homebirth community is a passionate group of people and I think emotions are running extremely high right now as real and valid concerns are being put forth. I think there has been a lot of knee jerk reaction and inflammatory behavior lately that has not been constructive or helpful and I hate to see that happening. I wanted to just say that, while I do think the revised rules still need work, I do not at all support the notion of throwing out all of the hard work that has been happening for the last year just because there are a few (albeit significant) points that need to be worked out. I personally do believe that you are working WITH us and not against us and I very much appreciate how you have demonstrated time and time again that you are willing to do that. I consistently see you responding to concerns, keeping lines of communication open, being respectful in the face of less than tactful comments and accusations and – most importantly – I see you giving genuine consideration to solutions and compromises when they are proposed. I fear that you may be under the impression that the homebirth community as a whole is not appreciative of your efforts during this process. I want to assure you that this is not the case.
I think there are some very serious issues of concern on the table and I hope to see the autonomy of homebirthing families respected when the department finalizes the changes to the rules. As the mother of two healthy children born at home I can assure you that I take my health and the health of my babies very seriously and I have done extensive research on all issues that would affect a healthy pregnancy and a safe and healthy labor and delivery for myself and my babies. That includes understanding all the testing and procedures made available to me, as well as the risks and benefits of both accepting and declining all those various things. Our goals are the same – healthly mom, healthy baby. I strongly believe that we should not lose the ability to continue care with our chosen provider simply because we decline a test, especially when we have made an INFORMED decision. I fully understand the department’s concern for healthy babies and healthy moms and I appreciate that the best outcome is the goal. However, that is what informed consent is all about. If we, as the birthing mom, understand the risks and benefits and still choose to decline, and our chosen care provider feels comfortable continuing care as well, then the mom assumes the responsibility for the outcome – whatever that may be. If these tests can be declined for births at freestanding birth centers, I see no reason why they cannot be declined for homebirth. Couldn’t there simply be formal ‘refusal’ forms that ensures that the mother understands the risks before declining?
Specifically in regards to the GBS test, a very well respected Licensed Midwife, Stephanie Soderblom, published a very thorough blog post regarding this test and if you haven’t seen it before it would be great if you’d read and consider the information there. Here is a link http://www.nurturingheartsbirthservices.com/blog/?p=790
Many women, like myself, chose homebirth in large part because we choose to be a more active participant in our care and we want to work with care providers who treat us as informed consumers capable of making informed decisions. My midwife provides me with lots of information and allows me to make my own decisions, with the understanding that I will take responsibility for those decisions. The simple fact is that most homebirthing women would rather have an unassisted homebirth than be forced to work with an OB. So if the state requires our midwife to abandon care because we chose to decline a test, the result is not going to be what you would like to have happen – that mom is most likely going to instead choose to birth at home unassisted (not birth with an OB in a hospital), and I think we both agree that this is not the safest option for anyone. I understand that you believe that you’d be protecting mom and baby by having her birth in a hospital instead, but that is not going to happen in the majority of cases. It just isn’t. Just as many VBAC mothers have chosen to birth unassisted because the current rules and regulations for homebirth don’t allow it, so will be the case for women who decline these tests. Please support informed consent and informed refusal.
Again, I thank you for continuing to work WITH us to find mutually agreeable solutions the issues that need to be resolved before the new rules become final. There are many good changes being proposed and I sincerely hope that this process continues to move forward.
Thanks. I appreciate the constructive ideas. We’ll continue to look at the testing requirements. We didn’t change much for testing requirements from what’s currently required- but, we’ll consider different options.
This particular area of the rules section D “A midwife shall inform clients, both orally and in writing, of the midwife’s scope of practice; the risks and benefits of home birth; the required tests and potential risks to a newborn if refused, and the need for written documentation of client’s refusal;”
Why would we need to document a refusal of midwifery care in general? If they come and interview and then dont agree to our scope of practice then they are just gone. Written refusals come up for certain parts of care then an individual written refusal is what would occur . No where is it stated that this is then a required transferr. Infact if an Rh negative mom refuses testing or treatment it is a required consult, which illustrates the idea that certain types of refusals need further follow up but does not mean complete transfer. Now it may be your intention to change the ability to refuse testing status , which is what the new draft appears to do. But the current rules allow for written refusals.
I agree with you, and it’s not our intent to have you document a client that refuses to use midwifery care. This rule is specific to refusing tests and treatment to the newborn (for instance, the newborn screening test or vitamin K). We just need documentation it was offered to the parents and they refused, in case there is a bad outcome. This has not significantly changed from the current rule that is in place.
I’ve gotten many comments about the refusal of the tests. I’m going to take it into consideration. I’ll take this back to my team.
Director Humble –
From the perspective of a Licensed Midwife in Arizona and as someone who has spent ten years studying health policy, I want to take a moment to offer my opinions on the current midwifery rules revision. I feel as if the new draft, with minor changes, will be a very positive step towards the professionalization of midwifery in this state. Further, after having spent the past 18 months closely involved with this rules rewrite process, I am able to see where changes have been made as a response to feedback. I appreciate the time dedicated to this effort and understand the long term implications of its success or failure.
In a letter dated April 23, 2013 I requested that DHS consider five things in it’s draft revisions: limited access to medications, emergency procedures, evidenced-based rules, client’s rights to refuse, and the implications of formal back up arrangements and calls to local hospital charge nurse. Some of these have been addressed and there is still work to be done.
There are many other positive changes in this draft revision that I think are important to acknowledge. I see that the access to medications has been fixed to the ability of the department by returning the medication language to previous draft version. I understand that the only way to truly address the legal ability to purchase, carry and administer will require a statute change. Emergency procedures have been improved dramatically, allowing for greater freedom for midwives to perform life saving techniques and eliminating language that requires the midwife to phone EMS prior to emergency measures. Formal backup requirements were removed and calls to local charge nurse delayed for a year.
Further changes include: the CPM process for licensure, the expansion of agencies through which continuing educations credits can be obtained; the inclusion of complete breech and VBAC with the exception of “failure to progress as a result of cephalopelvic insufficiency;” allowance for one hour for arrival of placenta; the clarification of SMI, addiction and substance; more appropriate explanation of abnormal fetal heart rates; verbal consultations with physicians or CNMs; moving several disease processes from transfer of care to consultation.
Most importantly, the make up and function of the advisory council is what I believe will provide lasting changes. An advisory committee, which I believe is as close to a true midwifery board we can achieve in Arizona at this time, made up of a majority of midwives and home birth consumers will give the midwives and home birth families a voice, and I assume will provide an opportunity for ongoing, progressive rules revisions through GRRC. This will largely address my concern about the rules being based on evidenced-based practice as I see with enough research presented that DHS is willing to revise the scope to reflect that research.
Among all of these improvements, there are a couple of concerns which remain among the midwives and consumers, as I know you are aware. The first deals with moving a positive GBS or refusal of RH blood work or treatment to transfer of care. The second is the client’s right to refusal of testing in general. Although I understand the department’s position of trying to determine levels of risk, an individual’s right to refuse testing or treatment and maintain their choice in care providers is vastly important. To coerce clients into testing violates their rights and is not true informed consent. These few remaining concerns are really easy to address by simply placing these conditions in consultation rather than transfer of care. Midwives voluntarily consult with other health care providers, when needed, on a regular basis. If adding these few things to consultation will reassure DHS that the client is making a truly informed consent, then I believe most of the community of midwives are consumers will openly support moving forward with the rules revision. Please consider them as viable options.
Personally, I support the rules revision and strongly encourage DHS not to “scrap” the whole thing and return to the previous rules. I have spoken to many midwives and consumers who feel the same. We understand the long-term benefits and that small steps towards improvement are better than no steps at all. I welcome communication from anyone within your department and am happy to offer my assistance if it will be of use as the rules revision is finalized. Thank you for your time and work towards creating change.
Sarah Butterfly, LM, CPM
[email protected]
623-206-8531
Thanks for the comment. It’s helpful when those that have been involved throughout the entire process point out the positive changes that we have made… Most of them based on comments from our midwives and their consumers.
We’re going to look at the possibility of moving the testing requirement to a consultation, if the client refuses the testing. I can’t guarantee we’ll make any changes… But, we’ll consider it.
Thank you, Director Humble, for considering other options. I think that is a possible compromise that both sides could live with.
Dir. Humble,
You said on your blog “However, my team is exploring other options that might be available for preventing GBS transmission to babies.”
I would like to encourage you to look into all the research out there about using Chlorhexidine or “Hibiclens” as a highly effective alternative to antibiotics.
Here are some quality references to pursue if you wish to learn more about this subject:
Helen references the 1992 Am. Journal of Obstetrics and Gynecology, 162(1):1171.
Vaginal disinfection with chlorhexidine during childbirth. Stray-Pedersen B, Bergan T, Hafstad A, Normann E, Grogaard J, Vangdal M. Int J Antimicrob Agents 1999 Aug;12(3):245-51
Lancet: Burman LG et al. Prevention of excess neonatal morbidity associated with group B streptococci by vaginal chlorhexidine disinfection during labour. Lancet 1992; 340: 65- 69.
Chlorhexidine versus sterile water vaginal wash during labor to prevent peripartum infection. Sweeten KM, Eriksen NL, Blanco JD. Am J Obstet Gynecol 1997 Feb;176(2):426-30
GBS/Vaginal Wash Alternative-long J Matern Fetal Med 2002 Feb;11(2):84-8 Chlorhexidine vaginal flushings versus systemic ampicillin in the prevention of vertical transmission of neonatal group B streptococcus, at term.
Here are some links of articles that include excerps of these studies:
http://www.blackhillsportal.com/dbs/womankind/files/File/GBS_information.pdf
http://www.ncbi.nlm.nih.gov/pubmed/10461843?dopt=AbstractJ
http://rixarixa.blogspot.com/2008/01/group-b-strep-information.html
This last was a blog but it included well documented information about other studies.
I request that you consider requiring midwives to treat those who wish to decline GBS testing or those who test positive for GBS with Chlorhexidine or “Hibiclens” as outlined in the above studies. Either with or without Physician consultation.
As a mother, who is a natural carrier of GBS, I have carefully researched this topic and have used Chlorhexidine or “Hibiclens” in both of my births as an alternative treatment to antibiotics, because of the associated risks with antibiotics.
Respectfully,
Danielle
Thank you for providing the articles and links. I’ll forward this on to my team to research.
Director Humble,
First, I want to thank you for taking the time to respond to comments here, as well as your willingness to work with everyone on a good policy for Arizona midwives. I’m truly grateful for this, and I know with certainty that many other midwife and home birth proponents are too.
I had a c-section 20 years ago because my labor was not progressing fast enough for my OB. My OB needed to get to a funeral of a fellow doctor and did not have time to wait for me to progress. Instead, he told me that my baby was in danger of dying and gave me a c section.
When I was pregnant with my next baby 9 years ago, I was crushed when I realized that it was going to be very difficult for me to have a VBAC with the baby. Our local hospital had a ban on VBACs and I would need to have the baby at an out of state hospital that was 2 1/2 hours away.
We had a successful VBAC! 🙂 Labor was stalled at 7 cm when the anesthetist put in an epidural, but then continued. There were quite a few interventions that made labor longer and more difficult.
My next VBAC was with my daughter. We had to do another out of town VBAC because our local hospital didn’t do them. After an anxious trip on the Pacific Coast Highway, we got to our hospital in Santa Cruz.
We got checked in, our doula arrived and my daughter came in less than 2 hours. This time, there were hardly any interventions. The lack of an epidural and the lack of hospital staff coming in and out of the room enabled me to walk around and have some peace as I labored with my daughter. This was my best birth.
My overall purpose in sharing this story is that my first VBAC at a hospital with a lot of interventions was harder, more stressful and more prone to resulting in a repeat c-section, while my second VBAC had hardly any interventions and went very well. There was, in fact, really no time for interventions, because the baby came so darn fast.
My husband and I are getting ready to try to have another baby in the next few months. We had hoped we could have a home birth for this one, so that we could avoid many of the hospital interventions we’ve experienced before. We were hoping to have less stress and more comfort by having a baby at home, with a competent midwife who would transfer us to the hospital if something went awry. However, it looks like we may have to have a hospital VBAC.
Because of my past experience with successful VBACs, I’m an awesome candidate for having a home birth. I hope others may have the chance of having a homebirth after cesarean (HBAC) here in Arizona in the near future.
Many people have already commented on and left links about what would be ideal with midwifery practice. I believe much of that is relevant and hope that the policies that result from this will be evidence-based and not based on opinions from people who are not proponents of homebirth and midwives who practice homebirths.
Thank you again.
I’ve been thinking about my initial comment here. It’s sad that midwives are so restricted and that it makes such an impact on women’s birth choices. MY birth choices. I would choose to have a HBAC with a midwife, but the state of AZ currently says “no”.
And if the state decides to say “yes” to HBACs (VBAC at home), then the choices I make that revolve around that would still be influenced by the State, especially with pregnancy testing and standard of care.
Ultimately, I don’t know if I would have to do the testing the State wants me to do to be able to HBAC at home with a midwife or if I would be able to go through some consult with a doctor, who will tell the same things I am already informed about…sigh…
I knew more about safe birthing practices than the attending OB at my last VBAC.
All of the forthcoming policy gets murky and infringes on my rights to make decisions about MY body and how I will birth MY baby. It’s a shame that politicians, medical people, and so many others think they should limit MY choices. And it’s all in the name of “increased safety for the mothers and babies”, which:
An increase of State restrictions will surely lead to MORE mothers doing unassisted homebirths and HBACs. It’s certainly an option for me, because I don’t like giving birth in hospitals. Despite the low amount of interventions at my best VBAC, there were still interventions that would have been avoided had I done an HBAC.
This is something you and your team will need to consider as you draw up policies for midwives.
There are women out there who don’t believe the State should limit their birthing choices choices and they WILL birth at home, regardless of whether or not they have a midwife.
I understand that you’re not telling us mothers HOW they need to birth their babies, but by putting together policy like this that restricts midwives, you are limiting our choices.
While I really appreciate that you are reading and answering comments and trying to come up with the best policies for midwives, consider the mothers (like me), who want a lot less interference and see this as limiting our choices. How you affect the midwives, affects us.
Thanks.
May 26, 2013
To: Director Will Humble
From: Rodrigo and Diane Palacios
Dear Director Humble,
We are writing to you to please consider the proposed rules regarding homebirth. As a teacher and a counselor, we take our professions very seriously, as we are dealing daily with the lives of others and know that our actions or interactions with others can be life changing in a positive or a negative way. We also know that the profession of midwifery is life changing. As a former homebirth couple with our licensed midwife and birth team, we are planning our second homebirth for August 2013. During our prenatal, birth, and post-partum experience, we received excellent care, as well as referrals for child birth classes, lactation support, literature, education, etc. Because of these supports and resources that we were provided by our midwife, we felt prepared for our birth experience.
We have made intentional choices to birth at home for all of our children. We have thoroughly researched our birthing options, and have chosen to pay out of pocket in order to have the pre-natal, birthing, and post-natal experience that the practice of midwifery has offered us. We have received excellent pre-natal, birthing, and post natal care and education. We feel very confident that our midwife and birth team are consummate professionals with our best interest at heart. We are deeply concerned that the New Licensing of Midwifery that is being proposed will not only affect us, the practice and professionalism of midwifery and many other couples who are also planning on home births. Our concerns are as follows:
Midwives have been trained, gone through licensing processes in order to practice good birth and care. They are held to national licensing standards and guidelines that they uphold, just as any licensed professional does. Midwives engage in ongoing education and clinical experience that allow them to continue to develop their profession. It is our concern that some of these new rules will hinder midwives ability to make adequate professional decisions in the moment.
For example, limiting access to certain medications that can be life saving in case of an emergency, such as hemorrhaging can be detrimental. Another concern is the proposed rule that would require a midwife to stop providing care during an emergency to call 911. As professionals, midwives know when it is appropriate and necessary to contact emergency services. Another rule that does not seem clinically appropriate is that a midwife would be required to contact the local hospital prior and post birth. In case of an emergency, the nearest hospital may not be clinically appropriate, due to not having a specialty in addressing the medical need. For example, if there is an issue with the baby, a Children’s Hospital would be more clinically appropriate, and depending on the issue with the mother, the midwife has the professional ability to determine which hospital can provide the continuum of care. Midwives have relationships with hospitals and providers to help to ensure a smooth transfer if need be. If a midwife does not have a relationship with a hospital or providers at a hospital, the care of either the mother or the baby can be jeopardized.
As we have mentioned before, we have experienced home birth once before and are looking forward to experiencing home birth again in August. In our experience, our midwife and birth team provided us with excellent care. She was and is available to us whenever we have a question or concern, and has been able to address our concerns in a timely and caring manner. In the birth of our son, our birth team had the freedom to make decisions based upon their expertise and without so many of the proposed restrictions. Had those restrictions been in place for our son’s birth, we may not have had the freedom to continue with our home birth, which would have been more dangerous to transfer during the middle of labor. The hard labor only lasted for seven hours, where five of those hours were spent pushing. With the new rule being proposed, I would have had to transfer in the middle of pushing, which is not only not best practices, but could have been very dangerous at the cost of our lives. Also, during pushing, unassisted our son’s head was able to exit, but due to his wide shoulders, our midwife and birth team made the wise decision to stand me up so that his shoulders could pass and the moment that I stood up, the rest of his body was successfully birthed. If midwives are unable to make these kids of in the moment, professional decisions, the risks of both a mother’s life and a baby’s life can be in danger. By limiting midwives decision processes, the state is limiting their ability to do their work professionally.
Our hope is that you are able to hear our concerns and take them into consideration, and allow midwives to practice as they have been trained and continue to be trained through medical and clinical education. Also, our hope is that the profession of midwifery can be respected as other professionals are respected, such as nurses and Doctors.
Thank you for your time,
Rodrigo Palacios
Diane Palacios, MA, MS, LAC, MS, LASAC
Thanks for the feedback. Please take a close look at the current regulations alongside the new draft rules for public comment. There are many positive changes since the last draft that may have already addressed some of your concerns:
~Midwives have more in-scope manuvers for both the baby and the placenta (for example, during shoulder dystocia).
~We’re requiring new midwife applicants to be NARM certified.
~We’ve allowed for more options for midwives to choose from in order to obtain continuing education.
~We added back in rules regarding medication. In fact, the medication scope would be just exactly as it is today. This final draft doesn’t change the language surrounding the administration of medications from what exists in the current reg’s.
~VBAC would be in scope under many circumstances- it is out of scope now
~Complete breech would be in scope
~We have changed the language around the 911 call, allowing the midwife to continue caring for her client while another member of the team calls 911.
~The current draft does still require the call to the labor and delivery unit. This is an important step to improving communication between our licensed midwives and other healthcare professionals. Not only will the hospital be better prepared if a transfer needs to come in, but they will get a better idea of how many home births in the community are successful.
I encourage you to take a look at the current rules and compare them to this final draft. You can view the final proposed rules for public comment at this website:
http://azdhs.gov/diro/admin_rules/documents/midwifery/licensing-of-midwifery-draft-rules-may24-2013.pdf
Dir. Humble,
I hope in the last meeting that consumers, the women who will ultimately be on the receiving end of midwifery care under the new regulations, will be afforded an opportunity for longer public comment, firstly.
Additionally, I suggest that you meet with the midwives before the last meeting with the additional committee members in attendance, in which case no one would be left out.
If that is possible, I am 100% certain many things could be clarified, explained, and many of the sticking points for both parties could be quickly and amicably resolved.
No one wants to waste their time and energy. And of course people want to be civil and productive. That is a given. But with fear mounting among consumers and the stakes so high for the midwives, people are highly emotional and charged. I think this could diffuse the situation and could be a win for all parties.
Thank you for your consideration.
Respectfully,
Lesley McKinley
Thanks. I’ll take this under consideration.
The Midwife Scope of Practice Advisory Committee includes representatives from CPMs, Nurse Midwives, Consumers and Physicians. The statute was set up that way to ensure that the advisory committee has representatives of various Stakeholders- and many of these groups don’t agree with each other on key points.
The Advisory Committee is what’s called a Public Body under the State’s Open Meeting Law. There are lots of requirements of public bodies… and one is that the Body needs to meet in public, not behind closed doors. From the very start of this process I have tried really hard to stay true to the open meeting requirements. That’s why I haven’t been meeting with individual groups outside of the Advisory Committee.
If I were to meet privately, I would potentially violate the Open Meeting Law and I would give the impression that the decisions are being made outside of that process. In addition, I would give the impression that one stakeholder group has preferential treatment.
I hope you understand where I’m coming from.
Dear Director Humble,
Thank you again for your efforts in this matter, it is truly appreciated. Throughout the entire process you have displayed a genuine concern to accommodate the concerns of the consumers and to protect the practice of midwifery. I recognize that as a whole the proposed changes would result in a better system, with the exception of the disregard for the right to self-determination. The principle of self-determination is of utmost concern and the determining factor in either embracing the new rules or remaining with the existing ones. Please considering the following as a solution to the issue of testing since it would be a suitable middle ground to harmonize the suggested standard of care endorsed by the medical community and the already existing Patient’s Bill of Rights.
California has a great self-determination clause which has been re-worded by a fellow midwife in the following way;
“In order to maintain patient autonomy, the state of Arizona recognizes that the patient may exercise their right to informed refusal for any of the above recommendations and guidelines – and, through written refusal, continue care with the midwife absolving her, and the state of Arizona, of legal responsibility/risk for the direct outcome as a result of that refusal. The pregnant patient has the legal right to self determination.”
In addition, I would like to address the newly added GBS positive provision requiring GBS positive clients to transfer care at 36 weeks. My concerns are the following:
1. According to the CDC http://www.cdc.gov/groupbstrep/about/fast-facts.html and other studies- 25-40% of women harbor GBS which would rule out these women right before they are due to have their baby; which leaves them the options of either relinquishing their planned home birth or venturing into an unassisted birth. There can be great difficulty finding another care provider so late in the pregnancy.
2. GBS is inconsistent in its growth, it progresses and recedes sometimes from one week to the next, hence a client could test positive one week and negative the next, and therefore rendering this test unreliable is assessing the total risk. In addition, the homebirth environment minimizes the exposure to bacteria and infections which are much more prevalent in the hospital setting.
3. There are alternative treatments other than the current medical standard. Studies on the use of chlorhexodine vaginal washes has shown great success in preventing newborn transmission and infection here: http://www.ncbi.nlm.nih.gov/pubmed/10461843?dopt=Abstract and http://www.sciencedirect.com/science/article/pii/014067369290393H and http://www.ncbi.nlm.nih.gov/pubmed/12375548.
4. Following the clause stated above in reference to self-determination, a suitable proposal for GBS is an informed refusal such as this: http://www.betterbirth.com/pdf/BetaStrep
5. Moving GBS positive testing to consultation is acceptable, yet this falls under the same topic of testing and the right to informed refusal.
6. Other options, including the involvement CNM’s, have been suggested as well, please consider all these alternatives.
Thank you again for your concern and efforts in seeking to improve care that will affect so many families and midwives currently and in the future. I hope to see these matters resolved in a satisfactory way that upholds the innate freedom and right for informed consent/refusal and self-determination.
Thank you,
Cheyanne Gastelum, home birth mother and licensed midwife.
We’ll take a look at this. And, its certainly a help when people include evidence-based information…thanks.
Director Humble,
I get the impression from a number of these posts that there is a good deal of fear among homebirth consumers and also among midwives. I’m sure you’re familiar with the Bismark quote – “Laws are like sausages, it is better not to see them being made.” For many people in this community, this is probably their first time seeing the behind-the-scenes on lawmaking, and it’s difficult to understand the need to balance requests, demands and requirements.
That said, I think adding a new restriction at the last moment that can have a HUGE impact, namely the GBS transfer-of-care requirement, unnerves people and makes them more fearful of the process. I have seen others providing counter-arguments and evidence with regards to GBS itself, so I won’t try to repeat that; I’m more concerned with the fact that a test that would require transfer of care, and would impact 20-40% of clients, was added at almost the last possible moment, in the very last draft. There is no requirement in HB. 2247 that I am aware of that would prevent the department from adding additional restrictions and enacting them over the objection of those who fought for the bill in the first place, and that is a very scary thought.
I suspect the reason you are seeing so much public angst is primarily due to this fear. The devil you know, ie. the current rules which are far from perfect, is less scary than the unknown which could be changed at the last minute.
One of the reasons we have developed so many drafts is so we can use an iterative process and identify problems and solutions as we go. I don’t like adding things to the final rules that we will file that nobody has seen before. The current draft is the second to the last stop. Now that we know the consternation GBS is causing… we can do something about it before we file the final rules at the end of June.
Thanks. We’re looking into the data, CDC guidelines, and the information provided by stakeholders. I can’t guarantee that we will change, but I’ve got my team looking into it.
Director Humble,
When you talk about your “team”, can you clarify who that group of people are? This question was brought up in a Facebook forum with many wondering the same thing. Is the team you are referring to members of your staff? Is it a special committee of people? Are there OB’s or other people from outside the AZDHS included? We would appreciate the xlarification.
Also, I very much appreciate that you have been actively engaged in this comment thread. Especially given that it’s a holiday weekend. Thank you.
Hello Mr. Humble
In response to someone’s comments, you stated:
“We currently have a statutory mandate to set standards for and license professional midwives. Having said that… it is a legitimate matter of public policy as to whether professional midwives should be licensed at all.
Some states have no licensing standards and do not license professional midwives.
Repealing the AZ statute that madates us to license and regulate midwives would require a statutory repeal- which is possible.”
What does this process involve? Is this something that I could initiate? Or, would you or some other government agency be the only ones that could do this?
Director Humble,
I have a couple of comments so I am going to post them separately so I don’t make each one really long. First of all, thank you for working on this issue with everyone. We realize you are very busy with all of the different things that the Department has to work on around Arizona.
In previous comments, you have expressed concerns about transparency. A lot of the consternation over some, not all, of the proposed draft rules centers around the perception of transparency.
HB2247 specifically states that, “On or before July 1, 2013, the department of health services shall consider adopting rules regarding midwifery that concern the following:
1. Reducing the regulatory burden on midwives who are licensed pursuant to title 36, chapter 6, article 7, Arizona Revised Statutes, and streamlining the regulation process.
2. Consistent with the requirements of title 36, chapter 6, article 7, Arizona Revised Statutes, revising the midwifery scope of practice pursuant to subsections B, C and D of this section.”
In subsection B, it states, “Any party that is interested in increasing the scope of practice of midwifery must submit a report to the director of the department of health services that contains the following:” and goes into details about the contents of the required report and the timeline for it to be considered.
First, due to the fact that HB2247 only makes reference to items that are “reducing the regulatory burden” and “any party that is interested in increasing the scope of midwifery,” many people are concerned that several items in the draft rules do the opposite.
Second, some of the same items were submitted into the draft rules without the required report by an interested party.
It doesn’t appear that there is a deadline for submitting new reports. Therefore many of the proposed changes that are beneficial, but not addressed in the consumer or midwives report submitted at the beginning would be fair game for inclusion if they had been submitted in a new report by an interested party. From what I see, any party could be yourself or anyone else at ADHS and there is still time to write those up.
However, since a new formal report was not submitted, people feel that transparency is lacking because the statutory process was not followed. The GBS issue is only one of those items and therefore caused a lot of consternation because evidence-based research was not given as required by law in subsection B-2.
Therefore, I would suggest that current draft rules be adjusted to include only changes requested by the consumer and midwives unless a new report is submitted and processed by the committee before July 1st. We appreciate that the health of mothers and babies is paramount. However, there is room to address those items in the regular rules process. HB2247 was very specific that only increases in scope be discussed in the diamond lane.
Director Humble,
A second topic for discussion would be a request that some of the verbiage in HB2247 be included in the draft rules for addressing future rule changes.
I really like that for each rule change in the current scope process, a report must be submitted that addresses the following items:
1. A definition of the problem and why an increase in the scope of practice is necessary, including the extent to which consumers need, and will benefit from, practitioners with the increased scope of practice.
2. The available evidence-based research that demonstrates that the interested current practitioners are competent to perform the proposed scope of practice.
3. The extent to which an increase in the scope of practice may harm the public, including the extent to which an increased scope of practice will restrict entry into the practice of midwifery.
C. On receipt of the report prescribed in subsection B of this section, the director shall appoint a midwifery scope of practice advisory committee to assist the director in adopting and amending rules related to midwifery scope of practice…
May we add similar items and process to the new rules to supplement the proposed rules committee. The change would be that a report is always required for every change. Also, “increase in scope” would be removed from the wording since the regular rules process may deal with limitations.
The basic idea would be to require that all new rule changes be accompanied by a report that gives supporting evidence either pro or con. It would demonstrate that the proposed change has been properly considered as to its potential effects on the profession of midwifery in Arizona, increase transparency, and prevent ad hoc changes without committee and stakeholder discussions in the process.
Director Humble,
You have clearly dedicated a great deal of time and effort to listening and responding to the comments posted here. Thank you. There are many positive changes in the most recent drafts as a direct result of the give-and-take made possible by the public comment forum.
In the midst of many varying opinions and suggestions for ways the draft might be altered, we are all seeking what will ultimately result in superior midwifery care resulting in ongoing satisfaction on the part of the families we serve and the best possible outcomes for mothers and their babies. Those of us who care for women during their pregnancies and births together have a vast wealth of knowledge and experience. We would do well to see each other as colleagues and allies, finding ways to work collaboratively in the same direction. Some of the most recent changes recommended to the rules draft require an ongoing working relationship between homebirth midwives, nurse-midwives and physicians, something which has proven to be the norm in other states and nations, resulting in very positive outcomes and high rates of satisfaction for women and their families. Although we come from different perspectives, we can, in service to women who deserve the most humane and transformative births possible, seek ways to offer them evidence-based options together. I have seen this kind of cooperative care bring excellent results, satisfactory to all involved. As we move forward may it be with great wisdom and discernment, for much is at stake for our current citizens and the ones who will born in the generations to come.
Again, Director Humble, we appreciate your efforts to look at the big picture, the now and the future of birth in our state.
Mr. Humble
I had both my daughters at home without any incident. I was GBS- with my first but GBS+ with my second. My midwife sent me to a holistic doctor, who gave a choice between a shot or pills that I would take prior to labor and another set of pills to take in labor. My daughter was perfect and healthy. However, had I been in the hospital, I know that with my weak contractions, I would have been offered pitocin multiple times. Also, because I had so much amniotic fluid and meconium staining, they would have wanted to whisk my precious baby off to the NICU. Instead, I was able to labor at my body’s pace with the help of a breast pump to naturally increase contraction strength without putting too much stress on me or my baby. She was born and suctioned right away to clear any meconium and her cord was checked for complications found with excessive fluid. She was brought to my chest and breathed right away and was able to nurse within minutes of her birth, which led to a much easier beginning of our nursing relationship. She has never had any health issues and is a happy, healthy 2 year old. There was absolutely no need for us to be in the hospital and had we been, our experience would have been vastly different and would have made for a rough beginning to our relationship and I, honestly, believe that our relationship would not be quite what it is now otherwise. GBS+ is somewhat common, but it effecting the baby is rare. Not to mention that a woman can be – at the time of testing but + at the time of birth and vice versa. Most midwives stay and look after the mother and child long enough to see any signs that baby is having issues with GBS and would be able to get baby to the hospital in short order anyway. Being in the hospital likely won’t have any effect on lessening GBS issues, but it will make for more stress on the mom and baby, especially on a mom who wanted to have a home birth. Please, re-think making that a reason to transfer.
May 28, 2013 at 11:06 am
Director Humble,
You have clearly dedicated a great deal of time and effort to listening and responding to the comments posted here. Thank you. There are many positive changes in the most recent drafts as a direct result of the give-and-take made possible by the public comment forum.
In the midst of many varying opinions and suggestions for ways the draft might be altered, we are all seeking what will ultimately result in superior midwifery care resulting in ongoing satisfaction on the part of the families we serve and the best possible outcomes for mothers and their babies. Those of us who care for women during their pregnancies and births together have a vast wealth of knowledge and experience. We would do well to see each other as colleagues and allies, finding ways to work collaboratively in the same direction. Some of the most recent changes recommended to the rules draft require an ongoing working relationship between homebirth midwives, nurse-midwives and physicians, something which has proven to be the norm in other states and nations, resulting in very positive outcomes and high rates of satisfaction for women and their families. Although we come from different perspectives, we can, in service to women who deserve the most humane and transformative births possible, seek ways to offer them evidence-based options together. I have seen this kind of cooperative care bring excellent results, satisfactory to all involved. As we move forward may it be with great wisdom and discernment, for much is at stake for our current citizens and the ones who will born in the generations to come.
Again, Director Humble, we appreciate your efforts to look at the big picture, the now and the future of birth in our state.
Director Humble,
Thank you for all the time you and your department have invested into this issue, and for remaining engaged. I find myself wondering if all this consternation over the scope of practice guidelines isn’t an indicator that the process has “come off the rails” a bit. It would seem to me as an interested observer that the rules are on the right track with regards to licensure. As the state has apparently recognized, there is no reason to duplicate efforts when there is an established national standard and certification process for midwives.
Given that, I am puzzled why the department seems to be taking the opposite approach with regards to scope of practice. As I’m sure you are aware, a key component of obtaining and maintaining certification through NARM is developing and maintaining practice guidelines in accordance with current accepted best practices and standards of care. As I believe you’ve discovered through this process, trying to “legislate” one size fits all guidelines that will cover every midwife and every patient is difficult at best, and potentially detrimental to public health at worst. Given that the state is going to recognize the validity of this national certification, why then wouldn’t the rules simply instruct midwives to practice in accordance with those guidelines? In doing so, you could achieve what the “one size fits all” rules never could. Rules that are uniquely tailored to the individual skills, experience, and education of every licensed midwife, address the unique needs of every qualifying mother to be, and that evolve naturally over time as best practices and evidence evolves.
Don’t get me wrong, it makes sense for the state to draw the boundaries and define what conditions, based on evidence, elevate risk beyond what is acceptable to the greater public health. But in doing so, I believe you need to employ the same standards hopefully used in all situations where individual rights must be compromised for the public good. That restriction should be made as narrow as possible, and implemented by the least restrictive means possible. One doesn’t have to look very hard to find this principle at work widely in the laws of this state. As an example, if GBS can be just as effectively treated by IV antibiotics in a co-care arrangement with birth still being attended by the midwife in the home, then the rules should be open enough to allow for that. If midwives have training in administering IV antibiotics, we should be finding ways to provide them with the authorization to do so.
If we can find our way back to rules that revolve around the sanctity and co-operative nature of the midwife/mother relationship, brings an outside expert/doctor in to assist in that care when necessary, and reserves direct intervention by the state for cases where there is a clearly demonstrated danger then it would seem to me that we could truly have a document which not only makes everyone happy but could be a national model for how consumers, midwives, doctors, and states can work together toward the best possible quality of maternity care.
Rob Smith,
Phoenix, AZ
Director Humble,
Thank you for being so willing to listen to feedback. I truly appreciate all the work you and your staff have done so far. I have concerns with many parts of the new proposed laws, but I’ll focus my comment here on the required transfer of care of GBS positive patients. I tested positive for GBS around 36 weeks pregnant with my first child, born on January 21st of this year. My husband and I transferred from an OB to a home birth midwife after our OB flat-out told us he didn’t have time for our questions. The care we received from our CPM was amazing, and I couldn’t imagine being “risked out” of her care so close to the end of my pregnancy due to GBS status. My husband and I are both college educated professionals that research EVERYTHING, so we were not worried when I tested positive for GBS. My very skilled midwife provided as little intervention as possible during birth, which allowed me to have a wonderful and successful home birth to my son. Her low-intervention approach allowed my son to be born in the caul, which helped further limit his risk. My healthy and growing son is now 4 months old and was not affected in any way by my GBS status. Based on my research that others have linked to above, babies have a less than 1% chance of being affected by the mother’s GBS status. Based on these very low statistics, please consider dropping this provision, or at least, just require consultation with a doctor.
Thanks again, I sincerely appreciate all the work you’ve done so far.
Susan Leduc
I had two birth center births administered by licensed Midwives with excellent outcomes and healthy babies. During the first, I need a dose of pitocin and I had GBS for the second birth and the Midwives did an excellent job caring for me and my daughters. Why do the rules need to change? For low risk births, a midwife is safer than a hospital, imho. There is no need to change rules for out of hospital births, however I would look into the practice of giving birth in a hospital. This is ridiculously unnecessary and a waste of the State’s precious funding when there are other issues that need to be addressed by AZDHS, such as poor families and their healthcare. Start there and come back to out of hospital birthing when its a problem. Your process is broken and you are hobbling midwives to do this most precious work.
Director Humble:
You keep referencing your statutory mandate which requires you to make things as safe as possible for mother and baby. I believe with all my heart that this is your desire and your committment. But the difficulty comes in when we have to start talking about who gets to define “safe”. I would be willing to bet that what I believe is safe and what you believe is safe would be two very different things. More often than not people in the medical field tend to rely heavily on tests and drugs and other medical crutches in order to bring about the elusive quality of what you consider “safety”. However, there are mountains and mountains of scientific evidence, largely ignored by the medical community at large, which paint a somewhat different picture. And when you add in the factors of clinical care within in a hospital setting, which often rely heavily on technology rather than science because of a fear based idea of birth, you have a recipe for medical, surgical, or otherwise managed birth which is, I believe, NOT safe at all. Please tell me, when I am giving birth, whose right is it to define safety, Director Humble. Yours?
Director Humble,
I am the mother of four healthy children. I have experienced birth in three different settings. My first was born with the help of an MD in a hospital. My second was born with the help of a CNM in a birth center. My third and fourth births were with the help of a Licensed Midwife in my home. I am concerned that a few of the recent draft changes are decreasing rather then increasing the scope of practice for midwives in Arizona. I have closely read the old rules and the current draft.
My greatest concern is the need for true informed consent with the legal right to decline tests, refuse treatments or the transfer of care. ACOG gave this statement about informed refusal:
“Once a patient has been informed of the material risks, benefits and alternatives, as well as the option to refuse, the patient has the right to exercise complete autonomy in deciding whether to undergo the recommended medical treatment, surgical procedure, or diagnostic test; to choose among a variety of treatments, procedures or tests; or to refuse to undergo these treatments, procedures or tests.”
American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 306. Informed Refusal. Obstet Gynecol. Dec 2004; 104 (6): 1465-1466, p 1466
http://www.ncbi.nlm.nih.gov/pubmed/15572515
The emergency action plan requirement to notify the hospital when labor begins and ends is also concerning to me. I would not hesitate to transfer if my midwife had any concerns about my labor or in an emergency. I do not feel that this respects patient privacy In a normal labor or birth. As I have reviewed the Summary of the HIPAA Privacy Rule, it would seem to be a violation of protected health information. It requires that both covered entities (such as my midwife and a hospital) “have or had a relationship with the individual and that the protected health information pertains to the relationship.” I would prefer that my individually identifiable health information, which would include my past, present or future physical health or condition, name, address, birth date, social security number, not be disclosed without a true medical reason. I do not think required notification in a normal labor should be required. The Summary of the HIPAA Privacy Rule also states that “a central aspect of the Privacy Rule is the principle of “minimum necessary” use and disclosure.”
I also hope that the requirement to transfer care for a positive Group B strep culture can be removed. I have received excellent prenatal care, labor support and postpartum care from my midwife. Thank you for your efforts to update the midwifery scope of practice.
Christie Gibbons
Director Humble,
I fully support a woman’s rights and I see this as a huge women’s rights issue. The proposed changes effect women who are and have always been capable of making decisions in regards to their own medical treatment as well as the midwives who have been providing excellent care for generations. I take issue with several parts of the proposed changes:
It is an infringement on my patient rights to be forced into testing. You cannot have informed consent without the option of informed refusal. I may choose to do all of the testing or I may choose a different less invasive option, the point is, it is my right to make an informed decision. If you take away informed refusal, you have forced testing and an infringement on my rights. Also these tests are not “only way for the midwife to establish that the birth will be low risk and safe for the health of the newborn and mom”.
Very specific practice guidelines should not be in rules and regulations. The board (established in the rules) should be able to provide practice guidelines based on evidence-based care, which will allow practice guidelines to stay up-to-date.
Midwives should be allowed to carry lifesaving medications. I find it ridiculous to even entertain the notion of removing this ability. I am a fan of logic, evidence-based care and thoughtful practices. It seems that this was a misstep that was not thought through. If your goal is improved or safer care, removing lifesaving options and putting a midwife in the position to call first and treat second is not going to help you achieve that goal.
There is a lot of passion for birthing options to remain exactly that: OPTIONS.
Please take all of these comments and suggestions with your best logic and give women in Arizona the options they want and deserve.
I am a current client of a midwife with my third baby. I have been with my midwife through my first two pregnancies as well. I am wondering why I have to pay for testing of my blood type when I already know what it is? Or why I have to pay for testing of rubella, HIV and Hepatitis when I already know the results?. I shouldn’t be forced to have these tests done when I know the results for a fact. It seems absolutely unnecessary and a waste of money. And if you are thinking that my husband is unfaithful to me, you are most certainly wrong. If I had any doubt, I would have him tested.
Director Humble,
Thanks for putting the time and effort into this situation. I was curious if you could give us some clarification on how things will play out the next few days. From my understanding if you do not publish a new draft by the end of the week, the decision will be left between the current rules and the current draft. If a new draft is published then the decision would be between the new draft and the old set of rules. Is that correct? After the June 3rd meeting the drafts will no longer be able to be changed and things will go into law July 1st? If anymore changes are made after that they will have to follow the regular set of rules to get the rules changed? Is that correct?! Thanks for any clarification you can offer!
Thanks again for taking time for this very important situation that matters so much to families. I’m VERY concerned about men and women not being able to make informed decisions for their babies. I’m amazed that Arizona would try to take away families’ true rights to safe informed written refusal for testing or particular treatments while still allowing continued care by a willing health care provider of their choice. I would understand the health care provider being allowed to make a choice if they wanted to continue care or not as more caution and care is needed in certain situations. I am not an advocate though of women being forced by the state to submit to certain testings or procedures that hasn’t been proven to be the safest or only option to treat things. This is very concerning to me and I truly hope you guys can find a way to look at the evidence that has been provided and realize that safer options, as well as the current health privacy rules for patients, are available and that all GBS+ women or women who refuse testing shouldn’t immediately be sent to the hospital or be required further hoops to jump through via consultation or the like. Thanks so much for considering our thoughts, this is a very important matter as midwifery offers such a personalized safe birth plan for many women in Arizona!! Thanks again!
Hello Mr. Humble
In response to someone’s comments, you stated:
“We currently have a statutory mandate to set standards for and license professional midwives. Having said that… it is a legitimate matter of public policy as to whether professional midwives should be licensed at all.
Some states have no licensing standards and do not license professional midwives.
Repealing the AZ statute that madates us to license and regulate midwives would require a statutory repeal- which is possible.”
What does this process involve? Is this something that I could initiate? Or, would you or some other government agency be the only ones that could do this?
Hello again,
I know there have been a lot of comments here and I wanted to make sure that this question wasn’t missed.
Thank you!
Pursuant to HB2247, Laws 2012, § 1(E), the Director is required to published reports within 30 days of each scope of practice public meeting containing the recommendations submitted to you from the Midwifery Scope of Practice Advisory Committee. I can find no such reports available for review on the website. Will you please direct me to where they are so that interested parties can prepare their public comments for the final meeting accordingly? All I can find are the actual reports that are to be reviewed by the committee, the agenda, minutes and public comments of these meetings.
Also, it is confusing as to how the final draft is to be prepared. What is the Department’s take on the timeline of when and how the final draft is to be prepared and submitted?
Director Humble,
After reviewing the bill which has prompted this entire conversation, I am concerned about a number of developments in the draft.
The bill clearly states that it is intended to decrease the regulatory burden for midwives, as well as to cause the consideration of an increase in scope of practice for midwives. The mandatory consults, hospital notifications, and other items that have been added to the draft constitute an added regulatory burden. The increase in transfer of care that these other items will cause will result in a decrease in scope of practice.
My next concern is how these additional items entered into the draft. The bill clearly requires that any proposed changes in scope must be submitted in a report that includes data which shows that the proposed change will benefit midwives and mothers. These additional items, such as the GBS restrictions, were added to the draft without the submission of a report and without any data to show that they will benefit midwives and mothers. Including changes without the changes being requested through a report that includes evidenced-based research is literally against the law (this particular law – HB2247).
Director Humble, I humbly request that you adhere to both the letter and the spirit of HB2247. The letter regarding the reports and research that must be submitted for any changes, and the spirit regarding the stated intent to decrease regulatory burden and increase scope of practice. Any changes that are not implemented in accordance with the law will not stand up in court.
In reviewing the public comments and your responses, I see that you have considered scrapping the entire draft and just using the old rules. Considering that the legislature passed the bill requiring you to go through this process with the intent of increasing the choices available to Arizona families, it would be a shame for you to come up empty-handed. That, and it would be a missed opportunity for the families of the state of Arizona.
(Direct contact info at bottom)
Dear Mr. Humble et al.,
ImprovingBirth.org is a national nonprofit that advocates for evidence-based care and humanity in childbirth. We became aware of your efforts to update Arizona’s midwifery guidelines after some of our supporters brought it to our attention.
First, we want to thank you for reconsidering the guidelines to expand the scope of midwifery care to include women who may benefit the most from individualized, supportive care: women who, otherwise, might be given no other options than Cesarean section. This is invaluable for these women who wish to avoid the increased risks that come with major abdominal surgery.
Second, we want to encourage you to push through. The guidelines you inherited do need some more work if they are to reflect a current understanding of the scientific evidence around best birth practices and of women’s legal rights in birth (for example, vaginal exams in and of themselves do not yield better health outcomes, but do increase the risk of infection, and we feel strongly that no woman under any circumstances should have to undergo an unwanted exam involving her sexual organs). But putting in that work means safer, healthier, happier, and more positive experiences for mothers and babies on the most important day of their lives. You have a unique opportunity to make a lasting impact on the forward movement of quality healthcare in Arizona. Your leadership on this effort is sorely needed and much appreciated.
We work with obstetricians, midwives, lawyers, and researchers, and would be happy to submit an opinion to you on how the guidelines might specifically be updated to reflect current practices and rights. We have made a preliminary review of the guidelines and believe that some fairly simple edits would go a long way towards bringing them current.
Thank you for undertaking such a meaningful task. As maternity care across the country changes, your efforts will set an example for other states as they look to improve their own practices to benefit families.
Please don’t hesitate to contact us if we may be of help in any way.
Gratefully,
Dawn Thompson, President
Cristen Pascucci, Vice President
Rebecca Dekker, Secretary
Dallas Bossola, Member
Amanda Hardy Hillman, Member
ImprovingBirth.org
Direct Contact: http://www.improvingbirth.org/contact-us/
Hi…
I just moderated several comments. I don’t have time today to answer each of the questions individually, but there was a common theme to many comments that I’ll try to address here.
I’ve heard loud and clear that consumers are concerned about the current and proposed future testing requirement. I’m willing to move the testing requirement from a requirement to the physician or certified nurse midwife consultation part of the rule (consultation between the CPM and physician or CNM). If the mom still doesn’t want testing and the CPM is still comfortable providing services after consulting with a physician or a certified nurse midwife then services can proceed as long as there is documented informed consent. This would include Group B Strep (GBS).
Regarding the regulatory burden on CPMs. The package as a whole must decrease regulatory burden on our Licensees. Our current application process is very cumbersome and complicated as are our currently required paper quarterly reports. The new proposed rules make these processes much easier and simple. Plus- we’re proposing to go with NARM certification. While there are some new requirements (emergency plan, phone call to the hospital before and after labor) the overall package is less burdensome- because the current application and reporting system is way too complicated.
When I refer to my Team, I’m refering to my staff in Licensing as well as my team in Maternal and Child Health in Public Health Prevention.
The web link to our materials are posted at: http://www.azdhs.gov/als/midwife/advisory-committee/
The draft final rules for public comment were published on Friday, May 24… giving us more than 30 days to file the final rules before the expiration of our Exempt Rulemaking Authority on June 30.
will
So we will not see the final rules before you file them? Am I understanding that correctly? This is so unacceptable. I would like to say I am shocked, but I’m afraid I have some what come to expect this sort of thing. What you are proposing still does not follow the law and I am amazed that this is getting pushed through. This is unacceptable.
Director Humble,
Is that to say that future revisions will not be posted for public comment? That they will be put into place sight unseen? Please clarify.
Thank you.
Will any other drafts be published? I know many of us would like to see the wording of the changes you are talking about with regards to testing.
ANY single thing that is included in the new rules that was not requested by either the midwives’ report or the consumers’ report is ILLEGAL. Those are the boundaries of HB2247. It states clearly that they/you may consider the things put into the reports submitted. It does not give power to add in whatever they/you feel like addressing.
Examples of what I am talking about. The bill clearly requires that any proposed changes in scope must be submitted in a report that includes data which shows that the proposed change will benefit midwives and mothers. Items such as the GBS restrictions, were added to the draft without the submission of a report and without any data to show that they will benefit midwives and mothers. Including changes without the changes being requested through a report that includes evidenced-based research is literally against the law (this particular law – HB2247).
You MUST comply with all laws Director Humble. Please consider that some laws are not more meaningful than others. If a report was not submitted with supporting data than many things that are being proposed can not be added in.
Thank you for your time, honesty and hard work on this.
Just because something that was TOTALLY illegal was almost slipped in (transfer of care if GBS+, phone call to the hospitals before and after birth, etc etc) does NOT make it acceptable for a seemingly LESS terrible (required consult) thing to get passed by and put through into the rules. Like Wendy, Micah, Robert Haasch, and others have stated, you are required by this law to consider decreasing the regulatory burden and consider increasing the scope of practice. Also, according to the law reports with data MUST be submitted for any changes. We are not taking this illegal action lightly and are very unhappy about this. Thank you so much for looking into these issues. If you think these changes are in women and children’s best interest the changes should be made the legal way through the regular rule making process, not thrown in with all the hard work everyone has done for this particular law. Thank you!
Director,
I appreciate your response above and please forgive me for being so direct however, you have not sufficiently responded to valid inquiries and concerns as to the legality of introducing ANY changes in rule at this time that have not been proposed in a properly submitted report, (namely the Midwife and Consumer reports), specifically items that request a DECREASE in regulatory burden and an INCREASE in scope of practice.
Your statement above “…the overall package is less burdensome…” lends me to believe that your interpretation of HB 2247 is that as long as the NET effect is in “favor” of midwives and their clients, that it was a job well done, so to speak.
I strongly beg to differ with you! The text of HB 2247 states that the task at hand for the Department is to consider 1. REDUCING regulatory burden, 2. INCREASING scope of practice pursuant to subsections B, C and D of the bill, and 3. Adopting national licensure testing standards. I do not read anywhere in the bill that up for consideration are adding ADDITIONAL burdens or REDUCING scope of practice as long as the “average” result is sufficient by anyone’s definition.
PLEASE help me to understand because from my viewpoint the department is not following the letter or the intent of the law which GREATLY concerns me.
I recommend in your final draft to consider this matter very seriously, and follow the task your department was given: To consider the issues that were properly submitted for request in DECREASING regulatory burden, INCREASING the scope of practice and adopting a national licensure testing standard. If you simply can not agree to the requests being made, then decline them all and leave the rules language as it is (which would be a HUGE disservice to all invested). If you are able to agree with at least some, or all, of the requests, then I encourage you to approve those that have been properly submitted with evidence-based backing, and leave the rest of the issues off the table, to be discussed during a REGULAR rule-making process sometime in the future.
Thank you.
Trena
Dir. Humble,
If you only read one more piece of “evidence based research”, please, read this one.
We matter, Mr. Humble. We matter. How we birth matters. How our babies are born matters. How we are treated matters. 1 in 3 births by surgery in the US is unacceptable and a disgrace. It’s absolutely a sign of our extreme disregard for women and women’s rights. And it needs to end. You can help.
We are not, however, going to beg for our rights. We will take them. We may be a small group, but we are growing. We will continue to push for equal treatment under the law.
If it takes the rest of my life, I will dedicate everything I am to normalizing birth and restoring power and autonomy to women while they birth. And I am not alone.
Giving birth transformed all of us. We make humans from scratch. And we deserve better. We deserve better, Mr. Humble.
http://www.improvingbirth.org/2013/05/selfish-women/
Sincerely,
Lesley McKinley
May 31, 2013
Office of the Director
150 N. 18th Avenue
Phoenix, AZ 85007
Re: Public Comment on Proposed Guidelines, Title 9, Chapter 16, Article 1 Licensing of Midwifery
To whom it may concern:
We are writing to express concern regarding several elements of the proposed guidelines for licensed midwives in the state of Arizona. As written, several of the proposed guidelines violate bodily autonomy, privacy, equal protection, and due process.
The legal issues involved in childbirth combine constitutional, administrative, civil, criminal and antitrust law. Such a system is optimal when each of these areas is free of bias, applied evenly, and supports the logic of the overall system, including the supremacy of the constitution and the distinct role of each branch of government.
Ideally, the regulatory system will set forth the parameters of a certain profession without constraining the privacy or free market rights of potential consumers even when the risk to consumers is grave. The right to refuse unwanted medical treatment and the right to make decisions for ones children are constitutionally protected privacy rights.
Courts take this individual right so seriously that they have held that one person cannot be required to undergo medical treatment to save another person, and that pregnant women have ultimate right of decision-making over their care, even to such an extreme as when their death is at stake.
“For our law to compel the Defendant to submit to an intrusion of his body would change every concept and principle upon which our society is founded. To do so would defeat the sanctity of the individual and would impose a rule which would know no limits and one could not imagine where the line would be drawn.”
The proposed guidelines threaten this right at R9-16-109 in each instance where the client’s ability to choose midwifery services is automatically restricted. The focus of the regulations should be on the profession of midwifery, and not on the choices of the client or the nature of her body.(See R9-16-109(A)8, and (A)19.)
The issue before us, however, is not the theoretical right of a mother to put herself or her baby at risk—but the very real right of any mother to protect herself and her baby by making informed decisions about the maternity care that directly impacts them both. It can, should, and must be assumed that any mother has the best interest of herself and her baby in mind when she is making decisions about care, and that she has the ultimate right to do so. When the state steps in to override that assumption and make care choices on behalf, or in spite of, the mother, it is a deeply problematic proposal.
The problems intrinsic to such a stance are particularly troubling in reference to two specific medical treatments included within the proposed guidelines: a vaginal exam as part of standard care and an episiotomy in case of emergency. These are two procedures—both invasive, almost certainly painful, and with risks of complications—that any woman must be free to decline. To impose upon a woman’s sexual organs the preferences of the state in her maternity care is unacceptable, in any setting: home or hospital.
When the European Court of Human Rights ruled in 2010 that birthing women have a fundamental human right to choose the circumstances in which they give birth, it held that the State violates that human right if “health professionals” cannot support women’s decisions without fear of legal punishment.
In addition, the Supreme Court of the United States prohibits professionals from limiting participation of other professionals in the marketplace, even when they aim to prevent “unwise and even dangerous choices.” The proposed rules threaten this right to the marketplace in each instance where the consumer is left with only a medical option. (See R9-16-108(K)2, (K)4c, (L)1g, (L)2c, not to mention R9-16-110, and R9-16-111(A)3, and R9-16-111(B).) Medicine and midwifery are different professions with distinct standards in an overlapping field. Although collegiality and continuity of care are ideal, mandating consultation between competing professionals opens the door to illegal monopoly through collusion and boycotting in violation of the Sherman Act.
The proposed rules also conflate scope of practice (regulatory) law with informed consent (negligence). Informed consent is an ethical and common law duty for all care providers. While the right to make medical decisions is not absolute, constraining that right requires the protections afforded by due process. The state can only override an individual’s decision-making process through proper adjudication. The proposed rules risk overstepping the state’s role in informed decision making at R9-16-108(C)g.
In fact, the obstetrician’s trade union, American College of Obstetricians and Gynecologists, states:
Seeking informed consent expresses respect for the patient as a person; it particularly respects a patient’s moral right to bodily integrity, to self-determination regarding sexuality and reproductive capacities, and to support of the patient’s freedom to make decisions within caring relationships. Informed consent not only ensures the protection of the patient against unwanted medical treatment, but it also makes possible the patient’s active involvement in her medical planning and care.
Informed consent is a meaningful right only when the complementary right of informed refusal is respected. Women in Arizona retain the services of doctors and midwives for their expertise, knowledge, and advice—not to enforce certain methods by which their babies must be born.
Finally, it is worth noting that the only person capable of performing a vaginal delivery is the person who is giving birth, not the care provider. ( See R9-16-108(B), and R9-16-109(C) and (D).) This clarification has important implications for all care providers in negligence law, while supporting the autonomy and privacy and pregnant people. This is an important foundation of human rights in childbirth.
Everyone involved in childbirth benefits from a legal and regulatory system that protects bodily autonomy, privacy, equal protection, and due process. Many jurisdictions have successfully enumerated regulations of the profession of midwifery without threatening these fundamental rights.
We understand that the state has to balance the constitutional rights of Arizona residents, with the need to promote health and safety. We believe that it is not only possible, but optimal, to respect the human rights and best interests of Arizona’s mothers by ensuring that state guidelines do not conflict with the rights of the individual.
Please contact us at any time if we may be of assistance in the future. We share with you a desire to see the best possible outcome for the mothers and babies of Arizona.
Sincerely,
Hermine Hayes-Klein, J.D.
Director, Human Rights in Childbirth
[email protected]
Indra Lusero, J.D.
Director, HRIC Legal Defense Network
[email protected]
References:
Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990); Troxel v. Granville, 528 U.S. 1151 (2000).
In re A.C., 573 A.2d 1235 (1990); McFall v. Shimp, 10 Pa. D. & C.3d 90 (Pa. Com. Pl., July 26, 1978).
McFall v. Shimp, 10 Pa. D. & C.3d 90 (Pa. Com. Pl., July 26, 1978).
See R9-16-109(A)8, and (A)19.
FTC v. Indiana Fed’n of Dentists, 476 U.S. 447 (1986)
See R9-16-108(K)2, (K)4c, (L)1g, (L)2c, not to mention R9-16-110, and R9-16-111(A)3, and R9-16-111(B).
“Exceptions to the Sherman Act for potentially dangerous goods and services would be tantamount to a repeal of the statute. In our complex economy, the number of items that may cause serious harm is almost endless.” National Soc’y of Prof. Engineers v. United States, 435 U.S. 679 (1978)
ACOG Committee Opinion on Informed Consent available at: http://www.acog.org/Resources%20And%20Publications/Committee%20Opinions/Committee%20on%20Ethics/Informed%20Consent.aspx
See R9-16-108(B), and R9-16-109(C) and (D).
See for example Texas Midwifery Regulations.
Mr. Humble,
I am glad you are considering feedback in regards to GBS testing. This is something that I am personally very concerned about. I tested positive while pregnant with my son. My OB and I had a very calm conversation about the risks of GBS and he was open and comfortable with me NOT taking the antibiotic. He stated that the very small risk was to baby was acceptable. Unfortunately for me and my sweet boy my OB wasn’t present for this birth. He was born very quickly and in a different hospital then planned. I was there for 7 minutes from my car door to him in my arms. Then the nightmare began. No, he didn’t get sick. But I had to fight the hospital for EVERYTHING. They didn’t even want to allow him to sleep in my room with me. At one time I had three nurses in my room (and this was right after my birth) very upset about my decision to keep him with me. There were no calm conversations. Just them talking AT me with no desire to hear me. In the end he DID stay with me. But the nurses called my room EVERY SINGLE HOUR to check on his status. Then I had to fight to take him home! After enduring this for 24 hours I had to sign a AMA form just so I could go home and get some peace and some sleep! Again, he had ZERO signs of illness at all. He was reactive, breathing fine, no temperature issues, eating wonderfully and this was my third baby, so I was well aware of normal baby behavior. This was also my LAST time agreeing to the GBS test including for my homebirth.
GBS testing should not be required. So many women would be risked out of homebirth without good cause.
Lets remember that even if they were tested many of these women who tested positive, will be negative on the day of birth. (Likewise, you may test negative and be positive at birth!) Yet their entire birth plan will have been changed by a test that someone else decided they need.
Midwives are MORE than qualified to explain the risks of GBS to any mother. Mother’s have the right to make the decisions that impact their baby and their birth. Informed rejection really shouldn’t take the option of homebirth away from mothers.
Thank you for listening to us!
Director Humble,
Having attended several meetings I continue to be amazed at the onesidedness of proceedings. Though I can understand the desire for autonomy amongst midwives and their clients, the welfare of the fetus has been ignored. This is especially troubling in regard to the proposals to expand the Scope of Practice for high risk deliveries such as multiples, breech and VBACs. As the Director of the Department of Health Services your role is to advocate for the public safety. At a minimum, I would suggest restricting the Scope of Practice from including multiples, malpresentations and VBACs until we have several years of statewide data that support the safety of uncomplicated deliveries.
Respectfully,
Eric Reuss MD MPH
Just a quick editorial note:
There have been some comments uploaded to the blog this weekend that I haven’t posted because they were a little too personal.
Let’s try to keep the conversation about the issues rather than the people.
Thanks…
How convenient, thanks for the silencing of a comment discussing the evidence for safety of Arizona midwives via the reports they have been submitting for years that have never been neglected and pointing out this comment completely void of evidence. What is personal is allowing a comment from a so-called “professional” insisting that we don’t care about our BABIES and then moderating our reaction to that.
EDIT: *that have been neglected
I appreciate all the time you have given to this issue. Thank you for writing this blog post – it really helped me clarify what has been rumbling around in my head and I couldn’t quite pin down until now.
The ADHS is approaching birth as something that needs to be established as “low-risk” in order to proceed at home. Those of us who have had a homebirth, and the care providers who support us, have a belief that pregnancy and birth are low-risk from the outset.
The medical model wants birth to be proven safe, the midwifery model believes birth is safe until it is proven otherwise. We will continue to go around and around about what is best for mothers and babies until some sort of resolution is found between those two disconnected approaches to pregnancy and birth.
I propose that the ADHS to do a field study of home and birth center midwifery care. Find a way to shadow a midwife or several midwives. Attend some home births. See the prenatal and postpartum care that is provided.
After the ADHS has a clearer picture of what midwifery care really is, then it will be in a better position to expand the scope of practice and write the regulations that affect a woman’s right to self-determination as a consumer of healthcare.
I thoroughly understand all of the issues and the current direction the department plans to take with regards to testing. I understand that Director Humble has suggested that if a client refuses any testing a midwife must consult with a physician or CNM. I appreciate that the rules will be changed to a consultation rather than forcing a midwife to terminate care if a client chooses to exercise her right to refuse testing. However, I have several concerns regarding consultation/testing.
In the current rules, there is no mention of testing for GBS. I am curious what prompted the inclusion of this test in the proposed rules. Is there evidence/documentation to show that this has been a concern/problem for midwifery clients? Is there documentation to prove bad outcomes because of positive GBS testing? If so, I believe that documentation (without identifying information) should be presented at the committee meeting. If this does not exist, why include more regulations that are not supported by evidence? If the evidence is lacking, I would propose that GBS testing be removed from the required testing. Most midwives already include GBS testing into their practice and women are testing positive. Measures, consistent with European standards, are often being taken to reduce colonization of GBS in these clients. Without the direction of the department, midwives have been offering this test and midwifery clients have been choosing treatment methods that, unless the department has documentation to prove otherwise, appear to be effective.
I am also concerned that consultation for GBS testing (and all other testing) will become burdensome. The CDC reports that 10-30% of women will test positive for GBS. Consulting with a physician/CNM every time a client tests positive or refuses the test could prove to be burdensome and redundant, not only for the midwife, but for the consulting physician/CNM. What is the point of consultation? Is it for midwives to have a better understanding of a positive test result, of treatment options, or what steps should be taken if the client refuses? Of course, I have no doubt that Arizona midwives already have this knowledge; however, if the department does not believe that midwives possess this knowledge, current evidence-based practices could be posted on the department’s website for midwives to reference when they are faced with client refusal or positive test results. Posting it on the website could provide the midwife with easy access to evidence based practice, reduce burden on the midwife and consulting physician/CNM. The information on the department’s website could also include an informed consent sheet for the midwife and client to fill out.
Hi…
The GBS testing came up during an internal meeting with my licensing team and our folks from maternal and child health. There have been bad outcomes from GBS and we wanted to make sure we are managing the risk. The idea to add GBS to the testing didn’t come from any outside Stakeholders- it was internal staff.
Over the last week we asked our epidemiology and statistics team to run the data for GBS. We can present that data tonight. While we have had bad outcomes- it doesn’t appear as though any of those bad outcomes were from home births.
Using these data we can move GBS to the midwife/physician/nurse midwife consulting part of the rule along with a specific informed consent for declining the test. If the licensed professional midwife is still comfortable providing services at that point she’ll be free to continue services.
I understand your hesitation based on lack of immediate clinical interventions in the home. As you consider this lack, remember that the vast majority of the time no intervention is needed at all. When interventions are needed, midwives are trained and equipped to provide most of them. When further intervention is needed, the woman and/or the baby will be immediately transferred to a hospital where more treatment can be provided. They are not going to stay at home if it becomes unsafe to do so, whether during labor or after birth. Women and their families want what is safest and best for themselves and their babies. I agree that a licensed midwife (LM) should not have to discontinue care if a woman declines testing and/or procedures recommended.
The welfare of BABIES is not being ignored. The welfare of babies and their moms is why midwifery is so important. Nobody has a baby’s welfare more in mind than its mother. Nobody protects a baby more than its mother.
Director Humble, I want to thank you and your team for all of your work and consideration during this process. I appreciate the transparency and the multiple opportunities for public comments in meetings and online. I appreciate that you have heard the concerns of the consumers and have been working with us to try to make the new rules better than the old. While there are still concerns, good progress has been made and I know that progress has required lots of time and effort on your part and that of your team and the advisory committee.
Dear Director Humble,
I am extremely concerned about the Midwifery Rules revisions. The latest draft of proposed rules does not respect the autonomy of pregnant women regarding their healthcare choices. I am particularly concerned about the added restrictions concerning Group B Strep Streptococcus (GBS) and compulsory ultrasounds.
The current draft does not allow a pregnant woman under the care of a midwife to refuse screening for GBS with or without informed refusal and legally continue to receive care from her midwife. The same woman, however, is not legally required to submit to such testing if she is under the care of a physician or certified nurse midwife in the hospital. Furthermore, a positive culture for GBS would result in an immediate transfer of care to a physician. This is particularly disturbing considering the ongoing debates surrounding GBS. This seems to illustrate a deliberate attempt on the part of the AZDHS to transfer women from under the care of their midwife and to a physician without any regard for the woman’s preference of caregiver, and without just cause.
The current draft of the rules indicated that compulsory ultrasounds will be required of midwifery clients on at least two occasions during pregnancy. The coercive nature of this regulation is another violation of the autonomy of Arizona women and a restriction of their choices and healthcare preferences. As with GBS screening and treatment measures, there is ongoing debate in the scientific community concerning the benefit and safety of this technology for both the unborn child and the mother. One study of 15,151 pregnant women published in the New England Journal of Medicine showed that an ultrasound scan does not improve fetal outcome.
Director Humble, pregnant women are fiercely protective of their unborn children; this is part of the reason many choose to birth at home with a midwife. It is a shame on the department to assume that these women must be protected from themselves and their choices. Women who give birth at home are informed, careful, and extremely concerned about the well being and treatment of their child. Furthermore, Arizona midwives are profoundly diligent in their care of the women they assist. Many midwives have been practicing for decades and have attended thousands of births (my own midwife has attended over 2000 births in her 30 years of practice)! Midwives are educated to understand pregnancy, complications, and risks. They are careful, and do not take risks that would put the women under their care at risk.
As Americans, pregnant women have the right to autonomy and a right to a choice in caregivers. They have a right to refuse tests and screenings and to continue their care under a midwife as they see appropriate. The current draft of Licensing of Midwifery does not give Arizona women the opportunity to make these choices.
Thank you for your time and concern. I hope that you will correct these issues in the final draft of the rules.
Mr. Will Humble, Director,
Arizona Department of Health Services
150 N. 18th Avenue
Phoenix, AZ 85007
June 3, 2013
Dear Mr. Humble:
We at the Coalition for Breech Birth have become aware of the legislative process related to out-of-hospital birth in Arizona. We have some feedback that we feel is important to consider.
On page 13 of the “Licensing of Midwifery Draft Rules”, section R9-16-108: C-1. b. ii., it states that a midwife should inform a client of their experience with complete breech, but does not include frank breech. We find this peculiar given that in studies on breech, both frank and complete breeches are included. In fact, frank and complete breeches are preferred equally by careproviders.
Page 16, R9-16-108: J-7 states : “Refer a client for an ultrasound at 36-37 weeks gestation to confirm fetal presentation and estimated fetal weight for a breech pregnancy.”
Our concern with this is that ultrasounds are notoriously inaccurate for estimating fetal weight at this point in pregnancy 1, thus increasing the risk that a woman will have major surgery based on inaccurate information. It also must be stated that the baby’s position can and does change after an ultrasound and even during labor.
In response to the prohibited practice and transfer of care, R9-16-109 C, 2, a. as well as R9-16-109 F, 2, a., both of which state that women whose babies are determined to have “fetal anomalies” cannot be attended by a midwife at home, this strikes us as very subjective. What is determined as an anomaly? Who makes the determination? How many women will undergo unnecessary dismissal from licensed midwifery care, which would then be further compounded by the potential for unnecessary major surgery? There are many anomalies that are not life threatening nor impact the safety to mother or baby either during the birth process or in the minutes or hours after. A cleft lip or an extra digit, both considered anomalies, for example, should not prevent a mother from delivering her breech at home. Anomalies need to be more tightly defined.
We would be remiss if we did not mention that underlying all of these concerns is the absence of informed consent/informed refusal. If families were being completely informed of the balance of risk between vaginal birth and surgery (including the significantly elevated risk of maternal disability or death as a consequence of cesarean surgery2), far more families would be opting to plan a vaginal birth. It should be noted that families would invariably consent to a transfer and possibly surgery, if indicated during labor.
According to Edward Goldman, JD, informed consent is characterized by “A competent (understands nature/consequences of actions) un-coerced patient who understands the procedure, its risks, benefits and alternatives then makes a free informed choice (no coercion or duress).”
If 65-70% of breech babies present as frank breech, then you are excluding informed choice from the majority of women pregnant with breech babies.
We ask that you consider these points when making a determination about licensing regulations for midwifes in Arizona.
Sincerely,
Christie Craigie-Carter
US Chapter Leader
Coalition for Breech Birth
References:
1. Blackwell S.C., & Refuerzo J., Chadha R., et al. (2009). Overestimation of fetal weight by ultrasound: Does it influence the likelihood of cesarean delivery for labor arrest? American Journal of Obstetrics and Gynecology. 200 (340), pp. 340. e1-340.e3.
2. Zelop C. & Heffner. L.J. (2004). The downside of cesarean delivery: Short- and long-term complications. Clinical Obstetrics and Gynecology. 47 (2). 386-393.
3. Goldman E. (2011). Informed Choice-Do We Need It? [PowerPoint slides]. Retrieved from:obgyn.med.umich.edu/sites/obgyn.med.umich.edu/files/InformedChoice-legalissues.ppt
Not being happy with the way things are proceeding, I sent the following letter to Governor Brewer’s office this morning:
June 3, 2013
Governor Brewer,
Thank you for signing HB2247 allowing for the formation of a committee to discuss midwife scope of practice in Arizona. I support the right of a woman to choose where and how they give birth. I believe that any woman who chooses a midwife as a birthing option has already carefully researched the options and is making an informed decision.
After more than a year of work, the results of this committee is coming to a conclusion. However, I am concerned that the results are not consistent with this law, HB2247. There are a number of items in the “final draft” that do not appear to meet the criteria of HB2247. For example, paragraph B requires the submittal and posting of a report detailing proposed changes and evidence supporting the need to include such changes. Yet there are several items in the proposal that neither the midwives nor consumers are happy about, items that I can find no report for. Furthermore, some testing requirements were added to the draft that were never brought up before the committee and were never publicly mentioned. This may suggest a possible violation of Arizona’s public meeting laws. Other proposed requirements may cause conflict with current HIPAA laws by requiring additional consultations with health care providers that have no history with the consumer. Instead of reducing regulatory burden as HB2247 requires in paragraph A, the purposed changes will increase the burden and tie midwives hands. Women will be left with fewer choices and fewer rights in regards to their child’s birth.
I request that your office look into the matter to ensure that HB2247 is followed and that no violations of Arizona or federal law occur in this important matter.
Andrew Gibbons, Concerned Citizen
I believe that all government agencies have a responsibility to answer to the people. Since the midwives and consumers of midwives in Arizona do not appear to be getting through to director Humble, and since he seems content to threaten them with the loss of all the work completed so far, I felt it was important that our elected officials knew of what I am seeing.
Dear Director Humble,
Today, my prayers are with you, the midwives, the doctors, us consumers and our children. Whatever happens at this meeting and whatever the outcome, I am grateful for your team and you hard work and considerations in these matters.
I know it is “too late” to have an impact on this session. However, for the future, for your own information and the development of your own personal beliefs on these matters, i would like to suggest that you follow the blog, http://birthwithoutfearblog.com/ and see for yourself just how beautiful and amazing this community is! I do wish you could attend several homebirths yourself, but i see how that would be problematic for you.
PLEASE do not let the nasty comments from all sides or pressures from the standard medical community discourage you from keeping the lines of communication open or doing what is right and honorable.
This is a huge burden we have all placed on you. I do not envy you that. It is also a great opportunity. You have found yourself on the forefront of a revolution. Whether you ever expected or desired to be here or not, your name – your character and what you do under this pressure – will forever be written into the history of human birth in America and will effect the freedoms and the care of Arizonan families for generations to come.
~ Blessings and Grace ~
Director Humble
I respectfully request that you remove the refusal of testing from consult. Midwives are trained professionals and capable of referring out and doing consults when necessary. Midwives don’t want to put their clients and babies at risk. They desire and have been trained to do what is best in these situations. They have been trained to recognize when things aren’t right and as you have already stated from your research the GBS issues have NOT been an issue for home birth. There are safe ways to handle GBS at a home birth. I for one, even if I refused testing or tested negative would find it wise to follow some of these precautionary guidelines because even if you test negative from my understanding you could be positive later. This additional burden of requiring informed written refusal of testing to be consult is illegal based on my rights to informed refusal as a person and also based on the law laid out to consider INCREASING the scope of midwifery care. I should not be required to jump through any additional hoops or pay any extra unnecessary fees if I have give my midwife informed written refusal. Please consider this and please consider staying within the guidelines of this law, which would require considering INCREASING scope, not limiting it. The legal ramifications of your decisions could be very costly. Thank you for considering our thoughts and opinions and for researching our safety.
Thank you Director Humble and your team for all of your hard work. The changes made in the meeting today were very good. I appreciate how much you have invested in this process.
To Director Humble and Team:
Thank you for hearing and understanding reason in regard to patient autonomy. Our rights to bodily integrity along with a respectful model of maternity care should be at the heart of public health, whether under the care of a Licensed Midwife or an Obstetrician.
I wholeheartedly believe, especially after this committee meeting tonight, that there is now a greater understanding on the part of ADHS regarding patient autonomy and feel less apprehensive about the future of Midwifery care in Arizona.
We in the home birth community will continue to engage in the democratic process with the end goal being respect for women who are pregnant, freedom for women who are pregnant, and choices for women who are pregnant.
We will also continue to advocate for a radical reduction in the skyrocketing c-section rate by bringing attention to evidence based research in favor of fewer unnecessary interventions, and more emphasis on respectful care and informed choice.
Thank you very much for your dedicated public service.
Regards,
Lesley McKinley
Dear Director Humble and Team,
Thank you for your hard work. It was great to see the efforts to uphold the right to self-determination as well as changes made to protect midwives. The changes last night were very good and welcome.
Director Humble –
Thank you for all of the time and effort you and your entire team have invested into making homebirths and midwifery a safe and integrated part of the health care system in Arizona. You have proven your commitment to your post as director, and that you strive for excellence in outcomes.
As we enter the final hours before the final midwifery rules document will be published and implemented, may I offer a solution to one of the controversial points of interest remaining in the draft – the requirement that a midwife call a hospital at the onset and completion of every labor.
Rural hospitals argue that they would alter their staffing to accommodate if they are aware that a labor is occurring and they would appreciate a heads-up. Urban hospitals groan and plead that we don’t burden them with unnecessary phone calls that will bog down their system.
You have stated that you are currently working on a hospital rules revision as well and expect hospitals to create a method for dealing with these phone calls – you also seem in favor of facilitating communication between midwives and hospitals so that hospitals are aware of how many uncomplicated homebirths we are doing.
THE SOLUTION SEEMS SIMPLER:
I propose that, while in the process of working on the rules revision for the hospitals….that the HOSPITALS be requested to write up what communication protocols THEY would like for the midwives to follow for their hospital. Each hospital could easily develop a one-page protocol with appropriate phone numbers and procedures that they would like the midwives to follow. If the hospital is one such as Dr Northups and would prefer a heads-up phone call at the onset of labor – that would be easily accommodated by the midwives in that area that intend to transfer to that hospital. If, however, the hospital would PREFER to be called upon decision to transport – that, too, could be easily accommodated. The hospital protocol could be listed on a website that may be accessed by the midwives.
This would encourage appropriate communication as well as increase patient safety as there would be no confusion as to who to call, when to call, how to handle that call…it would be CLEARLY stated by the hospital.
I do believe that I speak for most if not all of the Arizona licensed midwives when I say that I very much want to facilitate a good relationship with hospitals – and I STRONGLY believe that this is the best way to accomplish this goal.
You also tasked the newly created advisory committee to take the midwife reports (former ‘quarterlies’) and use the data for a variety of uses. It would be so simply to publish the outcomes of the reports for the hospitals annually – so that they could see the real numbers. ie. 632 homebirths occurred in 2014, 72 transfers to hospitals, 1 poor outcome.
If a hospital wishes to see how many good outcomes we are achieving, that data will be more available with the publishing of those numbers rather than by phone calls individually.
Thank you for considering this idea – I believe that if you communicate this idea with hospitals you will find them VERY favorable to this as preferable to what you are currently planning to include (required phone calls everywhere every time).
Great idea! Let the hospitals decide when/how to contact them.
Very much agree! Seems easier on all parties involved!
I agree with Stephanie 100%.
I think this is a great idea and would be a more simple solution to the problem.
I second this idea.. it sounds like a good plan for establishing positive communication between midwives and hospitals.
I absolutely agree that clear communication is paramount! Yes, the hospital protocol could be listed on a website that may be accessed by the midwives. I also appreciate the time and loving help from many of those involved, thank you!
I love this idea! I’m sure there would be much more cooperation and friendly collaboration if each hospital could develop their protocols to best serve their community with their specific resources/staff in mind. That would help the midwives facilitate effective communication with the hospitals and therefore keep everything running smoothly and safely! Please do consider it!
This is an excellent idea!
I agree about letting the hospitals decide how they want to handle when they are notified.
I think this is a really great idea. Stephanie articulated this perfectly.
This idea makes sense to me. It would allow things to be created for the needs of the area. Please consider it!
Well said, Stephanie.
This seems like a good compromise. Each mother knows which hospital they would like to be taken to, so it would be simple for the midwife to double check that specific hospital’s protocol during early labor to see if they should call at that point, if they need to transfer or not at all if the hospital so states. I think this is an excellent suggestion–thank you Stephanie.
I think this is a fantastic approach that could make everyone happy! The doctors that want an “early” heads up get one and the one’s that don’t want one aren’t annoyed by calls they don’t want. Great solution.
Brilliant idea! I would love to see such a statement implemented by the hospitals rather than having the midwife waste time and much needed focus on the family to make a call to a hospital in a perfectly uncomplicated labor. Saves everyone time, energy and as I could see happening a lot, confusion.
I also agree with Stephanie and to help with a positive relationship instead of burdening the hospitals with unnecessary phone calls for a perfectly healthy happy home birth that does not even come close to a hospital. Well said!
Wonderful idea Stephanie! I agree, it seems this would make things clear and simple for both parties.
Great idea of a way to handle this!
Dear Director Humble,
As stated in HB 2247, Section E legally requires that within thirty days after the piublication on the department website of those recommendations and publications of the draft of the proposed rules, the director shall conduct a public meeting to receive comment on the final draft of the proposed rules.” It was posted on the Midwifery Scope of Practice Advisory Committee Meeting Agenda for June 3 would provide time for Public Comment for 55 minutes. I attended the meeting yesterday with a prepared statement intending to comment. I signed the form when I checked in indicating that I wanted to make a comment in the time designated in the agenda.
I felt the advisory committee did an excellent job of resolving many of my concerns regarding informed consent and refusal. I request that informed consent and refusal also be extended to hospital notification in a normal labor. I appreciate and feel it is progress that you have removed the requirement to provide any personally identifiable client health information to the hospital. After a birth, I would like my midwife to be looking to my health and the health of my newborn. My midwife should not take time away from us to talk with a hospital obstetrical nurse about the start or end time of my healthy labor or birth. Even an OB on the committee that was strongly in favor of this requirement stated last night that it might not be as necessary in a city with larger hospitals. A CNM on the committee also did not seem to see how this would truly benefit mothers. By deciding to disregard the time for public comment, it felt that the voices of mothers and others were silenced at this critical meeting. As this was a legal requirement to hear public comment at this final draft meeting, do you plan to reschedule another meeting to allow for the required public comment time? Thank you for the positive changes that were made at this meeting!
Christie Gibbons
Director Humble. I wanted to take the time to thank you for hearing our voice and respecting our rights. Thank you for looking into the studies and data and respecting us as women and our right to make choices for our children.
Fatastic idea. This seems like a win-win for both midwives and hospitals. Hospitals should also have the chance to revise their contact policies at appropriate intervals as the system works itself out and issues are known.
I absolutely agree with Stephanie; much simpler than a one-size-fits-all approach.
Good idea regarding the Hospital rules. We will include a provision that hospitals have a simple protocol for how they want to interface with midwives with a 7/1/14 effective date. I’ve already contacted my rulewriters for both the Midwifery and Hospital Rules.
Thanks for your quick response and willingness to work with us on all these details. We REALLY appreciate it. So glad we have your support!
Great idea! Seems like that would make it easier and more efficient for both sides!
Dear Director Humble,
Though I was not able to attend Monday’s final Midwifery Scope of Practice meeting, I was able to watch nearly the entire meeting via live streaming – and I want to thank you so much for all of your work and for how you are handling these issues. I was incredibly impressed with your willingness to listen and to make alterations based on input and evidence, and the friendly and respectful way in which you conducted the meeting. You are a blessing to the birth community – thank you.
Diana
In regards to R9-16-115 D; that is, the people who make up the Midwifery Advisory Committee:
It is very important that everyone on the advisory committee, not just the midwives themselves and the consumer, has some kind of experience with the midwifery model of care and out-of-hospital birth attended by a midwife. This could be as simple as defining “experience” as something along these lines: who have at least observed a certain number of prenatal appointments with a midwife (to understand the format, content, and dynamics involved) and/or a certain number of out-of-hospital births attended by a midwife (to understand the environment, standard of care, and process of making decisions). This experience could take place at any point in their lives, not just after becoming a licensed physician – perhaps as a med student or while in residency. This would put everyone on the advisory committee on a level playing field. Everyone would speak the same language and visualize the same scenarios under discussion. Many miscommunications, misunderstandings, and misconceptions could be completely avoided, thus saving time and effort during committee meetings. Discussions would run more smoothly without the need for on-the-fly education and explanations of the midwifery model of care and out-of-hospital birth and the realities they encompass.
This change to the rules could be made simply by adding the same clause to the description of physician and CNM that is applied to the consumer: “who has used or who has significant experience with midwifery services”. These medical practitioners do exist. I know of one OB who went so far as to shadow a midwife for a whole year, and was positively impressed by what she learned from her observation. It is exactly that kind of appreciation for midwives and the clients they serve that this committee ought to demonstrate. At the very least, it is the sort of knowledge of the system obtained only by experience that the committee sorely needs.
I absolutely agree that the CNM and physician should have “significant experience with OUT OF HOSPITAL midwifery services. This has been discussed in several different committee meetings. Just as the member of the public should have significant experience, the CNM and physician must be held to the same standard. First and foremost, this committee is about midwifery services. All members must have that knowledge in order to create a cohesive and effective committee. If a pediatrician is added to the committee, as was discussed in the last committee meeting, the pediatrician should also have significant experience. Also, it is important to include the phrase “out of hospital” to the description. All members of the committee should have “significant experience with out of hospital midwifery services”
There is a cultural misunderstanding in America that needs to change both in the minds of many women and more especially in our medical community. That misunderstanding is this: midwifery is not an alternative to traditional hospital birth, hospital birth is an alternative to traditional midwifery care. An alternative made worse by the seeming inability of professionals to realize that just because we have the means to intervene in the natural birth process, doesn’t mean we should. An alternative that causes 1/3 of those who use it, to have their abdomen cut open. Often because of the catch-all cause of “failure to progress” which sometimes means that the medical staff is too impatient with the process. When is the medical field going to realize that attempting to force a natural process (such as birth) to conform to man made curves and time requirements, often results in the further need for additional intervention, culminating in the high cesarean section rate of this country.
I think the following information in important in view of what is currently happening in Arizona.
A large (n=62,415) multisite (19) study in the United States was published in the peer reviewed journal Obstetrics & Gynecology in 2010 by Jun Zhang, et. al., “Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes”, concludes that the contemporary labor pattern has changed from the Friedman Curve. The results showed that labor may take longer than previously thought. It may take a woman more than 6 hours to progress from 4 to 5 cm and more than 3 hours to progress from 5 to 6 cm of dilation. Their recommendation is to allow a woman to labor to for a longer period of time before 6 cm of cervical dilation which may reduce the rate of cesarean deliveries in the United States.
This study was used by the American Midwifery Certification Board (AMCB) as part of their ongoing recertification process for certified nurse midwives and certified midwives in the intrapartum module. The AMCB is the certifying body for the American College of Nurse-Midwives.
Both physicians and midwives who practice evidence based care would use this information when making decisions regarding progress of labor.
Thank you for the opportunity to post.
Jeanne Stagner, CNM ARNP MSN, PhD Student
I first want to say thank you for the measures that are being taken to protect our rights and human dignity. I was happy to watch the meeting Monday night and see progress and communication. I felt as if our voices were being heard and I do appreciate that!!! As my 5 year old said today, But Mom shouldn’t any woman who wants to have her baby at home be allowed to?! Why yes, dear, she should and she should be allowed to have a midwife there to help her!! Such wisdom from a 5 year old yet such naivety that that truly is the case. So I appreciate the communication and work that is being put into making midwifery care available to more women. There are a few concerns I still have though and would like to take the time to express those to you…
*I’m concerned about weight gain requirements. “Failure to gain 12 pounds by the beginning of 30 weeks gestation or gaining more than 8 pounds in any two-week period during pregnancy” Women come in all shapes and sizes. Midwives receive training on nutrition and diet. They can provide the necessary information to assist women with proper weight gain. This rule could be changed to read, “failure to maintain healthy weight gain” or even better could be completely taken out!! 🙂
*I’m unhappy that the age requirement is 21. I don’t understand this law and would appreciate qualified men and women who have gone through proper training and have been licensed to be allowed to practice regardless of age. Although I suppose 18 would be a reasonable requirement.
*I am appreciative of the measures that have been taken to protect informed written refusal. I would encourage you to continue to protect those rights to the fullest extent in the new rules. Please do not allow for any confusion in this area. This is a very important area and women are NOT taking this lightly!! Women should not have to consult with an OB or another practitioner, even a Naturopath, when doing informed written refusal. Midwives have been trained regarding the testing and are completely capable of explaining them to women (who many times have already studied the pros, cons, and risks themselves anyways). Midwives and/or consumers should NOT have to meet with, call or have any extra charges in order to make informed written refusal of testing. At the same time Midwives should still be completely allowed to serve these women who do informed written refusal of testing. Please respect our rights regarding informed written refusal and make the wording for these measures very clear in the rules, that we have these freedoms. Cause we DO have these rights and most women won’t just sit and take it if an attempt is made to take these freedoms away.
*Women should also NOT have to transfer care to a hospital for a positive GBS test. Again, midwives can inform them of options and set up a consult if that is necessary to get antibiotics or other prescriptions. Women should not be required to have to do one particular thing to treat this, and certainly shouldn’t be required to transfer to a hospital, but should be allowed to explore their options by themselves, with their midwives and with whomever else they decide to bring in and take the course of action that they see is in the best interest of their family.
*As a consumer, I want my midwife to be able to suture a tear without them having to call EMS! Honestly I’m unhappy about them having to call EMS for some of the other listed emergency procedures as well. But this is a basic one, all tearing should not be considered an emergency, if this remains in Emergency Measures, EMS would need to be called for every tear that needed suturing. That would be a waste of time and resources for EMS. In some areas, residents are charged for calls to EMS. Midwives are educated and trained on suturing. There is no reason it should not be in their scope of practice.
*I was also concerned about a midwife having to call to check in with the hospital at the beginning and end of labor. I do no feel like this is necessary and would appreciate this being taken out of the rules or at the very least be changed to the suggested proposal about allowing hospitals to create a policy about how to interact with the midwives.
*Dir. Humble said he would change the “at a minimum” wording when referring to the Midwifery Advisory Committee but I just wanted express my concern over this. I do not want it to be ambiguous and risk losing the majority. Since it is a Midwifery Advisory Committee its important the midwives have the majority and that the physician and member of the public have significant experience with out of hospital midwifery care. I request that right along with taking out the wording, At a Minimum, that it also be added that the physician and member of the public have significant experience with out of hospital midwifery care. I know there has been talk of adding a pediatrician as well, I request that he remain a non-voting member like Dir. Humble had mentioned and that this be set out clearly in the rules. I think he should also be required to have significant experience of out of hospital midwifery care as well.
Director Humble,
As we are nearing the end of this process I would like to take the time to thank you again for all of your energy and devotion to helping make our midwifery rules better for the future generation. Your team has worked very hard and I am appreciative of what you have invested.
I found this info posted by a consumer and it is very logical. Please consider their points below . The midwives understand the issues that need to be monitored because they could lead to other complications.
A call to a consult with a doctor may go something like this: “Hi Dr X. I am required to consult with you regarding a client who is is a gravida 6.”… “Ok. Are there any problems?? …”No.” ” So what do you need?”
These required consultations in the absence any type of complication are annoying to the providers who support us. Would you please consider changing these? The required consultations need to be for things that the doctor is not going to say something along the lines of “Ok watch her for complications associated with this.” That is already our job, and we don’t need to call a doctor to remind us to do our job.
R9-16-110 Many reasons for required consult aren’t necessary, depending on the patient, such as:
o A. 4. Age. 40years. No physician will be able to tell whether or not these women will have difficulties in labor. If the mother is healthy, she should be able to have a homebirth. Age discrimination is not acceptable.
o A. 3. Parity greater than 5. No physician will be able to tell whether or not these women will have difficulties in labor. If the mother is healthy, she should be able to have a homebirth.
o A.5. “Failure to gain 12 pounds by the beginning of 30 weeks gestation or gaining more than 8 pounds in any two-week period during pregnancy” Women come in all shapes and sizes. The Institute of Medicine makes recommendations on pregnancy weight gain based off of the pregnant woman’s weight. Weight gain recommendations for an underweight woman vary greatly from an overweight woman. Midwives receive training on nutrition and diet. They can provide the necessary information to assist women with proper weight gain. This rule could be changed to read, “failure to maintain healthy weight gain”. However, I believe it should be stricken completely.
o A. 10. excessive vomiting or continued vomiting after 20 weeks
o A. 12. Fever of at least or greater than 100.4 twice at 24 hours apart. Mothers often get sick. The requirements are too restrictive.
Thank you.
Also, I forgot to ask about the rules regarding suturing. I think at the meeting it was discussed to keep it as it is now where we can suture up to a 2nd degree without calling EMS. I hope that this will be the case. This is what we have been doing for many years, and I don’t know the logic of changing it. If it was required to call EMS many mothers would opt not to be sutured. After a lovely private home birth, families will not want their space invaded by an EMS team for something that is not an emergency. It would defeat much of their goal of a home birth.
Director Humble,
I would like to address a couple of issues in the new draft of Midwifery Scope of Practice.
As discussed in the final Midwifery Scope of Practice Advisory Committee meeting, currently midwives have the authority to suture an episiotomy or tear of the perineum to stop active bleeding under Emergency Measures, R9-16-111 A4. Suturing should be moved from Emergencies Measures to Responsibilities of a Midwife; Scope of Practice, R9-16-108. It is not uncommon for women to tear when birthing their baby. Not all tearing should be considered an emergency. Let us not forget that if this remains in Emergency Measures, EMS would need to be called for every tear that needed suturing. That would be a waste of time and resources for EMS. In some areas, residents are charged for calls to EMS. More importantly, midwives are educated and trained on suturing. There is no reason it should not be in their scope of practice.
I have torn with both of my children and my midwife expertly stitched me up with more care and deliberation then I have ever received from a Doctor. More importantly this is basic knowledge that all midwives have and it would be a huge waste of resources. Another reason is a midwife has experience and is specifically trained for suturing the perineum whereas a EMS is not specifically trained to suture such an important part of a women’s anatomy. During such a sacred, beautiful time right after birth to be invaded by a stranger who was going to place his or her hands on an area of my body that is very sensitive and private to begin with and then to have just gone through hell to birth my baby, this would be very uncomfortable for me to the point that I would rather let nature take it’s course in healing my tear. It is not fair for you to put us consumers in a position to have to choose no treatment because you strip away our midwife’s ability to do something that they already are fully trained and able to do. Please put suturing back in the Midwives Responsibility’s section.
I also ask that you would change the rules pertaining to the committee. Making it a rule that any Physician on the committee be held to the same standard as all the others in having “significant experience with OUT OF HOSPITAL midwifery services”. This is important for many obvious reasons. First of all the Doctors and Nurses in the medical community are not educated on normal, natural birth. They are trained for birth intervention, emergencies, and surgery. And I am thankful for that….because I know if I have an issue my midwife can’t handle a Dr. is trained to know what to do to save me and my child. However, on a committee specifically catering to consumers who have chosen a different path it is unfair to ask a Physician to serve on that committee when they have absolutely no frame of reference to what a normal, natural birth process looks like. I’m glad we have a Physician on our committee to offer a different perspective however, he/she needs to have significant experience with out of hospital midwifery services. For several reasons; 1) so the constant need of explaining how and why midwives do what they do is reduced (not that midwives shouldn’t be called to the carpet or asked to explain how or why they do something more fully but if a Physician has no frame of reference whatsoever this task is hugely cumbersome and gets in the way of the committee coming to a consensus on how to make home birth and midwifery practices safer and better) , 2) streamlining communication and therefore the committee is able to get more done in a shorter amount of time, 3) the Physician would be more likely to offer constructive criticism which could be accepted more readily by other committee members because they know the Physician has actual experience in that situation.
This requirement would truly be a great service to the committee and to the future of Midwifery in our state.
Thank you Dir. Humble for your time and patience. Also thank you for listening and doing your best to make positive changes for our future! Me and my future children are very grateful! 🙂
Danielle
Dear Director Humble and Team, These are my concerns and suggestions for the most recent proposed midwifery rules.
• Please allow midwives to attend VBAC and breech births during this next year as part of their training. The advisory committee, along with creating informed consents/refusal documents, can create some sort of training program. There needs to be a concrete plan.
• Although I think it is completely unnecessary, if there is to be calls to the hospitals regarding a woman in labor, I fully support the proposed idea that the hospital set the standard for these calls, whether or not they require them and what their requirements are.
• It only makes sense that the requirement age be the same as the NARM standards.
• Freidman’s curve is terribly outdated and VBAC or not, needs to be removed. Here are some studies regarding the need for these times constraints to be expanded. http://www.ncbi.nlm.nih.gov/pubmed/15561659 – http://www.sciencedirect.com/science/article/pii/S000293780200248X
• “Failure to dilate as a result of cephalopelvic insufficiency” – this phrase is all too frequently blamed for ‘unsuccessful’ vaginal births, usually due to interventions and lack of patience on the part of the care provider. This still eliminates a large majority of women who are prime candidates for having a VBAC.
• “Age. 40years.” No physician will be able to tell whether or not these women will have difficulties in labor. If the mother is healthy, she should be able to have a homebirth. Age discrimination is not acceptable.
• Parity greater than 5. No physician will be able to tell whether or not these women will have difficulties in labor. If the mother is healthy, she should be able to have a homebirth.
• “Failure to gain 12 pounds by the beginning of 30 weeks gestation or gaining more than 8 pounds in any two-week period during pregnancy” Women come in all shapes and sizes. The Institute of Medicine makes recommendations on pregnancy weight gain based off of the pregnant woman’s weight. Weight gain recommendations for an underweight woman vary greatly from an overweight woman. Midwives receive training on nutrition and diet. They can provide the necessary information to assist women with proper weight gain. This rule could be changed to read, “failure to maintain healthy weight gain”. However, I believe it should be stricken completely.
• “Excessive vomiting or continued vomiting after 20 weeks”- should be stricken
• “Fever of at least or greater than 100.4 twice at 24 hours apart.” Mothers often get sick. The requirements are too restrictive.
• As discussed in the final Midwifery Scope of Practice Advisory Committee meeting, currently midwives have the authority to suture an episiotomy or tear of the perineum to stop active bleeding under Emergency Measures, R9-16-111 A4. Suturing should be moved from Emergencies Measures to Responsibilities of a Midwife; Scope of Practice, R9-16-108. It is not uncommon for women to tear when birthing their baby. Not all tearing should be considered an emergency. Let us not forget that if this remains in Emergency Measures, EMS would need to be called for every tear that needed suturing. That would be a waste of time and resources for EMS. In some areas, residents are charged for calls to EMS. More importantly, midwives are educated and trained on suturing. There is no reason it should not be in their scope of practice.
• The proposed rules use the wording for member make-up “at a minimum”. I request that “minimum” be removed to avoid ambiguity or risk losing majority. Physician(s) should have significant experience with OUT OF HOSPITAL midwifery services. The member of the public must have “significant experience”. There is no reason the physician and CNM should not be held to the same standard.
Thank you for your excellent work on these rules, it is greatly admired and appreciated. I hope to see continued improvements!
Cheyanne Gastelum, Licensed Midwife
Midwife was very hard work , really is so