If you’re not closely connected to the natural birth community in Arizona, you may not have heard about the recent rewrite of the Midwives Scope of Practice. The process began a few months ago, with the original intent being to expand the rules to include VBAC (vaginal birth after cesarean) and breech births. An advisory board was created to work together to help create the new rules, and public meetings have been held to give consumers the chance to comment on the changes.
As the conversation has unfolded, the department has released ongoing drafts of the rules for public comment. The most recent draft is open for comment right now, and a final draft will be posted for public comment at the end of May. As each draft has been released, it has become more and more apparent that the scope of practice is in many ways becoming further restricted instead of more inclusive. The ability for midwives to practice without fear of prosecution is indeed in danger. At this time, it is EXTREMELY important that people are submitting comments, emails, Facebook posts, etc pointing out the issues that exist in the current draft.
Why does it matter? Well, even if you never find yourself in a position to choose a home birth in the state of Arizona, these amended rules as they stand will limit a woman’s bodily autonomy by affecting her ability to choose the birth setting she desires. The point is not whether or not home birth is right for you, it’s that we should all be able to choose whatever model of care that we desire and deem appropriate. The medical model of care in a hospital setting is right for some women, but others will only succeed at their desired birth experience with the different type of care and support that only a midwife provides.
What are some of the major issues with this draft of the new rules?
-Medication: Midwives in Arizona are currently allowed access to certain medications that would be deemed life-saving in the event of an emergency such as hemorrhage. The current draft removes any mention of the legality of a midwife possessing medications of any kind. This would GREATLY decrease the safety of home birth moms and babies.
-Chain of Events in Case of Emergency: The current draft requires a midwife to stop and call 911 before beginning any treatment in the case of an emergency.
-Contacting the Local Hospital: This draft requires midwives to call the Charge Nurse at the nearest hospital to notify them whenever a client goes into labor. The midwife must call again once the baby has been born.
-VBAC Restrictions: The draft specifically states that a midwife cannot attend a VBAC if the original cesarean was performed due to failure to progress or cephalopelvic insufficiency. The problem here is that these diagnoses are considered “catch-all” terms and are considered over-diagnosed even within the medical community.
-Patients Right to Choose: The current language requires a laundry list of mandatory testing, and states that a midwife must discontinue care of her client if the patient refuses these tests. A woman should have the right to be educated on the purpose of each test and choose what she wants to include without being threatened with loss of a care provider.
-Written Recommendation from a Physician: This draft includes a requirement for a written recommendation from a physician to attend the birth for some clients. Because a physician is highly unlikely to provide this recommendation due to potential liability themselves, this could be highly restrictive to the type of care that a midwife can provide.
The full text of the current draft of rules can be seen here.
Please join us in making sure that our voices are heard in support of Arizona midwives and a woman’s right to choose the type of birth she wants! It is my understanding that you do NOT have to be in the state of Arizona to submit a comment. Here is the link to submit comments to the department.
And here are some sample comments to help further clarify the issues that are being contested:
“R9-16-110 of the draft is looking to include a “written recommendation from a physician for treatment, referral, or transfer of care at the time a client is determined to have any of the following treatment…” The current rules do NOT require written recommendations. The purpose of the rule revision was to REDUCE burden. Not only is this INCREASING burden, but it is requiring midwives to do something that may be impossible. ACOG does not support formal agreements between homebirth practitioners and physicians. A written recommendation may be seen as that by a physician, making it impossible for a midwife to follow the rules. What will happen to the midwife and client if the midwife is not able to attain that written recommendation? The midwife will not be following her rules and the client may be in jeopardy of having to transfer care. Evidence should be provided to show WHY this INCREASE of burden is being added. Was oral consultation not sufficient? In your definition consultation means “communication between a midwife and physician”. Communication can be oral OR written. Do not restrict care by insisting that communication only written. Oral communication is sufficient and often preferable for a midwife and client. Above all, I stand by the bill which reads “reducing the regulatory burden on midwives”. Written recommendations do NOT reduce the burden.”
“Please add the following statement to the rules for licensed midwives….
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 am extremely grateful to see that VBAC is still included in the drafts. I believe this is a huge step in the right direction. It shows that the department is listening to the concerns of the consumers. I appreciate that more options are being opened up to the growing number of women who desire to achieve a VBAC. However, I have GREAT concern with some of the conditions suggested. It currently reads that a midwife can not attend a VBAC if their was a diagnosis of “failure to dilate” or cephalopelvic insufficiency”. I heard in the last meeting that it is supposed to read “failure to progress”. That does not make the problem better. Failure to progress, failure to dilate and cephalopelvic insufficiency/disproportion are ALL unacceptable. There is NO literature to support this rule. Listen to the members of the committee, including those from the medical community, who have mentioned may times that FTP is over diagnosed. FTP only tells you that a mother did not progress. It did not tell you WHY she did not progress. What if there was failed induction? What if it is an emotional issue that stalled labor? What if the baby was in a poor positioning? Maybe the care provider followed the Friedman’s Curve, which does NOT allow the typical mother enough time to labor to full dilation? There are too many variables in play. A woman should not be excluded from attempting a VBAC because she had a failed induction, an emotional block, a baby in a poor position, an impatient care provider, etc. Because the diagnosis of FTP does NOT explain WHY the woman had a cesarean section, it should NOT be used to determine whether or not she is capable of vaginal delivery. CPD is also highly disputed in the literature. It is difficult to ever give a TRUE diagnosis of CPD. The testing is unreliable. FTP and CPD are subjective, over diagnosed and would be completely inappropriate in the rules. Director Humble mentioned that if he allows VBAC, he does not want to make it so restrictive that no one can do it. Leaving in FTP and CPD would essentially make it impossible for most VBAC clients to qualify for a homebirth VBAC. Consumers and members of the committee have been asking from the beginning that this be removed from the rules. Listen to these important stakeholders!”
For more information and to stay updated on future meetings and drafts, please join the Rights for Homebirth facebook group here.