Midwifery, the law, and ethics

Last week’s post about the Survey Monkey Protest brought mixed responses from midwives and midwifery consumers, which was not a surprise and why I apologized to the midwives ahead of time for the trouble caused. What did surprise me was how many people (ok, granted is was less than 10 people), via Facebook posts and emails, cited either ethics or the trouble it would cause midwives as the reasons they were not in favor of this form of civil disobedience. Legality and ethics are not the same; sometimes what is illegal is actually the most ethical option. Midwives are already eyeball deep in harassment from the state, with most if not all practicing midwives charts now under investigation, so a few more false reports to deal with doesn’t add much. This general resistance to causing trouble or behaving illegally is very relevant to what is occurring in midwifery practice in Arizona right now.

Midwives are every day in a position of deciding whether or not to be compliant to rule and statute as they are currently being interpreted (as suggested by AzDHS in their training) therefore remaining legal or deciding to behave ethically within their practice and breaking the rules. Increasingly, remaining compliant is forcing midwives to either behave unethically or stop practicing entirely. At this point, and I think most midwives would agree with me, there is NO WAY to be compliant (aka legal) and continue a midwifery practice at all, let alone an ethical midwifery practice. To illustrate, here are a few of the more absurd instructions given to midwives by the state for how to legally practice:

  • Terminate care for any client who misses an appointment for any reason. Car broke down, your midwife is at another birth, Taking a vacation, you are sick, your 2 year old is sick – doesn’t matter, no more midwife.
  • Do vaginal exams in labor, regardless of need, regardless of whether the client consents, regardless of efficacy, regardless of circumstance at all. Convince all clients of the need for a vaginal exam whether there is a need or not.
  • If 911 is needed for any reason, terminate care and walk out as soon as emergency medical professionals arrive. Do not resume care at any point postpartum.
  • Weigh, take vitals, do a pee stick at every appointment. If your client doesn’t want to get weighed, your BP cuff breaks, she can’t pee in a cup? The midwife is in violation.
  • Run syphilis screening, period. Your clients cannot refuse. Technically they can refuse because individuals must consent to all medical procedures, but then the midwife is in violation.
  • Do diabetes screening. Technically in rule this is an optional test, however the state is actively harassing midwives whose clients have opted out of the test and then go on to having large babies (babies as little as 8.5 lbs are creating red flags).

This list could go on and on, and others have written here, here, here, and here about the absurdity of the state of Arizona AzDHS’ current interpretation of midwifery rule, but the point is that even the day to day practice of midwifery is threatened by legality. For decades, midwives in Arizona have been artful in balancing an ethical midwifery practice with what is required by the state to maintain a license. In recent years that balance has become more and more difficult if not impossible. Which brings us back to the Survey Monkey Protest. If midwives and midwifery consumers are concerned about a small action of civil disobedience like this being unethical because it is illegal or might cause the midwives some trouble… I worry greatly about the future of licensed midwifery care in Arizona.

Midwifery consumers, your midwife likely breaks the rules for you all the time or she wouldn’t be able to practice. Please educate your self about the and rules (here) and statutes (here and here) that govern out of hospital birth in AZ and then thank her for giving you good care in spite of these laws and their black and white interpretation.

Midwives, the state is unreasonably interpreting rules in black and white fashion with no concerns for safety and ethics.  They have not listened to our quiet, nice, professional requests for change. Maybe it is okay to shake things up a little to prove a point. We have to be willing to acknowledge that not everything that is legal is ethical and not everything that is ethical is legal. Remember that the International Confederation of Midwives established this code of ethics for midwifery practice which does not ever mention bowing to legal requirements at the expense of our clients.

Posted in AzDHS, Rights, Survey Moneky, Uncategorized | 11 Comments

Hey monkeys – read, share and act now!

Sister midwives, you have my apologies ahead of time for the trouble this will likely cause you in an already tough time. I am acknowledging this first and foremost and accept your rightful anger if it comes. I admit that this action will cause AzDHS to investigate all of us midwives even more, it will likely make them very angry, and it is not in the least bit professional that I am suggesting it. However, it seems that AzDHS is already on a witch hunt. Midwives are being regularly cited for ridiculous violations of rule, such as seeing a client at 6 weeks and 1 day postpartum or being told to terminate care if a client misses and appointment or does not want a blood test. We are all being investigated, no one is immune. Playing nice or taking the high road doesn’t make much sense anymore.

OK, consumers, midwives, students, home birth advocates – want to know one thing you can do right now? This will only be effective if A LOT of you are willing to work very quickly starting this weekend, because once the AZ Department of Health (AzDHS) catches wind of it on Monday, they will likely shut it down. They have already indicated that they know fabricating data is easy on this form. Apparently, the department has mentioned to several midwives that the are not capable of handling multiple false reports. In the end, if this works, they will look like asses and be incapable of keeping up. This requires a fair amount of naughtiness and I’m not sure if it’s legal or not (haven’t been able to find any reason it is illegal, but I am not a lawyer – if you are worried about the legalities, you might skip this one.) But, for those of you who are willing it just might shift things a little bit.

Monkeys will always come back to get you.

Remember in this post when I talked about some of the issues with the current survey monkey midwife reporting form in Arizona? Well point number two in that post made me think of stealing someone’s  idea that just might make the AZ Department of Health pay attention. Thank you to AzDHS for pointing out at that “training” that this kind of action would rile them. Thank you to the midwife who thought of this and spoke it aloud at a meeting a long time ago. I hope you don’t mind…

What to do:

  1. If you are a midwife (or anyine worried about getting caught), consider using a public computer. Forgive me for not trusting AzDHS and their website privacy policy.
  2. Go to this link and print out a list of all the licensed midwives (LMs) in Arizona. Using real midwives names and license numbers is important.
  3. Go to this link and familiarize yourself with the midwife reporting form. (Here is the training guide if you need it.)
  4. Read the tips below before you start.
  5. Spend as much time as you have from this point forward filling out reporting forms.
  6. Write me an email at onearizonamidwife@gmail.com with the number of reports you submitted and the date(s) submitted so we can get a rough idea of how many total.

Some important tips (please read these!) and things to remember:

  • Every time you start, commit to filling out a form for every LM in AZ, that way no one midwife will carry the brunt of the response from this action. There are 67 midwives on this list (it isn’t quite up to date, but that’s okay we will spare the newer midwives).
  • As stated above, using real midwives names and license numbers is essential. AzDHS will simply toss out any reports that contain obvious fake midwife info.
  • Get together with a friend, or 5, or 10. Make a party of it. The more numbers participating in the shortest time possible, the better.
  • Do not worry at all about understanding midwifery. The form is not that complicated and you do not need to know any technical information. Just fill in the blanks and check boxes.
  • For each report, make up a new “client or chart number” (question #4). If you use the same number over and over, AzDHS will catch the pattern.
  • For each report, vary your responses. Make them all abnormal in a minor way, but don’t be too outlandish. Not every midwife needs to suddenly attend twin births for VBAC moms. Just do simple things to flag reports such as making the end date of midwifery services more than 6 weeks past date of delivery or transferring to the hospital for some reason.
  • Don’t bother with submitting any normal reports, because AzDHS only flags and investigates the ones that are abnormal.
  • AzDHS has to look at every midwife abnormal report. This will make AzDHS will have a hard time differentiating what the midwives are actually submitting versus what is part of the protest. Their staffing and $$$ for investigations are already stretched thin.
  • If 100 people submit 67 reports, that is 6,700 reporting forms they have to puzzle though. Can you get 10 of your friends laptops together this weekend for a couple hours to submit reports? That’s 670.  Midwives in Arizona do about 700 birth per year TOTAL. Do you get what I am saying? AzDHS will have no idea what to do with this amount of “data.”
  • Don’t worry about messing up any valid data collection. To me and most midwives it looks like unfair regulation is the goal, rather than data collection. But even if AzDHS is genuinely trying to collect data, they have proven in the past they do not know how to do so.
  • You will be causing trouble for AzDHS, but also causing a little trouble for the midwives. Understand that AzDHS will contact us for every abnormal report.
  • Midwives, be ready for the response to this. Do not assume that the department is always right in their citations of you and tell them loud and clear that you will not comply when you are notified on a falsified report, that you do not have a client with that client or chart number, or birth date, etc.

This action is meant to at the least make AzDHS figure out a more secure system for data collection, use a LOT of their resources to filter through all the abnormal reports, contact midwives, and find which are valid. It is not likely to create long term change, but will make a loud statement that people are paying attention to their ways.

Happy reporting, and please remember to write me with the number of reports you submitted and any feedback.

Posted in Protest, Survey Moneky, Witch Hunt | Leave a comment

Protest this weekend!!!

Hello midwives, homebirth supporters, families.  Sorry for my absence over the past few weeks. Please check back Friday for information on a protest happening THIS weekend. After you get the details, spread the word. If you would like details ahead of time, email me at onearizonamidwife@gmail.com.  I will be checking my email frequently over the next few days.

Posted in AzDHS, Protest | 1 Comment

Midwives, drop the fear

This post is for the midwives, including me, as a reminder of who we are and where the power lies. Everyone else, make sure your midwife knows that you support her during this time of persecution. Tell her, mean it, show it.

Midwives, as a group you are some of the most resilient people I know. You have faced scrutiny, regulation, annihilation, prejudice, hatred for more than a century. Ever since physicians decided to take over birth in the US, there has been a concerted effort to portray us as the uneducated, the dirty, the foolish, the naive, the selfish. We know the truth is that we pursue knowledge endlessly, that we participate in peer review, that we are honest about not caring for clients who would be safer with another provider, that we are ethical and clean and respectful and smart and seek only to serve our clients. The public is constantly told otherwise with scare tactics and poor research. Yet, still we exist.

Midwives, you are some of the most courageous people on earth. Not only are you willing to assume the responsibility for protecting the health and well being of mothers and babies… You are willing to stand up to endless institutions that seek to eliminate normal birth, that seek to remove a woman’s choice, that seek to control women’s bodies. You are willing to support mothers in their choices and to do so in the safest way possible, you are committed to providing midwifery services even when it puts you and your family in legal or physical danger, you have refused to allow those institutions to strip away a woman’s basic rights to bodily autonomy during birth, even at great risk to yourselves. These things all require such courage.

Midwives, you are so exceptionally opinionated and outspoken when we sit in a room together. You form your ideas with care, consider every road and angle, argue passionately about the best way to move forward. Yet, most of the time you manage to voice those opinions with grace and respect.

For most of us, being a midwife is not simply an occupation. It is a way of being. It is a thing that rests on our hearts and lives in our souls. It screams for our hands to do their work, it makes our minds constantly seek more knowledge on how to better do that work, it makes out heart willing to break when the clients we love walk away in their baby bliss unknowing that we carry them in our hearts forever.

I ask you to let that resilience, that courage, that graceful demand that someone hear and see you replace the fear that right now runs through our community. Stop hiding. Stop playing the AzDHS game on their terms. There is no winning that way. Do your work and do it well and ethically and safely and full of awe and respect for the women you serve. Remember it is your heart and your hands and your years of hard work and study and the very core of your being that makes you a midwife. You being a midwife is NOT defined by the AzDHS or their licenses ‘allowing’ you to practice. Please let go of any fear you have about the power AzDHS is wielding during this time. Just be a midwife.

Posted in Uncategorized | Leave a comment

AzDHS is a bunch of wacky monkeys.

AzDHS is using Survey Monkey?!?

Arizona Department of Health (AzDHS) has long required your licensed midwives (LM) to submit reports to them about each an every pregnancy and birth they provide care for.  These forms have been problematic for many reasons. They have required the LM to give AzDHS identifiable information about you and your care. Their format has changed multiple times with fields being added or subtracted  at whim. There has been no consistent or accurate method of compiling or evaluating the data collected. Rumor has it that at one point, AzDHS being uncertain of what else to do with the boxes of paper reports, simply decided to shred them. It is no wonder that these ‘data collection’ forms were useless when trying to evaluate the safety of home births in Arizona a couple years ago.

In an attempt to fix these problems, AzDHS did two things – they took your name off the form and called it de-identified information and they created an electronic reporting form. An electronic reporting form has the potential to be secure, objective, use drop down lists or fill in the blank leaving little room for error, could be easy to compile and easy to retain copies for records.  Finally the state would have an accurate and usable method of collecting statistics on Arizona home births, right? Wrong. Here are some of the many problems with the “new” and “improved” electronic reporting forms for Arizona midwives.

1. The format AzDHS decided to use is a public Survey Monkey form. Let me say that again, Survey Monkey. If the mall wants to ask you about which stores you most frequently shop at, if your employers wants to find out how much vacation time everyone in your office wants, or if  the local fast food wants to know if your prefer fries or hash browns, they use Survey Monkey. AzDHS has decided it is a good way to also collect sensitive health care information.

2. The reporting form is open for use by anyone who has the link. Here is the link. Feel free to follow the link and browse through the reporting form at will. See what questions AzDHS is asking about your care. Pretend play that you are a midwife and fill in the blanks on the report at this link with whatever information you would like.  Try it lots of different ways to get all 45 questions.  Need a midwife’s name and license number to fill in, look here. See the training guide, also publicly posted, if you run into trouble.

3. The only way AzDHS “de-identified” the form is by removing your name. Linking your birthday, your due date, your child’s date of birth included in the report with the birth certificates filed by your midwife will easily allow AzDHS to know your personal birth information.

4. The form still contains several options for narrative answers. One of the big complaints about the old reports was that they were not simple and objective enough to analyze data from. This problem will persist when narratives answer questions about poor outcomes.

5. The midwife is unable to keep a copy of the report submitted unless she takes a screenshot or prints each page for her records. Once “Done” is clicked, the form is off and gone.  The midwife has no proof of when she did the report, what answers she gave, etc.

6. Nothing in this form, the requirements for its submission, or the data gathered from it will help in “protecting the health and safety of clients,” as was claimed in the letter from AzDHS regarding timely submission. It is strictly for regulation of midwives, or to catch us not appropriately filling in details. Midwives are being penalized for incorrectly filling out the form or turning it in late regardless of reason.

7. This form, or any regulatory reporting form, is a poor substitute for careful evaluation of complications or complaints. AzDHS is incapable of the type of critical chart evaluation needed to ensure quality care and no type of form will fix that.

8. The majority of the midwives in Arizona begged the state to utilize the MANA statistics project instead of the midwife reporting forms as a way to collect accurate data midwife attended births in the state.  The state decided to attempt again to collect and analyze this data themselves.

9. Oh, and once a form is started, AzDHS can view whatever answers submitted. So that playing around on the form you did in #2 – yeah, they got that (and will have to spend staffing time and money on evaluating it).

10. There are many errors in the form’s make up that create situations where the midwife is forced to falsify data. For example, if a client transfers out of a midwifes care and there is not a complication (say they just decide to birth in hospital or move out of state at 28 weeks), the survey form forces the midwife to say which hospital, ems, physicians office or certified nurse midwife the client goes to and what the medical reason for transfer is. Many times we don’t know who the new care provider is and there may not be a medical reason for transfer.

I encourage you to look at the Survey Monkey reporting form yourself and decide whether you believe it’s existence improves your and your baby’s  pregnancy and birth outcomes. As a midwife, I am sorry that I am forced to submit your story to the health department, especially since you have no choice in the matter and it will come to no good end for me as a midwifery or for midwifery in general. If you are ready to take some concrete action against AzDHS’s increased regulation, write me an email at onearizonamidwife@gmail.com for some ideas.

Posted in Enforcement, Survey Moneky | 1 Comment

AzDHS “training” on coercion

So today, AzDHS held a three hour “training”. Here are some of the more confusing or interesting gems AzDHS gave today:

Our goal is compliance.

Midwives are supposed to let you know in informed consent at start of care that we have to force you to do certain things.

Our goal is compliance.

You must periodically have a vaginal exam. Period. Every time your midwife assesses your labor, she has to do a vaginal exam. Required. All clients, not just VBAC and breech. You cannot refuse.

Our goal is compliance.

If you are in labor and refuse a vaginal exam, we have to force you. We cannot leave you during labor but we also have to terminate care if you decide not to have a vaginal exam. How to resolve this conflict was never answered.

Our goal is compliance.

The survey monkey report is not for regulation, it is just for ensuring compliance with the rules. (Re read that several times if you want, it will not become clear).

Our goal is compliance.

All clients must get a syphilis test before 28 weeks, citing ARS 36-693. If you do not, we cannot legally continue midwifery care.

Our goal is compliance.

All clients have NO right to decline weight, bp, pulse, urinalysis, edema assessment, measurement of fundal height, listening to fetal heart tones,  and palpation to find baby position AT EVERY PRENATAL VISIT.

Our goal is compliance.

All clients must attend prenatal visits every four weeks until 28 weeks, every 2 weeks between 28-36 weeks, and weekly from 36 weeks until birth. Get sick, go on vacation, don’t feel like seeing your midwife today – too bad.

Our goal is compliance.

The survey monkey reporting form is for “quality data collection”. Ha!

AzDHS says they are not trying to audit charts. Hmmmmm, they just enjoy browsing through hundreds of your records?

AzDHS is claiming that administrative staff and a couple RNs are better at reviewing your charts than the midwives on the midwifery advisory board established in the 2013 rules rewrite.

Midwives are required to notify the closest hospital that you are in labor, and when your baby arrives, if the hospital policy requires. How your midwife is to know hospital policy is still a mystery.

Any call to 911 requires us to terminate care. Any transfer to the hospital or physician, with few exceptions, requires us to terminate your care. Even if you are stable. Even if EMS or the hospital says return to care with your midwife.

Which of the rules clients can decline were decided according to what determines high versus low risk pregnancies. Diabetes screening is optional, weight is not. Explain that.

If you have ever been diagnosed with a mental illness, you cannot hire a midwife. Stability doesn’t matter, documented diagnoses does. (Ever try to lose a diagnosis?)

There was a very blatant threat that if we mess with the survey monkey, they will yank our licenses.

We (AzDHS) didn’t do our job before. 🙂

Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.
Let us get back to you on that.

Oh and just as a side note, the best summary of the midwives response to the department was made by Paula Matthews, LM when she said,  and this is my paraphrase…

I think you would clear up a lot of confusion if you simply stated that you are NOT interested in safey, but only whether or not we follow the rules.

Posted in Uncategorized | 9 Comments

Bullet Point List of What You Cannot Refuse, By Request

There has been a request for a simple bullet point list of what your midwife is supposed to make you do under current AZ midwifery rules, so here you go. This list in no way reflects my views as a midwife about what should or shouldn’t be considered safe for home birth; it is simply a summary straight from rule of what AZ says is required for home birth midwives. Arizona Department of Health (AzDHS) will say that you of course have the right to refuse, which is technically true. You just do not have the right to refuse and keep your midwife. In order for your midwife to be in compliance, you must consent to the following:

During pregnancy
A syphilis blood test before 28 weeks gestation
Prenatal visits on schedule (every 4 weeks until 28 weeks, every two weeks from 28 weeks to 36 weeks, weekly from 36 weeks until birth)
A home visit before 35 weeks gestation
Weight at every prenatal visit
Urinalysis at every visit (apparently there is room to waive this in writing, although the form offered by AzDHS to do so only states before 28 weeks, what happens after that?)
Blood pressure at every visit
Assessment of your legs for swelling at every visit
Measuring your fundal height at every visit
Listening for fetal heart tones at very visit
Feeling for baby’s position at every visit
If you are having a VBAC or breech baby, be within 25 miles of a hospital
Not return to your midwife’s care if you transfer to a physician

Transfer to a physician if any of the following occur:
Uterine surgery in history other than allowed VBACs
More than one prior cesarean
Prior cesarean with unknown incision, classical incision or vertical incision
Prior cesarean with any complications including infection
Prior cesarean with 18 months of current due date
Twins, triplets or more
History of Postpartum Hemmorhage of unknown cause that required a transfusion
Insulin dependent diabetes
Placenta previa
placenta accreta
Deep vein thrombosis
Pulmonary embolism
Uncontrolled gestational diabetes
Rh disease with positive titers
Active Tuberculosis
Active Syphilis
Active Hepatitis until treated and recovered
Active Gonorrhea until treated and recovered
Preeclampsia or eclampsia persisting after the second trimester
A blood pressure of 140/90 or an increase of 30/15 above your lowest BP twice in a row;
Anemia in the third trimester
A pelvis that will not safely allow a baby to pass through during labor
Serious mental illness
Evidence of substance abuse, including six months prior to pregnancy, to alcohol, narcotics, or other drugs
Gestational age greater than 34 weeks with no prior prenatal care;
A gestation beyond 42 weeks;
Prior cesarean due to “failure to progress as a result of cephalopelvic insufficiency”
Complications during a previous vaginal delivery after a Cesarean section
If your baby has any anomalies confirmed by ultrasound
If you are a VBAC and your baby is breech

During labor
Transfer to the closest OB hospital in case of an emergency
Your midwife phoning that hospital to tell them you are in labor and when your baby has arrived, if that hospital wants a call from the midwife
An initial physical assessment
Checking your vital signs (blood pressure, pulse, respirations, temperature) every 2-4 hours
Checking fetal heart tones every 30 minutes in labor, every15-20 minutes when pushing, after your bag of waters opens, and with any change of labor pattern
Periodic vaginal examinations (not just for VBAC and breech. this is how AzDHS says we are to assess “contractions, fetal presentation, dilation, effacement, and fetal position”  for all clients.)
Monitoring urine output
Urinalysis for ketones every two hours
Not return to your midwife’s care if you transfer to the hospital

Go to the hospital if any of the following occur:
Active  Genital herpes at the onset of labor
Any baby position other than flexed cephalic, frank breech, or complete breech positions
Labor beginning before the beginning of 36 weeks gestation;
Progress at at rate of less than 1-2cm per hour (VBAC or breech)
Push for more than 2 hours if this is your first baby (VBAC or breech)
Push for more than 1 hour if this is your second or greater baby (VBAC or breech)
A blood pressure of 140/90 or an increase of 30/15 above your lowest BP twice in a row;
Presence of ruptured membranes without onset of labor within 24 hours;
Abnormal fetal heart rate consistently less than 120 beats per minute or more than 160 beats per minute;
Presence of thick meconium, blood-stained amniotic fluid, or abnormal fetal heart tones;

During Postpartum
1 minute and 5 minute Apgar scores on baby
Physical exam of baby for “abnormalities”
Inspection of your perineum, vagina and cervix (requires a speculum) for tears
Taking your vital signs (blood pressure, pulse, respirations, temperature) every 15-20 minutes for the first hour
Taking your vital signs every 30 minutes for the second.
Breastfeed with your midwife’s help
A complete newborn physical
Erythromycin eye ointment for your baby (can be waived)
Vitamin k shot for baby before 72 hours of age (can be recommended rather than given)
A postpartum visit between 24 and 72 hours after birth
Vital signs for you (blood pressure, pulse, respirations, temperature) at every postpartum visit
Vital signs for baby (pulse, respirations temperature, fontanels, weight) at every postpartum visit
Your midwife must submit a birth certificate within 7 days
Your midwife must file a report to AzDHS about your care
Complete all postpartum care within 6 weeks (now the Department is saying before 6 weeks, so 5 weeks 6 days is your limit with your midwife)
Not return to you midwife’s care if you transfer to the hospital

Go to the hospital if any of the following occur:
A blood pressure of 140/90 or an increase of 30/15 above your lowest BP twice in a row
A postpartum hemorrhage of greater than 500 milliliters in the current pregnancy
A non-bleeding placenta retained for more than 60 minutes
Your midwife uses medications to control your bleeding
Your midwife sutures a tear or episiotomy
Your midwife uses oxygen for you or your baby for any reason
If your baby is less that 2000 grams (4# 6.4oz) at birth
If your baby is pale, blue, or grey in color after 10 minutes
If your baby has excessive edema
If your baby has respiratory distress
If your baby has major congenital anomalies

Required consultations: In addition to the things you must agree to DO, the following is a list of things you are required to allow your midwife to discuss with a physician or nurse midwife if they come up in your care. I separated them out for ease of reading the above, as there are so many.

During Pregnancy
No fetal movement felt before 22 weeks
A positive culture for Group B Streptococcus
History of seizure disorder
History of stillbirth
History of premature labor
Have has more than 5 babies
You are younger than 16
You are having your first baby over the age of 40
Your midwife cannot hear baby’s heart before 22 weeks
Failure to gain 12 pounds by the beginning of 30 weeks gestation
Gaining more than 8 pounds in any two-week period during pregnancy
Greater than 1+ sugar, ketones, or protein in the urine on two consecutive visits
Excessive vomiting or continued vomiting after the end of 20 weeks gestation
Symptoms of decreased fetal movement
A fever of 100.4° F or 38° C or greater measured twice at 24 hours apart
Tender uterine fundus
Effacement or dilation of the cervix, greater than a fingertip, accompanied by contractions, prior to the beginning of 36 weeks gestation
Measurements for fetal growth that are not within 2 centimeters of the gestational age
Persistent shortness of breath requiring more than 24 breaths per minute, or breathing which is difficult or painful
Heart disease
Kidney disease
Blood disease
Positive test result for HIV
Positive test result for Hepatitis B
Positive test result for Hepatitis C

During Labor and Birth
An abnormal progression of labor
An unengaged head at 7 centimeters dilation in active labor

Second degree or greater lacerations of the birth canal
Failure of the uterus to return to normal size in the current postpartum period
You baby weighs less than 2500 grams (5#8oz)
Your baby has congenital anomalies
Your baby has an Apgar score less than 7 at 5 minutes
Your baby has persistent fast breathing
Your baby has an irregular heartbeat
Your baby has persistent poor muscle tone
Your baby is younger than 36 weeks or older than 42 weeks age by exam
your baby has jaundice within 48 hours
Your baby has abnormal crying
Your baby has meconium staining of the skin;
Your baby is lethargic
Your baby is irritable
Your baby has poor feeding
Your baby is excessively pink
Your baby does not urinate or pass meconium (Poop) in the first 24 hours
Your baby has a hip click or incorrect angle
Your baby has an uncommon skin rash
Your baby’s temperature stays below 97.6° F or above 99.0° F

Posted in Rights, Rules | 15 Comments

What can I do?

What can I do? I cannot tell you the number of times this question has been posed to me and other midwives by home birth clients. What can I do to help my midwife, the midwives, midwifery and home birth as the state of Arizona Department of Health Services (AzDHS) actively tries to eliminate legal midwifery under the guise of safety? To tell you the truth, beloved home birth families, we midwives may not know the answer. The number of midwives now under scrutiny by AzDHS now approaches half of the actively practicing midwives in the state, and we are scared. Daily, more and more midwives are receiving requests for charts. We are holding on by the seat of out pants. We need you home birth clients, midwifery consumers, to understand what battles AZ midwives are currently fighting, and we need you to fight for your rights to a safe, legal home birth in the ways in which you know (or can make up). Speak out, write letters, form groups, call AzDHS, support your midwife, protest. Demand a system that respects your choice to a midwifery model of care. This fight is about your rights to have the kind of care you want, it is not about our right to practice. We have no practice without you. Your midwives are tough women (midwives have to be tough) and we will continue fight for your right to have a legal option for a home birth with a midwife, and we are scared and we cannot fight this fight without you.

As we audit our own charts for compliance, we find again and again that it is impossible to be in compliance with AzDHS rules around midwifery. It is impossible because midwifery is being regulated as if there are not human midwifery clients on the other end, and as if the state’s method of “supervision” actually serves to make birth safer. We are being told to force you to comply with expectations of monitoring, testing, vaginal exams, vitals or to tell you that we cannot be your midwives. We are being told to walk away from you when you make a healthcare choice for yourself or your baby that is different than what is written in those rule. We are being told that we are never to see you again if you transfer to a hospital for a complication, or for pain relief, or just because someone has a gut feeling. We are finding that even in cases with no complications and clients who consent to all routine procedures and monitoring, our charts are still not “in compliance.”

As we fill out this ridiculous survey monkey form with information about your birth experience, we watch over each other’s shoulders trying desperately to determine how AzDHS will choose to interpret our answers. We make sure to remind each other to screen shot or print each page because that is the only way we have a record of what we typed. We anticipate the fines for a report that was filed after the 30 day deadline, knowing there is consistency and some midwives are being fined by the day, or by the incident, or an arbitrary number no one can puzzle out. We know with more and more certainty that this “data collection tool” is really just an attempt to nail us to the wall. We remind each other to refrain from snarky comments in comment boxes, even if we erase them because it turns out AzDHS sees all drafts as well as the final submitted form.

As we, one by one, or as a group try to communicate with AzDHS about this current climate of regulation and how it does not increase safety or promote midwifery, we are met with messages of ‘we will get you’ masked in nice statements about the health and safety of moms and babies. The department of special licensing in AzDHS regulates midwifery and has no idea what midwifery is, and that comes through in their responses. They assume we can and will bully you, dear midwifery clients, into complying. That if you want a home birth with a midwife bad enough, you will do whatever AzDHS tells us to tell you what is best. They assume that what you are looking for is the same kind of birth care you would get at the hospital, just without pains meds and at home. They assume you need them to protect you from the midwives (who they license as safe and knowledgeable health care providers and you hire because you trust).

Consider the sum of this situation. There is no way to provide good, safe, ethical midwifery care under current rule so all charts will reflect rules violations. AzDHS has created a convoluted reporting form for gaining access to your information so they can examine those charts and then hand out punishment for violations. AzDHS does not have staff providing this oversight who actually know what midwifery care is or make an attempt to assess judgements in clinical care. This combination is at best folly, and at worst a structured attempt at eliminating legal midwifery from the state of AZ. 

Beloved home birth consumers, you are the reason we are midwives, and you must be the ones to decide what kind of midwifery care you want and demand that systems are put in place that support your choices. When clients ask me, “Dear midwife, what can I do for you?” my response is “No, dear client, what can I do for you?”  What sort of midwifery system do you want, who do you want to be in charge of your birth, what can you do to build and support that system?

Posted in AzDHS, Enforcement, Rights, Witch Hunt | Leave a comment

The Letter, Part Two – Your midwife has to abandon your care if…

This is part two of a discussion around a letter to Arizona licensed midwives (LMs) from the Arizona Department of Health (AzDHS); you can read part one in the previous post which discusses AzDHS attempts to remove your right to refuse. Today, I want to discuss how this statement – “There is no circumstance when the midwife’s scope of practice or the required actions, such as transfer of care or prohibited practice, can be waived.” – forces the midwife to behave in an unethical manner, decreases safety, and actually can endanger you and your baby. Remember, midwives in AZ are not assessed on whether they provide quality clinical care to their clients or whether they make sound decisions during the course of care. They are evaluated on whether they follow rules, period, even when it does not make sense.

According to AZ midwifery rules, “‘Transfer of care’ means that a midwife refers the care of a client or newborn to an emergency medical services provider, a certified nurse midwife, a hospital, or a physician who then assumes responsibility for the direct care of the client or newborn” and midwives are not to “continue midwifery services for a client who has or develops” any of the more than 25 items listed in rule. AzDHS is counselling midwives who question the transfer of care requirements to abandon your care if you refuse to see a CNM, physician or go to the hospital for certain conditions. This is in direct conflict with the AzDHS mission to “improve the health and wellness of people and communities in Arizona.”

Limiting access to prenatal care providers likely decreases safety in general, and women may have very valid reasons for choosing an LM in spite of a complicated medical history. It is up to the midwife to practice ethically and only provide services she is competent to provide. It is up to the client to decide whether her situation means she is safer at home with her chosen midwife than in the hospital. Many of the state’s restrictions on midwifery care are problematic, remove your right to choose to have licensed midwife to attend your birth at home, may create a dangerous situation if you are unable to secure a new care provider, yet they are not often urgently unsafe. Some of these conditions are in your medical history or occur during pregnancy with plenty of time for you to find another care provider (hospital based CNM, physician, another LM willing to continue care illegally).

However, there are a few common situations in which the AzDHS requires transfer of care in a way that clearly mean that your midwife must abandon your care regardless of your wishes, safety, and good continuity of care. Abandoning care is rarely the way to “improve the health and wellness of people and communities in Arizona.”  Here are a few of the more extreme examples of the requirements for abandoning care spelled out in the AZ midwifery rules:

  • If you are having a breech baby or a vaginal birth after cesarean, your labor progress must adhere to Freidman’s Curve, dilating 1 cm per hour if this is your first baby and 1.5-2cm per hour if it is your second or later baby. If you vary from this highly critiqued and inaccurate measure of progress, you must be transferred to the hospital.
  • If your pregnancy extends beyond 42 weeks, your midwife must terminate your care. If you call her in labor at 42 weeks and 1 day, she cannot legally come to your house. Your choices are to birth unassisted, hope your midwife has a collaborative relationship with an OB/CNM practice who will take over your case, or appear in an emergency room in labor and get whatever care provider is currently on staff.
  • If your bag of waters opens, you have 24 hours to begin labor until your midwife is to transfer your care. This is in spite of research that shows no increased risk of infection or complications in the absence of vaginal exams and induction methods. If more than 24 hours passes without contractions, even if you and your baby are doing just fine, your midwife can no longer attend your birth.
  • If you have a postpartum hemorrhage, your midwife calls EMS and treats you with medications until they arrive. If you are stable when EMS gets to your house and no longer bleeding, EMS may recommend that you stay home. Your midwife has to walk away – she is not longer able to treat you if you decide not to go to the hospital.
  • If your placenta takes more than 60 minutes to deliver, your midwife must transfer our care. Regardless of whether there is any immediate danger to you, regardless of a lack of bleeding, regardless of reason for your placenta taking its time. Your midwife is to call 911 and walk away as soon as EMS arrives.
  • If you transfer to the hospital during labor for any reason at all, your midwife is no longer able to see you as a clinical care provider for the remainder of your postpartum period. The hospital may tell you to follow up with your midwife; your midwife is not allowed to provide care.

Are you a midwifery client who has had to transfer to a medical care provider against your wishes? Are you a midwife who has had to terminate care of a client even when clinically it would have been better to continue care? Did your midwife continue care in spite of legal requirements to walk away? Take a minute to review the AZ midwifery rules and see if you can imagine yourself in a situation that requires your midwife to transfer your care. Does this way regulating home birth make you feel safe? I look forward to hearing your responses and reactions. Remember to protect your selves and your midwives by omitting any identifying information when sharing stories.

Posted in AzDHS, Enforcement, Rights, Rules | 3 Comments

The Letter, Part One – You have no right to refuse the following.

In mid May, all licensed midwives in the state of Arizona received a letter attached to an email from the Arizona Department of Health (AzDHS). This letter was a reminder that we midwives best be certain we are adhering to the rules or there will be consequences. It was a formal warning of the prosecutory process that has already begun.  There are so many pieces to this communication that need to be addressed, such as the threatening tone via statements like “in an effort to make sure you are all in compliance…,” or the importance placed on submitting timely reports (which in the past AzDHS stuffed in a box, or used for poor data analysis, or used as they are now doing to regulate midwives) or the way in which the letter implies that AzDHS is looking out for the safety and well being of parents and babies by enacting monetary fines on midwives.

You can read the letter your self and as you do, think of your rights as a home birth midwifery consumer. The reason I suggest you focus on your rights as a consumer is that the biggest piece of this letter that deserves A LOT of attention is the second bullet point which reads… “Second, rules cannot be waived. It is clearly spelled out in rule the circumstances in which clients have the rights to refuse certain tests. There is no circumstance when the midwife’s scope of practice or the required actions, such as transfer of care or prohibited practice, can be waived.”

As it stands now there are a slew of tests and procedures you must do in order to have a midwife be your legal prenatal care provider, attend your birth, or provide postpartum care and be in compliance with the rules. The only legal option if you want to decline certain testing and procedures is to not plan a home birth with a licensed midwife. Luckily, most midwives have more respect for you than they have had concerns for the state’s prosecution, so they give you the space to decline and will still provide care for you. However, now the state is targeting those midwives and your midwives run the risk of fines, license suspension or revocation by allowing you your legal right to refuse. Knowing this, in an effort to protect your midwife, you might consent to some routine procedures you would normally not do and for that your midwife will thank you, but it doesn’t come close to solving the problem.

It is one thing to limit midwives scope of practice (say, tell midwives they cannot perform surgery because they are not surgeons, or that they should not be administering narcotic pain medications, or that tools such as forceps are not appropriate for home births) and it is another thing all together to remove your rights as a midwifery consumer to decide what tests, procedures and medical care you want for your body. That is an infringement on your autonomy.

As midwives, according to AzDHS, We are supposed to force, coerce, manipulate, beg you to do quite a few ‘routine’ things, not allowing you any room for refusal.  This is contrary to the concept of shared decision making that is an impotant part of the midwifery model. During pregnancy, you are to follow a routine prenatal visit schedule including a home visit before 36 weeks gestation; you must have a syphilis blood test; at every visit your midwife is to take your blood pressure, weight, fundal height, listen to fetal heart tones, assess your legs for edema, and test your urine. During labor, your midwife is to check your vital signs every 2-4 hours listen to fetal heart tones every 15-30 minutes, test your urine and monitor your urine output, and do periodic vaginal exams. After birth, we are to look at your vagina, perineum and cervix for tears, check your vitals and massage your uterus every 15-30 minutes, help you pee, help you breastfeed, put antibiotic eye ointment in your baby’s eyes, give your baby vitamin K injections, and do a newborn blood spot screening by pricking your baby’s heal. Feel free to read the rules surrounding midwifery in Arizona.

This removal of your right to refuse has been addressed with AzDHS by your midwives many times. We ask, what if a client has a history of an eating disorder and stepping on the scale triggers previously traumatic events? What if a client sincerely knows she is not at risk for sexually transmitted infections and does not want syphilis testing? What if our clients have done their research and decided that they do not want their baby to have antibiotics placed in their baby’s eyes at birth, a vitamin K injection, or newborn heal prick? What if you miss your weekly prenatal visit because of a family emergency? What if the midwife has no reason to inspect a cervix for tears? What if the client does not want vaginal exams? What if the client has asked for an hour alone with her partner during labor and declines fetal heart rate monitoring during that time? How do we comply with a home visit before 36 weeks if a client transfers into care at 37 weeks? Their answer to all of these and other similar questions has been, essentially, that by choosing a licensed midwife you waive your rights to decline or choose with the exception of a certain few things.

As a midwife, I must argue that some of these required tests and procedures make a lot of sense and it is hard to imagine a midwife who does not want to monitor your or your baby’s well being, and many are outdated, not current standard of practice, or not based in research.  Yet, that is not the point. The point is that it is YOUR choice whether or not to agree to tests and procedures and if you refuse, your consequence should not be that you loose your midwife or that she runs the risk of penalty from a state regulatory agency for allowing you to refuse.  Your midwife should simply document the informed choice you have made and continue providing the best clinical care she can under the circumstances of your refusal. You would be allowed this right if you were birthing in the hospital and you should be allowed the same rights if you are birthing at home with a licensed midwife.

Part two of this post will discuss how not allowing rules to be waived sometimes forces the midwife to behave in an unethical manner, decreases safety, and actually can endanger you and your baby.

Posted in AzDHS, Enforcement, Rights, Rules | 7 Comments