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.

About One Arizona Midwife

I am a currently practicing, licensed midwife (LM) in Arizona.
This entry was posted in AzDHS, Rights, Survey Moneky, Uncategorized. Bookmark the permalink.

11 Responses to Midwifery, the law, and ethics

  1. Bethany says:

    I 100% agree with your point that ethical and legal are not always the same. I also agree that often, ethics trump legality, and I fully support midwives who choose to act in an ethical manner in order to care for and protect clients, even at the sake of their actions being illegal.

    I don’t disagree with civil disobedience altogether and I don’t disagree with doing *something* to take a stand. There is nobody is their right mind who is not an employee of AzDHS that would say these regulations and their interpretations are fair, ethical, or make any sense whatsoever (and I have to wonder how many DHS employees *actually* believe in what is being done here). Nobody is arguing that they are midwife regulation and not patient protection.

    The unethical part about the protest, though, is putting midwives’ licenses (and their businesses, and their incomes, and their families, and their legal status) on the line because of the civil disobedience. It’s assuming that all midwives are comfortable with that action and potentially causing them punishment for something they didn’t do. If each midwife wants to send the false reports, then by all means. I won’t say you’re acting unethically at all! But submitting the reports in someone else’s name is unequivocally unethical, in my opinion. That’s the other part about ethics– they are subjective. We don’t all share the same set of ethics or views on what constitutes ethical behavior. Until DHS sorts this all out, they don’t know which submissions are true and which aren’t, and that leaves room for negative consequences in the meantime passed onto women who had nothing to do with this. It’s like framing someone for a crime they didn’t commit, which I find hard to argue in favor of in terms of ethics.

    I know the frustrations we all have. I get how absolutely asinine these “regulations” are. I want to do something to fight it, to fix it, to make it stop. But I, personally, cannot be involved in this. I don’t blame those who choose to be, but I would urge them to consider whether, if the tables were turned, they would want someone putting them in the same spot. Midwife or not.

    • Hi Bethany. I hear you, really I do, and by no means should anyone uncomfortable with this action participate. One of the main points is that this system of reporting leaves midwives open to just such false reporting. I’d rather that point be made en masse and have AzDHS see that they need to develop a more fair process of supervision, or at least spend the minimal time and money it takes to password protect the site. If midwives submit false reports on their own behalf, they are in violation and do risk their licenses. If someone else submits a false report under a midwife’s name, I would hope that midwife would legally fight any accusations made by AzDHS. Those accusations would be unfounded and I’m sure the homebirth consumers and the media would have a hay day with midwives be held liable for reports on clients they did not ever have.

      • Angie Bond says:

        Using the consumer to make a point you won’t make yourself for fear of your license is absurd and cowardly. What the media would have a field day with is the stupidity of falsifying reports. I am assuming that you have gone to the media with consumers wanting to raise hell about the insecurity of their records? I have been asked on no less than 5 occasions to reach out to the media contacts that I have, which I have done, and in EVERY SINGLE CASE the midwives making those requests have refused to speak about their objections. Consumers have failed to show for the agreed upon times to tell their stories. Now it is expected that folks should believe media attention is wanted? Not buying it. Where are the pieces submitted to local papers, and stories submitted to news stations? Where is the youtube channel of individual stories of the abuses of AZDHS? Seemingly, these outlets have been ignored in favor of an action meant to be undertaken in a way that NO ONE is going to see, unless AZDHS wants it seen. This is not civil disobedience. It is cowardice.

    • Angie Bond says:

      I completely agree, Bethany. It is absurd to believe that it is right or ethical to endanger the licenses of midwives and care of families in Arizona. To what, to make a point? Certainly not the kind of point that *I* want made on my behalf as a home birth supporting consumer.

  2. julie finneaus says:

    My problem with the protest was that it devalues our arguments. In my eyes, it reduces us to the equivalence of spiteful children (it gives our opponents an opportunity to say, “See? you guys are out of control.”) Now, I’m walking a fine line here because I don’t know what else can be done. We literally have our hands tied, and are certainly backed into a corner. But if our main concerns are the new ways the rules are being interpreted, why use this as a vehicle for our dissent? It doesn’t make a lot of sense to me. If I was them right now, I’m certainly NOT thinking that we’ve made a good point and that I’m going to start thinking of ways to try and help us. I’m angry, and I’m not feeling very forgiving.

    I think civil disobedience is absolutely the right idea when a group of people are being discriminated against, which we are. But to think that this protest would have any other outcome than making them mad as hornets is absolutely absurd. And if that’s the case, then we’ve done nothing but hurt ourselves.

    My prediction is that this will result in more headaches for the home birth/midwifery community- not less. We need to come up with a better idea next time.

    • Diana says:

      Hi, One Arizona Midwife!

      I don’t know your identity, but I know you’re an Arizona midwife, so I already love you. 🙂 THUS, I hope that you will take the fact that I disagree with the above action discussed as a statement of friendship rather than spite.

      I agree with Julie’s comments above.

      “My problem with the protest was that it devalues our arguments. In my eyes, it reduces us to the equivalence of spiteful children (it gives our opponents an opportunity to say, “See? you guys are out of control.”)”

      A few points:

      (1) This action makes us look spiteful and out-of-control. It gives our opponents the feeling of self-justification when they say, “See? We told you so! These people need to be controlled! We need more regulation of licensed midwives!”

      (2) I have no problem with civil disobedience when it is necessary. But this seems to be more along the lines of toilet-papering the enemy, rather than thoughtful acts to make a point. It just makes the opposition angry while making us look bad at the same time.

      (3) I am not a midwife; therefore my viewpoint is extremely skewed. But don’t we have more important things to focus on first? It seems that issues such as mandated coerced tests/procedures and mandatory/coerced client abandonment are the true meat of the issue. Yes, the Survey Monkey thing should be taken care of (and according to one comment here, it has been now?), but it seems like that is a very minor issue.

      I would prefer to take all of the actions that have the potential to achieve results while also protecting the birth community’s reputation and image. For example:

      – Facebook action (making a concerted effort to share pertinent articles)
      – Interviews with the media
      – Articles with the media
      – Protests and rallies
      – Letter-writing campaigns
      – Phone call campaigns

      For example, what if you had asked the entire birth community – instead of putting in false reports – to stage a phone call campaign this past Monday, i.e. every single member of the birth community make a phone call to Director Humble’s office to request a secure method of making reports? Or another phone call campaign to protest various civil rights violations now mandated by the state of Arizona upon birthing mothers? Requests like that would both protect the community image and take much less time (rather than the hours upon hours that the false-report project would take each participant).

      The main (long-winded) point here is that I would prefer to combine effective activism with protecting the community image. If we act in ways that make us look badly, both to the media/public and to the state health department, it seems that the end result will be both damaged relationships (“Those midwives, they’re always causing trouble – we ought to do something about getting rid of them”) and short-term anger/annoyance – even if we do manage short-term gains.

      Thanks for listening!

      • Hi Diana. Thanks. I realize that some may interpret this as being out of control. Obviously, I disagree. I think your list of alternative ideas are all great. Please, please, please put them into practice. The reason I decided on promoting this action as opposed to another was not to throw a fit or “toilet-papering the enemy,” but rather for the specific administrative impact it would have on AzDHS. Phone calls, letter writing, protests, etc have their place but they don’t have much impact on the day to day operations of the health dept. They don’t impact their budget enough for them to pay attention. I agree fully with your third point that the rules must be changed to allow midwifery clients free choice in their healthcare. Until that happens, the problem midwives face is in the interpretation of the current rules and the use of the survey monkey reporting form as a means to seek out and find even the smallest violation of those rules. Rules that make it impossible, in their current interpretation, to practice legally. The survey monkey reporting form is a policing tactic by AzDHS and therefore a large issue in the fight for midwifery care in AZ. Again, I appreciate your other ideas for bringing awareness and encourage you to implement them. Thanks for your thoughts.

  3. Leia says:

    Who is in charge of AZDHS? I feel like using Survey Monkey is totally a violation of HIPPA and should be stopped at once!

  4. Will Humble says:

    Hi…

    My name is Will Humble and I’m the Director of the AZ Department of Health Services. Our initial information technology application for electronic report does, in fact, use Survey Monkey. There are no confidential fields at risk, however, we have recognized that we need a more contemporary/sophisticated tool for electronic reporting for Certified Professional Midwives (CPM).

    We’ve had a number of competing information technology priorities as an agency, which has delayed our implementation of a new CPM reporting database. We have recently completed some intensive I.T. initiatives (backup data centers, electronic medical records at the Arizona State Hospital etc.), and our new reporting application for certified professional midwives is being developed now and is scheduled to go live by the end of the year. It will have a secure password, will be able to be used with various browswers, and have a print feature.

    will

  5. Lori says:

    I would like to know what the results of this weekend activities were. Does One Arizona Midwife feel the actions were successful? How are you able to gauge this?

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