AZ Midwives – Scope of Practice

Background: Arizona midwives are in transition right now – where the state of midwifery ends up at the end of this transition will affect thousands of mothers, fathers, and their babies for so many years to come.

Arizona has had licensed midwives since 1978 (yes, they have only been legally recognized for 35 years) and there is a VERY LONG list of rules and regulations (R/R) that govern those midwives who are licensed. This list of R/R is what states what a midwife is allowed to do as a midwife…but, equally as important, it states what licensed midwifes (LMs) may NOT do as an LM.

These R/R have not been updated in about 15 years and therefore have not kept current with evidence-based practice in obstetrics – haven’t been fluid enough to conform to new ideas and discoveries.

To put it simply….the fact that the R/R are being revisited in Arizona is a BIG DEAL. It means that consumers (mothers) and midwives are fighting to expand our scope of practice, and the medical community is coming out in force to try and restrict the LMs in Arizona.

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My Summary of Last Night’s Advisory Committee Meeting

WillHumble

Will Humble, Director of the AZ Dept of Health

First I’d like to give a big thumbs up to Director Will Humble – who gently guided the meeting with respect as he listened to both sides present their findings, concerns, and opinions.

 

The main portion of the meeting began, and they didn’t get two slides into their powerpoint before it was effectively brought to a screeching halt. The largest controversy was the proposed expansion of the R/R to allow for LMs to legally attend the homebirth of VBACs (Vaginal Births after previous Cesarean Section), twins, and breeches. The proposed draft suggested implementing a requirement that each mother wishing to have a homebirth VBAC be required to consult with an OB and get a form (provided by the state) filled out and signed as proof that they visited with the OB and therefore understand the decision they are making.

Consumers on the panel argued it was insulting to require them to get this form as it’s insinuating that they aren’t bright enough to do their own research and make their own decisions. Besides, they have a care provider (LM) who can provide the same level of informed consent (education) that an OB would be able to provide.
Midwives on the panel argued that it’s an unobtainable requirement as no OB will ever sign that form due to liability concerns – therefore it continues to render VBACs illegal for LMs to attend.
OBs on the panel argued that VBACs can go tragically wrong very quickly and should always be done in a hospital regardless – and the fact that the birth certificates submitted by homebirth midwives shows that most of their clients are “self-pay” demonstrates that they are probably less educated, less professional, and less likely to be able to understand the research as well as the two consumer members of the panel who are educated professionals.

This type of lively discussion continued for well over an hour. Very little was agreed upon.

Finally, Director Will Humble opened the meeting to public comments (for those who had indicated upon entering that they wished to speak and submitted the form for it). Again, the division was clear…medical representative, one after the other, proudly stating they are the director of this group or the chairman of that medical group, stood to say that they have seen HORRIBLE things at the hospital, and if you’ve just seen these terrible things you’d know that births belong in hospitals!

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MY RESPONSE

I didn’t get a chance to speak, so I share my response here.

First and foremost, it greatly disturbs me how we so easily fall into the “us vs. them” division. Ladies and gentlemen – OBs, nurses, CNMs, LMs, Neonatologists, Perinatologists, NDs, DOs, MDs……..we are on the same team!! Do we not all have the same goal here? The best outcomes for moms and babies? If you think anything else, then please step back as I think you need to reapproach this topic from a completely different angle. Midwives don’t want emergencies or bad outcomes…neither do doctors.  Most importantly, neither do mothers!

Irestrictionst is being argued by the medical establishment, homebirth isn’t safe. Their answer to this problem – is to make it less safe by imposing greater restrictions as to what midwives can do. Do you really believe that restricting our access to emergency medication is in the patient’s best interest? Do you really think that making transporting to the hospital challenging and adversarial is in the patient’s best interest? Do you think that you are protecting women by making LMs unable to attend VBACs at home? Do you think that the choice here is homebirth or hospital birth? It is NOT! That is not the choice that this group of expectant mothers are considering!! They are considering an LM assisted homebirth VBAC or an UNASSISTED VBAC. Are you really arguing that if someone makes the decision to have a VBAC at home – because you disagree with it then you will make it your mission to make it as dangerous as you possibly can by removing a medical professional who can monitor heart tones, who can resuscitate a baby, who is trained to recognize the signs of problems…? That it is in THEIR best interest to ensure they have an unassisted birth rather than a midwife assisted birth?

Time and time again the medical community stood and described tragic outcomes they have seen, emergency situations that have occurred on their watch in the blink of the eye and how this demonstrates that births belong in hospitals – especially VBACs.

To all of those who stood I would ask this simple question: Have you ever seen a homebirth?

*crickets*
Why not?

Let’s compare and contrast for a moment…please. Indulge me.

Hospital births – deal with inductions, analgesics, anesthesia (epidurals), and many routine interventions that hinder the birthing process such as routine vaginal exams and in-and-out care providers as they care for 2-6 patients at a time.

Home births – one care provider (midwife) in constant presence with one patient in an unhindered unaugmented birth without interventions that increase risk.

OB_Epidural

An epidural – way too dangerous to do in a homebirth! But dangerous enough to restrict a woman’s right to choose one?

With all due respect to the members of the medical community who stood to speak out about the dangerous of homebirth because of what you’ve seen at your hospitals…. I agree with you!  The births as they occur in hospitals…I agree that *those births* are too dangerous to do at home!! That is why that is not our model of care. We aren’t bringing the risks into the home – we keep it as low risk as possible. Elective induction increases risk. (if it’s for medical reasons then it doesn’t matter where she intended to birth…she’d be in a hospital) Epidurals increase risk. Augmentation of the labor increases risk. (again, if it’s for medical reasons then the original intended place of birth is irrelevant as she’d be in the hospital being augmented) Having one care provider responsible for 3-4-5-6 people at the same time increases risk.  I think that the types of births you are used to would be INCREDIBLY dangerous to attempt at home!!

That is not what these mothers are doing.

I actually think that this argument is missing the point, however. We can argue all day about where it’s safest to give birth – but that diverts us from what I feel should be the TRUE discussion I think we need to be having….that is: when should a woman be allowed to choose risk? Do we respect woman’s autonomy when it comes to her body and her birth or not? She’s smart enough to choose an epidural and understand the risks/benefits that may come with that…but not smart enough to choose a VBAC and all of the risks/benefits that may come with that. We respect her enough to allow her to induce her 39 week pregnancy because her husband is being deployed overseas and wants to meet his baby before he leaves….but we don’t respect her enough to allow her to have a homebirth VBAC in the name of safety (and then will make it less safe by refusing to allow a care provider to be with her).

She can choose to ‘labor at home as long as possible”….but the thought of doing so with a midwife is somehow scary to them? Many CNMs and OBs have told VBAC mothers to just labor at home as long as possible to avoid many of the interventions of the hospital that they are hoping to avoid….so they are okay with that mother not getting to the hospital until pushing, but aren’t okay with that mother being monitored at home and just birthing at home because the risk of a catastrophic rupture is too great?

There seems to be this misconception in the medical community that what they see in hospitals is equal to what we are seeing in homebirths….and it’s simply not accurate. There are increased risks at every turn at the hospital, and we decrease those risks to the barest minimum at home. Lower infections due to less antibiotic resistant strains around a person’s home. Lower infections due to fewer invasive procedures like vaginal exams, breaking their water, episiotomies, and c-sections. Lower risk by providing one on one care. Lower risk by not introducing drugs into the process – either to induce or augment, or to provide pain relief.  We simply aren’t doing hospital births at home.

What you see at a hospital is NOT what we see at home…and our outcomes show that.

While I criticize you for not having any experience in homebirths before passing judgment – let me state that for 12 years I witnessed births exclusively in hospital settings. For 12 years I saw us introduce risk, then try and minimize what we just did. I’ve seen the hospital side and can truly understand why, if that’s all someone has seen, that they would be scared when they think of THOSE births being done in the home! But I would bet money that not a single “medical professional” who stood up to speak at the meeting had ever seen a homebirth.

ER2I also heard time and time again how hard it is on the medical professionals to receive the homebirthers who transfer to the hospital…how hard it is to see these “trainwrecks” (derogatory term, btw) come in ‘off the street’ and have to care for them. I ask you this….what other area of medicine has this complaint? Are there doctors in the ER complaining that they only see car drivers when they wreck? That they wish that the skier had called before taking to the slopes and not wait until they actually broke their leg? In what other area of medicine do they get upset at receiving the patient when there’s a problem?

None.

0NDRI4XH1emergencyEvery other area of medicine is expected to ONLY be there when there IS a problem! Obstetrics is the only time in our lives that we are expected to check ourselves into the hospital while totally healthy…the only area of medicine in which they complain when something goes wrong that you should have already been in the hospital. And that only happens during labor…because presenting to the hospital at 32 weeks for preterm labor doesn’t make them mad. Presenting to the hospital at 34 weeks because you are throwing up and can’t stop doesn’t make them mad. Presenting to the hospital at ANY OTHER TIME IN OUR LIVES when there is a problem doesn’t get them upset. The one instance is in labor. If you are in labor and present to the hospital because you have a problem then and only then they get upset because you should have been there sooner.

But my bottom line is this:
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I support a woman’s autonomy and respect her intelligence. I think that the woman should have the right to determine what level of risk she wants to assume when it comes to her birth. I think that the woman should be able to choose an epidural on demand or a homebirth. She should be able to choose an elective repeat cesarean or a VBAC at home.

At the beginning of this blog post I stated that we are all on the same team! We all want a good outcome!
I also believe STRONGLY that nobody wants a good outcome more than the mother does. Nobody. If she makes a decision – whether I agree with it or not – it is her decision to make. Why punish her? It’s not our family, it’s not our baby, it’s not our body. We should be there to help her…and make whatever she chooses as safe as it can be for her and her baby. She wants an epidural? Fine – but ensure a sterile field, good training for anesthesiologists, training for nurses dealing with epidural labors. She wants a homebirth VBAC? Fine – but ensure she has a trained care provider with her, monitoring her and the baby.

Who is this about? Is this about the medical establishment? About the midwives? How very arrogant we are to take that approach.
It’s about mothers and babies and families and I implore everyone to keep that in mind. Lets keep safety and respect foremost in our minds as we proceed forward. If the OBs and midwives fight and argue over territory then I believe they are demonstrating the biggest problem in obstetrics today – it’s not our territory to fight over. It doesn’t belong to either one of us – it belongs to the mother. Please, lets work together to make it as safe as it can be for her.

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