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Midwife Licensing Program
Midwife Licensing Rules Frequently Asked Questions (FAQs)
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Please click on the questions below to see their answers.
What is the difference between a statute, a code, and a rule, and how do they relate to laws?
A "statute" refers to an element found in the Arizona Revised Statutes (A.R.S.) which are literal laws that have been passed by the legislature. A "code" refers to elements found in the Arizona Administrative Code (A.A.C.) and they are often referred to informally as the licensing "rules". Codes, or rules, have the same force and effect as state law.
When exactly did the new licensing rules go into effect?
Rules are formally called the Arizona Administrative Code (A.A.C.), Title 9, Chapter 16, Article 1. Technically, new midwifery rules went into effect on July 1, 2013, but certain sections of the code will not be fully implemented until some specific things have taken place. Therefore, the new rules have three distinct "go live" dates which are as follows:
- As of July 1, 2013 the following rules were in effect:
- R9-16-101 through R9-16-107 (the administrative sections)
- R9-16-108, midwife's responsibilities; scope of practice: §§(A), and (C) through (H)
- R9-16-108(I) §§ (1) &: ( 2)
- R9-16-108(I)(5) through (9)
- R9-16-108(J)(1), (3), (5), and (6)
- R9-16-108(K) & (L)
- R9-16-111, Prohibited practice, Transfer of Care: §§(A) & (B) and (F) through (I)
- R9-16-112, Required Consultation
- R9-16-113, Emergency Measures
- R9-16-114, Midwife Report after Termination of Midwifery Services
- R9-16-115, Client and Newborn Records
- R9-16-116. Denial, Suspension, or Revocation of License; Civil Penalties; Procedures
- While R9-16-117, Midwifery Advisory Committee is technically in effect (we have been accepting applications since Jul 1, 2013, and decisions about membership appointments will be made on or before August 30, 2013) their initial work will be to develop the informed consents for a client to waive critical tests and their due date for those consents has been set for October 1, 2013.
- R9-16-108(I)(3) & (4)
- R9-16-109. Informed Consent for Midwifery Services
- R9-16-110. Assertion to Decline Required Tests
- R9-16-108 Subsections (B), (C)(1)(b), (C)(1)(d) and (J)(2) and (4).
Where can I find a copy of all applicable statutes and rules?
- A.R.S. Title 36, Chapter 6, Article 7
- A.R.S. Title 32, Chapter 32, Article 1 § 32-3211
- Arizona Administrative Code (A.A.C.) Title 9, Chapter 16, Article 1
Note: The new rules have not yet been published in the A.A.C., so an unofficial version of the rules is provided in the meantime.
Is the Survey Monkey® tool used for birth reporting secure? Is it HIPAA compliant?
Although Survey Monkey® is not secured, a Licensed Midwife enters data that is coded to a file number, the identification of which should be held in confidence by the Midwife and made available to the Department only upon request. Therefore, since nothing being entered can be identified to a specific person, the reporting tool does not need to be encrypted or in any other way made secure.
The Survey Monkey® for filing birth reporting asks questions to which Licensed Midwives may not have answers. What should be entered in those fields?
The Survey Monkey® tool has been altered so that if a Licensed Midwife does not have the required information, the field can be left blank and the system will still proceed to the next data entry screen.
What has happened to the Preceptor Affidavit for which signifies who is functioning as an apprentice under a Licensed Midwife? Are Licensed Midwives required to notify the Department of an apprentice?
All Preceptor and Apprenticeship qualifications and forms will now be issued through the North American Registry of Midwives (NARM). Licensed Midwives are NOT required to notify the Department of an apprentice.
How will Licensed Midwives complete the birth reports now?
Licensed Midwifes are required to use the Midwife Reporting Form that the state has developed to report home births.
How will Licensed Midwives file a birth certificate?
Licensed Midwives will continue to file birth certificates as they always have by submitting a completed Certificate of Live Birth. The signed worksheet MUST be submitted to the County Vital Records Registrar within 7 days after the birth in the county in which the birth occurred. Example a Maricopa County birth would be submitted to the Maricopa County Vital Registration office, etc.
Can a Licensed Midwife use the MANA stats project to report data on home births?
Midwives are required to use the Midwife Reporting Form. However, a Licensed Midwife may elect to also report home births using the MANA stats project so long as doing so is done under informed consent of the parent(s) and the system in HIPAA complaint or neutral in so far as personal health information is involved. If the Licensed Midwife does report births to the MANA stats project they MUST still report them directly to the Department using the Midwife Reporting Form
What are the circumstances under which a Licensed Midwife is required to obtain a medical consultation?
Licensed Midwives MUST obtain a consultation from a medical practitioner under the following circumstances:
- Any time a client is determined to have any of the following during the current pregnancy:
- A positive culture for Group B Streptococcus;
- History of seizure disorder;
- History of stillbirth, premature labor, or parity greater than 5;
- Age younger than 16 years;
- A primigravida older than 40 years of age;
- Failure to auscultate fetal heart tones by the beginning of 22 weeks gestation;
- 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;
- 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;
- Second degree or greater lacerations of the birth canal;
- Except as provided in R9-16-111(A)(20), an abnormal progression of labor;
- An unengaged head at 7 centimeters dilation in active labor;
- Failure of the uterus to return to normal size in the current postpartum period;
- Persistent shortness of breath requiring more than 24 breaths per minute, or breathing which is difficult or painful;
- Heart disease;
- Kidney disease;
- Blood disease; or
- A positive test result for HIV, Hepatitis B, or Hepatitis C.
- Any time a newborn demonstrates any of the following conditions:
- Weight less than 2500 grams or 5 pounds, 8 ounces;
- Congenital anomalies;
- An Apgar score less than 7 at 5 minutes;
- Persistent breathing at a rate of more than 60 breaths per minute;
- An irregular heartbeat;
- Persistent poor muscle tone;
- Less than 36 weeks gestation or greater than 42 weeks gestation by gestational exam;
- Yellowish-colored skin within 48 hours;
- Abnormal crying;
- Meconium staining of the skin;
- Poor feeding;
- Excessively pink coloring over the entire body;
- Failure to urinate or pass meconium in the first 24 hours of life;
- A hip examination which results in a clicking or incorrect angle;
- Skin rashes not commonly seen in the newborn; or
- Temperature persistently above 99.0° or below 97.6° F.
What happens if a Licensed Midwife does not obtain a medical consultation when required?
Licensed Midwives who fail to obtain medical consultation when such is required will be cited for violating A.A.C. R9-16-112 upon discovery by the Department. Such violations will likely result in an automatic referral to the Department's Enforcement Unit and an investigation may be opened requiring the Licensee to disclose all or some of their client files in order to determine the scope and severity of the violation. The scope and severity of the violation is used in determining what, if any, action will be taken against the license.
What are the circumstances under which a Licensed Midwife is required to transfer care a medical practitioner or medical setting?
Licensed Midwives MUST transfer care to a medical practitioner or medical setting under the following circumstances:
- Any time a client has or develops any of the following:
- A previous surgery that involved:
- An incision in the uterus, except as provided in R9-16-108(B)(1); or
- A previous uterine surgery that enters the myometrium;
- Multiple fetuses;
- Placenta previa or placenta accreta;
- A history of severe postpartum bleeding, of unknown cause, which required transfusion;
- Deep vein thrombosis or pulmonary embolism;
- Uncontrolled gestational diabetes;
- Insulin-dependent diabetes;
- Rh disease with positive titers;
- Genital herpes at the onset of labor;
- Hepatitis until treated and recovered, following which midwifery services may resume; or
- Gonorrhea until treated and recovered, following which midwifery services may resume;
- Preeclampsia or eclampsia persisting after the second trimester;
- A blood pressure of 140/90 or an increase of 30 millimeters of Mercury systolic or 15 millimeters of Mercury diastolic over the client's lowest baseline blood pressure for two consecutive readings taken at least six hours apart;
- A persistent hemoglobin level below 10 grams or a hematocrit below 30 during the third trimester;
- A pelvis that will not safely allow a baby to pass through during labor;
- A serious mental illness;
- Evidence of substance abuse, including six months prior to pregnancy, to one of the following, evident during an assessment of a client:
- Narcotics, or
- Other illicit drugs;
- Except as provided in R9-16-108(B)(2), a fetus with an abnormal presentation;
- Labor beginning before the beginning of 36 weeks gestation;
- A progression of labor that does not meet the requirements of R9-16-108(J)(4), if applicable;
- Gestational age greater than 34 weeks with no prior prenatal care;
- A gestation beyond 42 weeks;
- 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;
- A postpartum hemorrhage of greater than 500 milliliters in the current pregnancy;
- A non-bleeding placenta retained for more than 60 minutes;
- A client who had a prior Cesarean section and:
- More than one previous Cesarean section;
- A previous Cesarean section meeting the following preclusions:
- With a classical, vertical, or unknown uterine incision;
- Within 18 months before the expected delivery;
- With complications, including uterine infection;
- Due to failure to progress as a result of cephalopelvic insufficiency; or
- Complications during a previous vaginal delivery after a Cesarean section;
- Has a fetus:
- With fetal anomalies, confirmed by an ultrasound; or
- In a breech presentation.
- A vaginal delivery of a fetus in a breech presentation for a client who:
- Had a previous:
- Unsuccessful vaginal delivery or other demonstration of an inadequate maternal pelvis, or
- Cesarean section; or
- Has a fetus:
- With fetal anomalies, confirmed by an ultrasound;
- With an estimated fetal weight less than 2500 grams or more than 3800 grams; or
- In an incomplete breech presentation.
- Had a previous:
- A previous surgery that involved:
- Any time a newborn demonstrates any of the following conditions:
- Birth weight less than 2000 grams;
- Pale, blue, or gray color after 10 minutes;
- Excessive edema;
- Major congenital anomalies; or Respiratory distress.
The expectation is when a Licensed Midwife deems that transfer of care is needed as noted above or vis-á-vis a consultation with a medical practitioner, the transfer of care will occur. If the client refuses transfer of care, the Licensed Midwife must cease to provide midwifery services for that client.
What happens if a Licensed Midwife does not transfer care to a medical practitioner or medical setting when required?
Licensed Midwives who fail to transfer care to a medical practitioner or a medical setting when such is required will be cited for violating A.A.C. R9-16-111 upon discovery by the Department. Such violations will likely result in an automatic referral to the Department's Enforcement Unit and an investigation may be opened requiring the Licensee to disclose all or some of their client files in order to determine the scope and severity of the violation. The scope and severity of the violation is used in determining what, if any, action will be taken against the license.
What happens when a Licensed Midwife is referred to the Department's Enforcement Unit?
Licensed Midwives may be referred to the Department's Enforcement Unity only when a Midwife's violation(s) of statute or rule have been substantiated which indicate that a client's health and safety has been jeopardized by the Licensee (such as failure to obtain a required consultation or failure to transfer care to a medical practitioner or a medical setting when such are indicated.) The Department's Enforcement Unit can provide direction to the Office of Special Licensing as to investigative processes and actions to be taken and may make determinations as to what, if any, action will be taken against the license. If an action is taken against the license that action is posted on the Department's website and, depending on the type of action taken, may be reported to the Federal Data Banks as well.
What type of actions can be taken against the license of Midwife?
The Department may deny, revoke or suspend a license forever or for a specified period of time and may assess Civil Money Penalties depending upon the seriousness of a violation of law (rule or statute). Such actions, including entering into alternate agreements in lieu of such actions, are reportable to the Federal Data Banks.
For those Licensed Midwives who do not hold the Certified Professional Midwife (CPM) credential and are licensed after 1999, what happens if their renewal comes up prior to their obtaining that credential?
Licensed Midwives who are licensed after 1999 and are not CPM credentialed by the time of renewal are grandfathered in as Licensed Midwives but are prohibited from taking VBAC and breech cases in accordance with A.A.C. R9-16-108(B).
What happens if the applicant does not have all of the CE course work finished prior to obtaining their renewed license?
Licensed Midwives who have failed to complete all of their required hours of Continuing Education course work by the time they apply to renew their license will be sent a letter of incompleteness. That letter affords them 90 days to make their application complete. In such cases, the Licensed Midwife will usually be cited with a statement of deficiencies for violating the licensing rule A.A.C. R9-16-105 which requires the Licensee to obtain 20 continuing education units "during the term of the midwifery license". If The Licensee fails to make their application complete with 90 days, the application is considered withdrawn, the license is voided, and the Licensee's profile in the ADHS data system is closed out accordingly.
What happens if the applicant does not have CE course work that meets approval criteria prior to obtaining their renewed license?
Licensed Midwives who have applied to renew their license but the continuing education coursework they have completed fails to meet approval criteria will be sent a letter of incompleteness. That letter affords them 90 days to make their application complete. If The Licensee fails to make their application complete with 90 days the application is considered withdrawn, the license is voided, and the Licensee's profile in the ADHS data system is closed out accordingly.
If a Licensed Midwife accidentally allows their license to lapse, how can they reinstate their license?
Licensed Midwives who have allowed their license to lapse, for whatever reason must apply for an initial license under the new rules. Further, they must NOT provide midwifery services to anyone until their new license has been issued or they will be cited in violation of A.R.S. §36-759; which is a class 6 felony.
How will Licensed Midwives be trained to manage types of pregnancies that were not previously allowed in their scope of practice (i.e., VBACs or Breech deliveries)?
The Licensed Midwifery Advisory Committee established pursuant to A.A.C. R9-16-117 will provide recommendations for specific training for those midwives who are currently licensed, AND hold the CPM credential from NARM, but have not had recent training about managing VBAC and breech presentation cases. Licensed Midwives can also request specialized training from the listing of pre-approved entities listed in A.A.C. R9-16-105(2).
When must a Licensed Midwife file for a birth certificate?
Within 7 calendar days of the birth in accordance with A.A.C. R9-16-108(L).
Does a Licensed Midwife have to report a birth if care was transferred to another provider before labor and delivery of the newborn?
Yes! The Licensed Midwife is required to report to the Department all cased which they have accepted for midwifery services regardless of whether they did so to until labor and delivery. The objective of R9-16-114 is to provide on-going data on midwifery services, not just outcome data on births attended by midwives. Therefore, all services provided by Licensed Midwives are required to be reported to the Department using the Midwife Reporting Form
When must a Licensed Midwife report a case to the Department?
The Licensed Midwife is required to report a case to the Department within 30 calendar days after termination of midwifery services occurs in accordance with A.A.C. R9-16-114 using the Midwife Reporting Form
When must a Licensed Midwife report to the Department in the unfortunate event of a maternal or fetal death?
The Licensed Midwife must report a maternal or fetal death to the Department within 5 working days in accordance with A.A.C. R9-16-104(B).
When must a Licensed Midwife provide requested information to the Department?
The Licensed Midwife must requested information to the Department within 5 calendar days in accordance with A.A.C. R9-16-109(C) and R9-16-110(C), as otherwise directed under the authority of A.R.S. §36-756.01.
If your question was not answered here, please call the Offie of Special Licensing at (602)364-2079 and ask to speak to someone about midwifery swervices today!