by Allyson Fernstrom, Jessica Richardson, Elizabeth Morton, Lisa Keiser, Sylvia Miller, Janelle Hansen, Michelle Hottya, Marinah Farrell, Wendi Cleckner, and Tory Anderson
1. Arizona’s Licensed Midwives (LMs) are well-educated, qualified, tested, and certified through the Department of Health under the Office of Special Licensing. They gain experience through years of study and leveled apprenticeships. Some midwives enter the field already credentialed as registered nurses, certified nurse midwives, naturopathic physicians, public health administrators, North American Registry of Midwives (NARM), Certified Professional Midwife (CPM), and other advanced degrees. Claims that LMs are undereducated are false and misleading.
2. All homebirth clients must meet certain low-risk standards to qualify to birth at home. Midwives must ensure that candidates for homebirth have regular prenatal care, be offered routine prenatal testing, be checked periodically throughout the progress of labor, and meet additional criteria for Vaginal Birth After Cesarean (VBAC) and breech births such as being within 25 miles of a hospital. Pregnant women who do not meet the criteria are referred to an OB/GYN or CNM for a consultation to discuss possible transfer of care.
3. Risk of VBAC uterine rupture varies from 0.5-1% and risk of breech is 3%. This is less than or similar to other pregnancy or delivery risks; 12% preterm delivery, 7% gestational diabetes, 5% preeclampsia, 1% placental abruption, and 0.5% Placenta Previa.
4. Midwives are already required to provide clear and thorough informed consent (and informed refusal) by the state and by their professional credentialing organization, NARM. The recent rule revision update by the Department of Health increased the amount of informed consent required.
5. One of the most important patient rights is the right to choose or change your care provider. Limiting the scope of midwives unfairly takes away an individual’s freedom to choose a qualified care provider to attend her in her birth setting of choice.
6. Licensed Midwives are overseen by DHS. They are required to report their births and outcomes on a regular basis. In the past, these “quarterlies” were submitted by paper forms. Data collection has been improved with the new rules and will now be more detailed and submitted electronically.
7. All stakeholders, including Licensed Midwives, consumers, the medical community, members of the public and DHS, already debated homebirth safety and midwifery qualifications for over six months. The result of these deliberations was the consensus reached to modify midwifery licensure qualifications and expand their scope of practice. The expanded scope is still more limited than what midwives in other states can attend. Of the 26 states that license midwives, 23 states (including Arizona) allow midwives to attend VBAC. Arizona midwives have always been able to attend breech birth. SB1157 would take away a consumer right that has been in place for decades.
8. Supporting access to skilled midwives and providing healthy, safe choices for prenatal, birth and postpartum care is a pro-child, pro-mother and pro-family issue. Restricting access to midwifery care is counter to public health imperatives established by UNICEF, WHO, and UNFPA, among other health organizations world-wide.
9. Restricting midwives from attending VBAC and breech birth does not reduce risks to the mother or baby, especially in areas where the only alternatives are elective repeat cesarean or unassisted birth. Elective repeat cesareans carry additional risks beyond the first cesarean, including risks of dense adhesions, major complications, placenta accreta, blood transfusion, and hysterectomy (all risks increase with additional subsequent cesareans). Risks of VBAC, including uterine rupture, hysterectomy, and blood transfusion, all DECREASE with additional subsequent VBACs. Limiting access to VBAC potentially reduces the number of children a woman can have in the future and compels some women to attempt to give birth at home unassisted.
10. The risk of uterine rupture has been documented as high as 1% for woman with 1 previous cesarean. Of the 1% that may rupture, up 6.2% may be a catastrophic rupture resulting in infant death. This translates into an infant mortality of 0.062% or 1 out of every 1619 attempted VBACs, which is 8x lower than the 0.4% risk of infant mortality for all pregnancies.
In 2012 an estimated 1360 woman attempted a VBAC birth in AZ. Based on the statistical risk of catastrophic rupture there may have been 0-1 deaths due to rupture. 1360 attempted VBACs account for 1.58% of all 85,725 AZ births. Under the midwifery scope of practice, not all 1360 of these VBAC attempts would qualify for midwifery care, but based on an average of 1.58% of all births, 9 out of the annual average of 600 homebirths might be attempted VBAC. The number of homebirths or the infant mortality rate of homebirth would have to be 180 times greater for there to be a statistical chance of 1 death due to VBAC uterine rupture.