Arkansas Administrative Code › Agency 007 - ARKANSAS DEPARTMENT OF HEALTH › Division 43 - Family Health Branch › Rule 007.43.21-001 - Rules Governing the Practice of Licensed Lay Midwifery in Arkansas

Current through Register Vol. 49, No. 6, June, 2024
100.
GENERAL
			 PROVISIONS
101.
PURPOSE AND
			 AUTHORITY
Act 838 of 1983 provided for the lawful practice of Licensed
				Lay Midwifery in counties having 32.5% or more of their population below the
				poverty level.Act 481 of 1987 superseded Act 838 of 1983, and expanded the lay
				midwifery licensure statewide. These Rules govern the practice of Licensed Lay
				Midwives (LLMs) in Arkansas.
The following Rules are promulgated pursuant to the authority
				conferred by the Licensed Lay Midwife Act A.C.A. §
										17-85-101
				et seq. And A.C.A. §
										20-7-109.
Specifically, the LLM Act directs the Arkansas State Board of
				Health to administer the provisions of the Act and authorizes and directs the
				Board to adopt rules governing the qualifications for licensure of lay midwives
				and the practice of Licensed Lay Midwifery. The broad authority vested in the
				Board of Health, pursuant to ACA §
										20-7-109,
				to regulate and to ultimately protect the health of the public is the same
				authority the Board utilizes in enforcing the Rules, determining sanctions,
				revoking licenses, etc.
102.
ADMINISTRATION OF PROGRAM
The State Board of Health (BOH) has delegated the authority to
				the Arkansas Department of Health (ADH).
103.
DEFINITIONS
As used in these Rules, the terms below will be defined as
				follows, except where the context clearly requires otherwise:
1. ADVERTISEMENT AND ADVERTISING
Any statements, oral or written, disseminated to or before the
				public, with the intent of selling professional services, or offering to
				perform professional services. Advertising includes - but is not limited to -
				promotional literature, websites, and social media sites used for the purpose
				of selling services.
2.
			 APPRENTICE
A person who is training to become an LLM in Arkansas working
				under the direct supervision of a preceptor.
3. ARKANSAS DEPARTMENT OF HEALTH CLINICIAN
An ADH physician, Certified Nurse Midwife (CNM) or nurse
				practitioner providing ADH maternity services at a local health unit.
4. ARKANSAS RULES EXAMINATION
The exam that tests knowledge of the Rules Governing the
				Practice of Licensed Lay Midwifery in Arkansas.
5. AUTOMATIC LICENSURE
Granting the occupational licensure without an individual
				having met occupational licensure requirements provided under the Arkansas Code
				or by other provisions in these Rules.
6. BIRTHING/BIRTH CENTER
Any facility licensed by ADH which is organized to provide
				family-centered maternity care in which births are planned to occur in a
				home-like atmosphere away from the mother's usual residence following a
				low-risk pregnancy.
7.
			 CERTIFIED MIDWIFE (CM)
Individuals who have or receive a background in a
				health-related field other than nursing, and graduate from a midwifery
				education program accredited by the Accreditation Commission for Midwifery
				Education (ACME). Graduates of an ACME accredited midwifery education program
				take the same national certification examination as CNMs but receive the
				professional designation of certified midwife.
8. CERTIFIED NURSE MIDWIFE (CNM)
A person who is certified by the American College of Nurse
				Midwives and is also currently licensed by the Arkansas State Board of Nursing
				or the appropriate licensing authority of a bordering state to perform nursing
				skills relevant to the management of women's health care for compensation,
				focusing on pregnancy, childbirth, the postpartum period, care of the newborn,
				family planning, and the gynecological needs of women. The CNM must be
				currently practicing midwifery unless stated otherwise in these Rules.
9. CERTIFIED PROFESSIONAL MIDWIFE
			 (CPM)
A professional midwifery practitioner who has met the standards
				for certification set by the North American Registry of Midwives (NARM).
10. CLIENT
A pregnant woman, a postpartum woman for a minimum of thirty
				(30) days, or her healthy newborn for the first fourteen (14) days of life who
				is the recipient of LLM services.
11. CONSULTATION
The process by which an LLM who maintains primary
				responsibility for the client's care, seeks the advice of a physician, CNM, or
				ADH clinician. This may be by phone, in person or by written request. The
				physician, CNM, or ADH clinician may require the client to come into their
				office for evaluation.
12.
			 CONTACT HOUR
A unit of measure to describe 50-60 minutes of an approved,
				organized learning experience that is designed to meet professional educational
				objectives. It is a measurement for continuing education. One contact hour is
				equal to 0.1 CEU. Ten contact hours are equal to one (1) CEU.
13. LABOR SUPPORT ATTENDANT
An individual who is present at the request of the client to
				provide emotional or physical support for the client and her family.
14. LLM ASSISTANT
An individual who is present at the request of the LLM at any
				point during the course of midwifery care of the client to provide services
				under LLM supervision.
15.
			 LICENSED LAY MIDWIFE (LLM)
Any person who is licensed by ADH to practice midwifery and who
				performs for compensation those skills relevant to the management of care of
				women in the antepartum, intrapartum, and postpartum periods of the maternity
				cycle.Also manages care of the healthy newborn for the first fourteen (14) days
				of life.
16. LOCAL HEALTH
			 UNIT
A community-based ADH clinic site that provides medical and
				environmental services.
17.
			 MIDWIFERY BRIDGE CERTIFICATE
A certification administered by NARM awarded to CPMs following
				the completion of accredited approved continuing education contact hours based
				upon identified areas to address emergency skills and the International
				Confederation of Midwives (ICM) competencies.
18. NORTH AMERICAN REGISTRY OF MIDWIVES
			 (NARM)
The international certification agency that established, and
				continues to administer, certification for the credential "Certified
				Professional Midwife" (CPM) and the Midwifery Bridge Certificate (MBC).
19. PHYSICIAN
A person who is currently licensed by the Arkansas State
				Medical Board - or the appropriate licensing authority of a bordering state -
				to practice medicine or surgery. For the purposes of any sections of these
				Rules governing the care of pregnant and postpartum women, "physician" refers
				to those currently practicing obstetrics. For the purposes of any sections of
				these Rules governing the care of newborn infants, "physician" refers to those
				physicians who currently include care of newborns in their practices.
20. PRECEPTOR
A legally practicing obstetric or midwifery practitioner who
				participates in the teaching and training of apprentice midwifery students and
				meets NARM preceptor standards including credentials, years of experience, and
				birth attendance requirements. A preceptor assumes responsibility for
				supervising the practical (clinical obstetric) experience of an apprentice and
				for the midwifery services they render during their apprenticeship. In the case
				of transitional apprentices, the definition of preceptor in Appendix B
				applies.
21. REFERRAL
The process by which the client is directed to a physician, CNM
				or ADH clinician for management of a particular problem or aspect of the
				client's care, after informing the client of the risks to the health of the
				client or newborn.
22.
			 SUPERVISION
The direct observation and evaluation by the preceptor of the
				clinical experiences and technical skills of the apprentice while present in
				the same room.
23. TRANSFER
			 OF CARE
The process by which the LLM relinquishes care of her client
				for pregnancy, labor, delivery, or postpartum care to a physician, CNM or ADH
				clinician, after informing the client of the risks to the health or life of the
				client.
24. UNIFORMED
			 SERVICE MEMBER
An active or reserve component member of the United States Air
				Force, United States Army, United States Coast Guard, United States Marine
				Corps, United States Navy, United States Space Force, or National Guard; an
				active component member of the National Oceanic and Atmospheric Administration
				Commissioned Officer Corps; or an active or reserve component member of the
				United States Commissioned Corps of the Public Health Service.
25. UNIFORMED SERVICE VETERAN
A former member of the United States uniformed services
				discharged under conditions other than dishonorable
104.
SCOPE OF PRACTICE
1. The LLM may provide midwifery care
			 according to the protocols in these Rules only to healthy women, determined
			 through a physical assessment and review of the woman's health and obstetric
			 history, who are at low risk for the development of medical or obstetric
			 complications of pregnancy or childbirth and whose expected outcome is the
			 delivery of a healthy newborn and an intact placenta. The LLM shall be
			 responsible for care of the healthy newborn immediately following delivery and
			 for the first fourteen (14) days of life (unless care is transferred to a
			 physician or APRN specializing in the care of infants and children before
			 that). After fourteen (14) days the LLM is no longer responsible and the client
			 should seek further care from a physician or an APRN specializing in the care
			 of infants and children. If any abnormality is suspected, including - but not
			 limited to - a report of an abnormal genetic/metabolic screen or positive
			 antibody screen, the newborn must be sent for medical evaluation as soon as
			 possible but no later than 72 hours. This does not preclude the LLM from
			 continuing to provide counseling regarding routine newborn care and
			 breastfeeding.
2. Although the ADH
			 Licensed Lay Midwifery program is supervised by ADH physicians, each LLM is
			 encouraged to develop a close working relationship with one or more specific
			 physicians in obstetric and pediatric practice, or CNMs in obstetric practice
			 who agree to serve as a referral/consultation source for the LLM. This
			 relationship is optional. The referral physician and LLM relationship, or the
			 CNM and LLM relationship, can be terminated by either party at any
			 time.
3. Apprentice midwives and
			 LLM assistants may only work under the on-site supervision of their
			 preceptor.
4. At various points
			 during the course of midwifery care, the LLM must inform the client of the
			 requirement for tests, procedures, treatments, medications, or referrals
			 specified in Section 300 (Protocols) of these Rules which are for the optimal
			 health and safety of the mother and baby, and refusal is strongly discouraged.
			 However, continuing care of a client who refuses some of these requirements is
			 permitted if the LLM meets certain requirements as outlined in paragraphs 5
			 through 8.
5. LLMs that have a
			 current Certified Professional Midwife (CPM) credential but do not have a
			 Midwifery Bridge Certificate (MBC) may continue care of clients that:
a. Refuse the following tests listed in
			 Section 302.02 Prenatal Testing:
i. Pap
			 test/HPV test.
ii. Test for
			 Gonorrhea and Chlamydia.
iii. Test
			 for Syphilis.
iv. Hepatitis B
			 test.
v. HIV counseling and
			 test.
b. Refuse
			 recommended Rh immunoglobulin as outlined in 302.05.
c. Refuse a referral or to follow advice
			 against home birth as a result of the identification of these pre-existing
			 conditions listed in 303.02:
i. History of
			 seven (7) or more deliveries.
ii.
			 Maternal age greater than or equal to forty (40) at estimated date of
			 delivery.
iii. Previous infant
			 weighing less than five (5) pounds or more than ten (10) pounds.
iv. Pregnancy termination or loss >= three
			 (3).
d. Refuse the
			 newborn procedures listed in 308.03 and 308.04:
i. Administration of eye medication if
			 indicated.
ii. Administration of
			 Vitamin K.
6.
			 LLMs that have both a current CPM and the MBC, or LLMs that have a CNM or CM,
			 may continue care of clients that refuse any test, procedure, treatment,
			 referral, or medication, except for:
a. The
			 precluded conditions listed in Section 303.01;
b. The requirement of having the Risk
			 Assessments listed in Section 302.01; or
c. Conditions requiring immediate transport
			 as listed in Sections 305.01, 307.01, and 309.01.
7. LLMs that do not have a current CPM
			 credential are not permitted to continue care for clients who refuse any of the
			 required tests, procedures, treatments, medications or referrals specified in
			 these Rules except for recommended Rh immunoglobulin as outlined in 302.05.
			 Should a client refuse Rh Immunoglobulin the LLM must follow
			 104.#8.b-f.
8. Should a client of
			 the LLM with a CPM, CM, CNM, or CPM/MBC refuse any of the tests or procedures
			 pursuant to paragraphs 5 and 6:
a. The LLM
			 must inform the client that the LLM is only permitted to continue to provide
			 care to the client if the LLM's certification meets the required standard as
			 outlined in 5 and 6.
b. The LLM
			 must inform the client of the potential risks to herself or her baby. It is the
			 responsibility of the LLM to provide current evidence and adequate information,
			 both written and verbal, to the client regarding the risks of declining the
			 test, procedure, treatment, medication or referral, including the risks and
			 benefits of no action at all. This must include the review of any available and
			 relevant ADH-approved sources on each test, procedure, treatment, medication or
			 referral being refused.
c. The LLM
			 must document the client's refusal using the ADH Informed Refusal Form and
			 include:
i. The information shared with the
			 client as outlined in 8.b. and the ADH-approved sources used.
ii. The client's written assertion refusing
			 the test, procedure, treatment, medication or referral.
iii. The client's affirmation of her
			 understanding and acceptance of the risks.
iv. A plan of care for the condition,
			 including a plan for transfer of care if indicated.
d. The ADH Informed Refusal form must be
			 signed and dated by both the LLM and the client, and a copy kept by the LLM in
			 the client's file. Signing the form shows they have discussed the risks and
			 benefits of continuing under the care of the LLM.
e. Each signed refusal form must be
			 documented by completing an Incident Report form and noting the Informed
			 Refusal on the next LLM Caseload and Birth Report Log.
f. Documentation of refusal must be included
			 in the client's record in the event a client changes her mind concerning an
			 informed refusal.
9. It
			 is the responsibility of the LLM to engage in a process of continuous
			 evaluation, beginning with the initial consultation and continuing throughout
			 the provision of care. This includes continuously assessing safety
			 considerations and risks to the client and informing her of the same. The LLM
			 is expected to use their judgment in assessing when the client's condition or
			 health needs exceed the LLM's knowledge, experience or comfort level. The LLM
			 has the right and responsibility to terminate care under these
			 circumstances.
10. If any
			 medications that are provided by ADH or prescribed by a physician or CNM in
			 accordance with these Rules are administered at the home birth site, the LLM
			 shall document this in the client health record and include the following:
a. The name of the medication;
b. The lot number and date of
			 expiration;
c. The strength and
			 amount or dose of the medication;
d. The date and time the medication is
			 administered;
e. The name of the
			 prescriber; and
f. Document:
i. The name and the credentials of the nurse
			 administering the medication, or
ii. That the client, or LLM as agent to the
			 client, administered medication to the newborn.
11. The LLM is required to comply with all
			 provisions of HIPAA (Health Insurance Portability and Accountability
			 Act).
12. The LLM is required to
			 comply with all provisions of CLIA (Clinical Laboratory Improvement Amendments)
			 when tests are performed for the purpose of providing information for the
			 healthcare of midwife clients.
105.
TITLE PROTECTION
1. A person may not practice or offer to act
			 as a lay midwife in Arkansas unless licensed by the State Board of Health. It
			 is unlawful for any person not licensed as a lay midwife by the State Board of
			 Health to receive compensation for attending births as an LLM, or to indicate
			 that they are licensed to practice lay midwifery in Arkansas, excluding
			 licensed CNMs and licensed physicians.
2. Anyone unlawfully practicing lay midwifery
			 without a license shall be deemed guilty of a misdemeanor and upon conviction
			 thereof, shall be punished by a fine of not less than one hundred dollars
			 ($100) nor more than five hundred dollars ($500), or by imprisonment in the
			 county jail for a period of not less than one (1) week nor more than six (6)
			 months, or by fine and imprisonment.
3. The courts of this state having general
			 equity jurisdiction are vested with jurisdiction and power to enjoin the
			 unlawful practice of midwifery in a proceeding by the State Board of Health or
			 any member thereof, or by any citizen of this state in the county in which the
			 alleged unlawful practice occurred or in which the defendant resides, or in
			 Pulaski County.
4. The issuance of
			 an injunction shall not relieve a person from criminal prosecution for
			 violation of the provisions of this chapter, but remedy of the injunction shall
			 be in addition to liability to criminal prosecution.
5. An LLM must use the title "Licensed Lay
			 Midwife" or the initials "LLM" on all materials related to their practice,
			 including all promotional materials.
106.
DELEGATION OF LICENSED LAY
			 MIDWIFERY FUNCTIONS
1. An LLM assistant
			 may be engaged by the LLM to complement their work, but shall not be used as a
			 substitute for the LLM.
a. Tasks that may be
			 delegated to the LLM assistant before an assessment of the client's care needs
			 is completed by the LLM include:
i.
			 Noninvasive and non-sterile tasks if, in the judgment of the LLM, the LLM
			 assistant has the appropriate knowledge and skills to perform the
			 task.
ii. The collecting,
			 reporting, and documentation of temperature, weight, intake, output, and
			 contractions, indicating their frequency and duration.
iii. Reporting changes from baseline data
			 established by the LLM.
iv.
			 Assisting the client with ambulation, positioning or turning.
v. Assisting the client with personal
			 hygiene.
vi. Reinforcing health
			 teaching planned or provided by the LLM.
b. Tasks that must never be delegated to an
			 LLM assistant include, but are not exclusive to, the following:
i. The performance of a physical assessment
			 or evaluation.
ii. Physical
			 examination which includes - but is not limited to - fetal heart rate
			 auscultation, cervical exams, and blood pressure measurements.
iii. The provision of sterile invasive
			 treatments.
iv. The administration
			 of any prescription drugs.
v. The
			 use of any medical devices.
2. The LLM shall monitor and document the
			 care and procedures performed by any LLM assistant or labor support attendant
			 in the client's medical record.
3.
			 An LLM who has agreed to provide care to a client is held accountable to act
			 according to the standards of care set out in these Rules, until such a time as
			 that care is terminated by the client or the LLM in accordance with these
			 Rules.
4. An LLM may request a
			 registered nurse to perform selected acts, tasks or procedures that are outside
			 the scope of the LLM's practice but which do not exceed the scope of practice
			 of the nurse's license. It is the nurse's responsibility to be informed and act
			 in accordance with both the Arkansas Nurse Practice Act and the Arkansas State
			 Board of Nursing Rules.
5. An LLM
			 who also holds an Arkansas nursing license is required to act in accordance
			 with the following: the Rules Governing the Practice of Licensed Lay Midwifery
			 in Arkansas; the Arkansas Nurse Practice Act - as codified in Ark.Code Ann.
			 §
										17-87-101
			 - and the Arkansas State Board of Nursing Rules as promulgated by the Arkansas
			 State Board of Nursing. An LLM practicing under the scope of her nursing
			 license while acting as an LLM may be referred to the Arkansas State Board of
			 Nursing if any improper conduct is suspected.
107.
ADVERTISING
1. ADH permits advertising by LLMs regarding
			 the practice of Licensed Lay Midwifery in accordance with these
			 Rules.
2. No LLM shall disseminate
			 or cause the dissemination of any advertisement or advertising that is in any
			 way false, deceptive, or misleading. Any advertisement or advertising shall be
			 deemed to be false, deceptive or misleading if it:
a. Contains a misrepresentation of facts;
			 or
b. Makes only a partial
			 disclosure of relevant facts; or
c.
			 Contains any representation or claims as to services that the LLM cannot
			 legally perform; or
d. Contains any
			 representation, statement, or claim which misleads or deceives; or
e. Could lead a reasonably prudent person to
			 believe that the LLM is licensed to practice nursing or medicine when not so
			 licensed in the state of Arkansas.
3. Advertising that crosses into other states
			 must clearly state if any of the services offered are legal only in certain
			 states in which the LLM practices.
108.
IMMUNIZATIONS
All LLMs and their apprentices are strongly encouraged to have
				routine vaccinations to the fullest extent unless contraindicated, and not to
				rely on the immunization status of others or 'herd immunity' to protect them,
				their clients, and their families.
109.
MIDWIFERY ADVISORY BOARD
The BOH shall establish and appoint the Midwifery Advisory
				Board (MAB) to advise ADH and the BOH on matters pertaining to the regulation
				of midwifery.
1. PURPOSE, DUTIES, AND
			 RESPONSIBILITIES:
a. Reviewing and advising
			 ADH and the BOH regarding the Rules.
b. Reviewing and advising ADH regarding
			 approval of continuing education units (CEUs).
c. Reviewing and advising ADH regarding
			 quality improvement data and information.
d. Serving as community liaisons to educate
			 the public and other providers regarding the practice of midwifery.
e. Promoting the safe practice of midwifery
			 by addressing issues and concerns regarding the practice of midwifery of ADH,
			 BOH, public consumers of midwifery services, and LLMs.
f. Reviewing Reports:
i. Statistical Reports
A. A draft of the annual LLM statistical
			 report will be available to MAB members for comment prior to the presentation
			 to the BOH.
B. Up to two (2) MAB
			 members may consult with ADH program staff in determining the plan for the
			 collection of data.
ii.
			 Disciplinary Case Reports
A. ADH will notify
			 the MAB of all disciplinary hearings taken before the BOH.A copy of the final
			 order will be made available to the MAB.
2. COMPOSITION OF THE MAB
The composition of the MAB will be as follows:
a. Four (4) Arkansas LLMs
b. One (1) CNM, currently licensed as a CNM
			 in Arkansas, preferably practicing.
c. One (1) member at large.
d. Three (3) public consumers who have either
			 had a midwife-attended birth, are the spouse of someone who has had a
			 midwife-attended birth, or are persons who have been involved in promoting
			 midwifery or home birth in the state of Arkansas.
3. NOMINATION OF MEMBERS
Members of the MAB are appointed by the BOH. The BOH requests
				nominations from the MAB through ADH. The process for applying to serve on the
				MAB is as follows:
a. Individuals
			 interested in either proposing a nomination or serving on the MAB must obtain
			 an "Application for Midwifery Advisory Board Appointment" from the
			 MAB.
b. The applicant will complete
			 the application form and submit it to the MAB according to the
			 instructions.
4. TERMS OF
			 MIDWIFERY ADVISORY BOARD MEMBERS
a. Midwifery
			 Advisory Board (MAB) members shall serve terms of up to four (4)
			 years.
b. No member may serve more
			 than two (2) consecutive full terms.
c. Members may be eligible for reappointment
			 two (2) years after the date of the expiration of the second full
			 term.
5. ORGANIZATIONAL
			 STRUCTURE OF THE MIDWIFERY ADVISORY BOARD
a.
			 MAB members shall establish and annually review the By-Laws of the Midwifery
			 Advisory Board.
b. Additionally, an
			 organizational chart with delegation of duties of MAB members and officers
			 shall be developed.
c. MAB members
			 shall elect a chair, vice-chair and secretary at its first meeting each year
			 that will serve until their successors are elected.
d. The MAB will schedule and conduct meetings
			 at least two (2) times a year and at other times, as necessary.
110.
CONTINUING
			 EDUCATION ACTIVITIES OF THE MIDWIFERY ADVISORY BOARD
For the purpose of these Rules, the MAB will process the review
				of continuing education credits by the following criteria:
1. The application for review must be
			 received by the MAB at least sixty (60) days prior to the scheduled course
			 date, and shall be submitted simultaneously to ADH.
2. The MAB will review and evaluate the
			 application for the continuing education course and make a recommendation to
			 ADH.
3. The documentation will be
			 reviewed for appropriate content applicable to the protocols and clinical
			 practice of the Licensed Lay Midwifery program of Arkansas. Each application
			 shall be evaluated on the following criteria:
4. Completeness of application;
5. Agenda;
6. Intended audience;
7. Method of delivery (lecture, video,
			 correspondence, online, other);
8.
			 Course description and objectives; and
9. Biographical data for each speaker
			 including pertinent education and experience.
10. The recommendation of the MAB shall be
			 submitted in writing for ADH approval, no less than thirty (30) days prior to
			 the scheduled course date.ADH will make the final decision for approval of
			 continuing education courses, after consideration of timely received MAB
			 recommendations. All final decisions by ADH denying approval for continuing
			 education courses may be appealed to the Arkansas State BOH within thirty (30)
			 days of receiving the denial.