007.13.17 Ark. Code R. 001
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 Act 481 of 1987 superseded Act 838 of 1983, and expanded the lay midwifery licensure statewide.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 and Regulations govern the practice of Licensed Lay Midwives (LLMs) in Arkansas.
The following Rules and Regulations 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.
The State Board of Health (BOH) has delegated the authority to the Arkansas Department of Health (ADH).
As used in these Rules, the terms below will be defined as follows, except where the context clearly requires otherwise:
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.
A person who is training to become an LLM in Arkansas working under the direct supervision of a preceptor.
An ADH physician. Certified Nurse Midwife (CNM) or nurse practitioner providing ADH maternity services at a local health unit.
The exam that tests knowledge of the Rules and Regulations Governing the Practice of Licensed Lay Midwifery in Arkansas.
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.
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.
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.
A professional midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives (NARM).
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.
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.
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.
An individual who is present at the request of the client to provide emotional or physical support for the client and her family.
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.
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 Ufe.
A community-based ADH clinic site that provides medical and environmental services.
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.
The international certification agency that established, and continues to administer, certification for the credential "Certified Professional Midwife" (CPM) and the Midwifery Bridge Certificate (MBC).
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.
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.
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.
The direct observation and evaluation by the preceptor of the clinical experiences and technical skills of the apprentice while present in the same room.
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 Hfe of the client.
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.
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.
The composition of the MAB will be as follows:
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:
For the purpose of these Rules, the MAB will process the review of continuing education credits by the following criteria:
Applicants for initial licensure must meet the following requirements, except for those noted in Section 200. #3:
ADH may refiise to issue, suspend or revoke a license for violation of the Licensed Lay Midwife Act or any provision of these Rules, including - but not limited to - any of the following reasons:
Suspected cases involving violation of the Licensed Lay Midwifery Act or these Rules may be referred by ADH to the BOH for a hearing, according to the Arkansas Administrative Procedures Act. If the BOH finds that a person holding a license or permit has violated the Licensed Lay Midwifery Act or these Rules' sanctions, which include -but are not limited to - the following, may be imposed:
ADH will notify licensee of any actions to be imposed. Decisions may be appealed to the Circuit Court pursuant to the Arkansas Administrative Procedures Act.
Any applicable certification or licensing agencies will be notified of final actions on licenses including - but not limited to - NARM and any states where the midwife holds a license.
Inactive status is automatic on the day after the license expires. LLMs who do not maintain a current license will be considered inactive. Inactive status may be maintained for up to three (3) years. An LLM with inactive status may not practice midwifery until the license is reactivated. To reactivate a license with inactive status, the applicant must:
After three (3) years, a Ucense in inactive status automatically expires. To become re-licensed the applicant must successfully fulfill all of the requirements for initial licensure as outlined in Section 201.
Apprentices who hold a valid permit prior to the effective date of these Rules will follow the requirements found in Appendix B; Transitional Provisions and Forms.
An LLM will be responsible for notifying ADH of any apprentices accepted under their supervision within thirty (30) days of signing, but prior to the apprentice providing any services. The ADH Preceptor-Apprentice Agreement form (found in Appendix A or available on the ADH website) shall be used for this notification. Preceptors must meet all NARM preceptor requirements. Any changes in the apprentice's contact information must be provided to ADH by the LLM within thirty (30) days of the status change. If the apprentice is still under the LLM's supervision after three (3) years, the LLM must complete a new form indicating this status.
Should the Preceptor-Apprentice Agreement be terminated by either party, it is the responsibility of both parties to notify ADH immediately. An apprentice must not continue to perform under any preceptor(s) unless a new signed Preceptor-Apprentice Agreement is on file with ADH. A signed Preceptor-Apprentice Agreement for every preceptor under whom an apprentice trains must be signed and sent to ADH.
Apprentices shall follow all applicable Arkansas laws and these Rules.
Apprentices are required to comply with all provisions of HIPAA (Health Insurance Portability and Accountability Act).
The LLM must adhere to the LLM protocols as outlined in these Rules.
The following requirements must be met before a LLM can legally accept a client.
An LLM shall terminate care of a client only in accordance with this section unless a transfer of care results from an emergency situation.
If a transfer of care recommendation occurs during labor, delivery, or the immediate postpartum period, and the client refuses transfer the midwife shall call 911 and provide further care as indicated by the situation. If the midwife is unable to transfer to a health care professional, the client will be transferred to the nearest appropriate health care facility. The midwife shall attempt to contact the facility and continue to provide care as indicated by the situation.
Risk assessments shall be performed by a physician, a CNM or an ADH clinician. The purpose of these visits is to ensure that the client has no potentially serious medical conditions and has no medical contraindications to home birth. Each risk assessment must be filed in the client's medical record.
The risk assessments must be comprehensive enough for the LLM to identify potentially dangerous conditions that may preclude midwifery care, or that require physician or CNM consultation.
Each client must be evaluated by a physician, a CNM, or an ADH clinician at the following times:
The LLM must ensure each client receives the following services at or near the initiation of care from a physician, CNM, or ADH clinician. Exceptions to these required services are at the discretion of the physician, CNM, or ADH clinician who performs the risk assessment and must be documented in the client's medical record.
For LLMs who are trained in the collection of laboratory specimens and collect the specimens themselves, the specimens must be submitted to a standard lab. The reports and test results must be sent for review and interpretation by a physician, CNM or ADH clinician. All reports and test results, including reviews and interpretations, must be recorded in the client record.
If blood sugar testing is performed by the LLM, they shall use only an FDA approved device for CLIA (e.g. HemoCue Blood Glucose Analyzer), and follow the ADH approved standards for diabetes testing. The results of all testing must be interpreted by a physician, CNM, or ADH clinician within ten (10) days.
Routine antepartum visits must be made approximately every four (4) weeks during the first 28 weeks of gestation, approximately every two (2) weeks from the 28th to 36th weeks, and weekly thereafter until delivery.
At each visit the LLM will perform and record the following services:
Screening for Group B Strep according to ADH approved guidelines available on the ADH website.
The LLM is required to make, prior to delivery, at least one visit to the home where the birth will take place.
The LLM should inform the client of the equipment and supplies that must be available at the time of delivery. She should instruct the client and family of requirements for an aseptic delivery site.
The Newborn Care Package provided by ADH contains the required newborn medications and other necessary items and is available to all LLM clients. If the mother chooses to obtain the newborn care package from ADH, she must notify the local health unit in sufficient time to allow the local health unit one month to obtain the care package.
The LLM will discuss with her client the protocol for each of the following medications that require the client to make arrangements to obtain the prescriptions and establish a plan for the administration of medications prior to the onset of labor:
The LLM is responsible for advising the client of the law that requires newborn screening (A.C.A. § 20-15-302) and the procedure for conducting newborn screening. Information is available on the ADH website.
The LLM is responsible for advising the client of the newborn infant hearing screening law (A.C.A. § 20-15-1101 et seq.) and the available resources to obtain the newborn hearing screen. Information is available on the ADH website.
The LLM is responsible for advising the mother that beyond the first fourteen (14) days of life, the LLM is no longer responsible and the mother should seek further care from a physician or an APRN specializing in the care of infants and children. This does not preclude the LLM from providing counseling regarding routine newborn care and breastfeeding.
The LLM shall advise the mother of the necessity for newborn evaluation by a physician within 24 hours of birth when:
Each client is to have a risk a.ssessment (see Section 302.01) documented by a physician, CNM, or ADH clinician at or neai" the initiation of care and again around the 36* week. The following sections detail the actions to be followed by the LLM if the client exhibits or develops one of the specified conditions. The LLM will refer women for medical evaluation as soon as possible after the condition is identified. The LLM is expected to use /their judgment regarding the need for consultation, referral, or transfer when problems arise that are not specified in these Rules. In addition to the birth log, such care will be documented on an incident report and submitted to ADH.
The following conditions preclude midwifery care and the client must be transferred to a physician, CNM, or ADH clinician upon diagnosis. There may be additional high-risk conditions judged by either a physician, CNM, ADH clinician, or LLM that could also preclude midwifery care.
If any of the following pre-existing conditions are identified the client must be examined by a physician, CNM, or ADH clinician. A plan of care for the condition must be established, including a plan of for transfer of care if indicated, and execution of the plan of care must be documented. Midwives caring for these clients will be required to submit additional incident reports to ADH. If a referral is not made or if the clinician advises against home birth, the care must be transferred to a physician or CNM.
If any of the following antepartum conditions are identified, a physician/CNM consultation, referral or transfer is required and the client must be examined by a physician or CNM currently practicing obstetrics. ADH clinicians may accept referrals per ADH protocol. A plan of care for the condition must be established, and execution of the plan must be documented. Midwives caring for these clients shall submit additional required incident reports to ADH. If a referral is not made or if the clinician advises against home delivery the client must be transferred immediately to a physician or CNM.
0/7 days
As soon as possible but within one (1) hour following the onset of active labor (5-6 cm with regular and painful contractions) or as soon as possible but within one hour following the pre-labor rupture of membranes, the LLM must assess and record:
All services should be provided in a supportive manner and in accordance with these Rules.
The following INTRAPARTUM conditions preclude midwifery care, and when identified, the client must be transported to the planned hospital by the most expedient method of transportation available to obtain treatment/evaluation:
The following INTRAPARTUM conditions require consultation with a physician or CNM who has obstetric privileges in a hospital within fifty (50) miles of the delivery site. A plan of care must be established and execution documented. Midwives caring for these clients will submit additional required incident reports (found in Appendix A or available on the ADH website). If consultation is not available the client must be transported to the hospital per the emergency plan. If the client's condition is not stable she should be transported to the nearest hospital.
The LLM must remain in attendance for at least two (2) hours after the delivery and shall assess and record the following:
The following POSTPARTUM conditions preclude midwifery care and when identified, the client must be transported to the hospital indicated in the emergency plan by the fastest method of transportation available to obtain treatment/evaluation:
The following POSTPARTUM conditions require consultation with a physician or a CNM. A plan of care must be established and execution documented. Midwives caring for these clients will submit additional required incident reports to ADH (found in Appendix A or available on the ADH website).
The LLM shall be responsible for newborn care immediately following the delivery and care of the healthy newborn 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 mother 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 providing counseling regarding routine newborn care and breastfeeding.
The following services must be provided by the LLM as part of immediate newborn care:
Newborn should be placed at the breast as soon as stable after delivery. The bottle fed newborn should be offered formula of choice within the first two to three hours after birth. Instruct the mother in normal and abnormal feeding patterns.
All newborns must have a capillary blood sample within the required time frame for the newborn screening as mandated by law and as specified on the ADH collection form. Information can be obtained by contacting the ADH Newborn Screening program.
The LLM must instruct the mother in available resources to obtain the infant hearing screen. Assistance in completing and submitting the required form can be obtained by contacting the ADH Infant Hearing Program.
The LLM must instruct the mother in routine cord care.
The following NEWBORN conditions, when identified, require immediate transport of the newborn to the hospital by the most expedient method of transportation available to obtain treatment/evaluation. LLMs that participate in the care of these newborns are required to submit additional incident reports (found in Appendix A or available on the ADH website).
The newborn must be weighed weekly. During the first two (2) weeks of life the newborn must be immediately referred to a pediatric or family medicine provider for any illness or abnormal physical finding. The newborn must also be referred if there are any concerns about weight gain, feeding, elimination, development, or abnormal screening results.
The following NEWBORN conditions require immediate (unless otherwise indicated) consultation with a physician whose practice includes pediatrics. A plan of care must be established and execution documented. Midwives caring for these newborns will be required to submit additional required incident reports to ADH (found in Appendix A or available on the ADH website). If consultation is not available the newborn must be transported to the hospital listed in the plan of care.
The LLM is responsible for the coordination of the physician consultation with the child's parents, and must follow-up on this consultation and document the outcome in the client's record.
The LLM must consult a licensed physician or CNM whenever there are significant deviations from normal in either the mother or the newborn, and must act in accordance with the instructions of the physician or CNM. In those situations requiring transport to a hospital, the LLM must notify the emergency room or labor and delivery unit of the designated hospital of an imminent transport and provide a copy of the complete medical record to the appropriate staff at the receiving facility.
ADH will audit selected records from each LLM's practice each year. The purpose of the audit will be to confirm compliance with these Rules. The LLM will be required to submit the records for each client selected by ADH for auditing.
The LLM is required to track maternal and newborn events for thirty (30) days unless care is terminated by the client. Maternal events, pregnancy loss at any gestational age, or newborn events must be reported according to the following schedule. In each of these instances, LLMs will complete the required incident report (found in Appendix A or available on the ADH website) and submit it, with a complete copy of the client record, to ADH.
The LLM is responsible for ensuring that all required services are documented on client records maintained by the LLM. Each page of the client record must contain the client ID number. The records will remain confidential. They are subject to periodic review by ADH staff. All client records must be maintained for at least 25 years.
The LLM shall follow all applicable laws pertaining to vital records.
ADH shall review applications for licensure and issue licenses or permits.
ADH shall maintain a list of all LLMs and Apprentice Midwives in the State of Arkansas, and make this list available to the public.
ADH shall monitor perinatal outcomes of home births attended by LLMs and publish these statistics annually.
ADH shall also review LLMs' records to assure that such LLMs are practicing within regulatory guidelines and standards of care.
ADH will conduct investigations regarding complaints or deviations from the Rules.
ADH will consider all available information that is relevant and material to the investigations.
Where, in the opinion of the Director of ADH, the public's health, safety or welfare imperatively requires emergency action, ADH may temporarily suspend the license of an LLM pending proceedings for revocation or other action. All proceedings initiated under this provision shall be promptly instituted and determined. The licensee may request a hearing on a temporary suspension with five (5) days of receiving notice.
ADH shall administer the Arkansas Rules Examination at least three (3) times per year.
If any provision of these Rules and Regulations, or the application thereof to any person or circumstances, is held invalid, such invalidity shall not affect other provisions or applications of these Rules and Regulations which can give effect without the invalid provisions or applications; and to this end the provisions hereto are declared to be severable.
All Regulations and parts of Regulations in conflict herewith are hereby repealed.
This will certify that the Rules and Regulations Governing the Practice of Licensed Lay Midwifery in Arkansas were prepared pursuant to A.C.A. 20-7-109 and A.C.A. 17-85-101 et seq. A public hearing was held on the 21st day of September, 2017.
This will also certify that the foregoing Rules and Regulations Governing the Practice of Licensed Lay Midwifery in Arkansas were adopted by the Arkansas Board of Health at a regular session of same held in Little Rock, Arkansas on the 25"' day of January, 2018.
APPENDIX A: FORMS
I
APPENDIX B: TRANSITIONAL PROVISIONS AND FORMS
TRANSITIONAL APPRENTICES
Apprentices with active permits issued prior to the effective date of these Rules, henceforth referred to as "Transitional Apprentices", will have three (3) years from the date these Rules take effect to successfully complete their apprenticeship and submit an application for lay midwifery licensure to ADH, and request approval to sit for the NARM written examination under the requirements listed in this Appendix. If they have not done so by that date, it will be necessary for the applicant to fulfill the requirements listed in Section 201 (Initial Licensure).
For those apprentices holding valid Apprentice Permits, on or before the effective date of these Rules, the permit must be renewed by the permit's expiration date if necessary. Renewal will only occur upon application and favorable review by ADH. This review will assure that the lay midwife apprentice is acting under the supervision of the preceptor and in accordance with these Rules. The permit will be valid until three (3) years from the effective date of these Rules. If an apprentice has not obtained Arkansas licensure by that date, the applicant will no longer be considered a transitional apprentice and must follow the guidelines for licensure found in Section 201 (Initial Licensure).
To renew the permit, the Apprentice shall submit the following evidence at least sixty (60) days before the expiration date of the permit:
Transitional apprentices who are approved by ADH to sit for, and who pass, the NARM written examination will be issued a license upon completion of all other requirements.
A transitional apprentice who receives licensure must go through NARM and become certified as a CPM in order to be eligible to renew their license at the end of their initial licensure period. License renewal will follow the procedures outlined in Section 202.
Once the CPM certification is received, a notarized copy of the certificate or a verification letter sent directly from NARM must be submitted to ADH within thirty (30) days of certification.
Eligibility requirements for approval for transitional apprentices to sit for the NARM written examination:
Applicants for licensure must demonstrate competency in performing clinical skills during the antepartum, intrapartum, postpartum, and the immediate newborn periods. Each applicant must successfully complete an evaluation of clinical skills. The applicant must submit a statement that the following minimal practical experience requirements have been performed under the supervision of a physician, CNM, or LLM.
These forms should be submitted only after the applicant has a "pass" on each item, except for certain emergencies that may not occur during a preceptorship. The following required forms must be submitted:
APPENDIX C: CEU CALCULATIONS
CEU CALCULATIONS
CALCULATIONS FOR NUMBER OF CEUS REQUIRED FOR LLM RENEWAL OF LICENSE BASED ON ALL BEING RENEWED IN AUGUST EVERY 3 YEARS.
Months since license was | Number of CEUs |
issued | required |
36 | 30 hours |
35 | 29 hours |
34 | 28 hours |
33 | 27 hours |
32 | 27 hours |
31 | 26 hours |
30 | 25 hours |
29 | 24 hours |
28 | 23 hours |
27 | 23 hours |
26 | 22 hours |
25 | 21 hours |
24 | 20 hours |
23 | 19 hours |
22 | 18 hours |
21 | 17 hours |
20 | 17 hours |
19 | 16 hours |
18 | 15 hours |
17 | 14 hours |
16 | 13 hours |
15 | 12 hours |
14 | 11 hours |
13 | 10 hours |
12 | 10 hours |
11 | 9 hours |
10 | 8 hours |
9 | 7 hours |
8 | 6 hours |
7 | 5 hours |
6 | 4 hours |
5 | 3 hours |
4 | 3 hours |
3 | 2 hours |
2 | 1 hours |
1 | 0 hours |
007.13.17 Ark. Code R. 001