WSR 17-07-116 PROPOSED RULES DEPARTMENT OF HEALTH [Filed March 21, 2017, 2:45 p.m.]
Original Notice.
Preproposal statement of inquiry was filed as WSR 15-02-031.
Title of Rule and Other Identifying Information: Chapter 246-834 WAC, Midwifery, the department of health is revising sections of the midwifery chapter in order to clarify, streamline, and modernize rules. The department is also revising this WAC to include the elements of newborn care up to two weeks, as described in 2014 amendments to the midwifery law chapter 18.50 RCW, and 2014 amendments to chapter 70.83 RCW regarding newborn screening.
Hearing Location(s): Department of Health, Town Center 2, Room 158, 111 Israel Road S.E., Tumwater, WA 98501, on May 4, 2017, at 9:30 a.m.
Date of Intended Adoption: May 15, 2017.
Submit Written Comments to: Kathy Weed, P.O. Box 47852, Olympia, WA 98504-7852, email https://fortress.wa.gov/doh/policyreview, fax (360) 236-2901, by May 4, 2017.
Assistance for Persons with Disabilities: Contact Kathy Weed by May 1, 2017, TTY (800) 833-6388, or 711.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The proposed rules implement section 1 of 2SHB 1773 (chapter 187, Laws of 2014) that amended RCW 18.50.010 expanding the midwifery scope of practice to allow for care for the newborn up to two weeks of age. The proposed rules update requirements for approved schools, foreign trained applicants, and activating a license after an extended period of time. The proposed rules also clarify, streamline, and modernize rule language since the language in this chapter has had few updates since 1991.
Reasons Supporting Proposal: 2SHB 1773 allows the department to define typical elements of newborn care. A five year review of the chapter is also required under RCW 43.70.014. The proposed rule amendments are based on input from stakeholders, specifically midwives [and] other obstetric providers. Except for revising individual sections, a comprehensive review of this chapter has not been done since 1991. Additionally, amending the rules will make them more consistent with current law and midwifery practice.
Statute Being Implemented: RCW 18.50.010.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Department of health, governmental.
Name of Agency Personnel Responsible for Drafting, Implementation, and Enforcement: Kathy Weed, 111 Israel Road S.E., Tumwater, WA 98501, (360) 236-4883.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed rule would not impose more than minor costs on businesses in an industry.
A copy of the statement may be obtained by contacting Kathy Weed, 111 Israel Road S.E., Tumwater, WA 98501, phone (360) 236-4883, fax (360) 239-2901, email kathy.weed@doh.wa.gov.
A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Kathy Weed, P.O. Box 47852, Olympia, WA 98504-7852, phone (360) 236-4883, fax (360) 236-2901, email kathy.weed@doh.wa.gov.
March 21, 2017
John Wiesman, DrPH, MPH
Secretary
AMENDATORY SECTION (Amending WSR 92-02-018, filed 12/23/91, effective 1/23/92)
WAC 246-834-010 Definitions.
(((1) Academic director as used in these rules means the individual who is responsible for planning, organizing and implementing all aspects of the curriculum of a midwifery education program.
(2) Health care provider as used in RCW 18.50.108 means any licensed physician who is engaged in active clinical obstetrical practice.
(3))) The following definitions apply throughout this chapter unless the context clearly indicates otherwise:
(1) "Active practice" means twenty hours per month in prenatal and postpartum clinical care, or minimum of six births annually as the primary midwife;
(2) "Department" means the Washington state department of health;
(3) "Directly assisted" means the act where a student midwife is learning the skills of a midwife through hands-on clinical experience in gradually increasing degrees of responsibility while under supervision of a licensed midwife or other obstetric provider;
(4) "Lactation care and services" means evaluation, problem identification, treatment, education, and consultation regarding lactation and breastfeeding to mothers and neonates;
(5) "Nursing education" ((as used in these rules)) means completion of courses for credit in a school that is approved to train persons for licensure as registered nurses or licensed practical nurses, or courses in other formal training programs which include instruction in basic nursing skills((.
(4))), excluding nursing assistant training;
(6) "Practical midwifery experience" ((as used in these rules)) means performance ((in)) of tasks within the midwifery ((functions, prior to obtaining a license)) scope of practice, that is verified by affidavit, testimony or other sworn written documentation that verifies that the experience and its documentation is equivalent to that required of ((regularly)) students enrolled in an accepted midwifery ((students.
(5) Preceptor. A)) education program;
(7) "Preceptor" ((is)) means a licensed ((or legally practicing)) midwife or other obstetric practitioner licensed by their state or jurisdiction to provide maternity care who assumes responsibility for supervising the practical (clinical obstetric) experience of a student midwife((. The preceptor shall be physically present whenever the student is managing a birth, and shall evaluate in writing the student's overall performance.
(6) Supervision means the observation and evaluation of a student midwife's practical performance. A supervisor need not be physically present in nonbirth situations. However, when a student midwife undertakes managing a birth, the supervisor must be physically present.
(7) Survey visit is an information gathering and observational visit intended to provide the basis for the director's assessment of a school's compliance with all aspects of chapter 18.50 RCW.));
(8) "Primary attendant" means a student midwife who acts as primary midwife making intrapartum clinical decisions while under supervision of a licensed midwife or other obstetric provider;
(9) "Secretary" means the secretary of the Washington state department of health;
(10) "Supervision" means the observation and evaluation of a student midwife's practical performance. A supervisor must be physically present on-site and available to intervene when a student midwife performs any clinical care task at births and prenatal and postpartum care exams.
AMENDATORY SECTION (Amending WSR 99-03-064, filed 1/18/99, effective 2/18/99)
WAC 246-834-050 Examination requirements for licensure as a midwife.
((This rule provides the minimum examination requirements for licensure as a midwife.)) An applicant for midwifery licensure shall successfully pass:
(1) The midwifery examination offered by the North American Registry of Midwives (NARM) ((is the official examination for midwifery licensure. All applicants must complete this examination with a passing score. This examination shall be offered by the department of health midwifery program twice a year. If the applicant passes the examination within two years prior to applying for a Washington license, the department will accept the results.
(2) In addition to the NARM examination, all applicants must pass the Washington state specific component examination.));
(2) The Washington state licensure examination with a minimum passing score of eighty; and
(3) The midwifery jurisprudence examination with a passing score of one hundred percent, as offered by the department.
NEW SECTION
WAC 246-834-062 Initial or reinstating application for individuals who have not been in the active practice of midwifery.
This section applies to applicants for an initial license as a licensed midwife, or reinstatement of a midwifery license, who have not been in the active practice of midwifery prior to initial or reinstatement license application.
(1) Any applicant who has not been engaged in the active practice of midwifery for more than three years but less than five years prior to the date of application shall, in addition to the requirements for licensure as specified in WAC 246-834-060 and 246-834-140:
(a) Provide documentation of a minimum of ten births while acting as a birth assistant under the supervision of a preceptor within the last twelve months; and
(b) Provide documentation of completion of continuing education for the three years prior to application that meets the requirements of WAC 246-834-355.
(2) Any initial or reinstating applicant who has not been engaged in the active practice of midwifery for five or more years prior to the date of application shall, in addition to the requirements for licensure as specified in WAC 246-834-060 and 246-834-140:
(a) Provide documentation of a minimum of fifteen births while acting as a birth assistant under the supervision of a preceptor within the last twelve months;
(b) Provide documentation of completion of continuing education for the three years prior that meets the requirements of WAC 246-834-355; and
(c) If applying for reinstatement, retake and pass the current Washington state midwifery licensure examination.
(3) This section does not apply to any applicant who has been enrolled in a recognized educational program under WAC 246-834-135 or 246-834-065.
AMENDATORY SECTION (Amending WSR 98-05-060, filed 2/13/98, effective 3/16/98)
WAC 246-834-065 Application for examination—((Out-of-state education)) Foreign trained.
(((1) A midwife not licensed in the state of Washington)) An applicant for a midwife license who graduated from a foreign educational institution on midwifery outside of any U.S. jurisdiction may sit for the licensing examination ((without completing the required coursework or the midwife-in-training program provided the midwife meets the following requirements:
(a) Has completed a program preparing candidates to practice as a midwife provided such program is equivalent to the minimum course requirements of approved midwifery programs in Washington at the time of applicant's program completion. Proof of equivalency shall be submitted by the applicant with the application.
(b) The transcript of the applicant's completed midwifery program verifies that:
(i) All courses were completed with a grade of C (pass) or better; and
(ii) At least fifteen managed births were completed under the preceptorship of an experienced midwife approved by the candidate's educational program.
(c) If managed births completed under the preceptorship in (b)(ii) of this subsection are less than fifty, then affidavits of births the applicant has managed must be submitted in a sufficient number to prove that the applicant has managed a total of at least fifty births.
(2) The applicant shall submit to the department:
(i) A complete notarized application with the required fee.
(ii) Notarized copies of educational preparation or an official transcript verifying educational preparation or an official transcript verifying educational preparation to practice midwifery.
(iii) Declarations of managed births as required in subsection (1)(c) of this section.
(3) Applicants must demonstrate completion of seven clock hours of AIDS education as provided in chapter 246-12 WAC, Part 8)) provided the applicant completes all requirements in this section:
(1) Complete application requirements for licensure in WAC 246-834-060;
(2) Provide proof of a certificate or diploma from a foreign institution on midwifery of equal requirements conferring the full right to practice midwifery in the country in which it was issued. The diploma must bear the seal of the institution from which the applicant graduated. If applicable, the candidates must, at her or his own expense, present with the application a certified translation of the foreign certificate or diploma made by and under the seal of the consulate of the country in which the certificate or diploma was issued;
(3) Submit proof of completing at least three years of midwifery training including the study of basic nursing that meets the requirements under WAC 246-834-140(1);
(4) Submit proof of meeting minimum educational requirements under WAC 246-834-140 (2)(a) and (b);
(5) Submit to the department documentation of attendance at one hundred births that meets the requirements of WAC 246-834-140 (3)(a);
(6) Submit to the department documentation of prenatal care examinations of fifty women and early postpartum care examinations of fifty women that meets the requirements of WAC 246-834-140 (3)(b); and
(7) Demonstrate competency in the use and administration of legend drugs and devices described in RCW 18.50.115 and WAC 246-834-250. The applicant shall submit documentation of competency to the department on a department supplied form. A licensed health care professional who, within his or her scope of practice, is qualified in the use and administration of legend drugs and devices described in RCW 18.50.115 and WAC 246-834-250 must sign the form.
AMENDATORY SECTION (Amending WSR 99-03-064, filed 1/18/99, effective 2/18/99)
WAC 246-834-080 Examination failures.
(1) An applicant who has failed ((either)) the NARM examination or the Washington state ((specific component)) licensing examination, or both ((must)), shall retake and pass the examination(s) which he or she failed.
(2) The applicant who fails the Washington state licensing examination may sit for the ((examination)) reexamination if he or she:
(a) Applies to the department at least ((fifty-six)) fourteen days prior to the next scheduled examination; and
(b) Pays ((any)) the required fee as specified in WAC 246-834-990.
(((2))) (3) An applicant((s)) who fails the ((second retest)) NARM or Washington licensing examination three consecutive times shall ((be required to)) submit evidence to the secretary of completion of an individualized program of study approved ((in advance)) by the department prior to retaking the examination.
(((3) Applicants may have their examination hand-scored by submitting a request and appropriate fee directly to NARM within ninety days of the examination administration. A copy of their request must be sent to the department. The department will inform the applicant of the results of the hand-scored examination.))
NEW SECTION
WAC 246-834-135 Secretary accredited midwifery programs.
The secretary accepts midwifery education programs that meet the Midwifery Education Accreditation Council (MEAC) standards and competencies established in 2014 as accredited and approved courses of instruction.
AMENDATORY SECTION (Amending WSR 92-02-018, filed 12/23/91, effective 1/23/92)
WAC 246-834-140 ((Curriculum.)) Eligibility for state licensing examination.
Candidates for the state licensing examination shall meet the following conditions, unless applying under WAC 246-834-066 Certified professional midwife (CPM) licensure requirements:
(1) ((The basic curriculum)) Midwifery training shall be at least three academic years, and shall consist of both didactic and clinical instruction sufficient to meet the educational standards of the school and ((of chapter 18.50 RCW)) this section. However, ((the school may shorten)) the length of ((time for the program)) required training may be shortened, but not to less than two academic years, after consideration of the student's documented education and experience in the required subjects, if the applicant is a registered nurse or practical nurse licensed under chapter (( 18.88 RCW, a licensed practical nurse under chapter 18.78 RCW,)) 18.79 RCW, or has had previous nursing education or practical midwifery experience. ((The midwifery training shall not be reduced to a period of less than two academic years. Each student))
(2) The applicant must receive instruction in the following educational areas:
(a) Basic sciences (including biology, physiology, microbiology, anatomy with emphasis on female reproductive anatomy, genetics and embryology), normal and abnormal obstetrics and gynecology, family planning techniques, childbirth education, nutrition both during pregnancy and lactation, breast feeding, neonatology, epidemiology, community care, and medicolegal aspects of midwifery; and
(b) Basic nursing skills and clinical skills including, but not limited to, vital signs, perineal prep, catheterization, aseptic techniques, administration of medications both orally and by injection, local infiltration for anesthesia, venipuncture, administration of intravenous fluids, infant and adult resuscitation, and charting.
(3) The applicant must undertake the care of not less than ((fifty women in each of the prenatal, intrapartum and early postpartum periods. The care of up to thirty five women in each of the periods may be undertaken as a part of previous nursing education or practical midwifery experience as defined in WAC 246-834-010(5))) one hundred women in the intrapartum period. No less than fifteen of the one hundred women must be cared for in ((each)) the intrapartum period while the applicant was enrolled in the school from which the student graduates. ((The student need not see the same women throughout each of the periods. A candidate for licensure must observe an additional fifty women in the intrapartum period in order to qualify for licensure. Up to thirty five of these observations may be as a part of previous nursing education or practical midwifery experience as defined in WAC 246-834-010(5). No less than fifteen women must be observed in the intrapartum period while enrolled in the school from which the student graduates.
(2) Each school must ensure that the students receive instructions in the following instruction area:
(a) Instruction in basic sciences (including biology, physiology, microbiology, anatomy with emphasis on female reproductive anatomy, genetics and embryology) normal and abnormal obstetrics and gynecology, family planning techniques, childbirth education, nutrition both during pregnancy and lactation, breast feeding, neonatology, epidemiology, community care, and medicolegal aspects of midwifery.
(b) Instruction in basic nursing skills and clinical skills, including but not limited to vital signs, perineal prep, enema, catheterization, aseptic techniques, administration of medications both orally and by injection, local infiltration for anesthesia, venipuncture, administration of intravenous fluids, infant and adult resuscitation, and charting.
(c) Clinical practice in midwifery which includes care of women in the prenatal, intrapartal and early postpartum periods, in compliance with RCW 18.50.040.
(3) Provision shall be made for systematic, periodic evaluation of the curriculum.
(4) Any proposed major curriculum revision shall be presented to the secretary at least three months prior to implementation.))
(a) The applicant shall submit to the department documentation of attendance at one hundred births of which:
(i) At least thirty births where the applicant was the primary attendant under supervision of a qualified attendant;
(ii) At least twenty births where the applicant directly assisted;
(iii) At least fifty births that the applicant observed in addition to births counted in (d)(i) and (ii) of this subsection; and
(iv) Documentation for (a)(i) through (iii) of this subsection must include at least the date, client identifier, the applicants role at each birth, and the signature or initials of the qualified attendant at the birth of either: A licensed midwife, a CPM preceptor, a certified nurse midwife, or a practitioner licensed by their state or jurisdiction to provide maternity care. The applicant shall submit to the department the name and contact information of each signatory, if available. The department may approve exceptions to the required documentation in this subsection.
(b) The applicant shall submit to the department documentation of prenatal care examinations of fifty women and early postpartum care examinations of fifty women. The same women need not be seen for both examinations.
(i) No less than fifteen women must be cared for in the prenatal and postpartum periods while enrolled in the school from which the student graduates.
(ii) Documentation must include at least the date, client identifier, and the signature or initials of the qualified attendant at the care examination of either: A licensed midwife, a CPM preceptor, a certified nurse midwife, or a practitioner licensed by their state or jurisdiction to provide maternity care. The applicant must submit to the department the name and contact information of each signatory, if available. The department may approve exceptions to the required documentation in this subsection.
(4) The applicant shall demonstrate competency in the use and administration of legend drugs and devices described in WAC 246-834-250. The applicant shall submit documentation of competency to the department on a department supplied form. A licensed health care professional who, within his or her scope of practice, is qualified in the use and administration of legend drugs and devices described in RCW 18.50.115 and WAC 246-834-250 must sign the form.
AMENDATORY SECTION (Amending WSR 92-02-018, filed 12/23/91, effective 1/23/92)
WAC 246-834-160 Student midwife permit.
(1) A student midwife permit may be issued to any individual who has:
(a) Successfully completed an accredited midwifery program as specified in WAC 246-834-135, or is foreign trained as specified in ((RCW 18.50.040 (2)(a) and (b); and
(b) Undertaken)) WAC 246-834-065(1);
(b) Obtained a minimum period of midwifery training of at least three academic years as required by WAC 246-834-140;
(c) Met the minimum education requirements required in WAC 246-834-140 (2)(a) and (b);
(d) Documentation of undertaking the care of not less than fifty women in each of the prenatal, intrapartum and early postpartum periods as required by RCW 18.50.040 (2)(c) ((and by these rules; and
(c)));
(e) Satisfactorily completed the ((licensing)) NARM examination required by ((RCW 18.50.060)) WAC 246-834-050; and
(((d))) (f) Filed a completed application for student midwife permit under WAC 246-834-060 and accompanied by a nonrefundable fee as specified in WAC 246-834-990.
(2) The student midwife permit authorizes the individuals to practice and observe ((fifty)) women in the intrapartum period under the supervision of a licensed midwife((, licensed physicians or CRN ()) under 18.50 RCW, an allopathic physician under chapter 18.71 RCW, an osteopathic physician under chapter 18.57 RCW or certified nurse midwife(())) under chapter 18.79 RCW.
(3) Once all application requirements including clinical components are completed the applicant may be eligible to sit for the Washington state licensure examination.
NEW SECTION
WAC 246-834-255 Elements of care for the newborn.
The customary scope of care of a newborn up to two weeks of age by a licensed midwife includes, but is not limited to, clinical assessment, treatment, education, support and referral as described in this section. Newborn care shall not go beyond the scope of the midwife's education, training and experience.
(1) Immediate newborn care includes, but is not limited to:
(a) Appearance, pulse, grimace, activity and respiration (APGAR) assessment;
(b) Stabilization and monitoring of the newborn for a minimum of two hours postpartum;
(c) Early initiation and facilitation of breast or bottle feeding;
(d) Complete physical examination;
(e) Education for parents regarding care and monitoring of the normal newborn; and
(f) Physician consultation, referral and/or transfer of care in the event of significant deviations from normal.
(2) Other support may include:
(a) Neonatal resuscitation; and
(b) Legend drugs and devices allowed in RCW 18.50.115 and WAC 246-834-250.
(3) Subsequent care may include, but is not limited to:
(a) Evaluating the newborn for well-being such as jaundice, weight loss, and adequate feeding and elimination patterns;
(b) Newborn metabolic screening per RCW 70.83.020;
(c) Critical congenital heart disease screening per RCW 70.83.090;
(d) Lactation care and services; and
(e) Consultation and/or referral to pediatric care for any significant deviation from normal.
AMENDATORY SECTION (Amending WSR 98-05-060, filed 2/13/98, effective 3/16/98)
WAC 246-834-400 Expired license.
(1) If ((the)) a midwife's license under this chapter has expired for three years or less, to reinstate the license the practitioner ((must)) shall meet the requirements of chapter 246-12 WAC, Part 2.
(2) If ((the license has expired for over three years, the practitioner must:
(a) Demonstrate competence to the standards established by the secretary;)) a midwife's license under this chapter has expired and the practitioner has been engaged in the active practice of midwifery, to reinstate the license the practitioner shall:
(a) Submit verification of active practice; and
(b) Meet the requirements of chapter 246-12 WAC, Part 2.
(3) If a midwife's license under this chapter has been expired for more than three years but less than five years at time of application, and the practitioner has not been actively engaged in midwifery, the practitioner shall:
(a) Work as a birth assistant under the supervision of a department approved preceptor for a minimum of ten births; and
(b) Meet the requirements of chapter 246-12 WAC, Part 2.
(4) If a midwife's license under this chapter has been expired for more than five years at time of application, and the practitioner has not been actively engaged in midwifery, the practitioner shall:
(a) Work as a birth assistant under the supervision of a department approved preceptor for a minimum of fifteen births;
(b) Retake and successfully pass the Washington state licensing examination; and
(c) Meet the requirements of chapter 246-12 WAC, Part 2.
(5) A proposed preceptor shall:
(a) Hold an active license without restriction, current discipline, or conditions as a midwife under chapter 18.50 RCW, a certified nurse midwife under chapter 18.79 RCW, an allopathic physician under chapter 18.71 RCW, or an osteopathic physician under chapter 18.57 RCW;
(b) Have actively practiced at least three consecutive years or attended at least one hundred fifty births; and
(c) Have demonstrated ability and skill to provide safe, quality care.
NEW SECTION
WAC 246-834-450 Inactive license.
(1) A licensed midwife may obtain an inactive license. Refer to the requirements of chapter 246-12 WAC, Part 4.
(2) An inactive license must be renewed every year on the midwife's birthday according to WAC 246-12-100 and by paying the fee required under WAC 246-834-990.
(3) A midwife with an inactive license may return to active status.
(a) A midwife with an inactive license for three years or less who wishes to return to active status must meet the requirements of chapter 246-12 WAC, Part 4.
(b) A midwife with an inactive license for more than three years, who has been in active practice and wishes to return to active status must:
(i) Submit verification of active practice; and
(ii) Meet the requirements of chapter 246-12 WAC, Part 4.
(c) A midwife with an inactive license for more than three years but less than five, who has not been in active practice and wishes to return to active status must:
(i) Work as a birth assistant under the supervision of a department approved preceptor for a minimum of ten births; and
(ii) Meet the requirements of chapter 246-12 WAC, Part 4.
(d) A midwife with an inactive license for more than five years who has not been in active practice and wishes to return to active status must:
(i) Work as a birth assistant under the supervision of a department approved preceptor for a minimum of fifteen births;
(ii) Retake and successfully pass the Washington state licensing examination; and
(iii) Meet the requirements of chapter 246-12 WAC, Part 4.
(4) A proposed preceptor shall:
(a) Hold an active license without restriction, current discipline, or conditions as a midwife under chapter 18.50 RCW, a certified nurse midwife under chapter 18.79 RCW, an allopathic physician under chapter 18.71 RCW, or an osteopathic physician under chapter 18.57 RCW;
(b) Have actively practiced at least three consecutive years or attended at least one hundred fifty births; and
(c) Have demonstrated ability and skill to provide safe, quality care.
AMENDATORY SECTION (Amending WSR 12-19-088, filed 9/18/12, effective 11/1/12)
WAC 246-834-990 Midwifery fees and renewal cycle.
(1) Licenses must be renewed every year on the practitioner's birthday as provided in chapter 246-12 WAC, Part 2.
(2) The following fees are nonrefundable:
REPEALER
The following sections of the Washington Administrative Code are repealed:
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