No. 32884 (Amendment): Rule R156-77. Direct-Entry Midwife Act Rules

(Amendment)

DAR File No.: 32884
Filed: 08/13/2009 02:11:11 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

Senator Margaret Dayton sponsored S.B. 93 during the 2008 legislative session. That bill created the Direct-Entry Midwife Administrative Rules Committee and charged the Committee to make changes to the Direct-Entry Midwife Act Rule regarding the scope of practice for a licensed direct-entry midwife in Utah. The bill also created a new classification of services called "mandatory consultation" and placed several conditions identified in the rule into the category of mandatory consultation. As a result of this, the rule needs to be updated to reflect the statutory changes. (DAR NOTE: S.B. 93 (2008) is found at Chapter 365. Laws of Utah 2008, and was effective 05/05/2008.)

Summary of the rule or change:

Throughout the rule the term "rules" has been replaced with "rule" where applicable. In Section R156-77-102, adds definitions for "approved continuing education", "C-section", "LDEM (licensed direct-entry midwife) Outcome Database", "TOLAC" (trial of labor after cesarean section), "VBAC" (vaginal birth after cesarean section), and "weeks gestation". In Section R156-77-303, the proposed amendments require specific continuing education hours in the area of intrapartum fetal monitoring to renew a direct-entry midwife license and provides that a licensee must be able to document completion of the continuing education hours upon request of the Division. In Section R156-77-502, updates the MANA (Midwives Alliance of North America) Standards which are incorporated by reference to the 2005 edition. In Section R156-77-601, clarifies, rearranges, and establishes conditions that require consultation, mandatory consultation, collaboration, referral, waiveable transfer, and mandatory transfer. Section R156-77-602 is a new section which adds informed consent. This section adds to the standards for informed consent that already exists in the rule. Ten additional pieces of information are being added for a client with a previous c-section who is attempting a vaginal delivery after the c-section to know to fully provide informed consent for treatment. Sections R156-77-603 and R156-77-604 have been renumbered due to the addition of new Section R156-77-602. In Section R156-77-604, added that a licensee shall submit to the Division a copy of data submitted to MANA if so requested by the Division. Also added that a licensee must also submit outcome data to the LDEM Outcome Database at least annually.

State statutory or constitutional authorization for this rule:

• Subsection 58-1-106(1)(a)
• Subsection 58-77-202(4)
• Subsection 58-1-202(1)(a)
• Subsection 58-77-601(2)

This rule or change incorporates by reference the following material:

• Updates: MANA Standards and Qualifications for the Art and Practice of Midwifery, 08/13/2009

Anticipated cost or savings to:

the state budget:

The Division will incur minimal costs of approximately $75 to print and distribute the rule once the proposed amendments are made effective. Any costs incurred will be absorbed in the Division's current budget.

local governments:

The proposed amendments only apply to licensed direct-entry midwives, applicants for licensure in that classification and clients that utilize the services of a licensed direct-entry midwife. Local governments do not employ or utilize the services a licensed direct-entry midwives. As a result, the proposed amendments do not apply to local governments.

small businesses:

The proposed amendments only apply to licensed direct-entry midwives, applicants for licensure in that classification, and clients who utilize the services of a licensed direct-entry midwife. The governing statute, Title 58, Chapter 77, does not mandate reimbursement for the services of a licensed direct-entry midwife so there should be no general affect on a small business. However, a licensed direct-entry midwife could own a small business and the proposed changes to the standards may limit the type of clients accepted into the practice. The existing rule allows VBACs (vaginal birth after c-section); but the amended statute and proposed rule amendments establish some restrictions on the type or timing of a patient seeking a home birth after having had a c-section. This may cause a minimal loss of revenue to the licensed direct-entry midwife of approximately $1,500 - $2,000 per client.

persons other than small businesses, businesses, or local governmental entities:

The proposed amendments only apply to licensed direct-entry midwives, applicants for licensure in that classification, and clients who utilize the services of a licensed direct-entry midwife. The governing statute, Title 58, Chapter 77, does not mandate reimbursement for the services of a licensed direct-entry midwife business. However, a licensed direct-entry midwife could own a small business and the proposed changes to the standards may limit the type of clients accepted into the practice. The existing rule allows VBACs (vaginal birth after c-section); but the amended statute and proposed rule amendments establish some restrictions on the type or timing of a patient seeking a home birth after having had a c-section. This may cause a minimal loss of revenue to the licensed direct-entry midwife of approximately $1,500 - $2,000 per client. A client who has had a c-section may not be able to attempt a home birth with a licensed direct-entry midwife because of the proposed amendments. Such a client would be required to birth in an acute care facility attended by a physician and therefore the costs of delivering the baby could increase to $4,000 - $6,000 on average.

Compliance costs for affected persons:

The proposed amendments only apply to licensed direct-entry midwives, applicants for licensure in that classification, and clients who utilize the services of a licensed direct-entry midwife. As indicated above, the license direct-entry midwife may lose a few potential clients who would not be allowed to utilize the services of the midwife. This may cause a minimal loss of revenue to the licensed direct-entry midwife of approximately $1,500 - $2,000 per client. A client who has had a c-section may not be able to attempt a home birth with a licensed direct-entry midwife because of the proposed amendments. Such a client would be required to birth in an acute care facility attended by a physician and therefore the costs of delivering the baby could increase to $4,000 - $6,000 on average.

Comments by the department head on the fiscal impact the rule may have on businesses:

No fiscal impact to businesses is anticipated beyond that considered in the passage of Chapter 365, Laws of Utah 2008 (S.B. 93) and that addressed in the rule filing summary.

Francine A. Giani, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Commerce
Occupational and Professional Licensing
160 E 300 S
SALT LAKE CITY, UT 84111-2316

Direct questions regarding this rule to:

• Laura Poe at the above address, by phone at 801-530-6789, by FAX at 801-530-6511, or by Internet E-mail at [e-mail]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

10/15/2009

Interested persons may attend a public hearing regarding this rule:

• 09/17/2009 03:00 PM, Heber Wells Bldg, 160 E 300 S, Conference Room 474 (fourth floor), Salt Lake City, UT

This rule may become effective on:

10/22/2009

Authorized by:

Mark Steinagel, Director

RULE TEXT

R156. Commerce, Occupational and Professional Licensing.

R156-77. Direct-Entry Midwife Act Rule[s].

R156-77-101. Title.

[These rules are]This rule is known as the "Direct-Entry Midwife Act Rule[s]."

R156-77-102. Definitions.

In addition to the definitions in Title 58, Chapters 1 and 77, as used in Title 58, Chapter 77 or [these rules]this rule:

(1) "Accredited school", as used in [these rules]this rule, includes any midwifery school that has been granted pre-accredited status by MEAC.

(2) "Apgar score", as used in Section R156-77-601, means an index used to evaluate the condition of a newborn based on a rating of 0, 1, or 2 for each of the five characteristics of color, heart rate, response to stimulation of the sole of the foot, muscle tone, and respiration with 10 being a perfect score.

(3) "Appropriate provider", as used in Sections R156-77-601 and 602, means a licensed provider who is an appropriate contact person based on the provider's level of education and scope of practice.

(4) "Approved continuing education", as used in Subsection R156-77-303(3)(c), means:

(a) continuing education that has been approved by a nationally recognized professional organization that approves health related continuing education;

(b) a course offered by a post-secondary education institution that is accredited by an accrediting board recognized by the U.S. Department of Education, an MEAC approved midwifery program or accredited midwifery school, or an MEAC approved program or course; or

(c) continuing education that is sponsored or presented by MANA or any subgroup thereof, a government agency, a recognized direct-entry midwifery or health care association.

([4]5) "Collaborate", as used in Section R156-77-601, means the process by which an LDEM and another licensed health care provider jointly manage a specific condition of a client according to a mutually agreed-upon plan of care. The LDEM continues midwifery management of the client and may follow through with the medical management as agreed upon with the provider.

([5]6) "Consultation", as used in Section R156-77-601, means the process by which the LDEM discusses client status with an appropriate licensed health care provider by phone, written note, or in person. The provider may give a recommendation for management, but does not assume the management of the client.

([6]7) "CPR", as used in [these rules]this rule, means cardiopulmonary resuscitation.

(8) "C-section", as used in this rule, means a cesarean section.

([7]9) "LDEM", as used in [these rules]this rule, means a licensed direct entry midwife licensed under Title 58, Chapter 77.

(10) "LDEM Outcome Database", as used in Section R156-77-604, means a web based application created by the Division to collect data regarding the outcome of pregnancies and deliveries managed by an LDEM.

([8]11) "MANA", as used in [these rules]this rule, means the Midwives Alliance of North America.

([9]12) "MEAC", as used in [these rules]this rule, means the Midwifery Education Accreditation Council.

([10]13) "Midwifery Care", as used in [these rules]this rule, has the same meaning as the practice of direct-entry midwifery as defined in Subsection 58-77-102([7]8).

([11]14) "NARM", as used in [these rules]this rule, means the North American Registry of Midwives.

([12]15) "Refer", as used in Section R156-77-601, means the process by which an LDEM directs the client to an appropriate licensed health care provider for management of a specific condition. The LDEM continues midwifery management of the client.

(16) "TOLAC", as used in Section R156-77-602, means a trial of labor after cesarean section.

([13]17) "Transfer", as used in Section R156-77-601, means the process by which an LDEM relinquishes management of a client to an appropriate licensed health care provider. The LDEM may provide on-going support services as appropriate.

([14]18) "Unprofessional conduct," as defined in Title 58 Chapters 1 and 77, is further defined, in accordance with Subsection 58-1-203([5]1)(e), in Section R156-77-502.

(19) "VBAC", as used in this rule, means a vaginal birth after cesarean section.

(20) "Weeks gestation", as used in this rule, means the age of a pregnancy using accepted pregnancy dating criteria such as menstrual or ultrasound dating. A gestation week starts at the beginning of that week; therefore, 36 weeks gestation is the start of the 36th week of pregnancy.

R156-77-103. Authority - Purpose.

[These rules are]This rule is adopted by the division under the authority of Subsection 58-1-106(1)(a) to enable the division to administer Title 58, Chapter 77.

R156-77-302b. Qualifications for licensure - Education Requirements.

In accordance with Subsections 58-1-203(1) (b), 58-1-301(3), and 58-77-302(6), the pharmacology course requirement for licensure in Subsection 58-77-302(6) is defined herein. The course must be:

(1) offered by a post-secondary educational institution that is accredited by an accrediting board recognized by the Council for Higher Education Accreditation of the American Council on Education, a MEAC approved midwifery program or accredited midwifery school, or be a MEAC approved program or course; and

(2) at least eight clock hours in length and include basic pharmacotherapeutic principles and administration of medications including the drugs listed in Subsections 58-77-102([7]8)(f)(i) through (ix); or

(3) a general pharmacology course of at least 20 clock hours in length from a health-related course of study.

R156-77-303. Renewal Cycle - Procedures.

(1) In accordance with Subsection 58-1-308(1), the renewal date for the two-year renewal cycle applicable to licensees under Title 58, Chapter 77 is established by rule in Subsection R156-1-308a(1).

(2) Renewal procedures shall be in accordance with Section R156-1-308c.

(3) Each applicant for renewal shall comply with the following:

(a) submit documentation of holding a current Certified Professional Midwife certificate in good standing with NARM;[ and]

(b) submit documentation of current certifications in adult and infant CPR, and newborn resuscitation that meets the criteria established in R156-77-302a ; and

(c) complete at least two clock hours of approved continuing education in intrapartum fetal monitoring during each preceding two year licensure cycle which may be part of the hours required in Subsection (a) to maintain certification provided the hours meet the requirements established by NARM.

(4) A licensee must be able to document completion of the continuing education hours upon the request of the Division. Such documentation shall be retained until the next licensure renewal cycle.

R156-77-502. Unprofessional Conduct.

"Unprofessional conduct" includes:

(1) failure to practice in accordance with the knowledge, clinical skills, and judgments described in the MANA Core Competencies for Basic Midwifery Practice (1994), which is hereby adopted and incorporated by reference; and

(2) failing as a midwife to follow the MANA Standards and Qualifications for the Art and Practice of Midwifery ([1997]2005), which is hereby adopted and incorporated by reference.

R156-77-601. Standards of Practice.

Except as provided in Subsection 58-77-601(3)(b), and in accordance with Subsection 58-77-601(2), the standards and circumstances that require an LDEM to recommend and facilitate consultation, collaboration, referral, transfer, or mandatory transfer of client care are established herein. These standards are at a minimum level and are hierarchical in nature. If the standard requires at least consultation for a condition, an LDEM may choose to collaborate, refer, or transfer the care of the client.

(1) Consultation:

(a) antepartum:

(i) suspected intrauterine growth restriction;

(ii) severe vomiting unresponsive to LDEM treatment;

(iii) pain unrelated to common discomforts of pregnancy;

(iv) presence of condylomata that may obstruct delivery;

(v) anemia unresponsive to LDEM treatment;

(vi) history of genital herpes;

(vii) suspected or confirmed fetal demise after 14 weeks gestation;

(viii) suspected multiple gestation;

(ix) confirmed chromosomal or genetic aberrations;

(x) hepatitis C;[and]

(xi) prior c-section without a second trimester ultrasound to determine the location of placental implantation; and

(xi i) any other condition in the judgment of the LDEM requires consultation.

(2) Mandatory Consultation:

(a) incomplete miscarriage after 14 weeks gestation;

(b) failure to deliver by 42 weeks gestation;

(c) a fetus in the breech position after 36 weeks gestation;

(d) any sign or symptom of:

(i) placenta previa;

(ii) deep vein thrombosis or pulmonary embolus; or

(iii) vaginal bleeding after 20 weeks gestation, in a woman with a history of a c-section who has not had an ultrasound performed;

(e) Rh isoimmunization or other red blood cell isoimmunization known to cause erythroblastasis fetalis; or

(f) any other condition or symptom in the judgment of the LDEM that may place the health of the pregnant woman or unborn child at unreasonable risk.

([2]3) Collaborate:

(a) antepartum:

(i) infection not responsive to LDEM treatment;

(ii) seizure disorder affecting the pregnancy;

(iii) history of cervical incompetence with surgical therapy;

(iv) [mild hypertension defined as a sustained diastolic blood pressure of between 90 mm and 100 mm in two readings at least six hours apart]increase in blood pressure with a systolic pressure greater than 140mm or a diastolic pressure greater than 90mm in two readings at least six hours apart, no more than trace proteinurea or other evidence of preeclampsia; and

(vi) any other condition in the judgment of the LDEM requires collaboration;

(b) postpartum:

(i) infection not responsive to LDEM treatment; and

(ii) any other condition in the judgment of the LDEM requires collaboration.

([3]4) Refer:

(a) antepartum:

(i) thyroid disease;

(ii) changes in the breasts not related to pregnancy or lactation;

(iii) severe psychiatric illness responsive to treatment;

(iv) heart disease that has been determined by a cardiologist to have potential to affect or to be affected by pregnancy, labor, or delivery; and

(v) any other condition in the judgment of the LDEM requires referral;

(b) postpartum:

(i) bladder dysfunction;

(ii) severe depression; and

(iii) any other condition in the judgment of the LDEM requires referral;

(c) newborn:

(i) birth injury requiring on-going care;

(ii) minor congenital anomaly;

(iii) jaundice beyond physiologic levels;

(iv) loss of 15% of birth weight;

(v) inability to suck or feed; and

(vi) any other condition in the judgment of the LDEM requires referral.

([4]5) Transfer, however may be waived in accordance with Subsection 58-77-601(3)(b):

(a) antepartum:

(i) current drug or alcohol abuse;

(ii) [greater than a one and one-half pound estimated weight discrepancy between fetuses in a multiple gestation;

(iii) ]current diagnosis of cancer;

([iv]iii) persistent oligohydramnios not responsive to LDEM treatment;

( iv) confirmed intrauterine growth restriction;[

(vi) confirmed breech presentation;

(vii) twins;

(viii) two previous c-sections;]

(v) prior c-section with unknown uterine incision type provided a reasonable effort has been made to determine the uterine scar type and the client has signed an informed consent that meets the standards established in Section R156-77-602;

([ix]vi) history of preterm delivery less than 34 weeks gestation;

([x]vii) history of severe postpartum bleeding;

([xi]viii) primary genital herpes outbreak;

([xii]ix) [mild preeclampsia defined as a sustained diastolic blood pressure of 90 mm or greater in two readings at least six hours apart and 1+ to 2+ proteinurea]increase in blood pressure with a systolic pressure greater than 140mm or a diastolic pressure greater than 90mm in two readings at least six hours apart, and 1+ to 2+ proteinurea confirmed by a 24 hour urine collection of greater than 300 mg of protein; and[

(xiii) gestation greater than 43 weeks; and]

(x[iv]) any other condition in the judgment of the LDEM may require transfer;

(b) intrapartum:

(i) [non-reassuring fetal heart rate pattern indicative of fetal distress that does not respond to LDEM treatment;

(ii) ]visible genital lesions suspicious of herpes virus infection;

(ii[i]) [moderate]severe hypertension defined as a sustained diastolic blood pressure of greater than 110 mm or a systolic pressure of greater than 160 mm[in two readings at least six hours apart];

([iv]iii) excessive vomiting, dehydration, acidosis, or exhaustion unresponsive to LDEM treatment; and

( iv) any other condition in the judgment of the LDEM may require transfer;

(c) postpartum:

(i) retained placenta; and

(ii) any other condition in the judgment of the LDEM may require transfer;

(d) newborn:

(i) gestational age assessment less than [thirty-six (]36[)] weeks gestation;

(ii) major congenital anomaly not diagnosed prenatally;

(iii) persistent hyperthermia or hypothermia unresponsive to LDEM treatment; and

(iv) any other condition in the judgment of the LDEM may require transfer.

([5]6) Mandatory transfer:

(a) antepartum:

(i) severe preeclampsia or severe pregnancy -[ ]induced hypertension as evidenced by:

(A) a systolic pressure greater than 160mm or a diastolic pressure greater than 110mm in two readings at least six hours apart, or 3+ to 4+ proteinurea, or greater than 5gms of protein in a 24 hour urine collection; or

(B) a systolic pressure greater than 140mm or a diastolic pressure greater than 90mm in two readings at least six hours apart, at least 1+ proteinurea, and one or more of the following:

(1) epigastric pain;

(2) headache;

(3) visual disturbances; or

(4) decreased fetal movement;

(ii) eclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome (HELLP);

(iii) documented platelet count less than 75,000 platelets per mm ³ of blood;

(iv) [diagnosed partial placenta previa at week 36, or complete placenta previa at 32 weeks]placenta previa after 27 weeks of gestation;

(v) confirmed ectopic pregnancy;

(vi) severe psychiatric illness non-responsive to treatment;

(vii) human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS);

(viii) [mono-amniotic multiple gestation]diagnosed deep vein thrombosis or pulmonary embolism;

(ix) [twin-to-twin transfusion syndrome]multiple gestation;

(x) [three or more previous c-sections]no onset of labor by 43 weeks gestation;

(xi) [higher order (greater than two) multiple gestations]more than two prior c-sections;

(xii) prior c-section with a known uterine classical, inverted T or J incision, or an extension of an incision into the upper uterine segment;

(xiii) prior c-section without an ultrasound that rules out placental implantation over the uterine scar obtained no later than 35 weeks gestation or prior to commencement of care if the care is sought after 35 weeks gestation;

(xiv) prior c-section without a signed informed consent document meeting the standards established in Section R156-77-602;

(xv) prior c-section with a gestation greater than 42 weeks gestation;

([xii]xvi) [RH]Rh isoimmunization or other red blood cell isoimmunization known to cause erythroblastasis fetalis, with an antibody titre of greater than 1:8[in a mother carrying Rh positive baby or a baby of unknown Rh type];

([xiii]xvii) insulin-dependent diabetes;

([xiv]xviii) significant vaginal bleeding after 20 weeks gestation not consistent with normal pregnancy and posing a continuing risk to mother or baby; and

([xv]xiv) any other condition in the judgment of the LDEM [must be transferred]that could place the life or long-term health of the pregnant woman or unborn child at risk;

(b) intrapartum:

(i) signs of uterine rupture;

(ii) presentation(s) not compatible with spontaneous vaginal delivery;

(iii) fetus in breech presentation during labor unless delivery is imminent;

([iii]iv) progressive labor prior to [36]37 weeks gestation except miscarriages, confirmed fetal death, or congenital anomalies incompatible with life;

([iv]v) prolapsed umbilical cord unless birth is imminent;

(v i) clinically significant abdominal pain inconsistent with normal labor;

(vi i) seizure;

(vii i) [complete placenta previa]undiagnosed multiple gestation, unless delivery if imminent;

([viii]ix) suspected chorioamnionitis;

(x) prior c-section with cervical dilation progress in the current labor of less than one centimeter in three hours once labor is active;

(xi) non-reassuring fetal heart pattern indicative of fetal distress that does not immediately respond to treatment by the LDEM, unless delivery is imminent;

(xii) moderate thick, or particulate meconium in the amniotic fluid unless delivery is imminent;

(xiii) failure to deliver after three hours of pushing unless delivery is imminent; or

([ix]xiv) any other condition in the judgment of the LDEM [must be transferred]that would place the life or long-term health of the pregnant woman or unborn child at significant risk if not acted upon immediately;

(c) postpartum:

(i) uncontrolled hemorrhage;

(ii) maternal shock that is unresponsive to LDEM treatment;

(iii) severe psychiatric illness non-responsive to treatment;

(iv) signs of deep vein thrombosis or pulmonary embolism; and

(v) any other condition in the judgment of the LDEM [must be transferred]that could place the life or long-term health of the mother or infant at significant risk if not acted upon immediately;

(d) newborn:

(i) non-transient respiratory distress;

(ii) non-transient pallor or central cyanosis;

(iii) Apgar score at ten minutes of less than six;

(iv) low heart rate of less than 60 beats per minute after one complete neonatal resuscitation cycle;

(v) absent heart rate except with confirmed fetal death or congenital anomalies incompatible with life, or shoulder dystocia resulting in death;

(vi) hemorrhage;

(vii) seizure;

(viii) persistent hypertonia, lethargy, flaccidity or irritability, or jitteriness;

(ix) inability to urinate or pass meconium within the first 48 hours of life; and

(x) any other condition in the judgment of the LDEM must be transferred.

R156-77-602. Informed Consent.

In addition to the standards for informed consent established in Subsection 58-77-601(1)(b), an informed consent for a client with a previous c-section, must include the following information about a VBAC:

(1) TOLAC is associated with the risk of uterine rupture. Uterine rupture can cause brain damage or death of the baby and result in serious hemorrhage or hysterectomy in the mother.

(2) VBAC poses more medical risks to the baby than a scheduled repeat c-section.

(3) Repeat c-section poses more medical risks to the mother than VBAC.

(4) C-section after a failed TOLAC is associated with more risks than a c-section done before labor has begun.

(5) If a complication occurs from a TOLAC outside of a hospital setting, the risk to mother and baby may be higher due to the inherent delay in obtaining access to hospital care.

(6) Multiple c-sections are associated with, but not limited to, increased risks due to abnormal placental implantation, hermorrhage requiring hysterectomy, and other surgical and postoperative complications.

(7) The risks associated with TOLAC after two c-sections are greater than those after one c-section.

(8) Risks associated with TOLAC when the type of uterine scar is unknown are greater than when the uterine scar is known to be low transverse.

(9) A 2004 national birth center study revealed women who attempt TOLAC in a birth center setting have an overall transfer rate of 24%, and a vaginal delivery rate of 87%.

(10) A woman with no previous vaginal birth and two previous c-sections for documented failure to progress, has a very low vaginal delivery success rate.

R156-77-[ 602 ] 603 . Procedures for the Termination of Midwifery Care.

(1) The procedure to terminate midwifery care for a client who has been informed that she has or may have a condition indicating the need for medical consultation, collaboration, referral, or transfer is established herein:

(a) provide no fewer than three business days written notice, unless an emergency, during which the LDEM shall continue to provide midwifery care, to enable the client to select another licensed health care provider;

(b) provide a referral; and

(c) document the termination of care in the client's records.

(2) The procedure to terminate midwifery care to a client who has been informed that she has or may have a condition indicating the need for mandatory transfer is established herein:

(a) have the client sign a release of care indicating the LDEM has terminated providing midwifery care as of a specific date and time; or

(b) verbally instruct the client of the termination of midwifery care and document said instruction in the client record;

(c) make a reasonable effort to convey significant information regarding the client's condition to the receiving provider; and

(d) if possible, when transferring the client by ambulance or private vehicle, the LDEM accompanies the client.

R156-77-[ 603 ] 604 . Submission of Outcome Data.

In accordance with Subsection 58-77-601(5), an individual licensed as an LDEM must submit outcome data electronically to the MANA's Division of Research on the form prescribed by MANA, and in accordance to the policies and procedures established by MANA. Upon request of the Division, the licensee shall submit to the Division a copy of the data submitted to MANA. A licensee must also submit outcome data to the LDEM Outcome Database at least annually.

KEY: licensing, midwife, direct-entry midwife

Date of Enactment or Last Substantive Amendment: [ September 14, 2006 ] 2009

Authorizing, and Implemented or Interpreted Law: 58-1-106(1)(a); 58-1-202(1)(a); 58-77-202(4) 58-77-601(2)

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