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Access to Comprehensive Sexual and Reproductive Health Care Services
The American College of Nurse-Midwives (ACNM) affirms the following:
Everyone has the right to make choices regarding sexual and reproductive health (SRH) that meet their individual needs. Everyone has the right to access factual, evidence-based, unbiased information about available SRH care services in order to make informed decisions. Access to SRH care services should be available and affordable for those with limited means. Parenting, adoption, and abortion are all legal and appropriate SRH options within the ethical context of self-determination. Midwifery care includes fertility assessment and support of those who seek pregnancy. Midwifery care includes support of individuals who choose to not become pregnant as part of their reproductive life plans. As providers of SRH care, midwives may provide abortion care as expanded scope of practice depending on scope of practice regulations and credentialing approval in the state.
Background
Every individual has the right to safe, supportive, and affirming health care in which providers demonstrate respect for human dignity.^1 ACNM supports each person’s right to self- determination, access to comprehensive health information, and active participation in all aspects of an individualized plan of care. ACNM acknowledges that the wide range of cultural, religious, and ethnic diversity of certified nurse-midwives/certified midwives (CNMs/CMs) and their clients allows for a variety of personal and professional choices related to SRH. Individuals who seek midwifery care should have the ability to choose and access to all legally available health care options. Within this context, is important to note that the term access refers to geographical, logistical, political, economical, and health systems issues related to care, whereas choice refers to a personal decision, regardless of the ability to enact a chosen plan. When access is restricted, the ability to choose abortion is also restricted.^2
Education Regarding Contraception
Midwifery care includes comprehensive, evidence-based information about and provision of contraception.^3 According to the Core Competencies for Basic Midwifery Practice,^4 midwives should be able to apply knowledge, skills, and ability related to fertility awareness, hormonal and non-hormonal contraceptive methods, long acting reversible contraceptives, emergency post- coital contraception, and permanent sterilization.^4 Emergency post-coital contraception should be
readily available, affordable, and included as part of contraceptive counseling. Individuals who do not desire pregnancy at any point in their lifetimes should be supported and respected in that choice. Unbiased discussions about long-term reproductive life plans and support for individualized definitions of partnership, sexual relationships, and family are vital for all individuals.
Preconception Care and Fertility Support
Midwives provide preconception counseling and evaluation as well as fertility assessment, support, and referral as appropriate. Midwifery services include ensuring the health and well- being of individuals who are considering pregnancy before conception. Midwives care for individuals who identify as queer/questioning, bi-sexual, lesbian, transgender, or gender variant as they seek preconception care and fertility evaluation. Midwives must be knowledgeable about the reproductive health care needs of these populations and have resources available to support and advocate for their safe and appropriate care.^5
Support of Pregnancy Intentions
During pregnancy, the midwife must create a safe space for individuals to discuss plans related to that pregnancy. Parenting, adoption, and abortion decisions may be made easily or with difficulty, depending on individual circumstances, and initial intentions regarding the pregnancy may change based on life events, laboratory or diagnostic test results, or personal choice.
Referral processes for outside resources should be well established. These may include pregnancy care depending on risk category, abortion care depending on the midwife’s scope of practice, and adoption support services depending on practice resources. Immediate access to evidence-based, non-coercive information regarding all options demonstrates support and provides an integrated health system approach to midwifery care. Midwives may provide medication or aspiration abortion as part of expanded scope of practice.^6 Most expanded skills related to SRH care are not currently addressed in midwifery educational programs, but resources are available for midwives who wish to provide these services.^7 Additionally, midwives must be aware of all current laws and regulations that may restrict who, how, where, and when abortion care may be provided.^8
Exercises of Conscience
The midwife should create a safe space in which individuals can consider all options regarding decisions to plan a pregnancy, continue a pregnancy, or choose an adoption or parenting plan. However, during the care process, circumstances may arise that cause ethical conflict for the midwife. Such conflict may lead to moral distress for the midwife and present dilemmas regarding how to proceed with ethical, evidence-based care free from personal bias.^9
ACNM has addressed the issue of conscientious objection, in which circumstances are such that the midwife’s ethical or moral beliefs conflict with provision of midwifery care:
Midwives have an ethical, moral, and legal obligation to create a non-judgmental atmosphere of shared decision making based on mutual respect, adequate factual information, and freedom from bias or discrimination for the women and families in their care… and an obligation to notify
- Levi A. Conscientious objection or dishonorable disobedience? J Midwifery Womens Health. 2015;60(5):483-484.
- American College of Nurse-Midwives. Conscientious refusal and the profession of midwifery. http://www.midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/ 000301/ConscientiousObjectionPositionStatementFINAL2016.pdf. Approved March
- Accessed July 12, 2016.
- White Ribbon Alliance for Safe Motherhood. Respectful maternity care: the universal rights of childbearing women. http://whiteribbonalliance.org/wp- content/uploads/2013/10/Final_RMC_Charter.pdf October 2011. Accessed October 27, 2016
- Sister Song. Reproductive justice. http://sistersong.net/reproductive-justice/. Accessed April 6, 2017.
- Luna Z, Luker K. Reproductive justice. Annu Rev Law Soc Sci. 2013;9:327-352.
Note. Midwifery as used throughout this document refers to the education and practice of certified nurse-midwives (CNMs) and certified midwives (CMs) who have been certified by the American College of Nurse-Midwives (ACNM) or the American Midwifery Certification Board, Inc. (AMCB
Source: Board of Directors Approved: Board of Directors February, 1991 Updated: 1997 Reviewed: Clinical Standards and Documents Section August 2011 Reviewed & Revised: Clinical Practice & Documents Section October 2016
