AB 1308, Bonilla. Midwifery.
Existing law, the Licensed Midwifery Practice Act of 1993, provides for the licensing and regulation of midwives by the Board of Licensing of the Medical Board of California. The license to practice midwifery authorizes the holder, under the supervision of a licensed physician and surgeon, as specified, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn. The act requires a midwife to immediately refer all complications to a physician and surgeon. Under the act, a licensed midwife is required to make certain oral and written disclosures to prospective clients. Under the act, the board is authorized to suspend or revoke the license of a midwife for specified conduct, including unprofessional conduct consisting of, among other things, incompetence or gross negligence in carrying out the usual functions of a licensed midwife. A violation of the act is a crime.
This bill would, among other things, no longer require a physician and surgeon to supervise a licensed midwife. The bill would require, if a potential midwife client fails to meet the conditions of a normal pregnancy or childbirth, as defined, but still desires to be a client, that the licensed midwife refer the woman to a physician and surgeon for examination. The bill would require the board to adopt regulations specifying certain of those conditions. The bill would authorize the licensed midwife to assist the woman only if the physician and surgeon determines, after examination, that the risk factors presented by the woman’s disease or condition are not likely to significantly affect the course of pregnancy and childbirth. The bill would require a licensed midwife to immediately refer or transfer the client to a physician and surgeon if at any point during pregnancy, childbirth, or postpartum care a client’s condition deviates from normal. The bill would authorize the licensed midwife to resume primary care of the client if the physician and surgeon determines that the client’s condition or concern has been resolved, and to provide concurrent care if the client’s condition or concern has not been resolved, as specified.
This bill would additionally authorize a licensed midwife to directly obtain supplies and devices, obtain and administer drugs and diagnostic tests, order testing, and receive reports that are necessary to his or her practice of midwifery and consistent with his or her scope of practice. The bill would require a licensed midwife to make additional disclosures to prospective clients, including, among other things, the specific arrangements for referral of complications to a physician and surgeon, and to obtain written, informed consent of those disclosures, as prescribed. By increasing the duties of a licensed midwife under the Licensed Midwifery Practice Act of 1993, the violation of which is a crime, the bill would impose a state-mandated local program. The bill would authorize the board to suspend or revoke the license of a licensed midwife for failing, when required, to consult with a physician and surgeon, to refer a client to a physician and surgeon, or to transfer a client to a hospital. The bill would require, if a client is transferred to a hospital, that the hospital report each transfer of a planned out-of-hospital birth to, among others, the board, using a form developed by the board.
Existing law requires a licensed midwife who assists, or supervises a student midwife in assisting, in childbirth that occurs in an out-of-hospital setting to annually report specified information to the Office of Statewide Health Planning and Development.
This bill would authorize the board, with input from the Midwifery Advisory Council, to adjust the data elements required to be reported to better coordinate with other reporting systems, as specified.
Existing law requires an approved midwifery education program to offer the opportunity for students to obtain credit by examination for previous midwifery education and clinical experience.
This bill would, beginning January 1, 2015, prohibit new licensees from substituting clinical experience for formal didactic education.
Existing law requires a licensed alternative birth center, and a licensed primary care clinic that provides services as an alternative birth center, to meet specified requirements, including the presence of at least 2 attendants during birth, one of whom shall be either a physician and surgeon or a certified nurse-midwife.
This bill would provide that a licensed midwife may also satisfy that requirement.
The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for a specified reason.
The people of the State of California do enact as follows:
The Legislature finds and declares the following:
(a) Licensed midwives have been authorized to practice since 1993 under Senate Bill 350 (Chapter 1280 of the Statutes of 1993), which was authored by Senator Killea. Additional legislation, Senate Bill 1950 (Chapter 1085 of the Statutes of 2002), which was authored by Senator Figueroa, was needed in 2002 to clarify certain practice issues. While the midwifery license does not specify or limit the practice setting in which licensed midwives may provide care, the reality is that the majority of births delivered by licensed midwives are planned as home births.
(b) Planned home births are safer when care is provided as part of a collaborative delivery model in which medical professionals may freely consult on patient care to maximize patient safety and positive outcomes. For a variety of reasons, this integration does not always occur, and creates a barrier to the best and safest care possible.
Section 2507 of the Business and Professions Code is amended to read:
(a) The license to practice midwifery authorizes the holder to attend cases of normal pregnancy and childbirth, as defined in paragraph (1) of subdivision (b), and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn.
(b) As used in this article, the practice of midwifery constitutes the furthering or undertaking by any licensed midwife to assist a woman in childbirth as long as progress meets criteria accepted as normal.
(1) Except as provided in paragraph (2), a licensed midwife shall only assist a woman in normal pregnancy and childbirth, which is defined as meeting all of the following conditions:
(A) There is an absence of both of the following:
(i) Any preexisting maternal disease or condition likely to affect the pregnancy.
(ii) Significant disease arising from the pregnancy.
(B) There is a singleton fetus.
(C) There is a cephalic presentation.
(D) The gestational age of the fetus is greater than 370⁄7 weeks and less than 420⁄7 completed weeks of pregnancy.
(E) Labor is spontaneous or induced in an outpatient setting.
(2) If a potential midwife client meets the conditions specified in subparagraphs (B) to (E), inclusive, of paragraph (1), but fails to meet the conditions specified in subparagraph (A) of paragraph (1), and the woman still desires to be a client of the licensed midwife, the licensed midwife shall provide the woman with a referral for an examination by a physician and surgeon trained in obstetrics and gynecology. A licensed midwife may assist the woman in pregnancy and childbirth only if an examination by a physician and surgeon trained in obstetrics and gynecology is obtained and the physician and surgeon who examined the woman determines that the risk factors presented by her disease or condition are not likely to significantly affect the course of pregnancy and childbirth.
(3) The board shall adopt regulations pursuant to the Administrative Procedure Act (Chapter 3.5 (commencing with Section 11340) of Part of 1 of Division 3 of Title 2 of the Government Code) specifying the conditions described in subparagraph (A) of paragraph (1).
(c) (1) If at any point during a pregnancy, childbirth, or postpartum care a client’s condition deviates from normal, the licensed midwife shall immediately refer or transfer the client to a physician and surgeon. The licensed midwife may consult and remain in consultation with the physician and surgeon after the referral or transfer.
(2) If a physician and surgeon determines that the client’s condition or concern has been resolved such that the risk factors presented by a woman’s disease or condition are not likely to significantly affect the course of pregnancy or childbirth, the licensed midwife may resume primary care of the client and resume assisting the client during her pregnancy, childbirth, or postpartum care.
(3) If a physician and surgeon determines the client’s condition or concern has not been resolved as specified in paragraph (2), the licensed midwife may provide concurrent care with a physician and surgeon and, if authorized by the client, be present during the labor and childbirth, and resume postpartum care, if appropriate. A licensed midwife shall not resume primary care of the client.
(d) A licensed midwife shall not provide or continue to provide midwifery care to a woman with a risk factor that will significantly affect the course of pregnancy and childbirth, regardless of whether the woman has consented to this care or refused care by a physician or surgeon, except as provided in paragraph (3) of subdivision (c).
(e) The practice of midwifery does not include the assisting of childbirth by any artificial, forcible, or mechanical means, nor the performance of any version of these means.
(f) A midwife is authorized to directly obtain supplies and devices, obtain and administer drugs and diagnostic tests, order testing, and receive reports that are necessary to his or her practice of midwifery and consistent with his or her scope of practice.
(g) This article does not authorize a midwife to practice medicine or to perform surgery.
Section 2508 of the Business and Professions Code is amended to read:
(a) A licensed midwife shall disclose in oral and written form to a prospective client as part of a client care plan, and obtain informed consent for, all of the following:
(1) All of the provisions of Section 2507.
(2) The client is retaining a licensed midwife, not a certified nurse-midwife, and the licensed midwife is not supervised by a physician and surgeon.
(3) The licensed midwife’s current licensure status and license number.
(4) The practice settings in which the licensed midwife practices.
(5) If the licensed midwife does not have liability coverage for the practice of midwifery, he or she shall disclose that fact. The licensed midwife shall disclose to the client that many physicians and surgeons do not have liability insurance coverage for services provided to someone having a planned out-of-hospital birth.
(6) The acknowledgment that if the client is advised to consult with a physician and surgeon, failure to do so may affect the client’s legal rights in any professional negligence actions against a physician and surgeon, licensed health care professional, or hospital.
(7) There are conditions that are outside of the scope of practice of a licensed midwife that will result in a referral for a consultation from, or transfer of care to, a physician and surgeon.
(8) The specific arrangements for the referral of complications to a physician and surgeon for consultation. The licensed midwife shall not be required to identify a specific physician and surgeon.
(9) The specific arrangements for the transfer of care during the prenatal period, hospital transfer during the intrapartum and postpartum periods, and access to appropriate emergency medical services for mother and baby if necessary, and recommendations for preregistration at a hospital that has obstetric emergency services and is most likely to receive the transfer.
(10) If, during the course of care, the client is informed that she has or may have a condition indicating the need for a mandatory transfer, the licensed midwife shall initiate the transfer.
(11) The availability of the text of laws regulating licensed midwifery practices and the procedure for reporting complaints to the Medical Board of California, which may be found on the Medical Board of California’s Internet Web site.
(12) Consultation with a physician and surgeon does not alone create a physician-patient relationship or any other relationship with the physician and surgeon. The informed consent shall specifically state that the licensed midwife and the consulting physician and surgeon are not employees, partners, associates, agents, or principals of one another. The licensed midwife shall inform the patient that he or she is independently licensed and practicing midwifery and in that regard is solely responsible for the services he or she provides.
(b) The disclosure and consent shall be signed by both the licensed midwife and the client and a copy of the disclosure and consent shall be placed in the client’s medical record.
(c) The Medical Board of California may prescribe the form for the written disclosure and informed consent statement required to be used by a licensed midwife under this section.
Section 2510 is added to the Business and Professions Code, to read:
If a client is transferred to a hospital, the licensed midwife shall provide records, including prenatal records, and speak with the receiving physician and surgeon about labor up to the point of the transfer. The hospital shall report each transfer of a planned out-of-hospital birth to the Medical Board of California and the California Maternal Quality Care Collaborative using a standardized form developed by the board.
Section 2513 of the Business and Professions Code is amended to read:
(a) An approved midwifery education program shall offer the opportunity for students to obtain credit by examination for previous midwifery education and clinical experience. The applicant shall demonstrate, by practical examination, the clinical competencies described in Section 2514 or established by regulation pursuant to Section 2514.5. The midwifery education program’s credit by examination policy shall be approved by the board, and shall be available to applicants upon request. The proficiency and practical examinations shall be approved by the board. Beginning January 1, 2015, new licensees shall not substitute clinical experience for formal didactic education.
(b) Completion of clinical experiences shall be verified by a licensed midwife or certified nurse-midwife, and a physician and surgeon, all of whom shall be current in the knowledge and practice of obstetrics and midwifery. Physicians and surgeons, licensed midwives, and certified nurse-midwives who participate in the verification and evaluation of an applicant’s clinical experiences shall show evidence of current practice. The method used to verify clinical experiences shall be approved by the board.
(c) Upon successful completion of the requirements of paragraphs (1) and (2), the applicant shall also complete the licensing examination described in paragraph (1) of subdivision (a) of Section 2512.5.
Section 2516 of the Business and Professions Code is amended to read:
(a) Each licensed midwife who assists, or supervises a student midwife in assisting, in childbirth that occurs in an out-of-hospital setting shall annually report to the Office of Statewide Health Planning and Development. The report shall be submitted no later than March 30, for the prior calendar year, in a form specified by the board and shall contain all of the following:
(1) The midwife’s name and license number.
(2) The calendar year being reported.
(3) The following information with regard to cases in California in which the midwife, or the student midwife supervised by the midwife, assisted during the previous year when the intended place of birth at the onset of care was an out-of-hospital setting:
(A) The total number of clients served as primary caregiver at the onset of care.
(B) The number by county of live births attended as primary caregiver.
(C) The number, by county, of cases of fetal demise, infant deaths, and maternal deaths attended as primary caregiver at the discovery of the demise or death.
(D) The number of women whose primary care was transferred to another health care practitioner during the antepartum period, and the reason for each transfer.
(E) The number, reason, and outcome for each elective hospital transfer during the intrapartum or postpartum period.
(F) The number, reason, and outcome for each urgent or emergency transport of an expectant mother in the antepartum period.
(G) The number, reason, and outcome for each urgent or emergency transport of an infant or mother during the intrapartum or immediate postpartum period.
(H) The number of planned out-of-hospital births at the onset of labor and the number of births completed in an out-of-hospital setting.
(I) The number of planned out-of-hospital births completed in an out-of-hospital setting that were any of the following:
(i) Twin births.
(ii) Multiple births other than twin births.
(iii) Breech births.
(iv) Vaginal births after the performance of a cesarean section.
(J) A brief description of any complications resulting in the morbidity or mortality of a mother or a neonate.
(K) Any other information prescribed by the board in regulations.
(b) The Office of Statewide Health Planning and Development shall maintain the confidentiality of the information submitted pursuant to this section, and shall not permit any law enforcement or regulatory agency to inspect or have copies made of the contents of any reports submitted pursuant to subdivision (a) for any purpose, including, but not limited to, investigations for licensing, certification, or regulatory purposes.
(c) The office shall report to the board, by April 30, those licensees who have met the requirements of subdivision (a) for that year.
(d) The board shall send a written notice of noncompliance to each licensee who fails to meet the reporting requirement of subdivision (a). Failure to comply with subdivision (a) will result in the midwife being unable to renew his or her license without first submitting the requisite data to the Office of Statewide Health Planning and Development for the year for which that data was missing or incomplete. The board shall not take any other action against the licensee for failure to comply with subdivision (a).
(e) The board, in consultation with the office and the Midwifery Advisory Council, shall devise a coding system related to data elements that require coding in order to assist in both effective reporting and the aggregation of data pursuant to subdivision (f). The office shall utilize this coding system in its processing of information collected for purposes of subdivision (f).
(f) The office shall report the aggregate information collected pursuant to this section to the board by July 30 of each year. The board shall include this information in its annual report to the Legislature.
(g) The board, with input from the Midwifery Advisory Council, may adjust the data elements required to be reported to better coordinate with other reporting systems, including the reporting system of the Midwives Alliance of North America (MANA), while maintaining the data elements unique to California. To better capture data needed for the report required by this section, the concurrent use of systems, including MANA’s, by licensed midwives is encouraged.
(h) Notwithstanding any other law, a violation of this section shall not be a crime.
Section 2519 of the Business and Professions Code is amended to read:
The board may suspend or revoke the license of a midwife for any of the following:
(a) Unprofessional conduct, which includes, but is not limited to, all of the following:
(1) Incompetence or gross negligence in carrying out the usual functions of a licensed midwife.
(2) Conviction of a violation of Section 2052, in which event, the record of the conviction shall be conclusive evidence thereof.
(3) The use of advertising that is fraudulent or misleading.
(4) Obtaining or possessing in violation of law, or prescribing, or except as directed by a licensed physician and surgeon, dentist, or podiatrist administering to himself or herself, or furnishing or administering to another, any controlled substance as defined in Division 10 (commencing with Section 11000) of the Health and Safety Code or any dangerous drug as defined in Article 8 (commencing with Section 4210) of Chapter 9 of Division 2 of the Business and Professions Code.
(5) The use of any controlled substance as defined in Division 10 (commencing with Section 11000) of the Health and Safety Code, or any dangerous drug as defined in Article 8 (commencing with Section 4210) of Chapter 9 of Division 2 of the Business and Professions Code, or alcoholic beverages, to an extent or in a manner dangerous or injurious to himself or herself, any other person, or the public or to the extent that such use impairs his or her ability to conduct with safety to the public the practice authorized by his or her license.
(6) Conviction of a criminal offense involving the prescription, consumption, or self-administration of any of the substances described in paragraphs (4) and (5), or the possession of, or falsification of, a record pertaining to, the substances described in paragraph (4), in which event the record of the conviction is conclusive evidence thereof.
(7) Commitment or confinement by a court of competent jurisdiction for intemperate use of or addiction to the use of any of the substances described in paragraphs (4) and (5), in which event the court order of commitment or confinement is prima facie evidence of such commitment or confinement.
(8) Falsifying, or making grossly incorrect, grossly inconsistent, or unintelligible entries in any hospital, patient, or other record pertaining to the substances described in subdivision (a).
(b) Procuring a license by fraud or misrepresentation.
(c) Conviction of a crime substantially related to the qualifications, functions, and duties of a midwife, as determined by the board.
(d) Procuring, aiding, abetting, attempting, agreeing to procure, offering to procure, or assisting at, a criminal abortion.
(e) Violating or attempting to violate, directly or indirectly, or assisting in or abetting the violation of, or conspiring to violate any provision or term of this chapter.
(f) Making or giving any false statement or information in connection with the application for issuance of a license.
(g) Impersonating any applicant or acting as proxy for an applicant in any examination required under this chapter for the issuance of a license or a certificate.
(h) Impersonating another licensed practitioner, or permitting or allowing another person to use his or her license or certificate for the purpose of providing midwifery services.
(i) Aiding or assisting, or agreeing to aid or assist any person or persons, whether a licensed physician or not, in the performance of or arranging for a violation of any of the provisions of Article 12 (commencing with Section 2221) of Chapter 5.
(j) Failing to do any of the following when required pursuant to Section 2507:
(1) Consult with a physician and surgeon.
(2) Refer a client to a physician and surgeon.
(3) Transfer a client to a hospital.
Section 1204.3 of the Health and Safety Code is amended to read:
(a) An alternative birth center that is licensed as an alternative birth center specialty clinic pursuant to paragraph (4) of subdivision (b) of Section 1204 shall, as a condition of licensure, and a primary care clinic licensed pursuant to subdivision (a) of Section 1204 that provides services as an alternative birth center shall, meet all of the following requirements:
(1) Be a provider of comprehensive perinatal services as defined in Section 14134.5 of the Welfare and Institutions Code.
(2) Maintain a quality assurance program.
(3) Meet the standards for certification established by the American Association of Birth Centers, or at least equivalent standards as determined by the state department.
(4) In addition to standards of the American Association of Birth Centers regarding proximity to hospitals and presence of attendants at births, meet both of the following conditions:
(A) Be located in proximity, in time and distance, to a facility with the capacity for management of obstetrical and neonatal emergencies, including the ability to provide cesarean section delivery, within 30 minutes from time of diagnosis of the emergency.
(B) Require the presence of at least two attendants at all times during birth, one of whom shall be a physician and surgeon, a licensed midwife, or a certified nurse-midwife.
(5) Have a written policy relating to the dissemination of the following information to patients:
(A) A summary of current state laws requiring child passenger restraint systems to be used when transporting children in motor vehicles.
(B) A listing of child passenger restraint system programs located within the county, as required by Section 27362 of the Vehicle Code.
(C) Information describing the risks of death or serious injury associated with the failure to utilize a child passenger restraint system.
(b) The state department shall issue a permit to a primary care clinic licensed pursuant to subdivision (a) of Section 1204 certifying that the primary care clinic has met the requirements of this section and may provide services as an alternative birth center. Nothing in this section shall be construed to require that a licensed primary care clinic obtain an additional license in order to provide services as an alternative birth center.
(c) (1) Notwithstanding subdivision (a) of Section 1206, no place or establishment owned or leased and operated as a clinic or office by one or more licensed health care practitioners and used as an office for the practice of their profession, within the scope of their license, shall be represented or otherwise held out to be an alternative birth center licensed by the state unless it meets the requirements of this section.
(2) Nothing in this subdivision shall be construed to prohibit licensed health care practitioners from providing birth related services, within the scope of their license, in a place or establishment described in paragraph (1).
No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.
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