BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                            



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                                    THIRD READING


          Bill No:  AB 1308
          Author:   Bonilla (D)
          Amended:  7/9/13 in Senate
          Vote:     21

           
           SENATE BUSINESS, PROF. & ECON. DEV. COMMITTEE  :  10-0, 7/1/13
          AYES:  Lieu, Emmerson, Block, Corbett, Galgiani, Hernandez,  
            Hill, Padilla, Wyland, Yee
           
          SENATE APPROPRIATIONS COMMITTEE  :  Senate Rule 28.8
           
          ASSEMBLY FLOOR  :  72-0, 5/16/13 - See last page for vote


           SUBJECT  :    Midwifery

           SOURCE  :     American Congress of Obstetricians and  
                         Gynecologists, District IX, California


           DIGEST  :    This bill authorizes a licensed midwife to directly  
          obtain supplies, devices, obtain and administer drugs and  
          diagnostic tests, order testing and receive reports that are  
          necessary to his/her practice of midwifery; deletes the  
          requirement that the Medical Board of California (MBC) adopt  
          regulations defining the standard of care and level of  
          supervision required for the practice of midwifery; requires a  
          midwife to disclose his/her arrangements for the referral of  
          complications to a physician for consultation; and authorizes a  
          licensed midwife to be present at a licensed alternative birth  
          center.

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           ANALYSIS  :    

          Existing law:

           1. Licenses and regulates some 300 licensed midwives under the  
             Licensed Midwifery Practice Act of 1993, by the MBC.

           2. Creates the Midwifery Advisory Council (MAC) which is  
             required to make recommendations on matters specified by MBC.  


           3. Defines the practice of midwifery as the furthering or  
             undertaking by any licensed midwife, under the supervision of  
             a licensed physician who has current practice or training in  
             obstetrics, to assist a woman in childbirth so long as  
             progress meets criteria accepted as normal.  

           4. Requires the MBC to adopt regulations defining the  
             appropriate standard of care and level of supervision  
             required for the practice of midwifery by July 1, 2003.  

           5. Permits a licensed midwife 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 under the  
             supervision of a licensed physician and surgeon. 

           6. Requires a licensed midwife to disclose orally and in  
             writing:  (a) the scope of a midwife's practice, as  
             specified; (b) whether the licensed midwife has liability  
             coverage; (c) 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 (d) the procedure for reporting complaints to the MBC. 

           7. 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 (a)  
             meeting the standards for certification established by the  
             National Association of Childbearing Centers, and (b)  
             requiring the presence of at least two attendants during  
             birth, one of whom shall be either a physician and surgeon or  
             a certified nurse-midwife.  

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          This bill:

           1. Authorizes a midwife to directly obtain supplies and  
             devices, obtain and administer drugs and diagnostic tests,  
             order testing and receive reports that are necessary to  
             his/her practice of midwifery and consistent with his/her  
             scope of practice.

           2. Deletes the requirement specifying that the MBC adopt  
             regulations defining the appropriate standard of care and  
             level of supervision required for the practice of midwifery.

           3. Expands the existing oral and written disclosures required  
             of a licensed midwife to a prospective client to include the  
             specific arrangements for the referral of complications to a  
             physician and surgeon for consultation, and specifies that  
             the licensed midwife shall not be required to identify a  
             specific physician and surgeon.

           4. Authorizes a licensed midwife, in addition to a physician  
             and surgeon or a certified nurse-midwife, to be present at a  
             licensed alternative birth center.

           5. Makes a correcting change to refer to the American  
             Association of Birth Centers rather than the National  
             Association of Childbearing Centers.

           6. Makes legislative findings and declarations relating to  
             midwifery and licensed midwives.

           Background
           
           Midwifery program  .  A licensed midwife is an individual who has  
          been issued a license to practice midwifery by the MBC.  As  
          provided under the law, the practice of midwifery authorizes the  
          licensee, under the supervision of a licensed physician in  
          active practice, to attend cases of normal childbirth in a home,  
          birthing clinic or hospital environment.  Pathways to midwife  
          licensure include completion of a three-year postsecondary  
          education program in an accredited school approved by the MBC,  
          or through a Challenge Mechanism.  Prior to licensure, all  
          midwives must take and pass the North American Registry of  
          Midwives examination.

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          SB 1638 (Figueroa, Chapter 536, Statutes of 2006) required the  
          MBC to create and appoint a Midwifery Advisory Council.  The MAC  
          is made up of licensed midwives (at least half of the MAC must  
          be licensed midwives), a board member, a physician and a member  
          of the public (currently an individual who has used a licensed  
          midwife).  The MBC specifies issues for the MAC to  
          discuss/resolve and the MAC also identifies issues and obtains  
          approval from the MBC to develop solutions to the various  
          matters.  Some items that have been discussed include physician  
          supervision, challenge mechanisms, required reporting and  
          student midwives.  SB 1638 also required licensed midwives to  
          make annual reports to Office of Statewide Health Planning and  
          Development (OSHPD) on specified information regarding birth  
          outcomes, and required the reported data to be consolidated by  
          OSHPD and reported back to the MBC for inclusion in the MBC's  
          annual report.

          The MBC approves midwifery schools by conducting a comprehensive  
          assessment to evaluate the school's educational program  
          curriculum and the program's academic and clinical preparation  
          equivalent.  Schools wishing to obtain approval must submit  
          supporting documentation to verify that they meet the  
          requirements of Business and Professions Code (BPC) Section  
          2512.5.  Currently, there are 11 approved midwifery schools.  A  
          licensed midwife must complete 36 hours of continuing education  
          every two years in areas that fall within the scope of the  
          practice of midwifery as specified by the MBC.

          The licensee population in the midwifery program is small and  
          the number of disciplinary actions filed against licensees is  
          also proportionally small with a total of five disciplinary  
          actions being filed over the past three fiscal years.  Of the  
          four disciplinary actions that have been adjudicated, all have  
          been resolved with either revocation or license surrender.

           Physician supervision  .  BPC Section 2507 authorizes a licensed  
          midwife, under the supervision of a licensed physician and  
          surgeon who has current practice or training in obstetrics, 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.  

          BPC Section 2507(f) requires the MBC, by July 1, 2003, to adopt  

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          regulations defining the appropriate standard of care and level  
          of supervision required for the practice of midwifery.  Due to  
          the inability to reach consensus on the supervision issue, the  
          MBC bifurcated this requirement and in 2006 adopted Standards of  
          Care for Midwifery.  Three previous attempts to resolve the  
          physician supervision issue via legislation and/or regulation  
          have been unsuccessful due to the widely divergent opinions of  
          interested parties and their inability to reach consensus.

          Although required by law, physician supervision is essentially  
          unavailable to licensed midwives performing home births, as  
          California physicians are generally prohibited by their  
          malpractice insurance companies from providing supervision of  
          licensed midwives who perform home births.

          According to insurance providers, if physicians supervise or  
          participate in a home birth they will lose their insurance  
          coverage resulting in loss of hospital privileges.  The  
          physician supervision requirement creates numerous barriers to  
          care in that, if the licensed midwife needs to transfer a  
          patient/baby to the hospital, many hospitals will not accept a  
          patient transfer from a licensed midwife as the primary provider  
          who does not have a supervising physician.  California, along  
          with Arkansas and Louisiana, are currently the only states that  
          require physician supervision of licensed midwives.  Among  
          states that regulate midwives, most require some sort of  
          collaboration between the midwife and a physician.

          The MBC, through the MAC, has held many meetings regarding  
          physician supervision of licensed midwives and has attempted to  
          create regulations to address this issue.  The concepts of  
          collaboration such as required consultation, referral, transfer  
          of care and physician liability have been discussed among the  
          interested parties with little success.  There is disagreement  
          over the appropriate level of physician supervision with  
          licensed midwives expressing concern with any limits being  
          placed on their ability to practice independently.  The  
          physician and liability insurance communities have concerns over  
          the safety of midwife-assisted homebirths.  Specifically, they  
          are concerned with delays and/or the perceived reluctance of  
          midwives to refer patients when the situation warrants referral  
          or transfer of care.  The MBC has stated that it ultimately  
          believes that the physician supervision requirement needs to be  
          addressed through the legislative process.

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          In the MBC oversight hearing earlier this year, it was  
          recommended that the MBC should reach a consensus with  
          stakeholders on this issue and then submit a specific  
          legislative proposal to the Senate Business, Professions and  
          Economic Development Committee regarding the appropriate level  
          of supervision required for the practice of midwifery.

           Diagnostic lab accounts  .  This bill echoes an issue raised by  
          the MBC in its Sunset Report.  Licensed midwives have difficulty  
          securing diagnostic lab accounts, even though they are legally  
          allowed to have lab accounts.  Many labs require proof of  
          physician supervision.  In addition, licensed midwives are not  
          able to obtain the medical supplies they have been trained and  
          are expected to use including:  oxygen, necessary medications  
          and medical supplies that are included in approved licensed  
          midwifery school curriculum.  The inability for a licensed  
          midwife to order lab tests often means the patient will not  
          obtain the necessary tests to help the midwife monitor the  
          patient during pregnancy.  In addition, not being able to obtain  
          the necessary medical supplies for the practice of midwifery  
          adds additional risk to the licensed midwife's patient and  
          child.

          The MBC, through the MAC, held meetings regarding the lab order  
          and medical supplies/medication issues and has attempted to  
          create regulatory language to address this issue.  However,  
          based upon discussions with interested parties, it appears the  
          lab order and medical supplies/medication issues will need to be  
          addressed through the legislative process.

           FISCAL EFFECT  :    Appropriation:  No   Fiscal Com.:  Yes    
          Local:  Yes

           SUPPORT  :   (Verified  8/13/13)

          American Congress of Obstetricians and Gynecologists, District  
            IX, California (source)
          California Association of Midwives
          California Families for Access to Midwives

           ARGUMENTS IN SUPPORT  :    According to the author, "The  
          California Medical Board is responsible for the oversight of  
          licensed midwives in California.  Licensed midwives deliver  

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          children in a patient's home or at a birthing center.  The  
          Medical Board is under sunset review this year and has  
          recommended legislative action on several issues that it has  
          been unable to resolve in past discussions.  AB 1308 seeks to  
          remove barriers to midwifery while protecting patients.  One  
          such barrier is access to supplies and tests.  Currently,  
          midwives have the authority to obtain supplies in their scope of  
          practice.  Unfortunately, many times they encounter problems in  
          the field when a supplier or laboratory requires an ordering  
          physician to be listed.  Because midwives do not always have an  
          ordering physician, it can be difficult for them to obtain  
          supplies, order tests, or receive reports.  Ready access to  
          these supplies and tests is vital to the safe practice of  
          midwifery.  Another barrier is the ability to work in licensed  
          alternative birth centers.  Licensed midwives are the  
          out-of-hospital birth experts and it is consistent with this  
          expertise to authorize them to work in such a setting."

           ASSEMBLY FLOOR  :  72-0, 5/16/13
          AYES:  Achadjian, Alejo, Ammiano, Atkins, Bigelow, Bloom,  
            Blumenfield, Bocanegra, Bonilla, Bonta, Bradford, Brown,  
            Buchanan, Ian Calderon, Campos, Chau, Chávez, Chesbro, Conway,  
            Cooley, Dahle, Daly, Dickinson, Donnelly, Eggman, Fong, Fox,  
            Frazier, Garcia, Gatto, Gomez, Gordon, Gorell, Gray, Hagman,  
            Hall, Harkey, Roger Hernández, Jones, Jones-Sawyer, Levine,  
            Linder, Logue, Lowenthal, Maienschein, Mansoor, Medina,  
            Mitchell, Mullin, Muratsuchi, Nazarian, Nestande, Olsen, Pan,  
            Patterson, Perea, V. Manuel Pérez, Quirk, Quirk-Silva, Rendon,  
            Salas, Skinner, Ting, Torres, Wagner, Waldron, Weber,  
            Wieckowski, Wilk, Williams, Yamada, John A. Pérez
          NO VOTE RECORDED:  Allen, Beth Gaines, Grove, Holden, Melendez,  
            Morrell, Stone, Vacancy


          MW:k  8/13/13   Senate Floor Analyses 

                           SUPPORT/OPPOSITION:  SEE ABOVE

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