BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | AB 1308| |Office of Senate Floor Analyses | | |1020 N Street, Suite 524 | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- 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. CONTINUED AB 1308 Page 2 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. CONTINUED AB 1308 Page 3 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. CONTINUED AB 1308 Page 4 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 CONTINUED AB 1308 Page 5 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. CONTINUED AB 1308 Page 6 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 CONTINUED AB 1308 Page 7 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 **** END **** CONTINUED