BILL ANALYSIS Ó ----------------------------------------------------------------------- |Hearing Date:September 10, 2013 |Bill No:AB | | |1308 | ----------------------------------------------------------------------- SENATE COMMITTEE ON BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT Senator Ted W. Lieu, Chair Bill No: AB 1308Author:Bonilla As Amended:September 6, 2013Fiscal: Yes SUBJECT: Midwifery. SUMMARY: Removes the current statutory requirement for a licensed midwife to practice under the supervision of a physician and surgeon who has current practice or training in obstetrics, and instead specifies: (1) a midwife may assist in normal pregnancy and birth, and (2) for pregnancies that are not considered normal, the midwife must refer or transfer the client to a physician and surgeon. Expands and revises the written and oral information that must be given by a licensed midwife to require the information to be part of a client care plan and to provide the client's informed consent to the services of the licensed midwife. 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 or her practice of midwifery; requires the Medical Board of California (MBC) to adopt regulations specifying the conditions that shall be considered as a preexisting disease or condition likely to affect the pregnancy, or a significant disease arising from the pregnancy. Makes it a cause for disciplinary action by the MBC for a licensed midwife to fail to refer or transfer a client to a physician and surgeon when required to do so by law. NOTE : AB 1308 was heard in this Committee on July 1, 2013 and unanimously approved 10-0. The September 6, 2013 amendments to this measure rewrite the bill as defined in Senate Rule 29.10 (e), in that it: "makes a change of . . . policy significance that may be appropriate for review by a standing committee." Therefore, the bill has been referred to this Committee pursuant to Senate Rule 29.10 (b) for consideration. The Committee may by a vote of the majority of the membership do any of the following: 1) hold the bill, 2) return the AB 1308 Page 2 bill as approved by the committee to the Senate floor, or 3) refer the bill to a Fiscal Committee pursuant to Joint Rule 10.5. Existing law: 1)Licenses and regulates some 300 licensed midwives under the Licensed Midwifery Practice Act of 1993, by the MBC, within the Department of Consumer Affairs (DCA). (Business and Professions Code (BPC) § 2505 et seq.) 2)Creates the Midwifery Advisory Council (MAC) which is required to make recommendations on matters specified by MBC. (BPC § 2509) 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 as long as progress meets criteria accepted as normal. (BPC § 2507) 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. (BPC § 2507 (f)) 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. (BPC § 2507 (a)) 6)Requires a licensed midwife to disclose orally and in writing: (BPC § 2508) a) The scope of a midwife's practice, as specified; b) If 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)Establishes educational requirements for a midwifery license to include: (BPC § 2512.5) AB 1308 Page 3 a) Successful completion of a three-year postsecondary midwifery education program accredited by an accrediting organization approved by the MBC. b) The education program curriculum shall consist of not less than 84 semester units or 126 quarter units, as specified. c) The education program shall provide both academic and clinical preparation equivalent, but not identical to programs accredited by the American College of Nurse Midwives, and includes the following areas: i) The art and science of midwifery, as specified. ii) Communications skills, including principles of oral, written, and group communications. iii) Anatomy and physiology, genetics, obstetrics and gynecology, embryology and fetal development, neonatology, applied microbiology, chemistry, child growth and development, pharmacology, nutrition, laboratory diagnostic tests and procedures, and physical assessment. iv) Concepts in psychosocial, emotional, and cultural aspects of maternal and child care, human sexuality, counseling and teaching, maternal, infant and family bonding process, breast feeding, family planning, principles of preventive health, and community health. v) Aspects of the normal pregnancy, labor and delivery, postpartum period, newborn care, family planning, routine gynecological care in alternative birth centers, homes, and hospitals. 1)Provides that an approved midwifery education program shall offer the opportunity for students to obtain credit by examination for previous midwifery education and clinical experience, as specified. (BPC § 2513) 2)Requires each 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 (OSHPD) in a form specified by the MBC. (BPC § 2516) AB 1308 Page 4 3)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: (Health and Safety Code (HSC) § 1204.3) a) Meet the standards for certification established by the National Association of Childbearing Centers. b) Require 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: 1)Makes legislative findings and declarations, that : a) Licensed midwives have been authorized to practice since 1993, as specified, and that while there is no specified 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 client safety and positive outcomes. 1)Revises the midwife scope of practice to include attending cases of normal pregnancy and childbirth, and deletes the requirement that a licensed midwife practice under the supervision of a physician and surgeon who has current practice or training in obstetrics. 2)Provides that a licensed midwife shall only assist a woman in normal pregnancy and childbirth, defined as meeting the following conditions: a. There is an absence of any preexisting maternal disease or condition likely to affect the pregnancy and significant disease arising from the pregnancy. b. It is a single birth. c. The fetus is positioned head first during birth. d. The gestational age of the fetus at birth is more than 37 weeks, and less than 42 weeks. AB 1308 Page 5 e. Labor is spontaneous or induced in an outpatient setting. 3)Provides for the following, if there is a preexisting maternal disease or condition likely to affect the pregnancy, or if there is a significant disease arising from the pregnancy, and the woman still desires to be a client of the midwife: a. The midwife shall provide the woman with a referral for examination by a physician trained in obstetrics and gynecology. b. The midwife may assist the woman in pregnancy and childbirth only if an examination by a physician trained in obstetrics and gynecology is obtained and the physician determines that the risk factors presented are not likely to significantly affect the course of pregnancy and childbirth. c. The MBC is required to adopt regulations specifying the conditions that shall be considered as a preexisting disease or condition likely to affect the pregnancy, or a significant disease arising from the pregnancy. 1)Specifies the following regarding referral of a client to a physician: a. Requires that if the client's condition deviates from normal at any point in the pregnancy, childbirth or postpartum care, the midwife shall immediately refer or transfer the client to a physician. b. Provides that if the physician determines the risk factors of the client's disease or condition are not likely to significantly affect the course of pregnancy or childbirth, the midwife may resume primary care and assist the client in pregnancy, childbirth and postpartum care. c. Provides that if the physician determines the client's condition or concern is not resolved, the midwife may provide concurrent care with the physician if authorized by the client; however, the midwife may not resume primary care of the client. d. Prohibits a midwife from providing or continuing to provide 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. AB 1308 Page 6 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 or her practice of midwifery and consistent with his or her scope of practice. 2)Deletes the requirement for 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. 3)Revises and expands the existing oral and written disclosures required of a licensed midwife to a prospective client to include, as part of a client care plan, and obtain informed consent to the following: a. The client is retaining a licensed midwife, not a certified nurse midwife and the licensed midwife is not supervised by a physician and surgeon. b. The midwife's license status and license number. c. The practice setting in which the midwife practices. d. That many physicians do not have liability insurance coverage for services provided by someone having a planned out-of-hospital birth. e. The acknowledgement that if the client is advised to consult a physician, failure to do so may affect the client's legal rights in any professional negligence actions against a physician, licensed health care professional, or hospital. f. There are conditions outside the scope of practice of a licensed midwife that will result in a referral for consultation, or transfer to a physician. g. 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. h. If in the course of care, the client is informed that she has a condition requiring the need for a mandatory transfer; the midwife shall initiate the transfer. i. The availability of the text of the laws regulating licensed midwifery on the MBC's Internet Web site. AB 1308 Page 7 j. Consultation with a physician does not alone create a physician/client relationship or any other relationship with the physician. aa. The licensed midwife and consulting physician are not employees, partners, associates, agents or principles of one another. bb. The licensed midwife is independently licensed and practicing midwifery and is solely responsible for the services provided. 1)Provides that if a client is transferred to a hospital, the licensed midwife shall provide all related records and speak with the receiving physician about labor up until the point of transfer. Requires a hospital to report each transfer of a planned out-of-hospital birth to the MBC and the California Maternal Quality Care Collaborative on a form developed by the Board. 2)Provides that beginning January 1, 2015, applicants for a midwifery license shall not substitute clinical experience for formal didactic education. 3)Revises the annual report submitted by a licensed midwife to the Office of Statewide Health Planning and Development to delete the requirement to report the total number of clients served by the licensee. 4)Authorizes the MBC, with the input from the MBC's Midwifery Advisory Council, to adjust the data elements required to be reported to better coordinate with other reporting systems, as specified. 5)Provides that the MBC may take disciplinary action to suspend or revoke the license of a midwife for failing to do any of the following when required to do so by law: a. Consult with a physician and surgeon. b. Refer a client to a physician and surgeon. c. Transfer a client to a hospital. 1)In addition to a physician and surgeon or a certified nurse-midwife, also authorizes a licensed midwife to be present at a licensed alternative birth center. 2)Makes a correcting change to refer to the American Association of AB 1308 Page 8 Birth Centers rather than the National Association of Childbearing Centers. FISCAL EFFECT: Senate Appropriations Committee staff has indicated that this bill would have minor fiscal impact, and has recommended the bill be referred to the Senate Floor if approved by the Senate Committee on Business, Professions and Economic Development. COMMENTS: 1.Recent Amendments to the Bill. As noted above, the September 6, 2013 amendments to the bill are of policy significance and make it appropriate for this Committee to review the amendments. When the Committee heard the bill on July 1, there had been discussion, but no resolution, on the issue of physician supervision of licensed midwives. The current amendments to the bill reflect the negotiated agreement between the Sponsor of the bill, the American Congress of Obstetricians and Gynecologists, District IX, California, the California Association of Midwives, and California Families for Access to Midwives. The amendments remove the current statutory requirement for a licensed midwife to practice under physician supervision, and instead specify: 1) a midwife may assist in normal pregnancy and birth, and 2) for pregnancies that are not considered normal, the midwife must refer or transfer the client to a physician and surgeon. The amendments further expand and revise the written and oral information that must be given by a licensed midwife to require the information to be part of a client care plan and to provide the client's informed consent to the services of the licensed midwife. 2.Purpose. This bill is sponsored by American Congress of Obstetricians and Gynecologists, District IX, California (Sponsor). According to the Author, in addition to the amendments described above, the bill does the following: Authorizes midwives to order supplies, drugs, tests, and devices without an ordering physician listed. Currently, this is included in the scope of practice for licensed midwives. However, in the field, they are often unable to get access to supplies, drugs, and tests because the supplier requires listing of an ordering physician. This authority should help provide clarity to what should already be permissible. AB 1308 Page 9 Requires the MBC to revise regulations regarding licensed midwives before July 1, 2015. With the advent of this legislation, regulations may need to be modified to account for any changes. By pushing back the deadline for the MBC to draft regulations, we allow for this revision to occur. Clarifies that the regulations should identify complications necessitating referral to a physician or surgeon for purposes of a consultation. As medicine advances and we learn more about underlying health conditions and risk factors, it is important that the MBC continue to explore this topic, and that clients understand ahead of time, what the referral process will entail. Requires licensed midwives to include in their disclosure the specific arrangements for the referral of complications to a physician for a consultation. In this situation, a licensed midwife may continue care of the client. Current law requires disclosure of the specific arrangements of transfer of care of a client. In this situation, the physician would maintain care of the client. Allows licensed midwives to attend births at an alternative birth center. Licensed midwives are the experts in out-of-hospital births. It makes policy sense to authorize them to attend births in this setting. Many midwives attend births at birth centers which are not licensed. Birth centers have optional licensing requirements. Makes a technical change to replace the "National Association of Childbearing Centers" with the "American Association of Birth Centers." The National Association of Childbearing Centers changed its name in 2005. 1.Background on the 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 which offers a midwifery student the opportunity to obtain credit by examination for previous midwifery education and clinical experience (BPC § 2513(t)). Prior to licensure, all midwives must take and pass the North American Registry of Midwives (NARM) examination. AB 1308 Page 10 SB 1638 (Figueroa, Chapter 536, Statutes of 2006) required the MBC to create and appoint a Midwifery Advisory Council (MAC). The MAC is made up of licensed midwives (at least half of the MAC must be licensed midwives), a MBC member, a physician, and a member of the public (currently an individual who has received services from 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 Mechanism, required reporting, and student midwives. SB 1638 also required licensed midwives to make annual reports to 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 BPC § 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 5 disciplinary actions being filed over the past 3 fiscal years. Of the 4 disciplinary actions that have been adjudicated, all have been resolved with either revocation or license surrender. 2.Physician Supervision. As noted above, BPC § 2057 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 § 2507(f) required the MBC, by July 1, 2003, to adopt 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 (CCR § 1379.19). Three previous attempts to resolve the physician AB 1308 Page 11 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 client or their newborn to the hospital, many hospitals will not accept a client 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 until now. There has been 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 clients 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. In the MBC oversight hearing earlier this year, staff recommended that the MBC should reach a consensus with stakeholders on this issue and then submit a specific legislative proposal to the Committee regarding the appropriate level of supervision required for the practice of midwifery. The current amendments are the product of diligent negotiations by the AB 1308 Page 12 Author working with the Sponsor, licensed midwives, and consumer advocates for midwifery care. The amendments remove the requirement for physician supervision, and instead replace it with a client/physician consultation requirement for high-risk pregnancies. The amendments narrowly craft the description of normal pregnancies and births that a licensed midwife may assist in. The amendments require that for pregnancies that are not considered normal, the licensed midwife must refer or transfer the client to a physician. The amendments make it a cause for disciplinary action for a licensed midwife to fail to refer or transfer a client to a physician when required to do so. 3.Removal of Substitution of Clinical Experience. There are currently two pathways to licensure as a midwife in California: 1) by completion a three-year postsecondary education program in an accredited midwifery school approved by the board, or 2) by Challenge Mechanism. The challenge process specified in BPC § 2513(t) offers a midwifery student the opportunity to obtain credit by examination for previous midwifery education and clinical experience. This bill revises these provisions to specify that beginning January 1, 2015, applicants for a midwifery license shall not substitute clinical experience for formal didactic education. It is important to note that removing this Challenge Mechanism does not eliminate or affect the formal education requirement in the law. On the contrary, it actually reinforces it, by eliminating the ability to substitute on-the-job training for formal didactic teaching. This bill does nothing to the existing education requirements other than closing a loophole so that someone could not qualify through the Challenge Mechanism only with clinical experience. This amendment was requested by both ACOG and the MAC . 4.Diagnostic Lab Accounts. This bill echoes an issue raised by the MBC in its Sunset Report. Licensed midwifes 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 (CCR § 1379.30) The inability for a licensed midwife to order lab tests often means the client will not obtain the necessary tests to help the midwife monitor the client during pregnancy. In addition, not being able to obtain the necessary medical supplies for the practice AB 1308 Page 13 of midwifery adds additional risk to the licensed midwife's client and baby. The MBC, through the MAC, held meetings regarding the lab order and medical supplies and 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 and medication issues will need to be addressed through the legislative process. This bill authorizes midwives to order supplies, drugs, tests and devices without an ordering physician listed. 5.Oversight Hearings of the Medical Board of California (MBC) and SB 304. Earlier this year, this Committee, along with the Assembly Business, Professions and Consumer Protection Committee, conducted oversight hearings to review 14 regulatory boards within the DCA. The Committees began the review of these licensing agencies in March and conducted three days of hearings. Seven bills, authored by Senator Curren D. Price Jr., were introduced to implement legislative changes recommended in the Committees' Background Issue Papers for all of the regulatory entities reviewed this year. As a part of the review of the MBC, the Committees reviewed the MBC's administration of the licensed midwifery program and recommendations were made for a number of the programs and operations of the MBC. As a result, SB 304 (Price) was introduced to address a number of issues raised in the Sunset Review hearings. As a result, the two bills, AB 1308 and SB 304, work in concert with one another to address midwifery issues. The following summarizes issues directly related to licensed midwives in SB 304: a) Clarify Midwifery Education and Clinical Training. BPC § 2514 authorizes a "bona fide student" who is enrolled or participating in a midwifery education program or who is enrolled in a program of supervised clinical training to engage in the practice of midwifery as part of that course of study if: 1) the student is under the supervision of a physician or a licensed midwife who holds a clear and unrestricted California midwife license and who is present on the premises at all times client services are provided; and, 2) the client is informed of the student's status. There has been disagreement between the MBC and some members of the midwifery community regarding what constitutes a "bona fide student." The MBC believes the current statute is very clear regarding a student midwife. AB 1308 Page 14 Some members of the midwifery community hold that an individual who has executed a formal agreement to be supervised by a licensed midwife, but is not formally enrolled in any approved midwifery education program, qualifies the individual as a student in apprenticeship training. Many midwives consider that an individual may follow an "apprenticeship pathway" to licensure. A Task Force consisting of members of the MAC has recently been formed to examine this issue. However, the issue of students in apprenticeship training may need to be addressed by legislation. Thus, SB 304 has been amended to clarify: 1) when an individual is considered a bona fide student; and, 2) a written agreement does not meet the requirement of a program of supervised clinical training. b) Supervision of Midwifery Students by Certified Nurse-Midwives. The MAC has indicated that BPC § 2514 does not include certified nurse midwives (CNM) as being able to supervise midwifery students. The MBC recommended amending the law to include CNMs, who are licensed by the Board of Registered Nursing (BRN), as individuals who can supervise midwifery students. Currently, both physicians and CNMs are identified as being able to sign off on clinical experience for license midwife students pursuant to BPC § 2513, but supervision of training is not specifically identified in law. Accordingly, SB 304 has been amended to include CNMs as those who may supervise midwifery students. 6.Related Legislation. SB 304 (Price, 2013) as it relates to midwifery, clarifies that a "bona fide student" means an individual who is enrolled and participating in a midwifery education program or who is enrolled in a program of supervised clinical training as part of a board-approved postsecondary midwifery education program, and includes certified nurse-midwives as one of those who may supervise midwifery students. SB 304 also makes a number of additional changes to enhance the MBC's ability to take action against dangerous doctors and to effectively carry out its mandates to protect consumers in a timely manner. ( Status : This bill is in the Senate for concurrence in the Assembly amendments.) 7.Prior Legislation. SB 1638 (Figueroa, Chapter 536, Statutes of 2006) required the MBC to create and appoint a MAC. Required a licensed midwife to make an annual report to OSHPD regarding birth outcomes; required a licensed midwife who assists or supervises childbirth, occurring in an out-of-hospital setting, to annually report to OSHPD specified information regarding her practice for the previous year; and required the data to be consolidated by OSHPD and reported back AB 1308 Page 15 to the MBC for inclusion in the MBC's annual report. SB 1950 (Figueroa, Chapter 1085, Statutes of 2002) required the MBC to adopt regulations defining the appropriate standard of care and level of supervision required for the practice of midwifery. SB 1479 (Figueroa, Chapter 303, Statutes of 2000) expanded the disclosures required to be given by licensed midwives and also required midwives to register birth certificates for home births. SB 350 (Killea, Chapter 1280, Statutes of 1993) enacted the Licensed Midwifery Practice Act of 1993 to provide for the licensing and regulation of non-nurse and non-physician assistant midwives by the MBC. 8.Arguments in Support. The Sponsors of the bill, American Congress of Obstetricians and Gynecologists, District IX, California states that since the last committee hearing on the bill, the principles, including ACOG-IX, the California Association of Midwives, and California Families for Access to Midwives, working with the Author and staff, have arduously labored to come to an agreement on language as reflected in the bill. ACOG indicates that for the twenty years licensed midwives have been authorized to practice in California, there never has been a workable system where licensed midwives and medical professionals can seamlessly work together. This failure is bad for licensed midwives, physicians, the MBC, hospitals, hospital staff and most importantly, the pregnant woman, her pregnancy, and family. ACOG states that the bill is "a significant, if not historic, step forward to making the system better and safer for California mothers who choose out of hospital births, and for their babies." ACOG believes that, "hospitals are the safest settings for birth. However we respect the right of women to make an informed choice to deliver at home, and want to do everything possible to make this choice as safe as possible. Our priority is client safety. We believe this bill makes a marked step forward in improving client safety." The California Association of Midwives (CAM) states the bill addresses several longstanding issues with the statutory provisions governing the care provided by licensed midwives in California. CAM states the bill will remove the unattainable physician supervision requirement from California's Licensed Midwifery Practice Act. CAM contends: "With the ongoing implementation of the Affordable Care Act, it is more important than ever for affordable maternity care options to be made available to all families. Currently, the physician supervision requirement is a barrier to access because it AB 1308 Page 16 prevents Medi-Cal from recognizing licensed midwives as independent providers capable of providing comprehensive prenatal, birth, and postpartum care. As such, low income women are prevented from accessing care even though they can benefit greatly." AB 1308 also makes a number of additional changes to the midwifery authorizing statute which will promote high value, safe, coordinated midwifery care, as well as adding licensed midwives as providers in Alternative Birth Centers, according to CAM. The California Nurse-Midwives Association (CNMA) supports the bill stating the state of California recognizes two groups of professional midwives: "licensed midwives" regulated by the MBC and "certified nurse-midwives" regulated by the Board of Registered Nursing. Both groups contribute proudly to California's women's health care workforce, and specifically aim to provide women with safe birth options, including out-of-hospital. Certified nurse-midwives provide care in clinics, hospitals, birth centers, and in the home setting. While most nurse-midwives provide care in a hospital setting, some do choose to work in out-of-hospital settings, as well. CNMA states: "Home birth as provided by qualified [licensed midwives] and [certified nurse-midwives] is an essential option for the women and families of California, in line with a woman's right to self-determination and participation in her health care choices." California Families for Access to Midwives (CFAM), states the bill expands access to midwifery care, and allows most California women to benefit from the unparalleled level of comprehensive, empowering, low-cost maternity care that licensed midwives provide. CFAM states: "Midwives have always and will always provide an in immeasurably valuable service to women and their families. Unfortunately, the state of California has for two decades required licensed midwives to practice under the unobtainable, unnecessary, and discriminatory requirement of physician supervision. The requirement of physician supervision serves no practical purpose other than as a barrier to access, which prevents Medi-Cal families from receiving midwifery care. This has created an illogical two-tier maternity care system in which low-income Californians are denied the care from which they can most benefit." SUPPORT AND OPPOSITION: Support: American Congress of Obstetricians and Gynecologists, District IX, California (Sponsor) AB 1308 Page 17 California Association of Midwives California Families for Access to Midwives California Nurse-Midwives Association (CNMA) Opposition: None on file as of September 10, 2013 Consultant:G. V. Ayers