BILL ANALYSIS Ó
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|Hearing Date:September 10, 2013 |Bill No:AB |
| |1308 |
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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
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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)
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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)
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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.
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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.
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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.
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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
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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.
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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.
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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
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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
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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
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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.
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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
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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
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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
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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