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: 9/6/13 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 SENATE BUSINESS, PROF. & ECON. DEVEL. COMMITTEE : 10-0, 9/10/13 (pursuant to Senate Rule 29.10) AYES: Lieu, Emmerson, Block, Corbett, Galgiani, Hernandez, Hill, Padilla, Wyland, Yee 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 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; expands the disclosures required to be made by a midwife to a prospective client to include the specific procedures that warrant consultation with a physician and CONTINUED AB 1308 Page 2 surgeon; and makes other correcting and conforming changes. Senate Floor Amendments of 9/6/13 remove the current statutory requirement for a licensed midwife to practice under physician supervision, and to instead specify: (1) that a midwife may assist in normal pregnancy and birth, and (2) for those pregnancies that are not considered normal pregnancies, the midwife must refer or transfer the client to a physician and surgeon. ANALYSIS : Existing law: 1. Licenses and regulates some 300 licensed midwives under the Licensed Midwifery Practice Act of 1993, by the Medical Board of California (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 CONTINUED AB 1308 Page 3 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. This bill: 1. Makes legislative findings that planned home births are safer when care is provided as part of a collaborative delivery model in which medical professionals may freely consult on patient care to maximize patient safety and positive outcomes. 2. 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. 3. 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. E. Labor is spontaneous or induced in an outpatient setting. CONTINUED AB 1308 Page 4 1. Provides 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 CONTINUED AB 1308 Page 5 childbirth, regardless of whether the woman has consented to this care or refused care by a physician. E. 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. 1. Revises the oral and written disclosure required by a midwife to a prospective client to include a client plan, informed consent and additionally include the following: A. The client is retaining a licensed midwife, not a certified 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 to 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. 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. H. The availability of the text of the laws regulating licensed midwifery on the MBC's Internet Web site. I. Consultation with a physician does not alone create a physician-patient relationship or any other relationship CONTINUED AB 1308 Page 6 with the physician. J. Requires the informed consent to specifically state that the licensed midwife and consulting physician are not employees, partners, associates, agents or principals of one another. 1. Requires the licensed midwife to inform the patient that he/she is independently licensed and practicing midwifery and is solely responsible for the services he/she provides. 2. 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. 3. Provides that beginning January 1, 2015, applicants for a midwifery license shall not substitute clinical experience for formal didactic education. 4. 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. 5. Authorizes the MBC, with the input from the Board's MAC, to adjust the data elements required to be reported to better coordinate with other reporting systems, as specified. 6. 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. 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. 2. Makes a correcting change to refer to the American Association of Birth Centers rather than the National Association of Childbearing Centers. CONTINUED AB 1308 Page 7 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. 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 CONTINUED AB 1308 Page 8 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 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 CONTINUED AB 1308 Page 9 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. 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. CONTINUED AB 1308 Page 10 FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes Local: Yes SUPPORT : (Verified 9/9/13) American Congress of Obstetricians and Gynecologists, District IX, California (source) Birth Network of Monterey County California Association of Midwives California Families for Access to Midwives California Medical Board Central California Alliance for Health International Cesarean Awareness Network ARGUMENTS IN SUPPORT : According to the author, "The California Medical Board is responsible for the oversight of licensed midwives in California. Licensed midwives deliver 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, CONTINUED AB 1308 Page 11 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 9/11/13 Senate Floor Analyses SUPPORT/OPPOSITION: SEE ABOVE **** END **** CONTINUED