BILL ANALYSIS Ó
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|SENATE RULES COMMITTEE | AB 1308|
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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
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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
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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.
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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
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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
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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.
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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
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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
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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.
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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,
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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
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