BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                            



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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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          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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