BILL ANALYSIS Ó
AB 1308
Page 1
CONCURRENCE IN SENATE AMENDMENTS
AB 1308 (Bonilla)
As Amended September 6, 2013
Majority vote
-----------------------------------------------------------------
|ASSEMBLY: |72-0 |(May 16, 2013) |SENATE: |39-0 |(September 11, |
| | | | | |2013) |
-----------------------------------------------------------------
Original Committee Reference: B.,P. & C.P.
SUMMARY : Revises the scope of practice for a licensed midwife
(LM) to remove the requirement of supervision by a physician and
surgeon; authorizes a LM 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 authorizes a LM to attend cases of
normal birth. Specifically, this bill :
1)Authorizes a LM 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)Expands the existing oral and written disclosures required of
a LM to a prospective client to include the specific
arrangements for the referral of complications to a physician
and surgeon for consultation, but this bill clarifies that the
LM shall not be required to identify a specific physician and
surgeon.
3)Changes references from the National Association of
Childbearing Centers to the American Association of Birth
Centers.
4)Revises a LM's scope of practice by deleting the physician
supervision requirement and authorizing a LM to attend cases
of normal pregnancy and childbirth.
5)Revises the definition of midwifery practice to be "the
furthering or undertaking by any licensed midwife to assist a
woman in childbirth as long as progress meets criteria
accepted as normal."
AB 1308
Page 2
6)Defines "normal pregnancy and childbirth" to meet the
following conditions:
a) There is an absence of both of the following:
i) Any preexisting maternal disease or condition likely
to affect the pregnancy; and,
ii) Significant disease arising from the pregnancy.
b) There is a singleton fetus;
c) There is a cephalic presentation;
d) The gestational age of the fetus is greater than 37
weeks and less than 42 completed weeks of pregnancy; and,
e) Labor is spontaneous or induced in an outpatient
setting.
7)States that if a potential LM client meets all of the criteria
for a "normal pregnancy and childbirth" except i) or ii) in 6)
a) above, and the woman still desires to be a client of the
LM, the LM shall provide the woman with a referral for an
examination by a physician and surgeon trained in obstetrics
and gynecology.
8)Permits a LM to assist a potential midwife client who
otherwise meets the criteria for a normal pregnancy if a
physician and surgeon trained in obstetrics and gynecology
examines the woman and determines that the risk factors
presented by her disease or condition are not likely to
significantly affect the course of pregnancy and childbirth.
9)Requires the Medical Board of California (MBC) to adopt
regulations specifying the conditions for "preexisting
maternal disease or condition likely to affect the pregnancy"
and "significant disease arising from the pregnancy."
10)Requires a LM to immediately refer or transfer the client to
a physician and surgeon if at any point during a pregnancy,
childbirth, or postpartum care a client's condition deviates
from normal, and permits the LM to consult and remain in
consultation with the physician and surgeon after the referral
AB 1308
Page 3
or transfer.
11)Permits the LM to resume primary care of the client and
resume assisting the client during her pregnancy, childbirth,
or postpartum care if a physician and surgeon determines that
the client's condition or concern has been resolved such that
the risk factors presented by a woman's disease or condition
are not likely to significantly affect the course of pregnancy
or childbirth.
12)States that if a physician and surgeon determines that the
client's condition or concern has not been resolved, the LM
may provide concurrent care with a physician and surgeon and,
if authorized by the client, be present during the labor and
childbirth, and resume postpartum care, if appropriate, but
may not resume primary care of the client.
13)Prohibits a LM from providing or continuing to provide
midwifery 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 or surgeon, as specified.
14)States that the practice of midwifery does not include the
assisting of childbirth by any artificial, forcible, or
mechanical means, nor the performance of any version of these
means.
15)Clarifies that this bill does not authorize a LM to practice
medicine or to perform surgery.
16)Requires a LM to disclose in oral and written form to a
prospective client as part of a client care plan, and obtain
informed consent, for the following:
a) The client is retaining a LM, not a certified nurse
midwife, and the LM is not supervised by a physician and
surgeon;
b) The LM's current licensure status and license number;
c) The practice settings in which the licensed midwife
practices;
d) The fact that many physicians and surgeons do not have
liability insurance coverage for services provided to
AB 1308
Page 4
someone having a planned out-of-hospital birth;
e) The acknowledgment that if the client is advised to
consult with a physician and surgeon, failure to do so may
affect the client's legal rights in any professional
negligence actions against a physician and surgeon,
licensed health care professional, or hospital;
f) There are conditions that are outside of the scope of
practice of a LM that will result in a referral for a
consultation from, or transfer of care to, a physician and
surgeon;
g) Recommendations for preregistration at a hospital that
has obstetric emergency services and is most likely to
receive the transfer;
h) If, during the course of care, the client is informed
that she has or may have a condition indicating the need
for a mandatory transfer, the licensed midwife shall
initiate the transfer;
i) The availability of the text of laws regulating licensed
midwifery practices and the procedure for reporting
complaints to MBC, which may be found on MBC's Internet Web
site; and,
j) Consultation with a physician and surgeon does not alone
create a physician-patient relationship or any other
relationship with the physician and surgeon. The informed
consent shall specifically state that the LM and the
consulting physician and surgeon are not employees,
partners, associates, agents, or principals of one another.
The LM shall inform the patient that he or she is
independently licensed and practicing midwifery, and in
that regard is solely responsible for the services he or
she provides.
17)Requires the consent to be signed by both the LM and the
client and placed in the client's medical record.
18)Authorizes MBC to prescribe the form for the informed consent
statement required to be used by a LM.
19)Requires a LM to provide records, including prenatal records,
AB 1308
Page 5
and speak with the receiving physician and surgeon about labor
up to the point of the transfer if a client is transferred to
a hospital. The hospital shall report each transfer of a
planned out-of-hospital birth to MBC and the California
Maternal Quality Care Collaborative using a standardized form
developed by MBC.
20)Prohibits new licensees from substituting clinical experience
for formal didactic education beginning January 1, 2015.
21)Authorizes MBC, with input from the Midwifery Advisory
Council, to adjust the data elements required to be reported
to better coordinate with other reporting systems, including
the reporting system of the Midwives Alliance of North America
(MANA), while maintaining the data elements unique to
California.
22)Deems failure to do the following, if required by law, to be
unprofessional conduct:
a) Consult with a physician and surgeon;
b) Refer a client to a physician and surgeon; and,
c) Transfer a client to a hospital.
23)Makes legislative findings and declarations.
24)Makes technical and clarifying amendments
25)States that no reimbursement is required by this act because
the only costs that may be incurred by a local agency or
school district will be incurred because this act creates a
new crime or infraction, eliminates a crime or infraction,
changes the penalty for a crime or infraction, or changes the
definition of a crime.
The Senate amendments :
1)Permit a LM to directly obtain devices and obtain and
administer drugs and diagnostic tests that are necessary to
his or her practice of midwifery and consistent with his or
her scope of practice.
2)Clarify that the LM shall not be required to identify a
specific physician and surgeon for consultation regarding
AB 1308
Page 6
complications.
3)Change references from the National Association of
Childbearing Centers to the American Association of Birth
Centers.
4)Permit a LM to be one of at least two attendants required at
all times during birth.
5)Delete the requirement for the MBC to revise and adopt
regulations defining the supervision requirements between a
physician and a LM.
6)Revise a LM's scope of practice by deleting the physician
supervision requirement and authorizing a LM to attend cases
of normal pregnancy and childbirth.
7)Revise the definition of midwifery practice to be "the
furthering or undertaking by any licensed midwife to assist a
woman in childbirth as long as progress meets criteria
accepted as normal."
8)Define "normal pregnancy and childbirth" to meet the following
conditions:
a) There is an absence of both of the following:
i) Any preexisting maternal disease or condition likely
to affect the pregnancy; and,
ii) Significant disease arising from the pregnancy;
b) There is a singleton fetus;
c) There is a cephalic presentation;
d) The gestational age of the fetus is greater than 37
weeks and less than 42 completed weeks of pregnancy; and,
e) Labor is spontaneous or induced in an outpatient
setting.
9)State that if a potential LM client meets all of the criteria
for a "normal pregnancy and childbirth" except i) or ii) in 8)
a) above, and the woman still desires to be a client of the
AB 1308
Page 7
LM, the LM shall provide the woman with a referral for an
examination by a physician and surgeon trained in obstetrics
and gynecology.
10)Permit a LM to assist a potential midwife client who
otherwise meets the criteria for a normal pregnancy if a
physician and surgeon trained in obstetrics and gynecology
examines the woman and determines that the risk factors
presented by her disease or condition are not likely to
significantly affect the course of pregnancy and childbirth.
11)Require MBC to adopt regulations specifying the conditions
for "preexisting maternal disease or condition likely to
affect the pregnancy" and "significant disease arising from
the pregnancy."
12)Require a LM to immediately refer or transfer the client to a
physician and surgeon if at any point during a pregnancy,
childbirth, or postpartum care a client's condition deviates
from normal and permits the LM to consult and remain in
consultation with the physician and surgeon after the referral
or transfer.
13)Permit the LM to resume primary care of the client and resume
assisting the client during her pregnancy, childbirth, or
postpartum care if a physician and surgeon determines that the
client's condition or concern has been resolved such that the
risk factors presented by a woman's disease or condition are
not likely to significantly affect the course of pregnancy or
childbirth.
14)State that if a physician and surgeon determines that the
client's condition or concern has not been resolved, the LM
may provide concurrent care with a physician and surgeon and,
if authorized by the client, be present during the labor and
childbirth, and resume postpartum care, if appropriate, but
may not resume primary care of the client.
15)Prohibit a LM from providing or continuing to provide
midwifery 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 or surgeon, as specified.
16)State that the practice of midwifery does not include the
AB 1308
Page 8
assisting of childbirth by any artificial, forcible, or
mechanical means, nor the performance of any version of these
means.
17)Clarify that this bill does not authorize a LM to practice
medicine or to perform surgery.
18)Require a LM to disclose in oral and written form to a
prospective client as part of a client care plan, and obtain
informed consent, for the following:
a) The client is retaining a LM, not a certified nurse
midwife, and the LM is not supervised by a physician and
surgeon;
b) The LM's current licensure status and license number;
c) The practice settings in which the licensed midwife
practices;
d) The fact that many physicians and surgeons do not have
liability insurance coverage for services provided to
someone having a planned out-of-hospital birth;
e) The acknowledgment that if the client is advised to
consult with a physician and surgeon, failure to do so may
affect the client's legal rights in any professional
negligence actions against a physician and surgeon,
licensed health care professional, or hospital;
f) There are conditions that are outside of the scope of
practice of a LM that will result in a referral for a
consultation from, or transfer of care to, a physician and
surgeon;
g) Recommendations for preregistration at a hospital that
has obstetric emergency services and is most likely to
receive the transfer;
h) If, during the course of care, the client is informed
that she has or may have a condition indicating the need
for a mandatory transfer, the licensed midwife shall
initiate the transfer;
i) The availability of the text of laws regulating licensed
AB 1308
Page 9
midwifery practices and the procedure for reporting
complaints to MBC, which may be found on MBC's Internet Web
site; and,
j) Consultation with a physician and surgeon does not alone
create a physician-patient relationship or any other
relationship with the physician and surgeon. The informed
consent shall specifically state that the LM and the
consulting physician and surgeon are not employees,
partners, associates, agents, or principals of one another.
The LM shall inform the patient that he or she is
independently licensed and practicing midwifery, and in
that regard is solely responsible for the services he or
she provides.
19)Require the consent to be signed by both the LM and the
client and placed in the client's medical record.
20)Authorize MBC to prescribe the form for the informed consent
statement required to be used by a LM.
21)Require a LM to provide records, including prenatal records,
and speak with the receiving physician and surgeon about labor
up to the point of the transfer if a client is transferred to
a hospital. The hospital shall report each transfer of a
planned out-of-hospital birth to MBC and the California
Maternal Quality Care Collaborative using a standardized form
developed by MBC.
22)Prohibit new licensees from substituting clinical experience
for formal didactic education, beginning January 1, 2015.
23)Authorize MBC, with input from the Midwifery Advisory
Council, to adjust the data elements required to be reported
to better coordinate with other reporting systems, including
the reporting system of the Midwives Alliance of North America
(MANA), while maintaining the data elements unique to
California.
24)Deem failure to do the following, if required by law, to be
unprofessional conduct:
a) Consult with a physician and surgeon;
b) Refer a client to a physician and surgeon; and,
AB 1308
Page 10
c) Transfer a client to a hospital.
25)Make technical and clarifying amendments.
FISCAL EFFECT : According to the Senate Appropriations
Committee, pursuant to Senate Rule 28.8, negligible state costs.
COMMENTS :
1)Midwifery and physician supervision requirements . A LM is an
individual who has been issued a license to practice midwifery
by MBC, under the supervision of a licensed physician.
Midwifery is the profession of offering care to childbearing
women during pregnancy, labor and birth, and during the
postpartum period.
According to a 2013 sunset review report of MBC by the
California Senate Business, Professions, and Economic
Development (BPED) Committee, physician supervision is
essentially unavailable to LMs performing home births because
California physicians are generally prohibited by their
malpractice insurance companies from supervising LMs who
perform home births.
Existing law previously required MBC to adopt regulations by
July 1, 2003, defining both the appropriate standard of care
and the level of supervision required for the practice of
midwifery. However, due to its inability to reach a consensus
on the supervision issue, the MBC adopted the Standards of
Care for Midwifery in 2006 but delayed determining appropriate
supervision indefinitely. BPED reported that three previous
attempts to resolve the physician supervision issue through
legislation and/or regulation have been unsuccessful due to
the widely divergent opinions of interested parties.
Despite midwives' inability to obtain physician supervision,
midwives are currently performing midwifery without sanction
by MBC because a 1999 administrative court decision determined
that it was unfair to enforce the physician supervision
requirement because physician supervision is practically
unobtainable.
This bill would formally remove the physician supervision
requirement and allow LMs to assist cases of normal pregnancy
AB 1308
Page 11
and childbirth, as defined, while requiring an LM to consult
and refer to a physician and surgeon in cases deviating from
this standard. In case of a transfer to a physician and
surgeon, an LM is required to provide records, including
prenatal records, and speak with the receiving physician and
surgeon to ensure a safe and informed handover.
2)Midwife access to supplies, testing, and results . According
to the author, some LMs are also impeded by the supervision
requirement because many drug, testing, and device suppliers
require the name of an ordering physician to fulfill requests,
thereby delaying or blocking an LM's ability to obtain
supplies, order tests, and receive results. LMs who are
unable to establish an account with a local medical supply
company may have to order drugs and supplies from out of state
at significantly higher costs, or obtain them from another LM.
Continuity of care becomes an important patient issue when LMs
are unable to establish laboratory accounts or refer patients
for ultrasounds because patients then have to see a different
provider to get the appropriate tests. This may increase
costs and cause delay for patients, and can affect
time-sensitive testing windows, such as those for the genetic
screening done in early pregnancy. According to the author,
some patients have refused to seek out these laboratory tests
when they would have otherwise consented to them had they been
available through their licensed midwife.
This bill would explicitly authorize LMs to order the tests
and supplies necessary and appropriate to their practice
without naming a supervising physician.
3)Client disclosures . LMs are currently required to disclose
certain information to prospective clients, including whether
the midwife has liability coverage, the specific arrangements
for a hospital transfer, and complaint procedures. This bill
significantly expands the required disclosures to include
information about the midwife's license, abilities, and
practice settings, and the legal relationship between the LM
and any physician he or she may consult with for purposes of
liability. The midwife is required to provide a client care
plan and obtain informed consent for the information provided.
AB 1308
Page 12
4)Arguments in support . The California Nurse-Midwives
Association writes, "Home birth as provided by qualified LMs
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. Per the ACNM Home Birth Statement, 'ACNM supports the
right of women who meet selection criteria to choose home
birth.'
"AB 1308 addresses barriers that impede women's access to safe
out-of-hospital birth and access to birth provider of their
choice. Importantly, this bill will remove physician
supervision, recognize LMs as qualified birth attendants in
alternative birth center settings, and provide LMs ability to
directly order drugs and supplies for use consistent with
their scope of practice."
Analysis Prepared by : Sarah Huchel / B.,P. & C.P. / (916)
319-3301
FN:
0002775