BILL ANALYSIS Ó
AB 1308
Page 1
( Without Reference to File )
CONCURRENCE IN SENATE AMENDMENTS
AB 1308 (Bonilla)
As Amended September 6, 2013
Majority vote
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|ASSEMBLY: |72-0 |(May 16, 2013) |SENATE: |39-0 |(September 11, 2013) |
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|COMMITTEE VOTE: |13-0 |(September 12, |RECOMMENDATION: |concur |
|(B.,P. & C.P.) | |2013) | | |
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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.
AB 1308
Page 2
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."
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
AB 1308
Page 3
normal, and permits the LM to consult and remain in consultation
with the physician and surgeon after the referral 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;
AB 1308
Page 4
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
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 complications.
3)Change references from the National Association of Childbearing
Centers to the American Association of Birth Centers.
AB 1308
Page 6
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 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
AB 1308
Page 7
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
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
AB 1308
Page 8
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
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
AB 1308
Page 9
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,
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
AB 1308
Page 10
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 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.
AB 1308
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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.
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
AB 1308
Page 12
FN: 0002864