BILL ANALYSIS Ó
SB 408
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Date of Hearing: June 23, 2015
ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS
Susan Bonilla, Chair
SB 408(Morrell) - As Amended May 6, 2015
SENATE VOTE: 36-0
SUBJECT: Midwife assistants.
SUMMARY: Establishes minimum training requirements and duties
that may be performed by a midwife assistant.
EXISTING LAW:
1) Establishes the Medical Board of California (MBC), within the
Department of Consumer Affairs (DCA), to enforce the
provisions of the Medical Practice Act and to regulate the
practice of licensed midwifery. (Business and Professions
Code (BPC) §§ 2001; 2004; 2505)
2) Requires the MBC to create a Midwifery Advisory Council to
make recommendations to the MBC on matters related to the
practice of midwifery. (BPC § 2509)
3) Establishes the Board of Registered Nursing (BRN), within the
Department of Consumer Affairs (DCA), to enforce the
provisions of the Nursing Practice Act. (BPC § 2700 et seq.)
4) Authorizes the BRN to issue a certificate to practice nurse
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midwifery to a person who meets educational standards
established by the BRN. (BPC § 2746)
5) Authorizes certified nurse midwife (CNMs), under the
supervisions of a licensed physician and surgeon, to attend
to cases of normal childbirth and to provide prenatal,
intrapartum, and postpartum care. Also authorizes CNMs to
furnish drugs or devices. (BPC § 2746.5 ; 2746.51)
6) Permits the BRN, with the permission of the Director of the
DCA, to create advisory committees. (BPC § 2710.5)
7) Defines "medical assistant" as someone who may be unlicensed,
who performs basic administrative, clerical, and technical
supportive services for a physician, podiatrist, physician
assistant, nurse practitioner, or CNM. (BPC § 2069)
8) Defines "technical supportive services" as simple routine
medical tasks and procedures that may be safely performed by
a medical assistant who has limited training and who
functions under the supervision of a licensed physician,
surgeon, podiatrist, physician assistant, nurse practitioner
or CNM. (BPC § 2070(4))
9) Establishes training requirements and permitted functions for
medical assistants. (Title 16, California Code of
Regulations §§ 1366 et seq.)
THIS BILL:
1)Authorizes a midwife assistant to do all of the following:
a) Administer medication only by intradermal, subcutaneous,
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or intramuscular injections and perform skin tests and
additional technical support services upon the specific
authorization and supervision of a LM or CNM. A midwife
assistant may also perform these tasks and services in a
licensed clinic upon the specific authorization of a LM or
CNM.
b) Perform venipuncture or skin puncture for the purposes
of drawing blood upon specific authorization and under the
supervision of a LM or CNM, if the midwife assistant has
met the educational and training requirements for medical
assistants, as specified. Requires each employer of the
assistant to retain a copy of any related certificates as a
record.
c) Administer medications orally, sublingually, topically,
rectally, or by providing a single dose to a patient for
immediate self-administration, and administer oxygen at the
direction of the supervising LM or CNM. The LM or CNM
shall verify the correct medication and dosage before the
midwife assistant administers medication.
d) Assist in immediate newborn care when a LM or CNM is
engaged in a concurrent activity that precludes the
licensed midwife or CNM from doing so.
e) Assist in placement of the device used for auscultation
of fetal heart tones when a LM or CNM is engaged in a
concurrent activity that precludes the LM or CNM from doing
so.
f) Collect by noninvasive techniques and preserve specimens
for testing, including, but not limited to, urine.
g) Assist patients to and from a patient examination room,
bed, or bathroom.
h) Assist patient in activities of daily living, such as
assisting with bathing or clothing.
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i) Provide patient information and instructions as
authorized by the LM or CNM.
j) Collect and record patient data, including height,
weight, temperature, pulse, respiration rate, blood
pressure, and basic information about the presenting and
previous conditions.
aa) Perform simple laboratory and screening tests
customarily performed in a medical or midwife office.
bb) Perform additional midwife technical support services
under regulations and standards established by the MBC.
2)Shall not be construed as authorizing:
a) The licensure of midwife assistants.
b) The administration of local anesthetic agents by a
midwife assistant.
c) The MBC to adopt any regulations that violate the
prohibitions on diagnosis or treatment, as specified.
d) A midwife assistant to perform any clinical laboratory
test or examination for which he or she is not authorized,
as specified
3)Prohibits the employment of a midwife assistant for inpatient
care in a licensed general acute care hospital.
4) Defines the following terms:
a) A "midwife assistant" is a person, who may be
unlicensed, who performs basic administrative, clerical,
and midwife technical supportive services, is at least 18
years of age, and has met the same minimum amount of
training hours established for a medical assistant. The
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midwife assistant shall be issued a certificate by the
training institution or instructor indicating satisfactory
completion of the required training.
b) "Midwife technical supportive services" are simple,
routine medical tasks and procedures that may be safely
performed by a midwife assistant who has limited training
and who functions under the supervision of a LM or CNM.
c) "Specific authorization" means a specific written order
prepared by the supervising midwife authorizing the
procedures to be performed on a patient, that shall be
placed in the patient's medical record, or a standing order
prepared by the supervising midwife or supervising
nurse-midwife authorizing the procedures to be performed.
A notation of the standing order shall be placed in the
patient's medical record.
d) "Supervision" means the supervision of procedures by a
licensed midwife or certified nurse midwife, within his or
her scope of practice, who is physically present on the
premises during the performance of those procedures.
FISCAL EFFECT: According to the Senate Appropriations
Committee, pursuant to Senate Rule 28.8, this bill will result
in negligible state costs.
COMMENTS:
Purpose. This bill is sponsored by the Medical Board of
California . According to the author, "The proposed legislation
would define the role of a midwife assistant and allow these
individuals to perform duties very similar to those of a
traditional medical assistant. Specific duties listed?are tasks
such as: administering medicine, drawing blood, and recording
patient data. By defining a midwife assistant's duties, this
bill would create a standard of training for assistants and
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would protect the consumer and the midwife."
Background. The Midwifery Practice Act was implemented in 1994
and the first midwives were licensed in 1995. A LM is an
individual who has been issued a license to practice midwifery
by the MBC under the supervision of a licensed physician. LMs
may attend to cases of normal childbirth in a home, birthing
clinic, or hospital environment.
LM Training and Education. LMs complete a three year
post-secondary education program in an accredited school
approved by the MBC. All midwives must take and pass the North
American Registry of Midwives examination. LMs are also
required to 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.
Midwifery Advisory Council (Council). The MBC created the
Council in 2007. The Council is comprised of LMs, a MBC member,
a physician, and a member of the public. The MBC specifies
issues for the Council to discuss/resolve and the Council also
identifies issues and request approval from the MBC to develop
solutions to various issues.
MBC 2012 Sunset Review Report. In its 2012 Sunset Review Report,
the MBC highlighted the issue of "Midwife Students, Apprentices
and Assistants." The MBC indicated that it had concerns about
the use of assistants by LMs. Specifically, they indicated that
LMs were using midwife assistants despite the fact that there is
no definition of a midwife assistant in statute. They indicated
that because statute does not authorize a LM to train or
supervise a midwife assistant to assist with the delivery of an
infant, the issue needed to be addressed by defining the
qualifications of a midwife assistant in statute.
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CNM Training and Education. A CNM is a registered nurse who is
a graduate of a BRN approved nurse midwifery program and who
possesses evidence of certification issued by the BRN. CNMs
have acquired additional training in the field of obstetrics
and are certified by the American College of Nurse Midwives.
Certificates must be renewed biennially.
CNM Scope and Supervision. The CNM scope of practice includes
the comprehensive management of women's health care in a variety
of settings focusing particularly on pregnancy, childbirth, and
the postpartum period. It also includes the care of the
newborn, and the family planning and gynecological needs of
women throughout the life cycle. CNMs practice in collaboration
and consultation with physicians. The degree of collaboration
in this team approach depends upon the medical needs of the
individual woman or infant and the practice setting. By law,
nurse midwifery care requires the supervision of a licensed
physician and surgeon, but supervision does not require the
physical presence of the physician. However, if any
complications outside of the scope of the CNM arise, the CNM is
mandated to refer the patient to a physician immediately.
Additionally, the CNM is authorized to provide emergency care
until physician assistance can be obtained.
Nurse Midwife Advisory Committee (Committee). The BRN is
statutorily mandated to appoint a Committee, and the first
Committee was appointed in 1984. The Committee is comprised of
at least one CNM and one physician, who have demonstrated
familiarity with consumer needs, collegial practice and
accompanied liability, and related educational standards in the
delivery of maternal child health care. The Committee also has
at least one public member and may include such other members as
the BRN deems appropriate. The purpose of this Committee is to
advise the board on all matters pertaining to nurse midwifery as
established by the BRN, and, if necessary, to assist the BRN or
its designated representatives in the evaluation of applications
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for nurse midwifery certification.
Medical Assistants' Certification and Training. Medical
assistants are unlicensed, but certificated, individuals.
Medical assistants are regulated by the MBC. There are two
medical assistant certifying agencies that are recognized by the
National Commission for Certifying Agencies. These include: 1)
the American Association of Medical Assistants, who provide
Certified Medical Assistant certification and 2) the American
Medical Technologists who provide Registered Medical Assistant
certification.
A medical assistant must receive training either directly from a
physician, surgeon, podiatrist, registered nurse, licensed
vocational nurse, physician assistant or a qualified medical
assistant. Alternatively, a medical assistant may receive
training from a secondary, postsecondary or adult education
program in a public school authorized by the Department of
Education, in a community college program, or a postsecondary
institution accredited by an accreditation agency recognized by
the United States Department of Education or approved by the
Bureau for Private Postsecondary Education. Medical assistants
must also complete a minimum of 60 hours of continuing education
over 5 years.
Medical Assistant Scope and Supervision. Medical assistants can
perform basic administrative, clerical and technical supportive
services when conditions regarding supervision, training,
specific authorization and records are met. Medical assistants
can be supervised by physicians, surgeons, podiatrists or
optometrists. Additionally, if a medical assistant is working
in a community or free clinic, they may work under the direct
supervision of a physician assistant, nurse practitioner or CNM
when the supervising physician or surgeon is not on site, only
if the physician or surgeon has created a written protocol for
the activities of the medical assistant.
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Current Related Legislation. AB 1306 (Burke) of the current
Legislative Session, removes the physician supervision
requirement for CNMs allowing them to manage a full range of
primary health services, perform peripartum care, provide
emergency care when a physician is not present, and perform and
repair episiotomies in all practice settings. STATUS: This bill
is pending in the Senate Committee on Business, Professions and
Economic Development.
SB 407 (Morrell) of the current Legislative Session, authorizes
a health care provider to employ or contract LMs for the purpose
of providing comprehensive perinatal services. The bill would
expand the definition of "comprehensive perinatal provider" to
include a Licensed Midwife. STATUS: This bill is pending in the
Assembly Health Committee.
Previous Related Legislation. AB 1308 (Bonilla), Chapter 665,
States of 2013, removed the requirement for a LM to practice
under the supervision of a physician and surgeon and instead
permitted a LM to assist in normal pregnancy and birth, and for
pregnancies that are not considered normal, the LM must refer or
transfer the client to a physician and surgeon. The bill
authorized a LM to directly obtain supplies, devices, obtain and
administer drugs and diagnostic tests, order testing and receive
reports that are necessary to his or her practice of midwifery.
The bill also indicated that it is a cause for disciplinary
action by the MBC for a LM to fail to refer or transfer a client
to a physician and surgeon when required to do so by law.
SB 1638 (Figueroa), Chapter 536, Statutes of 2006, established
the Midwifery Advisory Council. The bill also required each LM
who assists, or supervises a student midwife in assisting, in
childbirth occurring in an out-of-hospital setting, to annually
report to the Office of Statewide Health Planning and
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Development certain information regarding his or her practice
for the previous year. The bill required the office to report
annually to the MBC those licensees who have complied with the
bill's requirements, and required the board to send a notice of
non-compliance to those licensees who have not. The bill
required the office to report the aggregate information to the
MBC, and required the MBC to report that aggregate information
to the Legislature in its own annual report.
SB 298 (Figueroa), Chapter 289, Statutes of 2001, authorized a
CNM to furnish or order controlled substances under certain
conditions. The bill defined the term "furnishing" to include
the ordering of a drug or device pursuant to a standardized
procedure or protocol and the transmitting of an order of a
supervising physician and surgeon.
SB 1479 (Figueroa), Chapter 303, Statutes of 2000, required a LM
in attendance at a live birth outside the hospital, where no
physician is present, to prepare and register a birth
certificate. This bill also made these provisions applicable to
live births that occur outside a state-licensed alternative
birth center.
ARGUMENTS IN SUPPORT:
The Medical Board of California supports the bill and writes,
"Currently there is no definition of a midwife assistant in
statute, or the specific training requirements or duties that a
midwife assistant may perform. Some LMs use other LMs as
assistants, while some use a midwife student who is enrolled in
a recognized midwifery school and who has an official agreement
with the students and midwifery school to provide clinical
training to the student midwife. Other LMs use someone who may
or may not have formal midwifery training and/or someone that
the LM has trained. The duties that a midwife assistant
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performs also varies greatly from LM to LM. This unregulated
practice is a serious consumer protection issue."
Planned Parenthood supports the bill and writes, "SB 408 will
expand midwifery care- particularly in rural and other
underserved areas- by allowing midwife assistant to legally
assist licensed midwives at out-of-hospital births. Typically,
two providers attend each birth, bur licensed midwives are
scarce in some areas of the state?By creating a new class of
medical personnel, licensed midwives will have a specifically
trained assistant to assist them in their practices."
The American Nurses Association of California supports the bill
and writes, "SB 408 would authorize a midwife assistant to
perform certain assistive tasks and duties under the supervision
of a LM or CNM?The bill would prohibit a midwife assistant from
being employed for inpatient care in a licensed general acute
care hospital. For these reasons, ANAC supports SB 408."
ARGUMENTS IN OPPOSITION:
None on file.
REGISTERED SUPPORT/OPPOSITION:
Support:
Medical Board of California (sponsor)
American Nurses Association of California
County of Santa Cruz Board of Supervisors
Monterey County Board of Supervisors
Planned Parenthood
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Opposition:
None on file.
Analysis Prepared by:Le Ondra Clark Harvey, Ph.D. / B. & P. /
(916) 319-3301