Information for CaLMs ~ MBC’s Oct 15th “Interested Parties” meeting

Like most Ca LMs, I received a notice from the Medical Board for the Interested Parties meeting at the MBC’s state offices in Sacramento on Oct 15th (1-4pm)

This event will set the tone for implementation of AB 1308 relative to:

(i) Any preexisting maternal disease or condition likely to affect the pregnancy.
(ii) Significant disease arising from the pregnancy.

Link to full text of Assembly Bill 1308

Background Information

The ONLY agenda items for the MBC’s  Interested Parties meeting are reviewing, discussing and proposing potential regulations to define B&P section 2507, lines (b),(1),(A),(i) and Section 2510 of the LMPA.

Section 2510 reads: If a client is transferred to a hospital, the licensed midwife shall provide records, including prenatal records, and speak with the receiving physician and surgeon about labor up to the point of the transfer. The hospital shall report each transfer of a planned out-of-hospital birth to the Medical Board of California and the California Maternal Quality Care Collaborative using a standardized form developed by the board.

Section 2507– relative language from lines (b),(1),(A),(i) reads:

(b) As used in this article, the practice of midwifery constitutes the furthering or undertaking by any licensed midwife to assist a woman in childbirth as long as progress meets criteria accepted as normal. (1) Except as provided in paragraph (2), a licensed midwife shall only assist a woman in normal pregnancy and childbirth, which is defined as meeting all of 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.

(ii) Significant disease arising from the pregnancy.

Short and long-term strategy for addressing these issues

First its important to ‘think big’ and think ‘long-term’. This is only the beginning of the a year long (or longer) regulatory process that only ends when the Office of Administrative Law (OAL) approves the ‘proposed’ regulation.

We have to remember that one of the most important things midwives and supportive childbearing families can do is to submit appropriately-targeted, high-quality written testimony before or at the regulatory hearings. By law,  all this material must be read and taken into consideration by the attorneys at OAL who decide whether or not the proposed reg is a lawful based on 6 legal requirement.

If we aren’t able to block unworkable policies and language during the “promulgation” process (i.e. what is proposed and voted on by the MBC) our next best hope is to be sure the OAL is fully and appropriate informed of the problems.

The second vital issue is for Ca LMs to be clear about the IP meeting’s agenda, which legally restricts us to just three topics.

Discussion at the October 15th meeting, as defined by its published “Agenda” is ONLY about lines (b),(1),(A),(i) in Sec 2507 and about 2710 (hospital reports for transfers by Ca LMs from OOH setting).

The October meeting is NOT going to address or even talk about the bigger and far more serious problems with language in AB 1308 requires LMs to “immediately” transfer care anytime during pregnancy, childbirth or PP that the client’s “condition” deviates from “normal“.

Relative to this provision, two facts are relevant.

Issue #1. In regard to health care, the concept ‘condition’ is like the word ‘temperature’ — everybody has a ‘temperature’, which is far different issue than having a fever (100.5 or greater).

Unless the word ‘temperature’ is defined by an adjective such as: “clinically significant elevation“, or in the case of “condition”, a ‘pathological, or clinically significant condition‘, they are both totally useless concepts from the standpoint of providing the necessary legal guidance required to be enforceable.

It is virtually impossible to  define this concept without coming back right to the idea of “pathological, or clinically-significant” condition.

At the heart of the phrase “clinically significant” is the vital distinction between “possible” and “probable”. A very large number of situations and ‘conditions’ carry within them a “possibility” of becoming pathological and resulting in a serious complication or worse. A very much smaller number of situations and conditions are associated with a high probability that a very serious complication or worse will occur.

A ‘clinically significant’ condition is one in which it is probable that a bad outcome will occur unless medical or surgical interventions are used.

Therefore a ‘significant’ medical condition implies a pathological state associated with the serious complications of childbearing likely to result in serious physical damage, disability or death for the parturient woman or her unborn or newborn baby.

The same linguist problem applies to the undefined concept of ‘normal‘.

Another easily-to-abused example that also has political implications is the undefined use of the word “qualified”. For most of the 20th century, the right to vote was limited in southern states by passing laws that restricted voting to “qualified” persons over a stated age. However these law usually didn’t define what made a person “qualified”.

This allowed any state official or county employees to define “qualified” as what ever they wanted it to be that particular day for that particular person or situation. For over a century, this undefined word was used to discriminate against the poor and ethnic minorities to keep them from voting.

In a contrasting example, there is a section in California Medical Practice Act that restricts the practice of medicine to “qualified” physicians. However, the MPA very specifically defines the concept  – a graduate from a MBC-approved medical school who holds a valid California state license to practice medicine that is in good standing.

Issue # 2 ~  Ca LMs are going to have to keep track of and report the specific nature and frequency of problems this language causes for us and our client families in preparation for finding a legislative or legal “remedy”.

I’ve been thinking about this for several months and have quite a few suggestions for strategies that are likely to be effective.

However, that is a conversation for another day.

A unified strategy for LMs & C-Fam @ the Oct 15th Meeting

1. The majority position by our State’s midwifery and consumer organizations, other supportive groups and individual midwives and families is that the MBC adopt into regulation:

The ‘Criteria for Client Selection‘ from the 2006 Standard of Care for California Licensed Midwives  (SCCLM), which was part “a” in the original regulation and part 2 which include VBAC protocols previously approved by ACOG as defining the issues in section 2507, lines (b),(1),(A),(i)

Here is the currently published language fro California Code of Regulations, Title 16:

Medical Board of California
Chapter 4. Licensed Midwives
Article 3.5. Midwifery Practice

§ 1379.19. Standards of Care for Midwives.

(a) For purposes of Section 2507(f) of the code, the appropriate standard of care for licensed midwives is that contained in the “Standard of Care for California Licensed Midwives” (September 15, 2005 edition) (“SCCLM”), which is hereby incorporated by reference.

(b) With respect to the care of a client who has previously had a caesarean section (“C-section”) but who meets the criteria set forth in the SCCLM, the licensed midwife shall provide the client with written informed consent (and document that written consent in the client’s midwifery record) that includes but is not limited to all of the following:

(1) The current statement by the American College of Obstetricians and Gynecologists regarding its recommendations for vaginal birth after caesarean section (“VBAC”).

(2) A description of the licensed midwife’s level of clinical experience and history with VBACs and any advanced training or education in the clinical management of VBACs.

(3) A list of educational materials provided to the client.

(4) The client’s agreement to: provide a copy of the dictated operative report regarding the prior C-section; permit increased monitoring; and, upon request of the midwife, transfer to a hospital at any time or if labor does not unfold in a normal manner.

(5) A detailed description of the material risks and benefits of VBAC and elective repeat C-section.

NOTE: Authority cited: Sections 2018 and 2507, Business and Professions Code. Reference: Section 2507, Business and Professions Code.

1. New article 3.5 heading and new section filed 2-7-2006; operative 3-9-2006 (Register 2006, No.6).


This quote from Legislative Council Digest shows just how high the stake are, as it states that violation of the LMPA is acrimeand then goes on to say:

“The bill would authorize the board to suspend or revoke the license of a licensed midwife for failing, when required, to consult with a physician and surgeon, to refer a client to a physician and surgeon, or to transfer a client to a hospital.”

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