The original (1917) California licensing provision for direct-entry midwives did a splendid job of modeling language for highly effective and ethical legislation for the practice of tradition (i.e., non-medical) midwifery in our State.
Each use of a critical word or phrase was followed, in the very next sentence, by a specific and expanded definition of the word, phrase or idea denoted in the law. This left no doubt in the reader’s mind as to what was intended by the legislative language.
The language in AB 1308 (2013) that currently requires LMs to transfer pregnant or laboring women, or their neonates, for “any time the c’lient’s condition deviates from normal” fails, by this standard, to define its terms in a meaningful way.
My suggestions for this critical ‘fix’ for AB 1308 (either ‘clean up’ legislation or regulation):
While we cannot replace the specific word “deviates” itself, the legal purpose of regulations is to give more specific guidance to the intent of the black-letter law. Additional modifying language would protect mothers from being arbitrarily medicalized for trivial reasons (or LMs begin prosecuted for failure to transfer for clinically insignificant reasons).
To do this we need to modify
This unconstitutionally “broad” and non-specific concept should be amended by adding (or defining in regulation) the words ‘pathological, or clinically significant or other vocabulary that indicate that immedicate transfer of care is to be based on a truly serious medical problem that is clinically significant — that is, substantially likely to have a negative influence on the wellbeing of mother or baby during the pregnancy, labor, birth, postpartum or neonatal period.
While we cannot replace the word “deviation”, this modifying language might work, since the legal role for regulations is to give more specific guidance to the intent of the black-letter law.
However, we must be prepared to push hard for this important correction. ACOG, CMA and CAPPLI can be counted on to scream bloody murder, since the unmodified words “any deviation from normal” is the clearly crown jewel of their newly expanded control over the licensed practice of directly entry mfry in California.
It would be interesting to ask Saras Vedam, as an academic and head of the British Columbia College of Midwives, what she makes of the legal burden inherent in the phrase “any deviation from normal” as applied to the entire landscape of pregnancy and childbirth. For example, it would be nice to note in regulation that minor deviations would call for careful or additional watching on the part of the midwife, but would not trigger referral or transfer of care unless they developed medical significance.
2. Append to the the word: “significant medical” to “condition”. Following the word ‘condition’, add: “that is likely to influence the normal progress of labor, the safe completion of the birth, or represents a serious risk to the health and wellbeing of the new mother or neonate”.
I’ve was busy writing Saturday’s rant on Section 2052, and today’s historical info, so I won’t get to read web files for the other historical material until tomorrow or the next day.
While I can plainly see that we have been out-manueved, I do believe in miracle and don’t think that all is lost.
I do however want to state again that it is a tactical error for the citizens of California (esp. childbearing parents and taxpayers!) to leave my experience with the Medical Board and the Legislature, my accumulated knowledge and scholarship, out of the political and legislative loop.
However, I’m planning to live long enough to see the words “a California licensed physician and surgeon with training and experience in midwifery” used as the legislatively determined standard for MDs who are called on to make legally binding decisions on the practice of midwifery (either need or timing of transfers of care, or determining if a disciplinary case should be filed or when testifying in LM standard of care cases).
============================= Topic #1 (of 2) ================================
How the history of obstetrical supervision connects to the contemporary predicament created by AB 1308:
The extreme restrictions on the practice of direct-entry (non-nurse) mfry originally intended by the CMA in 1993 LMPA were designed to be imposed on each individual LMs by her specific obstetrician supervisor. This is why the LMPA did not include a ‘standard of care’ or code of ethics.
This strategy was a legally successful 3-act play. This is how ACOG accomplished in 3 seemingly unrelated steps what it could not have achieved in one bold (and obvious) move.
ACT ONE, invented in 1974, was that obstetricians negotiated the political aspects of California’s first licensing law for nurse midwives. However, these individuals were representing the national agenda of ACOG, and NOT California midwives representing the needs of the California families.
However, this was a new form of midwifery practice that had little in common with the legacy practice of midwifery under the original 1917 direct-entry mfry provision, which had been repealed in 1949 (SB 966), which made the CNM law seems more distant from current direct-entry mfry than it really was.
The new nurse midwifery law allowed organized medicine to define the ‘modern’ and lawful practice of nurse-midwifery to be a medicalized discipline under the control of the medical profession, to be provided under obstetrically-defined parameters.
The goal of controlling mfry practice was implemented by mandating that nurse-midwives practice ONLY under obstetrician supervision.
As an aside, I must interject here that nearly everyone else involved in this 1974 legislation, including legislators, reporters, as well as others laypersons hearing of this decision, were not at all displeased by the arrangement. They accepted a mandated relationship btw midwives and obstetricians as a workable, commonsense arrangement — a safety feature that would guarantee quick access (a ‘stepping stone’) to appropriate and timely medical services for women receiving care from nurse midwives.
Unfortunately, the absolute control ceded to the obstetrical profession over the profession of midwifery was used to successfully erect both legal and practical stumbling blocks. These barriers to practice for CNM continue to the present day (note pending case against nurse-midwives with a OOH practice for the CNMs failure to have a supervising physician). The consequence is greatly reduced or in some cases, completely blocking access to midwifery care for families seeking out physiologically managed labor and birth.
In point of fact, the only thing the supervision provision has actually achieved was to prevent OOH CNMs and PHB LMs from qualifying for reimbursement under Medicaid-MediCal rules for low-income families (50% of all births in California). By preventing CNMs and LMs from providing the far more cost-effective mfry care to healthy women in low-income families, the obstetrical profession by default make sure taxpayers paid the ever-so-much higher cost of highly medicalized hospital care for this same healthy population.
With only the rarest of exceptions, all California obstetricians practice obstetrics under ACOG-generated policies and standards of practice. ACOG’s policies were in turn mirrored in the restrictive policies and prohibitions generated by the med-mal carriers. Together these two factors made sure that normal childbirth services for healthy women remained in the medical domain of hospitals and obstetrically-originating policies and protocols. As a conventional practice of obstetrics, which is both a surgical specialty and a hospital-based disciple, this meant that at a practical level, nurse-midwives were restricted to providing birth-related care only in a hospital setting or birth center that meet with ACOG’s approval.
Within the medical profession, it was expected that any obstetrician who agreed to be a supervisor would, as loyal and astute ACOG fellows, create the usual written protocols defining the rules for his CNM’s ‘physician-extenders role. Generally that would require any CNM practicing under supervision to immediately to consult, refer or transfer the care of ANY pregnant or laboring women who manifested ANY ‘deviation’ from “normal”, which would be the usual protocol defining care rendered by a physician extender/mid-level practitioner. Her authority as an independent entity (like a kid left home by himself on Sat. afternoon) would only apply to the totally “normal” aspects of reproductive biology. All other permutations of events require notifying the ‘higher ups’ (in business, this would be called your “supervisor”) so that critical decisions at make by those with a higher pay grade.
Just how much of an obstetrician-centric perspective this is can be discerned from the lack of any reference to such criteria in regard to the newborn. Obviously, requiring midwives to consult or refer to pediatricians was not seen by ACOG as the role of the obstetrical profession. Requiring midwives to refer a baby to a “physician and surgeon trained in obstetrics and gynecology” would make everyone laugh.
However, it useful to understand how obstetrical supervision occurs against a compelling but virtually invisible backdrop that sets the tone for obstetrics-centric policies and standards of practice. In important structural ways this creates a situation for an obstetrician-supervisor similar to the legal role of lawyers. Attorneys in the US also have the duel role of both representing their clients and also being designated as “officers of the court”. They are legally obligated to constrict their behavior to conform with court protocols as that reflect judicial custom and California Bar Association rules. This can represent a conflict of interest between the attorney’s duty to represent the interests of their client, and his own need to protect his interests — that is, the ability to continue practicing his profession.
Like attorneys, obstetricians also have a duel role that unless carefully adhered to can create career-threathening tsunami for them. An obstetrician who is out-of-sync with ACOG rules and policies runs the risk that other obstetrician will NOT agree to testify on their behalf in a legal case claiming negligence or incompetence. In medicine, the legal definition of ‘competency’ is defined by the testimony of other physicians who practice the same medical or surgical specialty. What they say will determine whether or not the defendant did or did not follow the ‘usual and customary’ standard of care. If the answer is no, the doctor will most often lose any such med-mal case.
These ‘customary” patterns of obstetrical practice have aggregated over time, and reflect both historical and contempary definitions and other policy and practice-related conclusions by the American College of Obstetricians and Gynecologists as an organization that lobbies for the interests of obstetricians.
In relation to planned home birth, ACOG has proudly and loudly been on the public record since 1974 (also the year the CNM law was passed) as rejecting OOH birth as a location for childbirth services, and defining it an on-going series of official statements that such an activity was substandard, thus a potentially dangerous practice that it formally does not sanction.
Under the obvious impact of ACOG’s policy-setting function as sole arbiter of obstetrical practice as a surgical specialty, the willing participation of any obstetrician in PHB — either directly or indirectly — would be deemed by an ACOG member called to testify in a court of law, to be a ‘substandard and thus a negligent activity. This is the definition of medical malpractice.
That the obstetrical control of mfry by organized medicine keeps CNMs tethered to hospital (i.e. not independent) practice is born out by the extremely small number of nurse midwives (Kate Bowland excepted!) who were ever able or willing to provide OOH services in California during in the 40 years since the Nurse Midwifery Practice Act was passed.
The reason was simple — virtually no obstetrician in California was able or willing to supervise a CNM who provided care in OOH setting. This refusal or inability of obstetricians to provide this technically essentially legal service by obstetricians reflects two realities.
First and foremost is the historical distaste by the obstetrical profession for the discipline of midwifery, which for the last century as been seen as an inferior (even dangerous) service. Likewise, information about the non-medical or physiologically-based (i.e. non-medical) management of normal childbirth in a healthy childbearing population has been absent from the medical school curriculum in the US for at least the last 100 years.
Historically and in contemporary times, the majority of obstetricians have, as amply documented by their own published statements, believed that mfry licensing laws were unnecessary — that is, that the services of midwives were unnecessary. Further more they see all mfry licensing laws as ill-conceived — a dangerous step backward. Equally egregious, they experience midwifery as displacing their services, thus seeing midwives thru the lens of an economic competitor.
The second (and absolute) barrier to obstetrical supervision of midwives desiring to provide care in OOH settings are the prohibitive policies of the med-mal carriers. They do not permit insured physicians to supervise OOH midwives unless the doctor arranges for an expensive rider or ‘surcharge’ to their regular policy. This immediately and drastically increases the cost of the obstetrician’s liability insurance premium.
In addition, it is widely believed by obstetricians that if they associated professionally with OOH midwives, they risk losing their liability coverage. Since hospitals require doctors to carry med-mal coverage to quality for admitting privileges, lack of med-mal insurance would instantly put the obstetrician out of the birth business.
Judge Cologne, J.D., an attorney, former CMA lobbyist and in 1994 was employed as chief lobbyist for CAPPI, made statements recorded during a 1994 MBC’s Implementation Committee meetings are highly revealing in this regard. Those present included myself, and approximately 20 other midwives (Maggie, Maria, Tonya Brooks, etc), several MBC employees, physician Board member Thomas Joas (an anesthesiologist appointed to chair the committee), the MBC’s legal counsel Anita Scuri, Joan Hall, lobbyist for the CMA and several consumers, including Tonya Brooks daughter and Todd Gastaldo, DC.
Judge Cologne began by noting that he had at one time been employed by the anti-trust division of the US Justice Department. As a result, he it was part of his job as a medical lobbyist to use his expertise in antitrust-related matters to advise and craft policies for his current and former employers (CMA and CAPPLI’s member med-mal carriers) to help them avoid being charged with violations of antitrust laws.
Judge Cologne assumed that the “lay” midwives present would be unfamiliar with ‘anti-trust’ laws, and so he provided a little tutorial, pointing out that organizations like med-mal carriers (who were regulated by the state) could not lawfully discriminate against a class or category of licensed healthcare providers, such as licensed midwives.
However, they could legally ‘protect’ themselves from behavior by physicians insured by their company that might be increase the likelihood of litigation and thus prove unprofitable to their company. He used the example of med-mal carriers all lawfully instituting policies that prohibit doctors from providing medical services in speciality or subspecialty that the doctor was not either board-certified, or could otherwise demonstrate appropriate formal education, clinical training, and the ability to demonstrate and document their competency in this non-standard type of medical care.
With that as background, he made it clear that med-mal insurance carriers could legally protect themselves against economic loss and that they genuinely believed that planned out-of-hospital childbirth services would inevitably result in lawsuit against the doctors they insured. Under these circumstances, their targeted actions disallowing participation in PHB by insured physician would not (as he defined the issue) violate antitrust laws.
Someone in the assembled group then ask him how this came about. He described being present when the boards of directors of the three California med-carriers (Doctors, Skippy and NorCal, which are all mutual companies owned by physicians, so their directors are also MDs) had discussed the issue of PHB subsequent to the 1993 passage of the LMPA. The consensus of opinion across the board members was that childbirth in any location other than a hospital was “dangerous” and should not be covered by the normal schedule of liability premiums.
Someone else in the group asked what kind of acutrial data was used by the members of these Boards to come to this conclusion, and he said readily said “none”, and quickly went on to explain that board members didn’t need any actuarial data, since the danger of PHB was so “obvious” and well-known.
He then returned to the issue of antitrust, and the proper relationship btw each med-mal carrier and the general category of license midwives practicing under physician supervision in California. While emphasizing again that liability insurers had an obligation not to discriminate, this did NOT mean that they could not increase the premiums they charged these obstetricians in an effort to prevent economic losses by the company.
Based on these opinions, med-mal carriers feared that obstetrician’s involvement in OOH birth (either to directly provide care or supervise another OOH attendant) deviated from the obstetrical standards (i.e., ACOG policies and guidelines) that “the courts” would interpret deviant behavior as malpractice and find an favor of the plaintiff, resulting in a big pay-out by the defending insurance carrier.
(Aside –> note NorCal’s1974 statement prohibiting insured physician from attending PHB)
Someone in the group asked if Judge Cologne knew how much of an increase in premiums this might be. He didn’t but stated it would probably double the cost, maybe more.
Another person asked about whether doctors that supervised midwives might loose their med-mal insurance.
He explained that that med-mal carriers, under the current definition of planned home birth as a dangerous activity prohibited by ACOG, could lawful considered the on-going participation in PHB by an insured obstetrician as reflecting poor judgment on the part of the doctor.
As a result, Judge Cologne opined that any physician qualified to supervised OOH midwives might well find his premiums jacked up to so high as to put him our of business, or have the carrier deny him coverage at the time of renewal.
End of hx material
Faced with the universal unavailability of obstetrical supervisors, the majority of CNMs were not willing to risk their license by being out of compliance with their licensing law.
[Aside#2: When the majority of California hospitals closed their midwifery services in the 1990s, it relegated the majority of CNMs to working as nurse-practitioners in physician offices and clinics.]
ACT TWO: In 1993, organized medicine was still king-of-the-hill when it came to lobbying the California legislation in 1993. They successfully insisted (over Sen Killea’s objections and better judgement) that the CNM law be virtually photo-copied into the LM licensing law. As a result the 1993 LMPA included the same (fatally-flawed) mandated physician supervision as applied to CNMs. This provision was widely considered by consumers, legislators and midwives to be unworkable, since the lack of access to obstetrical supervision was used by the medical profession to keep CNMs from practicing in OOH settings.
The major reason for a direct-entry midwifery “grass-roots” movement was the fatally-flawed nature of the 1974 Nurse-Midwifery Practice Act — specifically, the mandatory physician supervision provision, which made it impossible for CNMs to lawfully provide OOH care. This was the reason that many former nurses (me included) choose not to seek training and licensure as a nurse-midwife.
Since the ‘lay’ practice of midwives was the only other option left, and according to the Bowland Decision, lay midwifery was an illegal practice of medicine, groups of mothers and fathers, L&D nurses, childbirth educators and midwives (both lay and some CNMs) and others supporters of independent mfry began working in 1976 to get the law changed so that lay practice was not considered illegal (decriminalization) or a non-nurse licensing law passed.
Unfortunately, none of the six earlier bills had even gotten out of the Senate B&P committee. SB 350 by Senator Lucy Killea finally overcame that hurtle by agreeing to put the same physician supervision provision in the LMPA. She even got the CMA to state that if she would agree to put supervision into the LMPA, they (the CMA) would see that physician provided the legally-essential supervision. Of course, they could not and did not keep that promise.
Once the CMA removed its objection, the passed quickly. But everyone who worked on the legislation was justifiably discouraged that the new licensing bill contained the same old unworkable provision we had all labored so hard to eliminate. Our victory was a mixed bag.
Pertinent quote from transcript Sept. 1994 ~ speakers are Todd Gastaldo and Senator Killea: Joan Hall (CMA lobbyist) said after that ….. it wasn’t really legislative wisdom that changed it from a consultative relationship to a supervisoiral relationship. She said that it was the CMA, basically.
Senator Lucy Killea: ACOG and the California Medical Association. Yes, that was the only way we could …
Act 2.5 ~ a 20-year holding pattern:
There is little to gain from a blow-by-blow recounting of the ups and downs of physician supervision relative to LM practice during the 20 years following the implementation of the LMPA.
Suffice it it to say that:
(a) LMs, who for the most part only provide care in non-medical setting, were even less successful than CNMs in securing the legally-essentially supervision
(b) Unlike CNMs, the majority of LMs continued to practice even thought they were technically unable to comply with their licensing law.
LMs insisted that the legislative intent of the LMPA was that direct-entry midwifery care be available to childbearing families in California. With their own ears, they’d heard Sen Lucy Killea that the purpose of the LMPA was to “authorize
Pertinent quote from MBC transcript (?Jun 6 or Sept 1994) Senator Lucy Killea explaining why she carried the LMPA: I was trying to give the midwives, who are doing what they do best, despite the fact they don’t have the enabling legislation, I was trying to give them that enabling legislation.
Ca LMs generally believed that the licensing provision of the LMPA were designed to fill a critical need and the presence of licensed midwives as trained practitioners would make childbirth safer for women unable to afford, have access to, or personally unwilling to use hospital-base obstetrical services. Many of these women described their previous experience of laboring in a hospital as traumatizing and often refused to, as they put it: “return to the scene of crime”.
Women with previous bad experiences and strong feelings would instead choose to labor unattended in an OOH setting if denied the services of a trained midwife. Unfortunately, for women who have no risk-screening and prenatal care during pregnancy, an unattended birth, and no access to or uses of medical services in if an emergency arising during or following the birth, the mortality risk for their newborn is 20 to 40 times higher. The facts were simple — the provision of maternity services by LMs saved lives.
In 1999 the MBC brought disciplinary charges against a licensed midwife for practicing without a supervisor, the logical consequence of her inability to secure the cooperation of any obstetrician within a hundred mile radiance of the rural county where she lived and practiced. An obstetrician who testified during the hearing said he wouldn’t consider supervising midwives because he resented the economic competition.
After a five day trial, OAL Judge Roman ruled in favor of the midwife, upholding the right of LMs, after making a “good faith” effort was unable to secure a supervisor, to practice without a supervising physician.
The legal rational was based on the legislative “intent” language of the LMPA. He ruled that the Legislature, in authorizing the practice of direct-entry midwifery, as demonstrated by the bill’s own internal language, that childbearing women in California have access to trained midwives as part of a state-sponsored attempt to lower the infant mortality rate, as well as making cost-effective maternity care available to low-income families and those childbearing families who were seeking ‘alternatives’ to the routine medicalization of normal pregnancy and spontaneous childbirth in healthy women.
If obstetricians as an organized groups, systematically refused to assist Ca LMs in the goal by providing supervision, citing their distaste for OOH midwifery practice (Judge Roman used the word “hostility”) and associated economic barriers created by the med-mal carriers who claimed that physician supervision creates ‘vicarious liability” and is therefore prohibited under their standard contract, then it was lawful for individual LMs to make specific and alternative arrangements for medical services from non-supervisory physicians clients for each of their clients, in the event they required referral or transfer-of-care.
ACT THREE — After 20 years, ACOG finally decided that defining mfry as a medicalized discipline had not worked with LMs as it had with CNM. Furthermore, Judge Roman’s decision made it virtually impossible for ACOG to prevail on MBC to aggressively prosecuting LMs for practicing without physician supervisors, or to go to a Superior Court judge to secure an injunction against the unsupervised practice of midwifery by a licensed midwife.
Then the MBC itself chimed in, by admitting that supervision was obviously a failed strategy that had not worked in the previous two decades, and stating their intention to carry legislation to remove provision this from the LMPA as part of its Sunset Review omnibus legislation.
At this point, ACOG suddenly got busy and found a receptive legislature and developed a new, and from their standpoint, strategy better strategy for limiting the practice of midwifery. It would replace supervision by greatly restricting the LM scope of practice, while simultaneously mandating immediate referral or transfer of care for all ‘pre-existing conditions’ and all “deviations from normal” during pregnancy, intrapartum and postpartum.
Amendments to the LMPA introduced by AB1308 statutorily restricted (superseded) the original legislative authority for LMs. Originally the LMPA allowed LMs to provide care as long as progress met the definition of ‘normal’ and there was no present-tense complication. Under AB 1308, any pre-existing or current risk factor revealed or detected, and any ‘deviation from normal’ — indefinable words whose definition lies primarily in the eye of the beholder — requires the midwife to bail out and refer the client to an obstetrician.
Only if the pregnant woman can find, afford, and then convince a physician trained in obstetrics to make the type of statement required by the new law, will the LM be authorized to resume provide primary care. Basically the mother-to-be has no say in the matter and even if she is Christian Scientist or is otherwise covered by the religious exemptions clause (sec. 2063), she can never again received mfry care unless she is seen by an obstetrician, evaluated and the doctor is willing to declare that the particular situation in question is not likely to affect the labor or birth.
This allowed ACOG under AB 1308 to accomplish the goal that had previously failed, since the idea of physician supervision by individual obstetricians never allowed the obstetrical profession to successfully and uniformly control the actions of all LMs.
Immediately upon discovering or identifying some possible “deviation”, the midwife would have to refer the pregnant, laboring or pushing women to a physician with training in obstetrics and gynecology. Sine the newly written law which decrees referral or transfer of care to a physician trained in obstetrics and gynecology, it is silent about the referral of ‘deviations’ in a newborn.
Given that ‘deviation’ and ‘normal’ are such amorphous terms, the plain reading (or interpretation) of this law would mean the percentage of women who qualify (i.e. a perfect pre-pregnancy health record and no ‘deviations’ of any kind during each and every stage of pregnancy, labor, birth, and postpartum would be very small.
On a practical level, this essentially decrees that only clients with no risk factors at all will ultimately qualify for OOH mfry care by an LM, unless they are able get an obstetrician to authorize mfry care. This however, this is not be feasible during the labor and birth. Once the mother-to-be is transferred to the hospital, there will be no return to the physiologically-based of of her midwife.
Having the client or newly delivered mom experience anything that could possibly be described by even one obstetrician (i.e. the expert witness chosen by the Medical Board) as a ‘deviation will also make the LM the vulnerable to disciplinary action by the Medical Board each and every time there is a transfer of care. Again this is predicated on the fact the any physician who reads the record, and either is not professionally familiar with the practice of midwifery in a non-medical setting, or whose opinion about the issue of “deviation” from normal differs or contradicts that of the midwife, will trigger disciplinary action against that LM.
My take on these issues:
I dismissed (or missed) this as an ACOG strategy designed to hobble us as much as supervision had been intended to do. I believed that our standard of care was intended to remain in place, and we protective of us and our client’s rights of self-determination. Under those circumstances, we would remain as arbiters of referral and transfer of care in cases that did not involve breeches, twins, premature and post mature babies, or women with significant or substantive pre-existing medical conditions (i.e., X for breeches and twins, pretty much as before).
Personally, i trusted Shannon and Lorri (actually still do), but now believe they were only authorized to be a spokesperson for ACOG’s set-in-cement deal — take it or leave it — which mean absolutely NO modifying words to ideas such as “condition” and ‘deviation”.
They could not use their discretion (fueled by long-time empathy for midwives and the mothers we serve and I believe, a good heart) to subtly, judiciously, tweak the language so that determination of medical transfer remained within the realm of the LM’s clinical judgement (also being informed by the mother’s stated wishes and her right of self-determination), instead of an absolute black letter law that boxes us in before the fact, and second-guesses us after the fact. As was true of the lay practice of midwifery, this circumstance makes each LM just one hospital transfer and/or complaint by anyone (CMQCC, etc) away from being prosecuted.
If our current standard of care was repealed, or otherwise render moot, I, as stated before, believe that we have lost very important ground.
Equally important, we have utterly failed to gain the ground that makes mfry a truly independent profession — reasonable input and control over our own licensing laws, at a level that at least pretends to match the one enjoyed by other self-determining professionals.
As i mentioned earlier, I am looking forward to the day that our laws requires any physician legally involved in determining compliance “the” standard of care relative to midwifery (either practice or transfers of care issues, or determining whether a disciplinary case should be filed or if interrogating a LM or testifying about care provided by an LM, should identify that person as a:
“California licensed physician and surgeon with training and experience in midwifery”