Senate Analysis of AB 1308 as posted on August 13, 2013

by faithgibson on August 15, 2013

in AB1308, new regs & new legislative efforts, Physician Supervision Issues

What Ca LMs needs to know b4 reading:

First, this is the SAME language as before.

The changes expected to remove physician supervision as a prerequisite of practice can’t be made when the bill goes back to the Assembly for (yet) another hearing.

Second, this Senate analysis provides a number of interesting things, including “the facts” of physician supervision — that it isn’t available, and that EVERYBODY who is anybody, including the Legislature of California,  knows that it doesn’t work.

This is an officially-published public document that could be used in a court of law to established these same “facts” in relation to the current and fatally-flawed provision in the LMPA for physician supervision.

Third, the ‘source’ of its information is identified as ACOG. And onterestingly enough, it contains the exact same objectionable characterization that was used by the MBC in its assessment of the ‘supervision issues’ in the 300+ page Sunset Review document.

Last but not least, this Senate analysis give you the names of everyone who voted, and whether they voted for or against the bill.

The is very useful information that can be used in many helpful ways.

So enjoy 🙂

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SENATE RULES COMMITTEE | AB 1308|
Office of Senate Floor Analyses
1020 N Street, Suite 524
(916) 651-1520 Fax: (916) 327-4478
~~~~~~~~~~~~~~~~~~~~~~~~~~
THIRD READING

Bill No: AB 1308
Author: Bonilla (D)
Amended: 7/9/13 in Senate
Vote: 21

SENATE BUSINESS, PROF. & ECON. DEV. COMMITTEE : 10-0, 7/1/13
AYES: Lieu, Emmerson, Block, Corbett, Galgiani, Hernandez,
Hill, Padilla, Wyland, Yee

SENATE APPROPRIATIONS COMMITTEE : Senate Rule 28.8

ASSEMBLY FLOOR : 72-0, 5/16/13 – See last page for vote
SUBJECT : Midwifery

SOURCE : American Congress of Obstetricians and
Gynecologists, District IX, California
DIGEST : This bill authorizes a licensed midwife to directly
obtain supplies, devices, obtain and administer drugs and
diagnostic tests, order testing and receive reports that are
necessary to his/her practice of midwifery; deletes the
requirement that the Medical Board of California (MBC) adopt
regulations defining the standard of care and level of
supervision required for the practice of midwifery; requires a
midwife to disclose his/her arrangements for the referral of
complications to a physician for consultation; and authorizes a
licensed midwife to be present at a licensed alternative birth
center.

Existing law:

1. Licenses and regulates some 300 licensed midwives under the
Licensed Midwifery Practice Act of 1993, by the MBC.

2. Creates the Midwifery Advisory Council (MAC) which is
required to make recommendations on matters specified by MBC.
3. Defines the practice of midwifery as the furthering or
undertaking by any licensed midwife, under the supervision of
a licensed physician who has current practice or training in
obstetrics, to assist a woman in childbirth so long as
progress meets criteria accepted as normal.

4. Requires the MBC to adopt regulations defining the
appropriate standard of care and level of supervision
required for the practice of midwifery by July 1, 2003.

5. Permits a licensed midwife to attend cases of normal
childbirth and to provide prenatal, intrapartum and
postpartum care, including family-planning, care for the
mother and immediate care for the newborn under the
supervision of a licensed physician and surgeon.

6. Requires a licensed midwife to disclose orally and in
writing: (a) the scope of a midwife’s practice, as
specified; (b) whether the licensed midwife has liability
coverage; (c) the specific arrangements for the transfer of
care during the prenatal period, hospital transfer during the
intrapartum and postpartum periods and access to appropriate
emergency medical services for mother and baby, if necessary;
and (d) the procedure for reporting complaints to the MBC.

7. Requires a licensed alternative birth center, and a licensed
primary care clinic that provides services as an alternative
birth center, to meet specified requirements, including (a)
meeting the standards for certification established by the
National Association of Childbearing Centers, and (b)
requiring the presence of at least two attendants during
birth, one of whom shall be either a physician and surgeon or
a certified nurse-midwife.
This bill:

1. Authorizes a midwife to directly obtain supplies and
devices, obtain and administer drugs and diagnostic tests,
order testing and receive reports that are necessary to
his/her practice of midwifery and consistent with his/her
scope of practice.

2. Deletes the requirement specifying that the MBC adopt
regulations defining the appropriate standard of care and
level of supervision required for the practice of midwifery.

3. Expands the existing oral and written disclosures required
of a licensed midwife to a prospective client to include the
specific arrangements for the referral of complications to a
physician and surgeon for consultation, and specifies that
the licensed midwife shall not be required to identify a
specific physician and surgeon.

4. Authorizes a licensed midwife, in addition to a physician
and surgeon or a certified nurse-midwife, to be present at a
licensed alternative birth center.

5. Makes a correcting change to refer to the American
Association of Birth Centers rather than the National
Association of Childbearing Centers.

6. Makes legislative findings and declarations relating to
midwifery and licensed midwives.

Background

Midwifery program . A licensed midwife is an individual who has
been issued a license to practice midwifery by the MBC. As
provided under the law, the practice of midwifery authorizes the
licensee, under the supervision of a licensed physician in
active practice, to attend cases of normal childbirth in a home,
birthing clinic or hospital environment. Pathways to midwife
licensure include completion of a three-year postsecondary
education program in an accredited school approved by the MBC,
or through a Challenge Mechanism. Prior to licensure, all
midwives must take and pass the North American Registry of
Midwives examination.

SB 1638 (Figueroa, Chapter 536, Statutes of 2006) required the
MBC to create and appoint a Midwifery Advisory Council. The MAC
is made up of licensed midwives (at least half of the MAC must
be licensed midwives), a board member, a physician and a member
of the public (currently an individual who has used a licensed
midwife). The MBC specifies issues for the MAC to
discuss/resolve and the MAC also identifies issues and obtains
approval from the MBC to develop solutions to the various
matters. Some items that have been discussed include physician
supervision, challenge mechanisms, required reporting and
student midwives. SB 1638 also required licensed midwives to
make annual reports to Office of Statewide Health Planning and
Development (OSHPD) on specified information regarding birth
outcomes, and required the reported data to be consolidated by
OSHPD and reported back to the MBC for inclusion in the MBC’s
annual report.

The MBC approves midwifery schools by conducting a comprehensive
assessment to evaluate the school’s educational program
curriculum and the program’s academic and clinical preparation
equivalent. Schools wishing to obtain approval must submit
supporting documentation to verify that they meet the
requirements of Business and Professions Code (BPC) Section
2512.5. Currently, there are 11 approved midwifery schools. A
licensed midwife must 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.

The licensee population in the midwifery program is small and
the number of disciplinary actions filed against licensees is
also proportionally small with a total of five disciplinary
actions being filed over the past three fiscal years. Of the
four disciplinary actions that have been adjudicated, all have
been resolved with either revocation or license surrender.

Physician supervision . BPC Section 2507 authorizes a licensed
midwife, under the supervision of a licensed physician and
surgeon who has current practice or training in obstetrics, to
attend cases of normal childbirth and to provide prenatal,
intrapartum and postpartum care, including family-planning care
for the mother and immediate care for the newborn.

BPC Section 2507(f) requires the MBC, by July 1, 2003, to adopt
regulations defining the appropriate standard of care and level
of supervision required for the practice of midwifery. Due to
the inability to reach consensus on the supervision issue, the
MBC bifurcated this requirement and in 2006 adopted Standards of
Care for Midwifery. Three previous attempts to resolve the
physician supervision issue via legislation and/or regulation
have been unsuccessful due to the widely divergent opinions of
interested parties and their inability to reach consensus.

Although required by law, physician supervision is essentially
unavailable to licensed midwives performing home births, as
California physicians are generally prohibited by their
malpractice insurance companies from providing supervision of
licensed midwives who perform home births.

According to insurance providers, if physicians supervise or
participate in a home birth they will lose their insurance
coverage resulting in loss of hospital privileges. The
physician supervision requirement creates numerous barriers to
care in that, if the licensed midwife needs to transfer a
patient/baby to the hospital, many hospitals will not accept a
patient transfer from a licensed midwife as the primary provider
who does not have a supervising physician. California, along
with Arkansas and Louisiana, are currently the only states that
require physician supervision of licensed midwives. Among
states that regulate midwives, most require some sort of
collaboration between the midwife and a physician.

The MBC, through the MAC, has held many meetings regarding
physician supervision of licensed midwives and has attempted to
create regulations to address this issue. The concepts of
collaboration such as required consultation, referral, transfer
of care and physician liability have been discussed among the
interested parties with little success. There is disagreement
over the appropriate level of physician supervision with
licensed midwives expressing concern with any limits being
placed on their ability to practice independently. The
physician and liability insurance communities have concerns over
the safety of midwife-assisted homebirths. Specifically, they
are concerned with delays and/or the perceived reluctance of
midwives to refer patients when the situation warrants referral
or transfer of care. The MBC has stated that it ultimately
believes that the physician supervision requirement needs to be
addressed through the legislative process.

In the MBC oversight hearing earlier this year, it was
recommended that the MBC should reach a consensus with
stakeholders on this issue and then submit a specific
legislative proposal to the Senate Business, Professions and
Economic Development Committee regarding the appropriate level
of supervision required for the practice of midwifery.

Diagnostic lab accounts . This bill echoes an issue raised by
the MBC in its Sunset Report. Licensed midwives have difficulty
securing diagnostic lab accounts, even though they are legally
allowed to have lab accounts. Many labs require proof of
physician supervision. In addition, licensed midwives are not
able to obtain the medical supplies they have been trained and
are expected to use including: oxygen, necessary medications
and medical supplies that are included in approved licensed
midwifery school curriculum. The inability for a licensed
midwife to order lab tests often means the patient will not
obtain the necessary tests to help the midwife monitor the
patient during pregnancy. In addition, not being able to obtain
the necessary medical supplies for the practice of midwifery
adds additional risk to the licensed midwife’s patient and
child.

The MBC, through the MAC, held meetings regarding the lab order
and medical supplies/medication issues and has attempted to
create regulatory language to address this issue. However,
based upon discussions with interested parties, it appears the
lab order and medical supplies/medication issues will need to be
addressed through the legislative process.

FISCAL EFFECT : Appropriation: No Fiscal Com.: Yes
Local: Yes

SUPPORT : (Verified 8/13/13)

American Congress of Obstetricians and Gynecologists, District
IX, California (source)
California Association of Midwives
California Families for Access to Midwives

ARGUMENTS IN SUPPORT : According to the author, “The
California Medical Board is responsible for the oversight of
licensed midwives in California. Licensed midwives deliver
children in a patient’s home or at a birthing center. The
Medical Board is under sunset review this year and has
recommended legislative action on several issues that it has
been unable to resolve in past discussions. AB 1308 seeks to
remove barriers to midwifery while protecting patients. One
such barrier is access to supplies and tests. Currently,
midwives have the authority to obtain supplies in their scope of
practice. Unfortunately, many times they encounter problems in
the field when a supplier or laboratory requires an ordering
physician to be listed. Because midwives do not always have an
ordering physician, it can be difficult for them to obtain
supplies, order tests, or receive reports. Ready access to
these supplies and tests is vital to the safe practice of
midwifery. Another barrier is the ability to work in licensed
alternative birth centers. Licensed midwives are the
out-of-hospital birth experts and it is consistent with this
expertise to authorize them to work in such a setting.”

ASSEMBLY FLOOR : 72-0, 5/16/13

AYES: Achadjian, Alejo, Ammiano, Atkins, Bigelow, Bloom,
Blumenfield, Bocanegra, Bonilla, Bonta, Bradford, Brown,
Buchanan, Ian Calderon, Campos, Chau, Chávez, Chesbro, Conway,
Cooley, Dahle, Daly, Dickinson, Donnelly, Eggman, Fong, Fox,
Frazier, Garcia, Gatto, Gomez, Gordon, Gorell, Gray, Hagman,
Hall, Harkey, Roger Hernández, Jones, Jones-Sawyer, Levine,
Linder, Logue, Lowenthal, Maienschein, Mansoor, Medina,
Mitchell, Mullin, Muratsuchi, Nazarian, Nestande, Olsen, Pan,
Patterson, Perea, V. Manuel Pérez, Quirk, Quirk-Silva, Rendon,
Salas, Skinner, Ting, Torres, Wagner, Waldron, Weber,
Wieckowski, Wilk, Williams, Yamada, John A. Pérez

NO VOTE RECORDED: Allen, Beth Gaines, Grove, Holden, Melendez,
Morrell, Stone, Vacancy

          MW:k  8/13/13   Senate Floor Analyses 

                           SUPPORT/OPPOSITION:  SEE ABOVE

                                   ****  END  ****

 

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