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Legislation Will Expand Pregnancy Care Options for Medi-Cal Patients; Increase Access To Midwifery in Areas With Limited Providers
In an effort to expand health care options for pregnant women in California, two new bills were introduced today. The first, SB407, will expand pregnancy care options for families on Medi-Cal by including licensed midwife services under a component of the program. The bill is authored by Senator Mike Morrell, R-Rancho Cucamonga, co-authored by Senator Lois Wolk, D-Davis, and sponsored by the California Association of Midwives.
A second bill, SB408, will expand midwifery care – particularly in rural and other underserved areas – by allowing ‘midwife assistants’ to legally assist licensed midwives at births. Typically, two providers attend each birth, but licensed midwives are scarce in some areas of the state. This bill would allow a specially trained ‘midwife assistant’ to legally assist a licensed midwife, expanding the reach of existing providers. The bill is authored by Senator Mike Morrell, R-Rancho Cucamonga and sponsored by the Medical Board of California.
Get the full update here.
October 26, 2014: Interview with Sarah Davis, CAM Legislative Chair
Rosanna: Sarah, what happened at the medical board meeting this week that is news for California Midwives?
Sarah: The Medical Board meeting took place on Thursday and Friday, and was attended by myself and several other licensed midwives, and a student midwife. As usual, most of the agenda did not pertain directly to the midwifery program, as the Medical Board licenses physicians and since there are far more physicians than midwives, there are more committees, proposals, enforcement actions, etc relating to physicians than midwives.
Carrie Sparrevohn, chair of the Midwifery Advisory Council, which operates under the Medical Board, gave her report. She did not have any action items to present to the full Medical Board at this meeting.
Here is a link to her report, as submitted for materials for the meeting:
Medical Board legislative director Jennifer Simoes presented a proposal regarding midwife assistants. The proposal is a change to the law that would require a bill in the legislature. CAM supports this proposal, and in fact we worked on the language several years back, which was tweaked by Carrie and the Medical Board staff earlier this year.
When we are discussing midwife assistants for purposes of this proposal, we aren't discussing a person who only cleans up, carries equipment, etc. We are discussing a midwife assistant who performs some basic technical and clinical tasks.
Current law only allows two categories of people to assist an LM:
1. another midwife with her/his own California license (LM or CNM)
2. a student midwife who is enrolled in a Medical Board approved midwifery school and is directly supervised by the LM at all times.
This proposal will allow people who do not fall into either of those categories to become a midwife assistant by obtaining and documenting training. This will be beneficial to many midwives, particularly those in more rural areas, and areas with few midwives.
The Medical Board approved this proposal with no questions or concerns. The next step is for Medical Board staff to take the proposal to the legislature. So, this definitely isn't happening overnight, but it the wheels are turning.
Rosanna: Is it possible to see the language for the proposed midwife assistant legislation?
Yes! It is available as a publicly viewable document on the Medical Board's website, in the materials for the August Midwifery Advisory Council meeting.
Rosanna: There was some discussion on Facebook about this the last couple of days. What were some of the questions and discussion there?
We received some great questions and comment on Facebook. It came to my attention that many people aren't aware that there are currently only the two categories of assistants I mentioned above. Because they weren't aware of that situation, it seemed like further defining midwife assistants would create barriers to people becoming midwife assistants. Actually, because existing law is restrictive on who can currently assist, a change in law like this proposal will actually increase the pool of people who can be midwife assistants.
Another great question that came up is whether an expensive certification program will be required, as well as registration or licensing for the midwife assistant. The answer to all these questions is no. The Medical Board would have to further define the training required, but the intention (and the medical assistant model) is to allow the assistant to be trained by an individual licensed midwife or in a course or workshop.
Thanks to our engaged Facebook audience for these questions!
I also want to thank Karen Ehrlich for attending almost every Medical Board meeting over the last few years, and reporting back to CAM. We appreciate it!
Rosanna: Sarah, thanks for keeping us all informed, up to date and representing the interests of California Licensed Midwives and Families
Other news: please join us on CALMidwives@yahoogroups.com, a yahoo group for CAM member midwives and students. Send an email to Rosanna at email@example.com to join the group.
The regulation process, related to AB1308, moved forward this week with an expected Interested Parties Meeting in Sacramento at the Medical Board of California.
CAM was represented at the meeting by Constance Rock LM, Sarah Davis LM, Rosanna Davis LM, Rebekah LakeLM , Madeleine Shernock SM, Diana Vallarta LM and Lora Hart SM.
Members of the Midwifery Advisory Council, Faith Gibson (of CCM), individual midwives, consumer group representatives, ACOG representatives and MBC staff were among the attendees.
Madeleine Shernock, student midwife and CAM Region 5 Co-rep attended the meeting and gave her own account: read about it here.
Sarah Davis and Constance Rock, legislative representatives for CAM gave an overview of the meeting, on a conference call, Sunday October 19. Listen to the recording here. Listen to the call here.
The medical board reports it will publish an audio recording of the meeting within a couple of weeks.
The next interested parties meeting is expected to be in December. Check the medical board website for the most up to date information for meetings and recordings. Medical Board of California, scroll page to find previous events.
Also, recordings are being up-loaded to You Tube at Rosanna Davis' Channel.
Midwifery Law in California as of January 1, 2014
As of January 1, 2014, with the passage of California Assembly Bill No. 1308, the responsibilities and rights of Licensed Midwives in California were amended. While midwives in California have been able to obtain licensure through the Medical Board of California since 1995, the Licensing Law also required Licensed Midwives to obtain physician supervision. Supervision by a physician was untenable and created an obstacle to practicing midwifery legally as well as to accepting state-sponsored health insurance, or Medi-Cal.
With the implementation of AB1308, Licensed Midwives in California are no longer required to obtain physician supervision. Additionally, the law clarified that Licensed Midwives could “directly obtain supplies and devices, obtain and administer drugs and diagnostic tests, order testing, and receive reports that are necessary to the practice of midwifery and consistent with his or her scope of practice.” Finally, the law clarified Licensed Midwives’ Scope of Practice to define Normal pregnancy and childbirth as meeting all of the following conditions:
1. There is an absence of any preexisting maternal disease or condition likely to affect the pregnancy.
2. There is an absence of significant disease arising from the pregnancy.
3. There is a singleton fetus.
4. There is a cephalic presentation.
5. The gestational age of the fetus is greater than 37 0⁄7 weeks and less than 42 0⁄7 completed weeks of pregnancy.
6. Labor is spontaneous or induced in an outpatient setting.
Currently, Licensed Midwives are held by the Medical Board to the STANDARD OF CARE FOR CALIFORNIA LICENSED MIDWIVES. The editing of these standards of care is currently taking place, as of this writing, to adhere to the changes in statute created by AB1308. For up-to-date information about Licensed Midwives’ Requirements for Licensure and the Scope of Practice for a Licensed Midwife, visit: http://www.mbc.ca.gov/Licensees/Midwives/Midwives_Practice_Act.aspx
Kayti Buehler, LM, CPM
Thursday, October 10, 2013
San Francisco, CA -- During the 2013 California legislative session, attorneys in our San Francisco Office represented the California Association of Midwives (CAM) in an effort to remove ambiguities in the laws governing the scope of practice for licensed (direct-entry) midwives and lay the foundation for expanding care to underserved communities and individuals.
Prior to the changes made as a result of the firm’s lobbying efforts, state law imposed, or effectively erected, structural and financial barriers that significantly and unnecessarily restricted access to professional midwifery care in California. In particular, Business & Professions Code section 2507 required that licensed midwives practice “under the supervision of a licensed physician and surgeon.” Due to insurance limitations and other liability concerns, the required supervision was rarely available.
With the qualified support of the California Medical Board, licensed midwives successfully cared for women and babies during pregnancy, birth, and postpartum, and attended births in freestanding birth centers and in homes by relying on a variety of legal theories for working around the infeasible and outdated supervision requirement. The mere existence of the requirement, however, constrained the delivery of licensed midwife services in other contexts and thereby imposed unnecessary restraints. Numerous legislative efforts over the course of two decades had, unsuccessfully, attempted to eliminate this unworkable provision.
With the support of the bill’s author, Assemblywoman Susan Bonilla, CAM’s relentless activism, and sound legal advocacy and lobbying services provided pro bono by Paul Hastings, physician supervision was finally removed from the laws governing licensed midwives when Governor Jerry Brown signed AB 1308 into law on October 9, 2013. Although more work must be done to adapt programs, such as the state’s Medi-Cal reimbursement plan, to the changes effectuated by the bill, the most significant obstacle to making safe and economic maternity care by midwives more widely available has been removed.
The Paul Hastings team was led by partner Robert Hoffman, with assistance from senior associate Jill Yung.
September 23rd 2013
Below is a statement from CAM’s legal council at Paul Hastings Law Firm regarding misconceptions about AB 1308:
As explained by the California Medical Board (“Board”) in its 2012 Sunset Review Report, the laws governing licensure of midwives in California historically contained an unworkable requirement that licensed midwives practice under the supervision of a licensed physician and surgeon. Although mandated by law, supervision was “essentially unavailable to licensed midwives performing home births, as California physicians [were and] are generally prohibited by their malpractice insurance companies from providing [such] supervision.” The Board, through its Midwifery Advisory Council, tried repeatedly over the years to establish a more functional relationship between midwives and physicians, but was unable to resolve disagreements between licensed midwives, who “express[ed] concern with any limits being placed on their ability to practice independently,” and physicians and liability insurers, who expressed safety concerns based on a “perceived reluctance of midwives to refer patients when the situation warrants referral or transfer of care.” (See http://www.mbc.ca.gov/publications/sunset_report_2012.pdf.) Prior legislative efforts similarly failed to resolve this apparent impasse.
Backed by numerous studies demonstrating the general safety and costs savings associated with home births, the midwives successfully resolved the long-standing resistance to change in 2013. Specifically, the California Association of Midwives successfully lobbied for the passage of Assembly Bill 1308, which removes the physician supervision requirement from the law.
The bill also clarifies and highlights certain safety measures that were part of the “Standards of Care for California Licensed Midwives” (Sept. 15, 2005) (“SCCLM”) and incorporated into law by the Board’s regulations (see Cal. Code of Regs. tit. 16, 1379.19; http://www.mbc.ca.gov/allied/midwives_standards.pdf). The incorporation of these standards into statute has given some observers the impression that the law will significantly restrict the practice of licensed midwifery in California. This is not, however, the intent or effect of the Bill.
AB 1308 incorporates into statute for the first time a definition of “normal pregnancy and childbirth.” Specifically, a licensed midwife is only allowed to operate independently when “there is a singleton fetus,” “ there is a cephalic presentation,” “the gestational age of the fetus is greater than 37 0⁄7 weeks and less than 42 0⁄7 completed weeks of pregnancy,” and “labor is spontaneous or induced in an outpatient setting.” (Compare SCCLM at pp. 9-10 (requiring physician consultation when, among other things, labor is premature, membranes rupture prematurely, the fetal “lie is other than vertex at term,” or there is a “multiple gestation”).) In addition, where there is “any preexisting maternal disease or condition likely to affect the pregnancy” or “significant disease arising from the pregnancy,” a licensed midwife must ensure that her client consults with a physician and secures approval for an out-of-hospital birth.” The law tasks the Board with responsibility for identifying diseases and conditions that trigger the consultation requirement in subsequent regulations.
Given that the SCCLM incorporated into the Board’s prior regulations already identified several medical conditions that are not compatible with out-of-hospital birth, and recognizing that the Board has never suggested that more stringent standards are necessary, it is not expected that the Board will use its regulatory license to restrict the practice of licensed midwives. Indeed, such actions would violate the spirit of AB 1308, which was intended to remove barriers to care by midwives and make care more widely available. (See http://www.mbc.ca.gov/publications/sunset_report_responses.pdf.)
Some detractors of AB 1308 have suggested that the Board will craft the definition of “preexisting maternal disease or condition likely to affect the pregnancy” or “significant disease arising from the pregnancy” to apply to clients attempting vaginal births after cesarean sections (“VBACs”) and impose new physician consultation obligations. For the reasons already stated above, imposing new limitations on the scope of practice of licensed midwifes would not be consistent with the intent of AB 1308. Moreover, notwithstanding the fact that the Standards of Care identify “significant pelvic or uterine abnormalities . . . [including] invasive uterine surgery that may impact on the pregnancy” and “adverse obstetrical history” as abnormal conditions, the Board’s existing regulations expressly recognize that licensed midwives can assist clients with a VBAC. (See Cal. Code of Regs. tit. 16, 1379.19(b) (specifying the required client disclosures and investigatory obligations of a midwife who is considering accepting a VBAC client).) The Board has not previously prohibited VBACs – in fact, the regulations expressly condone them – and nothing in AB 1308 or the underlying Report that supported its adoption suggests that the Board should change its position now.