(1)The Nursing Practice Act provides for the licensure and regulation of registered nurses by the Board of Registered Nursing, which is within the Department of Consumer Affairs. A violation of the act is a crime. Existing law authorizes the board to appoint a committee of qualified physicians and nurses to develop standards for educational requirements, ratios of nurse midwives to supervising physicians, and associated matters.

This bill would delete those provisions and would instead require the board to appoint a committee of physicians and surgeons and nurses to make recommendations to the board on all matters relating to midwifery practice, including, but not limited to, education and appropriate standards of care.

(2)Existing law authorizes the holder of a certificate to practice nurse-midwifery to perform various functions under the supervision of a licensed physician and surgeon, including attending to cases of normal childbirth. Existing law defines the practice of nurse midwifery as the furthering or undertaking by any certified person, under the supervision of a physician and surgeon, to assist a woman in childbirth so long as progress meets criteria accepted as normal.

This bill would delete the requirement that a certified nurse-midwife practice under the supervision of a physician and surgeon and would authorize a certified nurse-midwife to attend to cases of normal pregnancy and childbirth, a term that would be defined by the bill as satisfying specified conditions, including, among others, the absence of preexisting diseases or conditions or significant diseases arising from pregnancy. The bill, however, would authorize a certified nurse-midwife to attend to a case of childbirth if a preexisting disease or condition or significant disease arises if all other conditions are satisfied and the potential midwife client obtains an examination by a physician and surgeon. The bill would prohibit a certified nurse-midwife from providing or continuing to provide care to a woman with a risk factor that will adversely affect the course of pregnancy and childbirth.

(3)Existing law authorizes a certified nurse-midwife to furnish drugs or devices, including controlled substances, in specified circumstances, including if drugs or devices are furnished or ordered incidentally to the provision of care in specified settings, including certain licensed health care facilities, birth centers, and maternity hospitals under physician and surgeon supervision.

This bill would also authorize a certified nurse-midwife to furnish drugs or devices when care is rendered in a home and would authorize the furnishing or ordering of drugs or devices under standardized procedures and protocols rather than under physician and surgeon supervision. The bill would authorize a certified nurse-midwife to procure supplies and devices, obtain and administer diagnostic tests, order laboratory and diagnostic testing, and receive reports, as specified. This bill would make it a misdemeanor for a certified nurse-midwife to refer a person for specified laboratory and diagnostic testing, home infusion therapy, and imaging goods or services if the certified nurse-midwife or his or her immediate family member has a financial interest with the person receiving a referral. By expanding the scope of a crime, the bill would impose a state-mandated local program.

(4)Existing law authorizes a certified nurse-midwife to perform and repair episiotomies and repair lacerations of the perineum in specified health care facilities only if specified conditions are met, including that the certified nurse-midwifes supervising physician and surgeon is credentialed to perform obstetrical care at the facility.

This bill would delete those conditions. The bill would require a certified nurse-midwife to establish procedures that relate to the performance and repair of the perineum that, among other things, ensures that all complications are referred to a physician and surgeon immediately.

(5)This bill would require a certified nurse-midwife who is not under the supervision of a physician and surgeon to provide a an oral and written disclosure to a client and obtain a clients written consent, as specified. The bill would provide that a violation of those provisions is not a crime. The

The bill would require each certified nurse-midwife who assists in or supervises in assisting in childbirth that occurs outside of a hospital to annually report specified information to the Office of Statewide Health Planning and Development, would require the office to annually report the information to the board, and would require the board to include the information in the boards annual report to the Legislature. The bill would provide that a violation of those provisions is not a crime.

(6)Existing law, the Naturopathic Doctors Act, provides for the licensure and regulation of naturopathic doctors by the Naturopathic Medicine Committee in the Osteopathic Medical Board of California. The act authorizes a naturopathic doctor to perform naturopathic childbirth attendance subject to specified requirements and conditions.

This bill would authorize a naturopathic doctor certified for the specialty practice of childbirth attendance to perform and repair episiotomies and lacerations of the perineum in certain health care facilities if specified conditions are met.

(8)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

(1)The Nursing Practice Act provides for the licensure and regulation of registered nurses by the Board of Registered Nursing, which is within the Department of Consumer Affairs, and requires the board to issue a certificate to practice nurse-midwifery to a licensee who meets specified qualifications. That act authorizes a certified nurse-midwife, under the supervision of a licensed physician and surgeon, 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, and provides that the practice of nurse-midwifery constitutes the furthering or undertaking by a certified person, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal. The act prohibits supervision from being construed to require the physical presence of the supervising physician. The act requires all complications to be referred to a physician immediately. A violation of the act is a crime.

This bill would instead authorize a nurse-midwife to practice in a variety of settings without supervision by a physician and surgeon subject to certain situations requiring consultation or comanagement with, or referral or transfer to, a physician and surgeon. The bill would also require all emergencies to be referred to a physician and surgeon immediately. By imposing new requirements, the violation of which would be a crime, this bill would impose a state-mandated local program. Affairs. A violation of the act is a crime. Existing law authorizes the board to appoint a committee of qualified physicians and nurses to develop standards for educational requirements, ratios of nurse midwives to supervising physicians, and associated matters.

(7)The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

The Nursing Practice Act provides for the licensure and regulation of registered nurses by the Board of Registered Nursing, which is within the Department of Consumer Affairs, and requires the board to issue a certificate to practice nurse-midwifery to a licensee who meets specified qualifications. That act authorizes a certified nurse-midwife, under the supervision of a licensed physician and surgeon, 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, and provides that the practice of nurse-midwifery constitutes the furthering or undertaking by a certified person, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal. The act prohibits supervision from being construed to require the physical presence of the supervising physician. The act requires all complications to be referred to a physician immediately. A violation of the act is a crime.

This bill would instead authorize a nurse-midwife to practice in a variety of settings without supervision by a physician and surgeon subject to certain situations requiring consultation or comanagement with, or referral or transfer to, a physician and surgeon. The bill would also require all emergencies to be referred to a physician and surgeon immediately. By imposing new requirements, the violation of which would be a crime, this bill would impose a state-mandated local program.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

ASSEMBLY THIRD READING

ATR Bill Id:AB 2682

Author:(Burke)

As Amended Ver:

Majority vote

SUMMARY: Authorizes a certified nurse-midwife (CNM) to attend cases of normal pregnancy and childbirth without the supervision of a physician and surgeon, requires the Board of Registered Nursing (BRN) to establish a nurse-midwifery practice committee, and makes conforming changes to child birth attendance requirements for naturopathic doctors. Specifically, this bill:

1. Adds CNMs to the list of licensees under existing anti-kickback provisions, prohibiting them from referring for services to entities they may have a financial interest in.
2. Requires CNMs to practice under physician and surgeon or an experienced CNM for at least 18 months before practicing without supervision, as specified.
3. Expands and makes mandatory the BRN's currently permissive authority to establish a committee to advise the board on all matters relating to nurse-midwifery practice.
4. Specifies that practice of nurse-midwifery constitutes the furthering or undertaking by any CNM to assist a woman in childbirth so long as progress meets criteria accepted as normal.
5. Defines "normal pregnancy and childbirth" as those that meet the following criteria:
   1. The following conditions exist as the pregnancy progresses:
      1. There is a single fetus.
      2. There is a cephalic presentation (the head of the fetus is in the correct position for birth).
      3. The gestational age of the fetus is greater than 37 weeks and less than 42 weeks of pregnancy at the time of delivery.
      4. Labor is spontaneous or induced in an outpatient setting.
   2. There is an absence of both of the following risk factors:
      1. Preexisting disease or conditions that adversely affect the pregnancy.
      2. Significant disease arising from the pregnancy.
6. Requires a CNM to provide a potential midwife client whose pregnancy progresses under normal conditions but also has a preexisting or new disease or condition that adversely affects the pregnancy with a referral for an examination by a physician and surgeon trained in obstetrics and gynecology before assisting the client. Unless in compliance with this requirement, a CNM may not provide or continue to provide midwifery care to a client with a risk factor that adversely affects the course of pregnancy and childbirth, regardless of whether the client has consented to this care or refused care by a physician or surgeon.
7. Outlines the protocols a CNM must follow if, at any point during pregnancy, childbirth, or postpartum care, a client’s condition deviates from the conditions of normal pregnancy and childbirth as follows:
   1. The CNM must immediately refer or transfer the client to a physician and surgeon and consult and remain in consultation with the physician and surgeon after the referral or transfer throughout the pregnancy.
   2. The CNM may resume care of a client with a disease or condition that adversely affects the pregnancy if a physician and surgeon determines that the client's condition is resolved to the extent that the risk factors will not adversely affect the pregnancy.
   3. If a physician and surgeon determines, after consulting with the attending CNM, that the client’s condition has not been resolved or the client's condition deviates from normal, the CNM may only provide care under the supervision of a physician and surgeon, may only be present during the labor and childbirth if authorized by the client, and may resume postpartum care if appropriate. A CNM not resume primary care of the client until a physician and surgeon determines the client’s condition has been resolved, as specified.
8. Requires, notwithstanding any other law, a CNM to refer to, or transfer care to, a physician and surgeon and document the referral or transfer in the client record in any of the following situations:
   1. The condition is beyond the CNM's scope of practice.
   2. There is evidence that a condition or disease will adversely affect the health or life of the mother or fetus and a physician surgeon has not determined that the client’s condition has been resolved, as specified.
   3. The necessary resources and personnel are not available in the setting of care.
9. Expands a CNM's authority to furnish or order drugs and devices incidentally to the provision of care rendered in a home.
10. Authorizes a CNM to directly procure supplies and devices, obtain and administer diagnostic tests, order laboratory and diagnostic testing, and receive reports that are necessary and within the scope of the CNM's practice.
11. Deletes the restrictions on the settings a CNM may perform and repair episiotomies and repair first-degree and second-degree lacerations of the perineum and makes conforming changes to the relevant requirements relating to protocols and procedures.
12. Requires a CNM who is not under the supervision of a physician or surgeon to disclose in oral and written form to a prospective client as part of a client care plan, and obtain informed consent for, specified information pertaining to the CNM's independent practice, including the lack of supervision by a physician and surgeon, license status and number, practice settings, liability coverage, access to additional information.
13. Requires the disclosure and consent to be signed by both the CNM and the client and that a copy of the disclosure and consent be placed in the client’s medical record.
14. Requires the BRN, in consultation with the Midwifery Advisory Council, to prescribe the form for the written disclosure and informed consent statement required to be used by a CNM.
15. Requires a CNM who assists in, or supervises in assisting, childbirth that occurs in an out-of-hospital setting to annually report to the Office of Statewide Health Planning and Development (OSHPD).
16. Requires the OSHPD report to be submitted no later than March 30, for the prior calendar year, in a form specified by the BRN and specified information relating to the CNM's practice, including data and information related to clients, geography, services, transfers, emergencies, and outcomes, among other epidemiological determinants, and any other information prescribed by the BRN in regulations.
17. Requires OSHPD to maintain the confidentiality of the information, as specified.
18. Requires OSHPD to work with the BRN and the Midwifery Advisory Council to develop methods for reporting and aggregating the data in the report, as specified, for the BRN to submit with its annual report to the Legislature.
19. Requires OSHPD to send to the BRN, by April 30, the CNMs who have met the reporting requirements for that year, requires the BRN to send a written notice of noncompliance to each licensee who fails to meet the reporting requirement and to withhold renewal of a license until the licensee has submit a complete report, prohibits the BRN from taking additional disciplinary action for non-compliance with the reporting requirement, and specifies that violation of the reporting requirement is not a crime.

Authorizes a naturopathic doctor certified for the specialty practice of naturopathic childbirth attendance to perform and repair episiotomies and repair first-degree and second-degree lacerations of the perineum in licensed general acute care hospitals and alternative birth centers, as specified, under the conditions that currently apply to CNMs but are deleted in this bill.

FISCAL EFFECT: According to the Assembly Appropriations Committee:

1. Minor and absorbable one-time costs to the Board of Registered Nursing to develop data reporting standards and modify any regulatory and enforcement protocols (Board of Registered Nursing Fund, Professions and Vocations Fund).
2. Minor and absorbable one-time costs to the Naturopathic Medicine Committee within the Osteopathic Medical Board to modify any regulatory and enforcement protocols (Naturopathic Doctors Fund).

Costs not likely to exceed $100,000 one-time to OSHPD to expand an existing data collection and reporting program to include CNMs, as specified. Ongoing data collection and reporting costs in a similar range (Health Data and Planning Fund).

COMMENTS:

Purpose. This bill is sponsored by the California Nurse-Midwives Association. According to the author, "[this bill] creates a level of parity in the law between Licensed Midwives and CNMs by removing the physician supervision requirements for CNMs, allowing them to practice independently within their scope of practice. Most pregnancies and births are completely normal physiologic events. When permitted to work to the full extent of their education and experience, CNMs can expertly manage more births in California. Untethering CNMs from physician supervision requirements will increase access to health care services for thousands of women in both urban and rural areas."

Background. Midwifery is a health care profession dealing with maternal care. The World Health Organization describes midwifery as the care of a person during pregnancy, labor, and the postpartum/postnatal period, including care of the newborn. Midwifery providers aim to prevent health problems in pregnancy, detect abnormal conditions, seek medical assistance when necessary, and provide emergency services when medical help is unavailable.

Midwifery is similar to the medical specialty of obstetrics, except that midwifery excludes medical services. While pregnancy creates additional physical and emotional stress, under normal conditions it is not itself an illness or ailment requiring medical treatment. Therefore, medical services are not always necessary but providers monitor for when they are.

There are three categories of non-physician licensees that are specifically trained and authorized to provide midwifery services and monitor for abnormal conditions: (1) CNMs, who are licensed registered nurses with an additional advanced practice certificate in nurse-midwifery; (2) licensed midwives, who must complete a three-year postsecondary midwifery education program to become licensed; and (3) licensed naturopathic doctors with an addition specialty certificate in naturopathic childbirth attendance.

Abnormal conditions signal a high-risk pregnancy, increasing the risk of complications requiring medical services to protect the mother or fetus. According to the federal National Institutes of Health (NIH), "high-risk pregnancy refers to anything that puts the mother or fetus at increased risk for poor health during pregnancy or childbirth. A pregnancy is considered high risk if the mother has chronic health conditions such as high blood pressure or diabetes, or if she weighs too much or too little. Any pregnancy where complications are more likely than normal is considered a high-risk pregnancy."

In California, the only licensees that may independently attend all stages of childbirth and any medically necessary services resulting from complications are physicians and surgeons and osteopathic physicians and surgeons who are trained in obstetrics, maternal-fetal medicine (perinatology), or are otherwise trained to do so. Other licensees may provide midwifery services under some form of physician supervision, including physician assistants and nurse practitioners.

Scope. The CNM legal scope of practice starts with the direct and indirect care that is included in the practice of nursing. In addition, CNMs can perform additional medical services if authorized under standardized procedures developed with a physician or within an organized health system. Advanced practice certificates increase the individual competence of a licensee, allowing for a broader range of services and protocols under standardized procedures. CNMs and naturopathic doctors are similar in that they work under standardized procedures or protocols in the childbirth setting.

Licensed midwives are authorized to provide midwifery services and maternal care short of medical services (the presence of abnormal conditions). In all three cases, a licensee must refer to a qualified provider if the condition is beyond the licensee’s individual competence or legal scope of practice under the license.

Education. CNMs are licensed registered nurses with a certificate to practice midwifery from the BRN. In addition to the education needed for licensure as a registered nurse, CNMs complete additional training in the field of obstetrics and are certified by the American Midwifery Certification Board or an equivalent program. Naturopathic doctors similarly meet the default license requirements and obtain a midwifery certificate or its equivalent.

Licensed midwives complete a three-year postsecondary education program in an accredited midwifery school approved by the BRN. Upon completion of educational requirements, including clinical experience evaluation, the candidate also must successfully complete the comprehensive licensing examination administered by the North American Registry of Midwives’ (NARM).

Practice Settings. Licensed Midwives and naturopathic doctors can practice in home, birth centers, and clinics. CNMs can practice in the same settings, but as registered nurses they can also practice in hospital and other medical settings.

Physician Supervision. This bill removes the requirement that a CNM practice under standardized procedures for normal childbirth, which is currently authorized for licensed midwives. Standardized procedures are standard practice for nurses and other healthcare professionals, particularly in health facilities. They must be developed with a physician or within an organized health system, but it can be difficult to establish standardized procedures if in a remote location.

California is one of five states have full supervision requirements (Nebraska, North Carolina, South Carolina, and Florida). Twenty-seven states and the District of Columbia authorize CNMs to practice without physician supervision. Other states have partial supervision requirements that limit the services CNMs can provide and where they can provide them.

Analysis Prepared by: Vincent Chee / B. & P. / (916) 319-3301 FN: 0003157

Date of Hearing: May 23, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 2682

Author:(Burke) – As Amended Ver:May 22, 2018

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY:

This bill modifies the scope of practice and supervision requirements for certified nurse-midwives (CNMs) and naturopathic doctors. Specifically, this bill:

1. Deletes the requirement that CNMs practice under the supervision of a physician and authorizes them to attend to cases of normal pregnancy and childbirth after a 18-month period of supervised practice, as specified.
2. Specifies situations in which a CNM must refer to a physician.
3. Recasts existing law that authorizes Board of Registered Nursing (BRN) to establish a committee to develop standards regarding nurse-midwives, and instead requires the board to appoint a committee to make recommendations to the board on all matters relating to midwifery practice.
4. Authorizes a CNM to furnish drugs or devices when care is rendered in a home, and authorizes the furnishing or ordering of drugs or devices under standardized procedures and protocols, rather than under physician supervision.
5. Authorizes a CNM to procure supplies and devices, obtain and administer diagnostic tests, order laboratory and diagnostic testing, and receive reports, as specified.
6. Adds CNM to existing health care provider financial conflict-of-interest rules related to referrals.
7. Lifts facility-based restrictions on a CNM's ability to perform and repair episiotomies and lacerations of the perineum, and requires a CNM to establish procedures whereby complications or conditions beyond their scope are referred to a physician.
8. Requires a CNM not under physician supervision to provide written disclosure to a client and obtain a client’s written consent to treatment, as specified.
9. Requires a CNM who assists in or supervises in assisting in childbirth that occurs outside of a hospital to annually report specified information to the Office of Statewide Health Planning and Development. Requires the office to annually report the information to the BRN, and requires the BRN to include the information in the board’s annual report to the Legislature.
10. Authorizes a naturopathic doctor certified for the specialty practice of childbirth attendance to perform and repair episiotomies and lacerations of the perineum in certain health care facilities if specified conditions are met.

FISCAL EFFECT:

1. Minor and absorbable one-time costs to the Board of Registered Nursing to develop data reporting standards and modify any regulatory and enforcement protocols (Board of Registered Nursing Fund, Professions and Vocations Fund).
2. Minor and absorbable one-time costs to the Naturopathic Medicine Committee within the Osteopathic Medical Board to modify any regulatory and enforcement protocols (Naturopathic Doctors Fund).
3. Costs not likely to exceed $100,000 one-time to OSHPD to expand an existing data collection and reporting program to include CNMs, as specified. Ongoing data collection and reporting costs in a similar range (Health Data and Planning Fund).

COMMENTS:

1. Purpose. This bill is sponsored by the California Nurse-Midwives Association. According to the author, it creates a level of parity in the law between Licensed Midwives and CNMs by removing the physician supervision requirements for CNMs, allowing them to practice independently within their scope of practice. The author indicates most pregnancies and births are completely normal physiologic events, and when permitted to work to the full extent of their education and experience, CNMs can expertly manage more births in California. Untethering CNMs from physician supervision requirements will increase access to health care services for thousands of women.
2. Background. The World Health Organization describes midwifery as the care of a person during pregnancy, labor, and the postpartum/postnatal period, including care of the newborn. Midwifery providers aim to prevent health problems in pregnancy, detect abnormal conditions, seek medical assistance when necessary, and provide emergency services when medical help is unavailable.

There are three categories of non-physician licensees that are specifically trained and authorized to provide midwifery services and monitor for abnormal conditions: (a) CNMs, who are licensed registered nurses with an additional advanced practice certificate in nurse-midwifery; (b) licensed midwives, who must complete a three-year postsecondary midwifery education program to become licensed; and (c) licensed naturopathic doctors with an addition specialty certificate in naturopathic childbirth attendance.

1. Scope. The CNM legal scope of practice starts with the direct and indirect care that is included in the practice of nursing. In addition, CNMs can perform additional medical services if authorized under standardized procedures developed with a physician or within an organized health system. Advanced practice certificates increase the individual competence of a licensee, allowing for a broader range of services and protocols under standardized procedures. CNMs and naturopathic doctors are similar in that they currently work under standardized procedures or protocols in the childbirth setting.

Licensed midwives are authorized to provide midwifery services and maternal care, but not medical services. In all three cases, a licensee must refer to a qualified provider if the condition is beyond the licensee’s individual competence or legal scope of practice under the license.

This bill is an expansion of the scope of independent practice for CNMs, with strict parameters on referrals to physicians and with physician oversight of drug and device prescribing through standardized procedures and protocols.

1. Recent amendments. According to the author, this bill was amended on May 21, 2018, to reflect the outcome of a negotiated compromise. Current support and opposition has not been verified.
2. Prior and Related Legislation. SB 457 (Bates), of the current session, would have revised the requirements for physicians and surgeons, LMs, and CNMs who attend cases of pregnancy and out-of-hospital childbirth, including specifying risk factors, referral requirements, and settings.

AB 1612 (Burke), of the current session, was similar to this bill and was referred to this committee and not heard. AB 1306 (Burke), of the 2015-16 session, was also similar to this bill and failed passage on the Assembly Floor.

AB 1308 (Bonilla), Chapter 665, Statutes of 2013, removed the requirement that a licensed midwife (LM) practice under supervision of a physician and surgeon for normal pregnancy and childbirth.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing:

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Evan Low, Chair

ABPCA Bill Id:AB 2682

Author:(Burke) – As Introduced Ver:February 15, 2018

SUBJECT: Nurse-midwives.

SUMMARY: Authorizes a certified nurse-midwife (CNM) to attend cases of normal childbirth without the supervision of a physician and surgeon, as specified.

EXISTING LAW:

1. Provides for the licensure and regulation of the practice of nursing by the Board of Registered Nursing (BRN) under the Nursing Practice Act and authorizes the BRN to issue a certificate to practice nurse-midwifery to a person who meets educational standards established by the BRN. (Business and Professions Code (BPC) §§ 2700-2838.4)
2. Declares that it is the intent of the Legislature to recognize the existence of overlapping functions between physicians and registered nurses and to permit additional sharing of functions within organized health care systems that provide for collaboration between physicians and registered nurses. These organized health care systems include, but are not limited to, licensed health facilities, clinics, home health agencies, physicians’ offices, and public or community health services. (BPC § 2725(a))
3. Defines “the practice of nursing” as those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require a substantial amount of scientific knowledge or technical skill, including all of the following:
   1. Direct and indirect patient care services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures. (BPC § 2725(b)(1))
   2. Direct and indirect patient care services, including, but not limited to, the administration of medications and therapeutic agents, necessary to implement a treatment, disease prevention, or rehabilitative regimen ordered by and within the scope of licensure of a physician, dentist, podiatrist, or clinical psychologist, as defined by Section 1316.5 of the Health and Safety Code. (BPC § 2725(b)(2))
   3. The performance of skin tests, immunization techniques, and the withdrawal of human blood from veins and arteries. (BPC § 2725(b)(3))
   4. Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition, and (A) determination of whether the signs, symptoms, reactions, behavior, or general appearance exhibit abnormal characteristics, and (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures. (BPC § 2725(b)(4))
4. Defines “standardized procedures” as either of the following:
   1. Policies and protocols developed by a licensed health facility through collaboration among administrators and health professionals including physicians and nurses. (BPC § 2725(c)(1))
   2. Policies and protocols developed through collaboration among administrators and health professionals, including physicians and nurses, by an organized health care system which is not a licensed health facility, subject to any guidelines for standardized procedures established by the Medical Board of California and the BRN. (BPC § 2725(c)(2))
5. Authorizes the BRN to appoint a committee of qualified physicians and nurses, including, but not limited to, obstetricians and nurse-midwives, to develop the necessary standards relating to educational requirements, ratios of nurse-midwives to supervising physicians, and associated matters. (BPC § 2746.2)
6. Authorizes a CNM, under the supervision of a licensed physician and surgeon, 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 § 2746.5(a))
7. Defines “the practice of nurse-midwifery” as the furthering or undertaking by a certified person, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal, but not the assisting of childbirth by any artificial, forcible, or mechanical means, nor the performance of any version. (BPC § 2746.5(b))
8. Provides that physician “supervision” does not require the physical presence of the supervising physician. (BPC § 2746.5(c))
9. Authorizes a CNM to furnish or order drugs or devices, including Schedule II-V controlled substances, pursuant to physician supervision, standardized procedures and protocols, and other conditions, as specified. (BPC § 2746.51)
10. Authorizes a CNM to perform and repair episiotomies and to repair first-degree and second-degree lacerations of the perineum in a licensed acute care hospital and a licensed alternate birth center if certain requirements are met, including that episiotomies are performed pursuant to protocols developed and approved by the supervising physician and surgeon. (BPC § 2746.52)
11. Establishes the Medical Board of California to regulate the practice of medicine and administer and enforce the Medical Practice Act. (BPC §§ 2000-2525.5)
12. Restricts the practice of medicine, which includes any system or mode of treating the sick or afflicted, or diagnosis, treatment, operation for, or prescription for any ailment, blemish, deformity, disease, disfigurement, disorder, injury, or other physical or mental condition of any person, to specified licensees. (BPC § 2052)
13. Establishes a license to practice midwifery under the Licensed Midwifery Practice Act of 1993, requires the Medical Board of California to administer and enforce the act, and specifies requirements related to referrals, disclosures, and education, among others. (BPC §§ 2505-2523)
14. Requires the Medical Board of California to create and appoint a Midwifery Advisory Council consisting of licensees of the board in good standing, who need not be members of the board, and members of the public who have an interest in midwifery practice, including, but not limited to, home births, as specified, and requires the council to make recommendations on matters specified by the board. (BPC § 2509)
15. Defines “the practice of midwifery” as the furthering or undertaking by any licensed midwife to assist a woman in childbirth as long as progress meets criteria accepted as normal. (BPC § 2507(b))
16. Authorizes a licensed midwife to attend cases of normal pregnancy and childbirth, as defined, and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn. (BPC § 2507(a))
17. Defines normal pregnancy and childbirth as meeting all of the following conditions:
    1. There is an absence of both of the following:
       1. Any preexisting maternal disease or condition likely to affect the pregnancy.
          (BPC § 2507(b)(1)(A)(i))
       2. Significant disease arising from the pregnancy. (BPC § 2507(b)(1)(A)(ii))
    2. There is a singleton fetus. (BPC § 2507(b)(1)(B))
    3. There is a cephalic presentation. (BPC § 2507(b)(1)(C))
    4. The gestational age of the fetus is greater than 370/7 weeks and less than 420/7 completed weeks of pregnancy. (BPC § 2507(b)(1)(D))
    5. Labor is spontaneous or induced in an outpatient setting. (BPC § 2507(b)(1)(E))
18. Establishes the Naturopathic Medicine Committee within the Osteopathic Medical Board to regulate the practice of naturopathic medicine and enforce and administer the Naturopathic Doctors Act. (BPC §§ 2450.3, 3610-3686)
19. Authorizes a naturopathic doctor to attend to childbirth if the naturopathic doctor: (1) is certified in the specialty practice of naturopathic childbirth attendance, as specified; (2) maintains certification in neonatal resuscitation and cardiopulmonary resuscitation; and (3) files with the Naturopathic Medicine Committee a written plan that includes, among other things, supervision by a licensed physician and surgeon who has current practice or training in obstetrics to assist a woman in childbirth so long as progress meets criteria accepted as normal and the plan provides that all complications shall be referred to a physician and surgeon immediately. (BPC §§ 3650-3655)

THIS BILL:

1. Deletes the requirement that a CNM attend or assist in normal childbirth under the supervision of a physician and surgeon.
2. Specifies that "nurse-midwifery care" emphasizes informed consent-shared decisionmaking, preventative care, early detection, and referral of complications. A certified nurse-midwife shall consult with and, if necessary, comanage with, refer to, or transfer care to, a physician and surgeon in any of the following situations:
   1. The condition is beyond the certified nurse-midwife’s scope of practice, based on education and preparation.
   2. There is evidence that a condition or disease likely jeopardizes the health or life of the newborn or mother.
   3. The necessary resources and personnel are not available in the setting of care.
3. Requires the consultations, referrals, and transfers made be documented in the patient record.
4. Requires that all emergencies shall be referred to a physician and surgeon immediately.

FISCAL EFFECT: Unknown. This bill is keyed fiscal by Legislative Counsel.

COMMENTS:

Purpose. This bill is sponsored by the California Nurse-Midwives Association. According to the author, "[this bill] creates a level of parity in the law between Licensed Midwives and CNMs by removing the physician supervision requirements for CNMs, allowing them to practice independently within their scope of practice. Most pregnancies and births are completely normal physiologic events. When permitted to work to the full extent of their education and experience, CNMs can expertly manage more births in California. Untethering CNMs from physician supervision requirements will increase access to health care services for thousands of women in both urban and rural areas."

Background. Midwifery is a health care profession dealing with maternal care. The World Health Organization describes midwifery as the care of a person during pregnancy, labor, and the postpartum/postnatal period, including care of the newborn. Midwifery providers aim to prevent health problems in pregnancy, detect abnormal conditions, seek medical assistance when necessary, and provide emergency services when medical help is unavailable.

As a result, midwifery is similar to the medical specialty of obstetrics, except that midwifery services exclude medical services. While pregnancy creates additional physical and emotional stress, under normal conditions it is not itself an illness or ailment requiring medical treatment. Therefore, medical services are not always necessary. Instead, midwifery providers attending to a childbirth will monitor for abnormal conditions.

There are three categories of non-physician licensees that are specifically trained and authorized to provide midwifery services and monitor for abnormal conditions: (1) CNMs, who are licensed registered nurses with an additional advanced practice certificate in nurse-midwifery; (2) licensed midwives, who must complete a three-year postsecondary midwifery education program to become licensed; and (3) licensed naturopathic doctors with an addition specialty certificate in naturopathic childbirth attendance.

Abnormal conditions signal a high-risk pregnancy that increase the risk of complications requiring medical services to protect the mother or fetus. According to the federal National Institutes of Health (NIH), “high-risk pregnancy refers to anything that puts the mother or fetus at increased risk for poor health during pregnancy or childbirth. A pregnancy is considered high risk if the mother has chronic health conditions such as high blood pressure or diabetes, or if she weighs too much or too little. Any pregnancy where complications are more likely than normal is considered a high-risk pregnancy.”

In California, the only licensees that may independently attend all stages of childbirth and any medically necessary services resulting from complications are physicians and surgeons and osteopathic physicians and surgeons who are trained in obstetrics, maternal-fetal medicine (perinatology), or are otherwise trained to do so. Other licensees may provide midwifery services under some form of physician supervision, including physician assistants and nurse practitioners. While CNMs, licensed midwives, and specified naturopathic doctors practice midwifery, there are differences in their scope of practice, education requirements, practice settings, and supervision requirements.

Scope. The CNM legal scope of practice starts with the direct and indirect care that is included in the practice of nursing. In addition, CNMs can perform additional medical services if authorized under standardized procedures developed with a physician or within an organized health system. Advanced practice certificates increase the individual competence of a licensee, allowing for a broader range of services and protocols under standardized procedures. CNMs and naturopathic doctors are similar in that they work under standardized procedures or protocols in the childbirth setting.

Licensed midwives are authorized to provide midwifery services and maternal care short of medical services (the presence of abnormal conditions). In all three cases, a licensee must refer to a qualified provider if the condition is beyond the licensee’s individual competence or legal scope of practice under the license.

Education. CNMs are licensed registered nurses with a certificate to practice midwifery from the BRN. In addition to the nursing education needed for licensure, CNMs complete additional training in the field of obstetrics and are certified by the American Midwifery Certification Board or an equivalent program. Naturopathic doctors similarly meet the default license requirements and obtain a midwifery certificate or its equivalent.

Licensed midwives complete a three-year postsecondary education program in an accredited midwifery school approved by the board. These schools usually are accredited by the Midwifery Education and Accreditation Council (MEAC), whose accreditation mirrors that of the U.S. Department of Education (DOE) requirements, and satisfies Medical Board of California criteria. Upon completion of educational requirements, including clinical experience evaluation, the candidate also must successfully complete the comprehensive licensing examination administered by the North American Registry of Midwives’ (NARM).

Alternatively, a midwifery student and prospective applicant can use the challenge method, which provides the opportunity to obtain credit by examination for previous midwifery education and clinical experience. This opportunity is provided by one approved “challenge process” program. Maternidad La Luz (MLL), in El Paso, TX, is the only board-approved challenge process mechanism available for California licensure. Those using the challenge method must still pass the NARM.

Practice Settings. Licensed Midwives and naturopathic doctors can practice in home, birth centers, and clinics. CNMs can practice in the same settings, but as registered nurses they can also practice in hospital and other medical settings under standardized procedures.

Physician Supervision. This bill removes the requirement that a CNM practice under standardized procedures for normal childbirth similar to licensed midwives. Because standardized procedures must be developed with a physician or within an organized health system, it can be difficult to establish standardized procedures if in a remote location.

According to the author, although the supervision requirement tethers CNMs to practice only where a physician can supervise, it does not consist of actual oversight of health care delivery, inspection or review of charts, co-signature on prescriptions, direct care of the patient or evaluation of CNM patients at any point during pregnancy or well-woman care.

California is one of five states have full supervision requirements (Nebraska, North Carolina, South Carolina, and Florida). Twenty-seven states and the District of Columbia authorize CNMs to practice without physician supervision. Other states have partial supervision requirements that limit the services CNMs can provide and where they can provide them.

Prior Related Legislation. SB 457 (Bates) of 2017 would have revised the requirements for physicians and surgeons, LMs, and CNMs who attend cases of pregnancy and out-of-hospital childbirth, including specifying risk factors, referral requirements, and settings. NOTE: This bill died pursuant to Joint Rule 56.2 in the Senate Committee on Business and Professions.

AB 1612 (Burke) of 2017 would have authorized a CNM to furnish and order drugs and devices related to care rendered in a home under standardized procedures and protocols; authorized a CNM to directly procure supplies and devices, to obtain and administer drugs and diagnostic tests, to order laboratory and diagnostic testing, and to receive reports that are necessary to his or her practice and consistent with nurse-midwifery education preparation; authorized a CNM to perform and repair episiotomies and to repair first-degree and second degree lacerations of the perineum, in a licensed acute care center, as specified, in a home setting and in a birth center accredited by a national accrediting body approved by the BRN; required a CNM when performing those procedures, to ensure that all complications are referred to a physician and surgeon immediately. NOTE: This bill died pending a hearing in the Assembly Committee on Appropriations.

AB 1306 (Burke) of 2016 would have removed specified physician and surgeon supervision requirements for CNMs, increased educational requirements, modified practice parameters, established a Nurse-Midwifery Advisory Committee within the Board of Registered Nursing (BRN), and subjected CNMs to the ban on the corporate practice of medicine, as specified, among other changes. NOTE: This bill failed passage on the Assembly floor when the Assembly refused to concur in Senate amendments on a vote of 31-21-28.

AB 1308 (Bonilla), Chapter 665, Statutes of 2013 removed the requirement that a licensed midwife (LM) practice under supervision of a physician and surgeon for normal pregnancy and childbirth; required the Medical Board of California to adopt regulations specifying the conditions that trigger a referral requirement; authorized an LM to directly obtain supplies and devices, obtain and administer drugs and diagnostic tests, order testing, and receive reports that are necessary to his or her practice of midwifery; and authorizes a LM to attend cases of normal birth.

SB 1638 (Figueroa), Chapter 536, Statutes of 2006 required the MBC to adopt regulations defining the appropriate standard of care and level of supervision required for the practice of midwifery.

SB 1950 (Figueroa), Chapter 1085, Statutes of 2002, required the MBC to adopt regulations defining the appropriate standard of care and level of supervision required for the practice of midwifery.

SB 1479 (Figueroa), Chapter 303, Statutes of 2000, expanded the disclosures required to be given by LMs and also required midwives to register birth certificates for home births.

SB 350 (Killea), Chapter 1280, Statutes of 1993, enacted the Licensed Midwifery Practice Act of 1993 to provide for the licensing and regulation of non-nurse and non-physician assistant midwives by the MBC.

ARGUMENTS IN SUPPORT:

The California Nurse-Midwives Association (CNMA), a co-sponsor of this bill, writes in support, "[this bill] will improve health outcomes for women and babies, increase access to high quality women’s health care, and permit women to choose for themselves their preferred reproductive health providers. Currently California faces an urgent maternal and newborn care crisis…. In past years, the [CNMA] sponsored [AB 1306 (Burke) of 2016 and 1612 (Burke) of 2017] to remove physician supervision. This year we are proposing language that will alleviate the burden of physician supervision, while still requiring physician consultation, co-management, and/or transfer of care for women whose conditions fall outside of a nurse-midwife's scope of practice."

CNMA concludes by arguing that full physician supervision "has been eliminated in all but 5 states in the U.S. California is needlessly limiting women’s health care access at a time when we should be doubling down on our commitment to women and families. The quality and safety of nurse-midwifery care has been evident for decades. In the face of a women’s health provider shortage, and the crisis of maternal mortality and increased cesarean rates, the imperative looms over California to grant broader access to women’s health care."

The United Nurses Associations of California/Union of Health Care Professionals (UNAC/UHCP), a co-sponsor of this bill, writes in support, "[t]his bill contains meaningful patient protections, and mandates consultation with, and if appropriate, transfer of care to a physician or surgeon if any of the following apply:

1. The condition is outside the scope of practice of the CNM
2. The health of the newborn or the mother are in jeopardy
3. The necessary resources or equipment are not available"

"In addition, the bill requires all emergencies to be immediately referred to a physician or surgeon. By making clear that CNMs can provide health care services without the supervision requirement, this bill will lower the cost of health care and improve access for patients."

A Voice for Choice Advocacy writes in support, "[t]he changes to the statute outlined in this bill are already situations which licensed midwives, who are not nurses, have the ability to practice without supervision by a physician or surgeon. Therefore, [CNMs], who have more training, should be given the same level of parity in the law between [LMs] and [CNMs] by removing the physician supervision requirements for CNMs, allowing them to practice independently within their scope of practice."

The American College of Nurse-Midwives writes in support, "[this bill] will not change how CNMs and obstetricians work together to care for women, babies, families, and individuals. CNMs will continue to practice in collaboration with physicians, but without the barriers imposed by supervisory language."

"The benefits of autonomous practice for CNMs are well-established. Because it so clearly supports women and newborns’ access to high quality, affordable care, full practice authority for CNMs is strongly supported by the ACNM, and is consistent with the evidence-based recommendations of the National Academy of Medicine. By eliminating substantial impetus for CNMs to obtain a supervisory practice agreement with a physician before providing care within their skills, education and scope of practice to patients, [this bill] can be said to be advancing access to quality care. [This bill] eliminates supervisory practice requirements for CNMs and its passage is an important stepping stone to improving outcomes, increasing access, and reducing costly and unnecessary regulations that are a barrier to care."

The American Nurses Association\California (ANA\C), writes in support, "Alarming fact is that today, in nine counties in California, women still do not have access to health care providers. That should give us a pause. CNMs provide timely, appropriate & high quality of care and their education and training prepares them to provide such care."

"CNMs are a longstanding, vital, effective and important part of California’s healthcare delivery system. There has been a significant research done over the many years that support the safe and effective practice of a nurse midwife. CNMs are members of the inter and intra-professional teams, work collaboratively with physicians and registered nurses alike, refer patients to surgeons or specialist physicians when their conditions change BEYOND the accepted and established scope of practice – all based on years of nursing education, certification training, practice and Nursing Practice Act regulations. The groundbreaking Institute of Medicine Report recommends all advanced practice registered nurses practice to the full practice authority to increase access to care."

Anthem, Inc. writes in support, "[this bill] allows a CNM to provide a full range of primary gynecological and obstetric care services for women in specific settings and location independent of a licensed physician and surgeon. This measure also ensures the practice of midwifery emphasizes informed consent-shared decision-making, preventative care, early detection, and referral of complications with childbirth. Overall, [this bill] improves the professional standards for CNMs thus ensuring the best quality of care for clients…. The shortage of qualified health professionals calls for new laws that expand whom we allow to deliver women's health care services in California. Anthem believes that [this bill] achieves this goal without sacrificing the standard of care that a woman could receive from a licensed physician or surgeon."

The Association of California Healthcare Districts (ACHD) writes in support, "ACHD represents 79 Healthcare Districts throughout California, in both urban and rural settings. The Districts offer a variety of services aimed at improving community health including acute hospital care, public health services, primary care clinics, dental clinics, and long term care/skilled nursing. In many instances, Healthcare Districts are the sole source of health care in the community — serving as an integral part of the safety net for the State' s uninsured and underinsured."

"Healthcare Districts located in rural and remote areas of the state have a difficult time recruiting health professionals to their areas. In many communities, doctors cannot support themselves financially in an independent practice. This makes it extremely difficult for rural communities to attract and retain physicians. ACHD supports a number of solutions to increase access to care, including allowing certified nurse-midwives to practice without supervision by a physician and surgeon in certain circumstances. By expanding the ability of certified nurse-midwives to practice independently, [this bill] would allow patients to receive continuous prenatal care, should there not be access to a physician. [this bill] is a positive step toward expanded access to gynecologic and family planning care to in rural and underserved areas in Califomia."

The California Association for Nurse Practitioners (CANP) writes in support, "[e]nrollment in the state's Medi-Cal program is projected at 13-5 million Californians for 2018-19 according to the state Departrnent of Healthcare Services — an increase of nearly 5 million people since 2011. Coupled with the estimated 1.5 million individuals enrolled in Covered California this year, the state must aggressively pursue practices and policies to streamline and increase access to care. [This bill] will assist in this effort by allowing nurse-midwives to work collaboratively with physicians to provide women's health care services across the state, including pregnancy and delivery care. By removing the physician supervision requirement, [this bill] will not change the way nurse-midwives currently practice or hinder the current high-quality care provided. However, [this bill] will improve access to care and provide women with greater choice when selecting their women's health care services providers.

The California Association of Licensed Midwives (CALM) writes in support, "[u]ntil 2014, California [LMs], who specialize in out-of-hospital maternity care, were saddled with the unworkable and often unattainable physician supervision requirement, which served only to limit access to the growing number of families seeking midwifery care. For this and other reasons, in 2013, the legislature overwhelmingly voted to remove the physician supervision requirement from the [LM] practice act and bring California’s law in line with the rest of the US."

"As one of the largest, most diverse states in the nation that has long taken a lead in enacting sound, progressive policies. California’s maternity care system should reflect our state's core values in support of evidence-based care, the ability to make personal decisions about our health care, and equal access for all Californians to the full range of providers and models of care."

The California Association of Nurse Anesthetists (CANA) writes in support, "[this bill] economically un-tethers nurse-midwives from physicians creating the opportunity to expand women's health care services where they are most needed, within CNMs' current scope of practice. Removing supervision would allow CNMs to partner collaboratively with physicians and expand options beyond working as a physician's employee. It would also eliminate the barriers that physicians encounter from malpractice carriers that prohibit them from supervising CNMs due to unfounded fears of vicarious liability."

"The current supervision language contradicts national and international standards. Physician collaboration is and has always been a hallmark of nurse-midwifery care and [this bill] will not change that." CANA notes that this bill "would directly and positively affect the California health care system by enhancing physician and nurse-midwife collaboration, improving access to health services, lowering health care costs, improving quality of care, and providing greater innovation in health care delivery."

California Families for Access to Midwives (CFAM) writes in support that consumers of midwifery services "want greater access to CNMs in all birth settings because they know that the quality of care from CNMs increases their safety and satisfaction in the pregnancy, birth and postpartum period. They also know that the more maternity care providers there are to choose from, the better chance they have of having their needs as a consumer met…. CFAM wants California to be a leader for the country in improving maternity care outcomes, and we believe that increasing access to CNM care is part of the solution to the problem of devastatingly high rates of maternal and neonatal morbidity and mortality, especially in communities of color. By removing physician supervision from [CNMs] we believe that access to high-quality, evidence based maternity care will be increased."

The California Hospital Association (CHA) writes in support, "CHA supports the bill's premise — that California's more than 1,200 CNMs should have full practice authority to the extent of their certification, education and training…. This broad scope of practice, combined with the ability to provide care in a variety of settings — including hospitals, community clinics and private practices — makes CNMs well suited to play a significant role in the clinical delivery systems of the future under the Affordable Care Act. Perhaps most importantly, they will help fill California's well-publicized gap in the number of primary care providers needed to serve the state's population."

"[This bill] would facilitate timely access to quality care by removing the physician supervision requirement and allowing CNMs greater independence in meeting the health care needs of the millions of individuals added to California's health care system under the Affordable Care Act. As of 2010 (the most recent data available), more than 23 percent of California's CNMs were not working in their chosen field; almost half attributed this to difficulty in finding a position. With the passage of [this bill], CNMs will have limitless employment and independent practice opportunities to serve Californians."

Govern for California writes in support, "[u]ntethering CNMs from physician supervision requirements would increase access to health care services for women all across California, and especially in less affluent and less densely populated areas of the state."

The National Perinatal Association writes in support, "we are facing a workforce crisis within the field of women’s health that significantly curbs a woman’s ability to access safe perinatal care, including family planning, prenatal care, labor and delivery services and postpartum support for women and their families. This crisis has been years in the making, and we can no longer waste time. Nine California counties have NO practicing obstetrician and 19 counties have 5 or fewer obstetricians. There is now strong, mounting evidence that greater access to nurse-midwifery care is a critical strategy to curbing this crisis."

ARGUMENTS IN OPPOSITION:

The American College of Obstetricians and Gynecologists (ACOG), District IX California is opposed to the bill unless amended, stating that "[w]hile ACOG has had productive conversations with the author’s office, we unfortunately have not yet been able to agree on amendments that would accommodate our concerns to ensure the safety of our patients."

The California Medical Association (CMA) is opposed to the bill unless amended, stating that this bill "does not define practice settings or the conditions of employment within those settings. The bill also requires that emergencies be immediately referred to a physician, but does not specifically require a referral in cases of pregnancy complications or abnormal birth in women whose pregnancies were previously considered under the category of 'normal.' Lastly, [this bill] is silent on which entity would be responsible for the regulatory oversight of independently practicing CNMs. Therefore, CMA would like to see amendments that address the concerns outlined above and are consistent with previously agreed upon principles surrounding the independent practice of midwifery."

The California Right to Life Committee, Inc. (CRLC) writes in opposition, "CRLC must continue to oppose the involvement of [CNMs] in activities without a physician's direct oversight except in cases emergency. We must also oppose the family planning care component that continues as one of the services. Family planning products include use of contraceptives that can act as abortifacients."

The Osteopathic Physicians and Surgeons of California (OPSC) is opposed to the bill unless amended, stating that this bill "would allow CNMs to practice independently without the safeguards associated with physician consultation, supervision, standardized procedure and written protocol…. While CNMs may be equipped to handle some aspects of primary care, they are not physician equivalents and building assumptions to that effect into their scope of practice would be a disservice to patients."

IMPLEMENTATION ISSUES:

Referral and Comanagement. This bill removes the requirement that a CNM work under standardized procedures/the supervision of a physician during normal childbirth. Because standardized procedures are a method for ensuring competence to provide medically necessary services, this bill instead limits the provision of services to non-high-risk pregnancies and requires immediate referral and comanagement with a qualified physician. However, the bill does not currently specify what the relationship between a physician and the referring CNM. If this bill passes this Committee, the author may wish to clarify the CNM- physician comanagement relationship and what the CNM’s options are if there is no physician or the physician refuses.

REGISTERED SUPPORT:

California Nurse-Midwives Association (co-sponsor)

United Nurses Association of California (co-sponsor)

A Voice for Choice Advocacy

ACCESS Women’s Health Justice

ACT for Women and Girls

American Association of Birth Centers

American College of Nurse-Midwives

American Nurses Association\California

Anthem, Inc.

Association of California Healthcare Districts

Beach Cities Midwifery

Best Start Birth Center

Black Women for Wellness

California Association for Nurse Practitioners

California Association of Clinical Nurse Specialists

California Association of Licensed Midwives

California Association of Nurse Anesthetists

California Families for Access to Midwives

California Hospital Association

California Latinas for Reproductive Justice

Educate. Advocate.

Empower Family California

Essential Access Health

Govern for California

If/When/How

Maternal and Child Health Access

NARAL Pro-Choice California

National Council of Jewish Woman, California

National Health Law Program

National Perinatal Association

Nevada County Citizens for Choice

UC Berkeley School of Law, Center for Reproductive Rights and Justice

John Leopold, Supervisor, County of Santa Cruz

20 Licensed Obstetrician-Gynecologists

Numerous individuals, including RNs, CNMs, NPs, and medical students

REGISTERED OPPOSITION:

American College of Obstetricians and Gynecologists, District IX California

California Medical Association
California Right to Life Committee

Osteopathic Physicians and Surgeons of California

Analysis Prepared by: Vincent Chee / B. & P. / (916) 319-3301