Existing law provides for the licensing and regulation of health facilities by the State Department of Public Health and generally makes a violation of those provisions a crime. Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and generally makes a willful violation of the act a crime.

Existing law requires a health facility to provide emergency services and care upon request for any condition in which the person is in danger of loss of life or serious injury or illness. Existing law requires a health care service plan to reimburse providers for emergency services and care.

Existing law defines emergency services and care for these purposes to mean medical screening, examination, and evaluation by a physician and surgeon, or other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility, among other things.

This bill would specify that the above-described provisions would not require physician supervision of a licensed nurse-midwife in the labor and delivery unit, obstetric triage, or dedicated emergency obstetric evaluation unit, when the nurse-midwife is providing care to the extent authorized by, and consistent with, specified licensing and certification provisions, or when the nurse-midwife is specifically requested by the treating physician and surgeon to provide obstetric consultation.

By changing the scope of 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.

Existing law provides for the licensing and regulation of health facilities by the State Department of Public Health and generally makes a violation of those provisions a crime. Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and generally makes a willful violation of the act a crime.

Existing law requires a health facility to provide emergency services and care upon request for any condition in which the person is in danger of loss of life or serious injury or illness. Existing law requires a health care service plan to reimburse providers for emergency services and care.

Existing law defines emergency services and care for these purposes to mean medical screening, examination, and evaluation by a physician and surgeon, or other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility, among other things.

This bill would specify that the above-described provisions would not require physician supervision of a licensed nurse-midwife in the labor and delivery unit, obstetric triage, or dedicated emergency obstetric evaluation unit, when the nurse-midwife is providing care to the extent authorized by, and consistent with, specified licensing and certification provisions, or when the nurse-midwife is specifically requested by the treating physician and surgeon to provide obstetric consultation.

By changing the scope of 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.

Existing law provides for the licensing and regulation of health facilities by the State Department of Public Health and generally makes a violation of those provisions a crime. Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and generally makes a willful violation of the act a crime. Existing

Existing law requires a health facility to provide emergency services and care upon request or when a for any condition in which the person is in danger of loss of life or serious injury or illness, and illness. Existing law requires a health care service plan to reimburse providers for emergency services and care. Existing

Existing law defines emergency services and care for these purposes to mean medical screening, examination, and evaluation by a physician and surgeon, or other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility, among other things.

This bill would specify that a nurse-midwife, as specified, does not require physician supervision when the nurse-midwife is providing emergency services and care within the scope of their authorized licensure. the above-described provisions would not require physician supervision of a licensed nurse-midwife in the labor and delivery unit, obstetric triage, or dedicated emergency obstetric evaluation unit, when the nurse-midwife is providing care to the extent authorized by, and consistent with, specified licensing and certification provisions, or when the nurse-midwife is specifically requested by the treating physician and surgeon to provide obstetric consultation.

By changing the scope of 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.

Under existing law, the Department of Consumer Affairs is comprised of various boards, bureaus, commissions, committees, and similarly constituted agencies that license and regulate the practice of various professions and vocations. Existing law authorizes the director to create an interdepartmental committee to assist and advise the director in the implementation of the directors duties, as provided.

This bill would make nonsubstantive changes to those provisions.

 THIRD READING 

Bill No: AB 1696

Author: Stefani (D)

Amended: 5/18/26 in Assembly

Vote: 21

SENATE HEALTH COMMITTEE: 11-0, 6/24/26

AYES: Weber Pierson, Valladares, Caballero, Durazo, Gonzalez, Grove, Menjivar, Padilla, Pérez, Rubio, Smallwood-Cuevas

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 74-1, 5/26/26 - See last page for vote

SUBJECT: Emergency services and care: nurse-midwives

SOURCE: California Nurse-Midwives Association

DIGEST:

This bill prohibits provisions of law requiring hospitals to stabilize patients with an emergency medical condition, or when they are in active labor, without regard to ability to pay, from requiring supervision of a certified nurse-midwife in the labor and delivery unit, obstetric triage, or dedicated emergency obstetric evaluation unit, when the nurse-midwife is practicing within their scope of practice.

ANALYSIS:

Existing law:

1. Licenses and regulates hospitals, including a general acute care hospital, by the California Department of Public Health (CDPH). Permits general acute care hospitals, in addition to the basic services all hospitals are required to offer, to be approved by CDPH to offer special services, including, among other services, an emergency department (ED). [Health and Safety Code (HSC)§1250 and §1255, et seq.]
2. Requires EDs, under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) and also under similar provisions of state law (state EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Both federal and state EMTALA impose this requirement on any hospital that operates an ED. [42 USC §1395dd and HSC §1317]
3. Defines “emergency services and care,” under state EMTALA, as medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate persons under the supervision of a physician, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person’s license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. [HSC §1317.1(a)(1)]
4. Defines “active labor,” for purposes of state EMTALA, as labor at a time which either of the following would occur: (1) there is inadequate time to effect safe transfer to another hospital prior to delivery; or, (2) a transfer may pose a threat to the health and safety of the patient or the fetus. [HSC §1317.1(c)]
5. Prohibits a person needing emergency services and care from being transferred from a hospital to another hospital for any nonmedical reason (such as the person’s inability to pay for any emergency service or care) unless certain conditions are met, including that the person is examined and evaluated by a physician, including, if necessary, consultation prior to transfer, and also has been provided with emergency services so that it can be determined, within reasonable medical probability, that the transfer will not create a medical hazard to the person. [HSC §1317.2]
6. Defines “consultation,” for purposes of state EMTALA, as the rendering of an opinion or advice, prescribing treatment, or the rendering of a decision regarding hospitalization or transfer by telephone or other means of communication. Specifies “consultation” includes review of the patient’s medical record, examination, and treatment of the patient in person by a consulting physician, or by other appropriate licensed persons acting within their scope of license under the supervision of a consulting physician, who is qualified to give an opinion or render the necessary treatment. [HSC §1317.1(i)]
7. Specifies, for purposes of state EMTALA, that a patient is “stabilized” when, in the opinion of the treating physician, or other appropriate licensed persons acting within their scope of licensure under the supervision of a treating physician, the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from, or occur during, the release or transfer of the patient. [HSC §1317.1(j)]
8. Licenses and regulates nurses, including certified nurse-midwives (CNMs) through the Board of Registered Nursing. States that the certificate to practice nurse-midwifery authorizes the holder to attend cases of low-risk pregnancy and childbirth, and to provide prenatal care, intrapartum care, and postpartum care, as specified. [Business and Professions Code [BPC] §2700 et seq. and §2746.5]
9. Defines “low-risk pregnancy,” for purposes of the scope of practice of CNMs, as a pregnancy in which all of the following conditions are met:
   1. There is a single fetus;
   2. There is cephalic presentation at the onset of labor;
   3. The gestational age of the fetus is between 37 and 42 weeks at the time of delivery;
   4. Labor is spontaneous or induced; and,
   5. The patient has no preexisting disease or condition, arising out of the pregnancy or otherwise, that adversely affects the pregnancy and that the CNM is not qualified to independently address. [BPC §2746.5]

This bill prohibits state EMTALA from requiring physician supervision of a CNM in the labor and delivery unit, obstetric triage, or dedicated emergency obstetric evaluation unit, when the CNM is providing care to the extent authorized by their scope of practice, or when the CNM is specifically requested by the treating physician to provide obstetric consultation, notwithstanding provisions of state EMTALA that permit other appropriate licensed persons, acting within their scope of license under the supervision of a physician, to examine and evaluate, provide consultation, or determine whether a patient is stabilized.

Comments

According to the author:

California is facing a worsening shortage of obstetric providers; labor and delivery units are closing around the state. Mandatory physician supervision decreases access to care by superficially limiting the ability of nurse-midwives to act at the top of their license and increases costs by requiring redundancy in care delivery. Further, per the Legislative Analyst’s Office Analysis of California’s Physician-Supervision Requirement for Certified Nurse-Midwives, physician supervision is “unlikely to improve patient safety and quality.” The California state Legislature responded in 2020 via SB 1237 (Dodd) by eliminating physician supervision of nurse-midwives, with clear statutory delineation of when physician involvement is required. However, the Health and Safety Code still requires that nurse-midwives have physician supervision for patients who come to the hospital and require the EMTALA-mandated medical screening and evaluation. This means that a nurse-midwife can evaluate and treat the same patient for the same issue without physician supervision if they are in the clinic or admitted to the hospital, but is required to have physician supervision if the care episode falls under EMTALA. This causes confusion for patients, for nurse-midwives, and for hospital staff. This bill is needed to eliminate confusion about when a patient is appropriate for nurse-midwife care or when the nurse-midwife requires physician supervision.

Background

EMTALA. EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or “dumping” these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services to provide a medical screening and treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is “stabilized” when their medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from their release or transfer. If a hospital is unable to stabilize a patient within its capability, the patient is required to be transferred to an appropriate facility with the necessary specialized treatment services. Once a patient is stabilized, if they need post-stabilization care, the hospital will typically seek more information about the medical history of the patient, including whether they have insurance.

EMTALA definition of emergency department includes labor and delivery units. As described above, both state and federal EMTALA apply to hospitals with an ED. In implementing regulations, the Centers for Medicare and Medicaid Services (CMS) define “dedicated emergency department” as any department or facility of the hospital that either: (1) is licensed by the state as an ED; (2) held out to the public as providing treatment for emergency medical conditions; or (3) one-third of visits to the department in the preceding calendar year actually provided treatment for emergency medical conditions on an urgent basis. In explaining this definition, CMS stated that the third prong of this definition includes individuals who may present as unscheduled ambulatory patients to units, including labor and delivery units or hospital urgent care centers, where patients are routinely evaluated and treated for emergency medical conditions. In other words, because pregnant patients regularly go into labor and come to the labor and delivery unit of a hospital on an unscheduled basis, this makes the labor and delivery unit an “emergency department” under EMTALA.

The author and sponsor point out that because EMTALA covers labor and delivery units where CNMs work, CNMs should be able to provide the necessary EMTALA-required medical screening, consultation, or determination of whether the patient is stable enough for discharge or transfer without supervision, as long as it is within their scope of practice (low-risk pregnancies).

Background on CNMs. CNMs are advanced practice registered nurses who have specialized education and training to provide primary care, prenatal, intrapartum, and postpartum care. These individuals are licensed by the California Board of Registered Nurses (BRN), have acquired additional training in the field of obstetrics, and are certified by the American College of Nurse Midwives. In order to obtain a certificate to practice as a CNM, the applicant must provide proof to the BRN that they have either graduated from a BRN approved program in nurse-midwifery or satisfied equivalent standards as set forth in the BRN’s regulations. The nurse-midwifery certificate authorizes the CNM to attend cases of low-risk pregnancy and childbirth, as well as immediate care for the newborn, along with family planning and interconception care.

Prior to 2020, CNMs were required to practice under the supervision of a physician under standardized procedures and protocols. Standardized procedures were developed collaboratively by nurses, physicians, and the administration of the organized health care system. While supervision by a physician was required for CNMs to provide patient care, that supervision did not require the physical presence of a physician, and physicians were limited to supervising no more than four CNMs at a time.

SB 1237 (Dodd, Chapter 88, Statutes of 2020) revised the current practice authorization for CNMs. SB 1237 eliminated the requirement for a CNM to practice midwifery according to standardized procedures or protocols with a physician. By doing this, SB 1237 did not change the scope of work that a CNM could perform, but permitted a CNM to perform their work without physician supervision.

Related/Prior Legislation

SB 667 (Dodd, Chapter 497, Statutes of 2023) clarifies a CNM’s authority to treat and provide care for common gynecologic conditions; permits a CNM to admit or discharge a patient if a CNM has privileges at a general acute care hospital; clarified that a CNM is a practitioner for purposes of certifying a disability; and, includes CNMs as a laboratory director for purposes of performing specified laboratory tests, among other technical changes.

SB 1237 (Dodd, Chapter 88, Statutes of 2020) removes the requirement for a CNM to practice midwifery according to standardized procedures or protocols with a physician; revised the provisions defining the practice of midwifery; authorizes a CNM to attend cases out of a hospital setting; authorizes a CNM to furnish or order drugs or devices in accordance with standardize protocols with a physician; requires a CNM to provide specified disclosures to a patient; and, establishes new reporting a data collection requirements.

SB 233 (Pavley, Chapter 333, Statutes of 2011) clarifies the state EMTALA law to explicitly permit appropriate licensed personnel to perform consultations and treatment in an emergency department if within their existing scope of practice.

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

SUPPORT: (Verified 8/4/26)

California Nurse-Midwives Association (source)

Access Reproductive Justice
American Nurses Association/California
Aria Medical

Board of Registered Nursing
California Association for Nurse Practitioners
California Association of Nurse Anesthesiology
California Clinical Nurse Specialist Association

California Latinas for Reproductive Justice
California Women's Law Center
Gender Equity Policy Institute
March of Dimes
National Health Law Program
Nurses for Sexual & Reproductive Health
Reproductive Freedom for All California
Western Center on Law & Poverty, Inc.

OPPOSITION: (Verified 8/4/26)

None received

ARGUMENTS IN SUPPORT:

This bill is sponsored by the California Nurse-Midwives Association, which states that “most CNMs provide direct patient care in hospital settings on labor and delivery units, evaluating and treating patients who present with a variety of pregnancy and postpartum health concerns. The triage area of a labor and delivery unit serves as an ED for pregnant and postpartum individuals. Individuals present to triage when they are experiencing contractions and want to know if they are in labor. They might also present with other urgent issues not appropriate for assessment in the clinic, such as severe headaches, nausea and vomiting, abdominal pain, or infection related to breastfeeding. When CNMs provide care in labor and delivery triage, this care falls under the category of “emergency services and care,” regulated by the state EMTALA provisions of state law. These sections are California’s core patient-protection laws for emergency care, and ensure people who need emergency services and care are not refused treatment or improperly transferred because of their ability to pay, insurance status, or other nonmedical reasons. Currently, this code section requires that non-physicians must act under physician supervision when providing emergency services and care, including consultation and stabilization. However, the state removed this requirement of physician supervision for CNMs in 2020, and this bill would update the law to reflect CNMs current practice authority.”

ASSEMBLY FLOOR: 74-1, 5/26/26

AYES: Addis, Aguiar-Curry, Ahrens, Alanis, Alvarez, Arambula, Ávila Farías, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Caloza, Carrillo, Castillo, Chen, Connolly, Davies, DeMaio, Elhawary, Ellis, Flora, Fong, Gabriel, Gallagher, Garcia, Gipson, Jeff Gonzalez, Mark González, Hadwick, Haney, Harabedian, Hart, Hoover, Irwin, Jackson, Johnson, Kalra, Krell, Lee, Lowenthal, Macedo, McKinnor, Nguyen, Ortega, Pacheco, Papan, Patel, Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Ransom, Michelle Rodriguez, Rogers, Blanca Rubio, Schiavo, Schultz, Sharp-Collins, Solache, Soria, Stefani, Ta, Tangipa, Valencia, Wallis, Ward, Wicks, Wilson, Zbur, Rivas

NOES: Sanchez

NO VOTE RECORDED: Bains, Dixon, Lackey, Muratsuchi, Celeste Rodriguez

Prepared by: Vincent D. Marchand / HEALTH / (916) 651-4111

8/6/26 11:43:00

**** END ****

 CONSENT  

Bill No: AB 1696

Author: Stefani (D)

Amended: 5/18/26 in Assembly

Vote: 21

SENATE HEALTH COMMITTEE: 11-0, 6/24/26

AYES: Weber Pierson, Valladares, Caballero, Durazo, Gonzalez, Grove, Menjivar, Padilla, Pérez, Rubio, Smallwood-Cuevas

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 74-1, 5/26/26 - See last page for vote

SUBJECT: Emergency services and care: nurse-midwives

SOURCE: California Nurse-Midwives Association

DIGEST:

This bill prohibits provisions of law requiring hospitals to stabilize patients with an emergency medical condition, or when they are in active labor, without regard to ability to pay, from requiring supervision of a certified nurse-midwife in the labor and delivery unit, obstetric triage, or dedicated emergency obstetric evaluation unit, when the nurse-midwife is practicing within their scope of practice.

ANALYSIS:

Existing law:

1. Licenses and regulates hospitals, including a general acute care hospital, by the California Department of Public Health (CDPH). Permits general acute care hospitals, in addition to the basic services all hospitals are required to offer, to be approved by CDPH to offer special services, including, among other services, an emergency department (ED). [Health and Safety Code (HSC)§1250 and §1255, et seq.]
2. Requires EDs, under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) and also under similar provisions of state law (state EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Both federal and state EMTALA impose this requirement on any hospital that operates an ED. [42 USC §1395dd and HSC §1317]
3. Defines “emergency services and care,” under state EMTALA, as medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate persons under the supervision of a physician, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person’s license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. [HSC §1317.1(a)(1)]
4. Defines “active labor,” for purposes of state EMTALA, as labor at a time which either of the following would occur: (1) there is inadequate time to effect safe transfer to another hospital prior to delivery; or, (2) a transfer may pose a threat to the health and safety of the patient or the fetus. [HSC §1317.1(c)]
5. Prohibits a person needing emergency services and care from being transferred from a hospital to another hospital for any nonmedical reason (such as the person’s inability to pay for any emergency service or care) unless certain conditions are met, including that the person is examined and evaluated by a physician, including, if necessary, consultation prior to transfer, and also has been provided with emergency services so that it can be determined, within reasonable medical probability, that the transfer will not create a medical hazard to the person. [HSC §1317.2]
6. Defines “consultation,” for purposes of state EMTALA, as the rendering of an opinion or advice, prescribing treatment, or the rendering of a decision regarding hospitalization or transfer by telephone or other means of communication. Specifies “consultation” includes review of the patient’s medical record, examination, and treatment of the patient in person by a consulting physician, or by other appropriate licensed persons acting within their scope of license under the supervision of a consulting physician, who is qualified to give an opinion or render the necessary treatment. [HSC §1317.1(i)]
7. Specifies, for purposes of state EMTALA, that a patient is “stabilized” when, in the opinion of the treating physician, or other appropriate licensed persons acting within their scope of licensure under the supervision of a treating physician, the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from, or occur during, the release or transfer of the patient. [HSC §1317.1(j)]
8. Licenses and regulates nurses, including certified nurse-midwives (CNMs) through the Board of Registered Nursing. States that the certificate to practice nurse-midwifery authorizes the holder to attend cases of low-risk pregnancy and childbirth, and to provide prenatal care, intrapartum care, and postpartum care, as specified. [Business and Professions Code [BPC] §2700 et seq. and §2746.5]
9. Defines “low-risk pregnancy,” for purposes of the scope of practice of CNMs, as a pregnancy in which all of the following conditions are met:
   1. There is a single fetus;
   2. There is cephalic presentation at the onset of labor;
   3. The gestational age of the fetus is between 37 and 42 weeks at the time of delivery;
   4. Labor is spontaneous or induced; and,
   5. The patient has no preexisting disease or condition, arising out of the pregnancy or otherwise, that adversely affects the pregnancy and that the CNM is not qualified to independently address. [BPC §2746.5]

This bill prohibits state EMTALA from requiring physician supervision of a CNM in the labor and delivery unit, obstetric triage, or dedicated emergency obstetric evaluation unit, when the CNM is providing care to the extent authorized by their scope of practice, or when the CNM is specifically requested by the treating physician to provide obstetric consultation, notwithstanding provisions of state EMTALA that permit other appropriate licensed persons, acting within their scope of license under the supervision of a physician, to examine and evaluate, provide consultation, or determine whether a patient is stabilized.

Comments

According to the author:

California is facing a worsening shortage of obstetric providers; labor and delivery units are closing around the state. Mandatory physician supervision decreases access to care by superficially limiting the ability of nurse-midwives to act at the top of their license and increases costs by requiring redundancy in care delivery. Further, per the Legislative Analyst’s Office Analysis of California’s Physician-Supervision Requirement for Certified Nurse-Midwives, physician supervision is “unlikely to improve patient safety and quality.” The California state Legislature responded in 2020 via SB 1237 (Dodd) by eliminating physician supervision of nurse-midwives, with clear statutory delineation of when physician involvement is required. However, the Health and Safety Code still requires that nurse-midwives have physician supervision for patients who come to the hospital and require the EMTALA-mandated medical screening and evaluation. This means that a nurse-midwife can evaluate and treat the same patient for the same issue without physician supervision if they are in the clinic or admitted to the hospital, but is required to have physician supervision if the care episode falls under EMTALA. This causes confusion for patients, for nurse-midwives, and for hospital staff. This bill is needed to eliminate confusion about when a patient is appropriate for nurse-midwife care or when the nurse-midwife requires physician supervision.

Background

EMTALA. EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or “dumping” these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services to provide a medical screening and treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is “stabilized” when their medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from their release or transfer. If a hospital is unable to stabilize a patient within its capability, the patient is required to be transferred to an appropriate facility with the necessary specialized treatment services. Once a patient is stabilized, if they need post-stabilization care, the hospital will typically seek more information about the medical history of the patient, including whether they have insurance.

EMTALA definition of emergency department includes labor and delivery units. As described above, both state and federal EMTALA apply to hospitals with an ED. In implementing regulations, the Centers for Medicare and Medicaid Services (CMS) define “dedicated emergency department” as any department or facility of the hospital that either: (1) is licensed by the state as an ED; (2) held out to the public as providing treatment for emergency medical conditions; or (3) one-third of visits to the department in the preceding calendar year actually provided treatment for emergency medical conditions on an urgent basis. In explaining this definition, CMS stated that the third prong of this definition includes individuals who may present as unscheduled ambulatory patients to units, including labor and delivery units or hospital urgent care centers, where patients are routinely evaluated and treated for emergency medical conditions. In other words, because pregnant patients regularly go into labor and come to the labor and delivery unit of a hospital on an unscheduled basis, this makes the labor and delivery unit an “emergency department” under EMTALA.

The author and sponsor point out that because EMTALA covers labor and delivery units where CNMs work, CNMs should be able to provide the necessary EMTALA-required medical screening, consultation, or determination of whether the patient is stable enough for discharge or transfer without supervision, as long as it is within their scope of practice (low-risk pregnancies).

Background on CNMs. CNMs are advanced practice registered nurses who have specialized education and training to provide primary care, prenatal, intrapartum, and postpartum care. These individuals are licensed by the California Board of Registered Nurses (BRN), have acquired additional training in the field of obstetrics, and are certified by the American College of Nurse Midwives. In order to obtain a certificate to practice as a CNM, the applicant must provide proof to the BRN that they have either graduated from a BRN approved program in nurse-midwifery or satisfied equivalent standards as set forth in the BRN’s regulations. The nurse-midwifery certificate authorizes the CNM to attend cases of low-risk pregnancy and childbirth, as well as immediate care for the newborn, along with family planning and interconception care.

Prior to 2020, CNMs were required to practice under the supervision of a physician under standardized procedures and protocols. Standardized procedures were developed collaboratively by nurses, physicians, and the administration of the organized health care system. While supervision by a physician was required for CNMs to provide patient care, that supervision did not require the physical presence of a physician, and physicians were limited to supervising no more than four CNMs at a time.

SB 1237 (Dodd, Chapter 88, Statutes of 2020) revised the current practice authorization for CNMs. SB 1237 eliminated the requirement for a CNM to practice midwifery according to standardized procedures or protocols with a physician. By doing this, SB 1237 did not change the scope of work that a CNM could perform, but permitted a CNM to perform their work without physician supervision.

Related/Prior Legislation

SB 667 (Dodd, Chapter 497, Statutes of 2023) clarifies a CNM’s authority to treat and provide care for common gynecologic conditions; permits a CNM to admit or discharge a patient if a CNM has privileges at a general acute care hospital; clarified that a CNM is a practitioner for purposes of certifying a disability; and, includes CNMs as a laboratory director for purposes of performing specified laboratory tests, among other technical changes.

SB 1237 (Dodd, Chapter 88, Statutes of 2020) removes the requirement for a CNM to practice midwifery according to standardized procedures or protocols with a physician; revised the provisions defining the practice of midwifery; authorizes a CNM to attend cases out of a hospital setting; authorizes a CNM to furnish or order drugs or devices in accordance with standardize protocols with a physician; requires a CNM to provide specified disclosures to a patient; and, establishes new reporting a data collection requirements.

SB 233 (Pavley, Chapter 333, Statutes of 2011) clarifies the state EMTALA law to explicitly permit appropriate licensed personnel to perform consultations and treatment in an emergency department if within their existing scope of practice.

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

SUPPORT: (Verified 8/4/26)

California Nurse-Midwives Association (source)

Access Reproductive Justice
American Nurses Association/California
Aria Medical

Board of Registered Nursing
California Association for Nurse Practitioners
California Association of Nurse Anesthesiology
California Clinical Nurse Specialist Association

California Latinas for Reproductive Justice
California Women's Law Center
Gender Equity Policy Institute
March of Dimes
National Health Law Program
Nurses for Sexual & Reproductive Health
Reproductive Freedom for All California
Western Center on Law & Poverty, Inc.

OPPOSITION: (Verified 8/4/26)

None received

ARGUMENTS IN SUPPORT:

This bill is sponsored by the California Nurse-Midwives Association, which states that “most CNMs provide direct patient care in hospital settings on labor and delivery units, evaluating and treating patients who present with a variety of pregnancy and postpartum health concerns. The triage area of a labor and delivery unit serves as an ED for pregnant and postpartum individuals. Individuals present to triage when they are experiencing contractions and want to know if they are in labor. They might also present with other urgent issues not appropriate for assessment in the clinic, such as severe headaches, nausea and vomiting, abdominal pain, or infection related to breastfeeding. When CNMs provide care in labor and delivery triage, this care falls under the category of “emergency services and care,” regulated by the state EMTALA provisions of state law. These sections are California’s core patient-protection laws for emergency care, and ensure people who need emergency services and care are not refused treatment or improperly transferred because of their ability to pay, insurance status, or other nonmedical reasons. Currently, this code section requires that non-physicians must act under physician supervision when providing emergency services and care, including consultation and stabilization. However, the state removed this requirement of physician supervision for CNMs in 2020, and this bill would update the law to reflect CNMs current practice authority.”

ASSEMBLY FLOOR: 74-1, 5/26/26

AYES: Addis, Aguiar-Curry, Ahrens, Alanis, Alvarez, Arambula, Ávila Farías, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Caloza, Carrillo, Castillo, Chen, Connolly, Davies, DeMaio, Elhawary, Ellis, Flora, Fong, Gabriel, Gallagher, Garcia, Gipson, Jeff Gonzalez, Mark González, Hadwick, Haney, Harabedian, Hart, Hoover, Irwin, Jackson, Johnson, Kalra, Krell, Lee, Lowenthal, Macedo, McKinnor, Nguyen, Ortega, Pacheco, Papan, Patel, Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Ransom, Michelle Rodriguez, Rogers, Blanca Rubio, Schiavo, Schultz, Sharp-Collins, Solache, Soria, Stefani, Ta, Tangipa, Valencia, Wallis, Ward, Wicks, Wilson, Zbur, Rivas

NOES: Sanchez

NO VOTE RECORDED: Bains, Dixon, Lackey, Muratsuchi, Celeste Rodriguez

Prepared by: Vincent D. Marchand / HEALTH / (916) 651-4111

8/5/26 14:57:37

**** END ****

SENATE COMMITTEE ON HEALTH

Senator Akilah Weber Pierson, Chair

BILL NO: AB 1696

SUBJECT: Emergency services and care: nurse-midwives

SUMMARY:

Prohibits provisions of law requiring hospitals to stabilize patients with an emergency medical condition, or when they are in active labor, without regard to ability to pay, from requiring supervision of a certified nurse-midwife in the labor and delivery unit, obstetric triage, or dedicated emergency obstetric evaluation unit, when the nurse-midwife is practicing within their scope of practice.

Existing law:

1. Licenses and regulates hospitals, including a general acute care hospital, by the California Department of Public Health (CDPH). Permits general acute care hospitals, in addition to the basic services all hospitals are required to offer, to be approved by CDPH to offer special services, including, among other services, an emergency department (ED). [HSC §1250 and §1255, et seq.]
2. Requires EDs, under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) and also under similar provisions of state law (state EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Both federal and state EMTALA impose this requirement on any hospital that operates an ED. [42 USC §1395dd and HSC §1317]
3. Defines “emergency services and care,” under state EMTALA, as medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate persons under the supervision of a physician, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person’s license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. [HSC §1317.1(a)(1)]
4. Defines “active labor,” for purposes of state EMTALA, as labor at a time which either of the following would occur: (1) there is inadequate time to effect safe transfer to another hospital prior to delivery; or, (2) a transfer may pose a threat to the health and safety of the patient or the fetus. [HSC §1317.1(c)]
5. Prohibits a person needing emergency services and care from being transferred from a hospital to another hospital for any nonmedical reason (such as the person’s inability to pay for any emergency service or care) unless certain conditions are met, including that the person is examined and evaluated by a physician, including, if necessary, consultation prior to transfer, and also has been provided with emergency services so that it can be determined, within reasonable medical probability, that the transfer will not create a medical hazard to the person. [HSC §1317.2]
6. Defines “consultation,” for purposes of state EMTALA, as the rendering of an opinion or advice, prescribing treatment, or the rendering of a decision regarding hospitalization or transfer by telephone or other means of communication. Specifies “consultation” includes review of the patient’s medical record, examination, and treatment of the patient in person by a consulting physician, or by other appropriate licensed persons acting within their scope of license under the supervision of a consulting physician, who is qualified to give an opinion or render the necessary treatment. [HSC §1317.1(i)]
7. Specifies, for purposes of state EMTALA, that a patient is “stabilized” when, in the opinion of the treating physician, or other appropriate licensed persons acting within their scope of licensure under the supervision of a treating physician, the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from, or occur during, the release or transfer of the patient. [HSC §1317.1(j)]
8. Licenses and regulates nurses, including certified nurse-midwives (CNMs) through the Board of Registered Nursing. States that the certificate to practice nurse-midwifery authorizes the holder to attend cases of low-risk pregnancy and childbirth, and to provide prenatal care, intrapartum care, and postpartum care, as specified. [BPC §2700 et seq. and §2746.5]
9. Defines “low-risk pregnancy,” for purposes of the scope of practice of CNMs, as a pregnancy in which all of the following conditions are met:
   1. There is a single fetus;
   2. There is cephalic presentation at the onset of labor;
   3. The gestational age of the fetus is between 37 and 42 weeks at the time of delivery;
   4. Labor is spontaneous or induced; and,
   5. The patient has no preexisting disease or condition, arising out of the pregnancy or otherwise, that adversely affects the pregnancy and that the CNM is not qualified to independently address. [BPC §2746.5]

This bill: Prohibits state EMTALA from requiring physician supervision of a CNM in the labor and delivery unit, obstetric triage, or dedicated emergency obstetric evaluation unit, when the CNM is providing care to the extent authorized by their scope of practice, or when the CNM is specifically requested by the treating physician to provide obstetric consultation, notwithstanding provisions of state EMTALA that permit other appropriate licensed persons, acting within their scope of license under the supervision of a physician, to examine and evaluate, provide consultation, or determine whether a patient is stabilized.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, no state costs.

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, California is facing a worsening shortage of obstetric providers; labor and delivery units are closing around the state. Mandatory physician supervision decreases access to care by superficially limiting the ability of nurse-midwives to act at the top of their license and increases costs by requiring redundancy in care delivery. Further, per the Legislative Analyst’s Office Analysis of California’s Physician-Supervision Requirement for Certified Nurse-Midwives, physician supervision is “unlikely to improve patient safety and quality.” The California state Legislature responded in 2020 via SB 1237 (Dodd) by eliminating physician supervision of nurse-midwives, with clear statutory delineation of when physician involvement is required. However, the Health and Safety Code still requires that nurse-midwives have physician supervision for patients who come to the hospital and require the EMTALA-mandated medical screening and evaluation. This means that a nurse-midwife can evaluate and treat the same patient for the same issue without physician supervision if they are in the clinic or admitted to the hospital, but is required to have physician supervision if the care episode falls under EMTALA. This causes confusion for patients, for nurse-midwives, and for hospital staff. This bill is needed to eliminate confusion about when a patient is appropriate for nurse-midwife care or when the nurse-midwife requires physician supervision.
2. EMTALA. EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or “dumping” these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services to provide a medical screening and treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is “stabilized” when their medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from their release or transfer. If a hospital is unable to stabilize a patient within its capability, the patient is required to be transferred to an appropriate facility with the necessary specialized treatment services. Once a patient is stabilized, if they need post-stabilization care, the hospital will typically seek more information about the medical history of the patient, including whether they have insurance.
3. EMTALA definition of emergency department includes labor and delivery units. As described above, both state and federal EMTALA apply to hospitals with an ED. In implementing regulations, the Centers for Medicare and Medicaid Services (CMS) define “dedicated emergency department” as any department or facility of the hospital that either: (1) is licensed by the state as an ED; (2) held out to the public as providing treatment for emergency medical conditions; or (3) one-third of visits to the department in the preceding calendar year actually provided treatment for emergency medical conditions on an urgent basis. In explaining this definition, CMS stated that the third prong of this definition includes individuals who may present as unscheduled ambulatory patients to units, including labor and delivery units or hospital urgent care centers, where patients are routinely evaluated and treated for emergency medical conditions. In other words, because pregnant patients regularly go into labor and come to the labor and delivery unit of a hospital on an unscheduled basis, this makes the labor and delivery unit an “emergency department” under EMTALA.
   
   The author and sponsor point out that because EMTALA covers labor and delivery units where CNMs work, CNMs should be able to provide the necessary EMTALA-required medical screening, consultation, or determination of whether the patient is stable enough for discharge or transfer without supervision, as long as it is within their scope of practice (low-risk pregnancies).
4. Background on CNMs. CNMs are advanced practice registered nurses who have specialized education and training to provide primary care, prenatal, intrapartum, and postpartum care. These individuals are licensed by the California Board of Registered Nurses (BRN), have acquired additional training in the field of obstetrics, and are certified by the American College of Nurse Midwives. In order to obtain a certificate to practice as a CNM, the applicant must provide proof to the BRN that they have either graduated from a BRN approved program in nurse-midwifery or satisfied equivalent standards as set forth in the BRN’s regulations. The nurse-midwifery certificate authorizes the CNM to attend cases of low-risk pregnancy and childbirth, as well as immediate care for the newborn, along with family planning and interconception care.
   
   Prior to 2020, CNMs were required to practice under the supervision of a physician under standardized procedures and protocols. Standardized procedures were developed collaboratively by nurses, physicians, and the administration of the organized health care system. While supervision by a physician was required for CNMs to provide patient care, that supervision did not require the physical presence of a physician, and physicians were limited to supervising no more than four CNMs at a time.
   
   SB 1237 (Dodd, Chapter 88, Statutes of 2020) revised the current practice authorization for CNMs. SB 1237 eliminated the requirement for a CNM to practice midwifery according to standardized procedures or protocols with a physician. By doing this, SB 1237 did not change the scope of work that a CNM could perform, but permitted a CNM to perform their work without physician supervision.
5. Prior legislation. SB 667 (Dodd, Chapter 497, Statutes of 2023) clarifies a CNM’s authority to treat and provide care for common gynecologic conditions; permits a CNM to admit or discharge a patient if a CNM has privileges at a general acute care hospital; clarified that a CNM is a practitioner for purposes of certifying a disability; and, includes CNMs as a laboratory director for purposes of performing specified laboratory tests, among other technical changes.
   
   SB 1237 (Dodd, Chapter 88, Statutes of 2020) removes the requirement for a CNM to practice midwifery according to standardized procedures or protocols with a physician; revised the provisions defining the practice of midwifery; authorizes a CNM to attend cases out of a hospital setting; authorizes a CNM to furnish or order drugs or devices in accordance with standardize protocols with a physician; requires a CNM to provide specified disclosures to a patient; and, establishes new reporting a data collection requirements.
   
   SB 233 (Pavley, Chapter 333, Statutes of 2011) clarifies the state EMTALA law to explicitly permit appropriate licensed personnel to perform consultations and treatment in an emergency department if within their existing scope of practice.
6. Support. This bill is sponsored by the California Nurse-Midwives Association, which states that most CNMs provide direct patient care in hospital settings on labor and delivery units, evaluating and treating patients who present with a variety of pregnancy and postpartum health concerns. The triage area of a labor and delivery unit serves as an ED for pregnant and postpartum individuals. Individuals present to triage when they are experiencing contractions and want to know if they are in labor. They might also present with other urgent issues not appropriate for assessment in the clinic, such as severe headaches, nausea and vomiting, abdominal pain, or infection related to breastfeeding. When CNMs provide care in labor and delivery triage, this care falls under the category of “emergency services and care,” regulated by the state EMTALA provisions of state law. These sections are California’s core patient-protection laws for emergency care, and ensure people who need emergency services and care are not refused treatment or improperly transferred because of their ability to pay, insurance status, or other nonmedical reasons. Currently, this code section requires that non-physicians must act under physician supervision when providing emergency services and care, including consultation and stabilization. However, the state removed this requirement of physician supervision for CNMs in 2020, and this bill would update the law to reflect CNMs current practice authority.

SUPPORT AND OPPOSITION:

Support: California Nurse-Midwives Association (sponsor)

Access Reproductive Justice
American Nurses Association/California
Aria Medical
California Association for Nurse Practitioners
California Association of Nurse Anesthesiology
California Clinical Nurse Specialist Association

California Latinas for Reproductive Justice
California Women's Law Center
Gender Equity Policy Institute
March of Dimes
National Health Law Program
Nurses for Sexual & Reproductive Health
Reproductive Freedom for All California
Western Center on Law & Poverty, Inc.

Oppose: None received

-- END --

ASSEMBLY THIRD READING

ATR Bill Id:AB 1696

Author:(Stefani)

As Amended Ver:May 18, 2026

Majority vote

SUMMARY

Clarifies that a nurse-midwife, as specified, does not require physician supervision in the labor and delivery unit, obstetric triage, or dedicated emergency obstetric evaluation unit of a general acute care hospital when the nurse-midwife is providing emergency services and care within the scope of their authorized licensure, or when the nurse-midwife is specifically requested by the treating physician to provide obstetric consultation.

Major Provisions

COMMENTS

Certified Nurse-Midwives (CNMs) are licensed registered nurses (RNs) with additional training in the field of obstetrics and certification by the American Midwifery Certification Board or an equivalent program. As a result of their additional training, they are considered advanced practice RNs. As a result of that training, CNMs are also specifically authorized to perform midwifery services and attend cases of low-risk pregnancies and childbirth. CNMs provide midwifery and nursing services in many settings, including the home, birth centers, clinics, and hospitals. California CNMs currently attend approximately 14% of births in California but could provide greater health care access with workforce expansion. Nurse-midwifery is a mandated Medi-Cal benefit but access to midwifery care across the state is highly variable. They are a key component of the 2025 California Department of Health Care Services' Birthing Care Pathway Report, a comprehensive care model road map for Medi-Cal members at a time when California is facing a worsening shortage of obstetric providers and labor and delivery units are closing around the state.

According to a 2019 California Health Care Foundation report, "California's Midwives: How Scope of Practice Laws Impact Care," mandatory physician supervision decreases access to care by superficially limiting the ability of licensed providers to act at the top of their license. According to a 2020 Legislative Analysts' Office report (LAO report), "Analysis of California's Physician-Supervision Requirement for Certified Nurse-Midwives," physician supervision is not well-defined and "unlikely to improve patient safety and quality." The LAO report notes that,"
"physician supervision" does not mean the physician must do any of the following: be physically present; examine the patient or ever meet the patient; sign or review any charts; or oversee patient care in any way. The California state legislature responded in 2020 by passing SB 1237 (Dodd) Chapter 88, Statutes of 2020 which established the parameters for the independent scope for CNMs and defines when a nurse-midwife can collaborate or must refer care to a physician, eliminating direct physician supervision of CNMs, with clear statutory delineation of when physician involvement is required, as noted in existing law, above.

Emergency Medical Treatment and Labor Act (EMTALA). EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or "dumping" these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services to provide a medical screening and treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an Emergency Department (ED) and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is "stabilized" when the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result from the release or transfer of the patient.

Health and Safety Code (HSC) Section 1317 mirrors federal EMTALA requirements, stating that any patient who comes to an emergency department must receive an appropriate medical screening exam (MSE) regardless of insurance status and ability to pay, among other things. The MSE is used to determine if there is in fact a medical emergency. An MSE involves the same skills that are core to nurse-midwifery care in other settings: conducting a medical history, performing a physical exam, ordering labs or imaging, when indicated.

"Emergency services and care" (ESC) is a regulatory term indicating that hospitals are obligated to provide care when a patient presents to the ED; it is not defined by the acuity of patient status.

Nurse Assessments. Nurse-midwives currently provide ESC evaluating pregnant patients who arrive at the hospital seeking urgent care without an appointment. The patients who present for ESC fall into three buckets: emergency medical condition, non-emergency medical condition, and active labor. Existing nurse-midwife scope of practice already provides the framework to provide ESC appropriate to the skills, training and qualifications of the midwife. The physician supervision requirement in state EMTALA (HSC Section 1317.1) is unnecessary because nurse-midwives already have the level of physician involvement delineated in their scope of practice: policies and protocols signed by a physician, including delineation of "the parameters for consultation, collaboration, referral, and transfer of a patient's care." Patients evaluated to have emergency medical conditions are required to be immediately referred to a physician by Business and Professions Code (BPC) Section 2746.5 (h)(1).

Not every patient who comes to an ED presents with a medical emergency. If a patient presents with a medical emergency, this is not appropriate for nurse-midwifery care. For those who are not suffering a medical emergency but require care within CNM current scope of practice, the CNM serves as a critical part of the care team - allowing the physicians to focus their time on those patients whose acuity requires their care. For those patients who present with non-emergency issues, CNMs can and should provide this care as intended by SB 1237– with policies and protocols with physicians in place, but not mandatory physician supervision. This bill removes the physician supervision requirement stated in the health and safety code leaving intact the policies and procedures for physician involvement already specified in BPC Section 2746.5.

Labor and Delivery and Emergency Services. According to the California Hospital Association guidance regarding whether labor and delivery is considered an ED, "When and Where Does EMTALA Begin and End?" labor and delivery service is considered by the Centers for Medicaid and Medicare Services (CMS) to be a dedicated ED. Therefore, the labor and delivery service must comply with all of the EMTALA obligations. These include signage, central log, opening of medical records and on-call coverage, as well as policies for mental status exams, necessary stabilizing treatment and an appropriate transfer (if required) for any individual who presents to the department seeking or in need of examination or treatment for any emergency medical condition.

CMS guidance (clarifying policies related to the Responsibilities of Medicare-Participating Hospitals in Treating Individual with Emergency Medical Conditions, final rule) states that, "…we note that the proposed definition would encompass not only what is generally thought of as a hospital's "emergency room" but would also include other departments of hospitals, such as labor and delivery departments and psychiatric units of hospitals, if these departments provide emergency psychiatric or labor and delivery services, or both, or other departments that are held out to the public as an appropriate place to come for medical services on an urgent, nonappointment basis."

Disparities in maternity care. Midwives play a critical role in advancing health equity, particularly in perinatal and reproductive health. Black and Indigenous birthing people in California experience significantly higher rates of maternal morbidity and mortality compared to white patients, driven by structural racism, implicit bias, and unequal access to high-quality care. Midwifery care has been shown to reduce interventions such as cesarean birth, preterm birth, and low birth weight—outcomes that disproportionately affect these communities. By increasing access to midwives, this bill supports a model of care that improves clinical outcomes where disparities are most pronounced. Of note, the University of California, San Francisco Center for Health Equity recently included "access to midwifery care" as a strategy to improve person-centered care for Black birthing people.

According to the Author

California families deserve high-quality, evidence-based maternity care that improves outcomes while reducing unnecessary costs. The author states that despite leading the nation in health care innovation, we continue to see rising maternal morbidity, persistent racial disparities, and unsustainable spending. Evidence consistently shows that midwifery care improves outcomes, reduces unnecessary interventions, and lowers costs. However, outdated regulatory structures limit the ability of the health care system to fully utilize this proven model of care. The author contends that this bill addresses inconsistencies in existing law enabling a more efficient, equitable, and patient-centered maternity care system. The author concludes that by aligning policy with evidence, this bill will improve outcomes for families across California while advancing health equity and fiscal responsibility.

Arguments in Support

The California Nurse-Midwives Association (CNMA) is the sponsor of this bill and notes that Nurse-midwives are advanced practice clinicians who provide perinatal and reproductive health care. Most nurse-midwives provide direct patient care in hospital settings on labor and delivery units, evaluating and treating patients who present with a variety of pregnancy and postpartum health concerns. The triage area of a labor and delivery unit serves as an ED for pregnant and postpartum individuals. Individuals present to triage when they are experiencing contractions and want to know if they are in labor. They might also present with other urgent issues not appropriate for assessment in the clinic: severe headaches, nausea and vomiting, abdominal pain, or infection related to breastfeeding, for example. CNMA states that when nurse-midwives provide care in labor and delivery triage units, this care falls under the category of “emergency services and care” and is regulated by HSC Sections 1317-1317.10.4. This code ensures that people who need emergency services and care are not refused treatment or improperly transferred because of their ability to pay, insurance status, or other non-medical reasons. These sections are California's core patient-protection laws for emergency care, similar in purpose to the federal EMTALA law. Under Title 22 of the California Code of Regulations, "Emergency Department” means any location in a hospital licensed to provide emergency medical services where those services are provided - which includes hospital labor and delivery triage units. Pregnant and early postpartum individuals will typically be instructed to bypass the ED and go directly to labor and delivery triage units for their "emergency services and care." CNMA also notes that, currently, this code section requires that non-physicians must act under physician supervision when providing emergency services and care, including consultation and stabilization. However, the state removed the requirement of physician supervision for nurse-midwives in 2020 through SB 1237 (Dodd). This bill would update the Health and Safety Code to reflect nurse-midwives' current practice authority without physician supervision. CNMA concludes that this allows nurse-midwives and physicians to perform their work without unnecessary administrative barriers and is consistent with current California law for nurse-midwifery practice.

Arguments in Opposition

None to the current version of the bill.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, no state costs.

VOTES

ASM HEALTH: 15-1-0

YES: Bonta, Chen, Addis, Aguiar-Curry, Ahrens, Caloza, Carrillo, Mark González, Johnson, Patel, Patterson, Rogers, Schiavo, Sharp-Collins, Stefani

NO: Sanchez

ASM APPROPRIATIONS: 12-0-3

YES: Wicks, Hoover, Arambula, Calderon, Caloza, Fong, Mark González, Krell, Pacheco, Pellerin, Solache, Ta

ABS, ABST OR NV: Dixon, Muratsuchi, Tangipa

UPDATED

VERSION: May 18, 2026

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0003064

ASSEMBLY THIRD READING

ATR Bill Id:AB 1696

Author:(Stefani)

As Amended Ver:May 18, 2026

Majority vote

SUMMARY

Clarifies that a nurse-midwife, as specified, does not require physician supervision in the labor and delivery unit, obstetric triage, or dedicated emergency obstetric evaluation unit of a general acute care hospital when the nurse-midwife is providing emergency services and care within the scope of their authorized licensure, or when the nurse-midwife is specifically requested by the treating physician to provide obstetric consultation.

Major Provisions

COMMENTS

Certified Nurse-Midwives (CNMs) are licensed registered nurses (RNs) with additional training in the field of obstetrics and certification by the American Midwifery Certification Board or an equivalent program. As a result of their additional training, they are considered advanced practice RNs. As a result of that training, CNMs are also specifically authorized to perform midwifery services and attend cases of low-risk pregnancies and childbirth. CNMs provide midwifery and nursing services in many settings, including the home, birth centers, clinics, and hospitals. California CNMs currently attend approximately 14% of births in California but could provide greater health care access with workforce expansion. Nurse-midwifery is a mandated Medi-Cal benefit but access to midwifery care across the state is highly variable. They are a key component of the 2025 California Department of Health Care Services' Birthing Care Pathway Report, a comprehensive care model road map for Medi-Cal members at a time when California is facing a worsening shortage of obstetric providers and labor and delivery units are closing around the state.

According to a 2019 California Health Care Foundation report, "California's Midwives: How Scope of Practice Laws Impact Care," mandatory physician supervision decreases access to care by superficially limiting the ability of licensed providers to act at the top of their license. According to a 2020 Legislative Analysts' Office report (LAO report), "Analysis of California's Physician-Supervision Requirement for Certified Nurse-Midwives," physician supervision is not well-defined and "unlikely to improve patient safety and quality." The LAO report notes that,"
"physician supervision" does not mean the physician must do any of the following: be physically present; examine the patient or ever meet the patient; sign or review any charts; or oversee patient care in any way. The California state legislature responded in 2020 by passing SB 1237 (Dodd) Chapter 88, Statutes of 2020 which established the parameters for the independent scope for CNMs and defines when a nurse-midwife can collaborate or must refer care to a physician, eliminating direct physician supervision of CNMs, with clear statutory delineation of when physician involvement is required, as noted in existing law, above.

Emergency Medical Treatment and Labor Act (EMTALA). EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or "dumping" these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services to provide a medical screening and treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an Emergency Department (ED) and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is "stabilized" when the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result from the release or transfer of the patient.

Health and Safety Code (HSC) Section 1317 mirrors federal EMTALA requirements, stating that any patient who comes to an emergency department must receive an appropriate medical screening exam (MSE) regardless of insurance status and ability to pay, among other things. The MSE is used to determine if there is in fact a medical emergency. An MSE involves the same skills that are core to nurse-midwifery care in other settings: conducting a medical history, performing a physical exam, ordering labs or imaging, when indicated.

"Emergency services and care" (ESC) is a regulatory term indicating that hospitals are obligated to provide care when a patient presents to the ED; it is not defined by the acuity of patient status.

Nurse Assessments. Nurse-midwives currently provide ESC evaluating pregnant patients who arrive at the hospital seeking urgent care without an appointment. The patients who present for ESC fall into three buckets: emergency medical condition, non-emergency medical condition, and active labor. Existing nurse-midwife scope of practice already provides the framework to provide ESC appropriate to the skills, training and qualifications of the midwife. The physician supervision requirement in state EMTALA (HSC Section 1317.1) is unnecessary because nurse-midwives already have the level of physician involvement delineated in their scope of practice: policies and protocols signed by a physician, including delineation of "the parameters for consultation, collaboration, referral, and transfer of a patient's care." Patients evaluated to have emergency medical conditions are required to be immediately referred to a physician by Business and Professions Code (BPC) Section 2746.5 (h)(1).

Not every patient who comes to an ED presents with a medical emergency. If a patient presents with a medical emergency, this is not appropriate for nurse-midwifery care. For those who are not suffering a medical emergency but require care within CNM current scope of practice, the CNM serves as a critical part of the care team - allowing the physicians to focus their time on those patients whose acuity requires their care. For those patients who present with non-emergency issues, CNMs can and should provide this care as intended by SB 1237– with policies and protocols with physicians in place, but not mandatory physician supervision. This bill removes the physician supervision requirement stated in the health and safety code leaving intact the policies and procedures for physician involvement already specified in BPC Section 2746.5.

Labor and Delivery and Emergency Services. According to the California Hospital Association guidance regarding whether labor and delivery is considered an ED, "When and Where Does EMTALA Begin and End?" labor and delivery service is considered by the Centers for Medicaid and Medicare Services (CMS) to be a dedicated ED. Therefore, the labor and delivery service must comply with all of the EMTALA obligations. These include signage, central log, opening of medical records and on-call coverage, as well as policies for mental status exams, necessary stabilizing treatment and an appropriate transfer (if required) for any individual who presents to the department seeking or in need of examination or treatment for any emergency medical condition.

CMS guidance (clarifying policies related to the Responsibilities of Medicare-Participating Hospitals in Treating Individual with Emergency Medical Conditions, final rule) states that, "…we note that the proposed definition would encompass not only what is generally thought of as a hospital's "emergency room" but would also include other departments of hospitals, such as labor and delivery departments and psychiatric units of hospitals, if these departments provide emergency psychiatric or labor and delivery services, or both, or other departments that are held out to the public as an appropriate place to come for medical services on an urgent, nonappointment basis."

Disparities in maternity care. Midwives play a critical role in advancing health equity, particularly in perinatal and reproductive health. Black and Indigenous birthing people in California experience significantly higher rates of maternal morbidity and mortality compared to white patients, driven by structural racism, implicit bias, and unequal access to high-quality care. Midwifery care has been shown to reduce interventions such as cesarean birth, preterm birth, and low birth weight—outcomes that disproportionately affect these communities. By increasing access to midwives, this bill supports a model of care that improves clinical outcomes where disparities are most pronounced. Of note, the University of California, San Francisco Center for Health Equity recently included "access to midwifery care" as a strategy to improve person-centered care for Black birthing people.

According to the Author

California families deserve high-quality, evidence-based maternity care that improves outcomes while reducing unnecessary costs. The author states that despite leading the nation in health care innovation, we continue to see rising maternal morbidity, persistent racial disparities, and unsustainable spending. Evidence consistently shows that midwifery care improves outcomes, reduces unnecessary interventions, and lowers costs. However, outdated regulatory structures limit the ability of the health care system to fully utilize this proven model of care. The author contends that this bill addresses inconsistencies in existing law enabling a more efficient, equitable, and patient-centered maternity care system. The author concludes that by aligning policy with evidence, this bill will improve outcomes for families across California while advancing health equity and fiscal responsibility.

Arguments in Support

The California Nurse-Midwives Association (CNMA) is the sponsor of this bill and notes that Nurse-midwives are advanced practice clinicians who provide perinatal and reproductive health care. Most nurse-midwives provide direct patient care in hospital settings on labor and delivery units, evaluating and treating patients who present with a variety of pregnancy and postpartum health concerns. The triage area of a labor and delivery unit serves as an ED for pregnant and postpartum individuals. Individuals present to triage when they are experiencing contractions and want to know if they are in labor. They might also present with other urgent issues not appropriate for assessment in the clinic: severe headaches, nausea and vomiting, abdominal pain, or infection related to breastfeeding, for example. CNMA states that when nurse-midwives provide care in labor and delivery triage units, this care falls under the category of “emergency services and care” and is regulated by HSC Sections 1317-1317.10.4. This code ensures that people who need emergency services and care are not refused treatment or improperly transferred because of their ability to pay, insurance status, or other non-medical reasons. These sections are California's core patient-protection laws for emergency care, similar in purpose to the federal EMTALA law. Under Title 22 of the California Code of Regulations, "Emergency Department” means any location in a hospital licensed to provide emergency medical services where those services are provided - which includes hospital labor and delivery triage units. Pregnant and early postpartum individuals will typically be instructed to bypass the ED and go directly to labor and delivery triage units for their "emergency services and care." CNMA also notes that, currently, this code section requires that non-physicians must act under physician supervision when providing emergency services and care, including consultation and stabilization. However, the state removed the requirement of physician supervision for nurse-midwives in 2020 through SB 1237 (Dodd). This bill would update the Health and Safety Code to reflect nurse-midwives' current practice authority without physician supervision. CNMA concludes that this allows nurse-midwives and physicians to perform their work without unnecessary administrative barriers and is consistent with current California law for nurse-midwifery practice.

Arguments in Opposition

The California Chapter of the American College of Emergency Physicians (California ACEP), is opposed to this bill and states that, while it is intended to bring conformity with independent practice rights that were granted to CNMs by the passage of SB 667 (Dodd), Chapter 497, Statues of 2023, as drafted AB 1696 could have application in the ED. California ACEP notes that Section 2746.5 of the BPC as amended in 2023 by SB 667 grants independent practice to CNMs in low-risk situations. Specifically, subdivision (a) states: "the certificate to practice nurse-midwifery authorizes the holder to attend cases of low-risk pregnancy and childbirth" (emphasis added). It was not intended to grant CNMs independent practice in the ED. In fact, subdivision (h)(1) specifically states: "A certified nurse-midwife shall refer all emergencies to a physician and surgeon immediately." California ACEP contends that patients arrive at EDs with high-risk conditions. By its very definition, when a patient comes to an ED they are seeking emergency care. That care does not fall within the scope of independent practice contemplated or authorized by BPC Section 2746.5.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, no state costs.

VOTES

ASM HEALTH: 15-1-0

YES: Bonta, Chen, Addis, Aguiar-Curry, Ahrens, Caloza, Carrillo, Mark González, Johnson, Patel, Patterson, Rogers, Schiavo, Sharp-Collins, Stefani

NO: Sanchez

ASM APPROPRIATIONS: 12-0-3

YES: Wicks, Hoover, Arambula, Calderon, Caloza, Fong, Mark González, Krell, Pacheco, Pellerin, Solache, Ta

ABS, ABST OR NV: Dixon, Muratsuchi, Tangipa

UPDATED

VERSION: May 18, 2026

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0003064

ASSEMBLY THIRD READING

ATR Bill Id:AB 1696

Author:(Stefani)

As Amended Ver:March 16, 2026

Majority vote

SUMMARY

Clarifies that a nurse-midwife, as specified, does not require physician supervision when the nurse-midwife is providing emergency services and care within the scope of their authorized licensure.

Major Provisions

COMMENTS

Certified Nurse-Midwives (CNMs) are licensed registered nurses (RNs) with additional training in the field of obstetrics and certification by the American Midwifery Certification Board or an equivalent program. As a result of their additional training, they are considered advanced practice RNs. As a result of that training, CNMs are also specifically authorized to perform midwifery services and attend cases of low-risk pregnancies and childbirth. CNMs provide midwifery and nursing services in many settings, including the home, birth centers, clinics, and hospitals. California CNMs currently attend approximately 14% of births in California but could provide greater health care access with workforce expansion. Nurse-midwifery is a mandated Medi-Cal benefit but access to midwifery care across the state is highly variable. They are a key component of the 2025 California Department of Health Care Services' Birthing Care Pathway Report, a comprehensive care model road map for Medi-Cal members at a time when California is facing a worsening shortage of obstetric providers and labor and delivery units are closing around the state.

According to a 2019 California Health Care Foundation report, "California's Midwives: How Scope of Practice Laws Impact Care," mandatory physician supervision decreases access to care by superficially limiting the ability of licensed providers to act at the top of their license. According to a 2020 Legislative Analysts' Office report (LAO report), "Analysis of California's Physician-Supervision Requirement for Certified Nurse-Midwives," physician supervision is not well-defined and "unlikely to improve patient safety and quality." The LAO report notes that, "physician supervision" does not mean the physician must do any of the following: be physically present; examine the patient or ever meet the patient; sign or review any charts; or oversee patient care in any way. The California state legislature responded in 2020 by passing SB 1237 (Dodd) Chapter 88, Statutes of 2020 which established the parameters for the independent scope for CNMs and defines when a nurse-midwife can collaborate or must refer care to a physician, eliminating direct physician supervision of CNMs, with clear statutory delineation of when physician involvement is required, as noted in existing law, above.

Emergency Medical Treatment and Labor Act (EMTALA). EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or "dumping" these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services to provide a medical screening and treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an Emergency Department (ED) and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is "stabilized" when the patient's medical condition is such that, within reasonable medical probability, no material deterioration of the patient's condition is likely to result from the release or transfer of the patient.

Health and Safety Code (HSC) Section 1317 mirrors federal EMTALA requirements, stating that any patient who comes to an emergency department must receive an appropriate medical screening exam (MSE) regardless of insurance status and ability to pay, among other things. The MSE is used to determine if there is in fact a medical emergency. An MSE involves the same skills that are core to nurse-midwifery care in other settings: conducting a medical history, performing a physical exam, ordering labs or imaging, when indicated.

"Emergency services and care" (ESC) is a regulatory term indicating that hospitals are obligated to provide care when a patient presents to the ED; it is not defined by the acuity of patient status.

Nurse Assessments. Nurse-midwives currently provide ESC evaluating pregnant patients who arrive at the hospital seeking urgent care without an appointment. The patients who present for ESC fall into three buckets: emergency medical condition, non-emergency medical condition, and active labor. Existing nurse-midwife scope of practice already provides the framework to provide ESC appropriate to the skills, training and qualifications of the midwife. The physician supervision requirement in state EMTALA (HSC Section 1317.1) is unnecessary because nurse-midwives already have the level of physician involvement delineated in their scope of practice: policies and protocols signed by a physician, including delineation of "the parameters for consultation, collaboration, referral, and transfer of a patients care.” Patients evaluated to have emergency medical conditions are required to be immediately referred to a physician by Business and Professions Code (BPC) Section 2746.5 (h)(1).

Not every patient who comes to an ED presents with a medical emergency. If a patient presents with a medical emergency, this is not appropriate for nurse-midwifery care. For those who are not suffering a medical emergency but require care within CNM current scope of practice, the CNM serves as a critical part of the care team - allowing the physicians to focus their time on those patients whose acuity requires their care. For those patients who present with non-emergency issues, CNMs can and should provide this care as intended by SB 1237– with policies and protocols with physicians in place, but not mandatory physician supervision. This bill removes the physician supervision requirement stated in the health and safety code leaving intact the policies and procedures for physician involvement already specified in BPC Section 2746.5.

Labor and Delivery and Emergency Services. According to the California Hospital Association guidance regarding whether labor and delivery is considered an ED, “When and Where Does EMTALA Begin and End?”" labor and delivery service is considered by the Centers for Medicaid and Medicare Services (CMS) to be a dedicated ED. Therefore, the labor and delivery service must comply with all of the EMTALA obligations. These include signage, central log, opening of medical records and on-call coverage, as well as policies for mental status exams, necessary stabilizing treatment and an appropriate transfer (if required) for any individual who presents to the department seeking or in need of examination or treatment for any emergency medical condition.

CMS guidance (clarifying policies related to the Responsibilities of Medicare-Participating Hospitals in Treating Individual with Emergency Medical Conditions, final rule) states that, "…we note that the proposed definition would encompass not only what is generally thought of as a hospital's "emergency room" but would also include other departments of hospitals, such as labor and delivery departments and psychiatric units of hospitals, if these departments provide emergency psychiatric or labor and delivery services, or both, or other departments that are held out to the public as an appropriate place to come for medical services on an urgent, nonappointment basis."

Disparities in maternity care. Midwives play a critical role in advancing health equity, particularly in perinatal and reproductive health. Black and Indigenous birthing people in California experience significantly higher rates of maternal morbidity and mortality compared to white patients, driven by structural racism, implicit bias, and unequal access to high-quality care. Midwifery care has been shown to reduce interventions such as cesarean birth, preterm birth, and low birth weight—outcomes that disproportionately affect these communities. By increasing access to midwives, this bill supports a model of care that improves clinical outcomes where disparities are most pronounced. Of note, the University of California, San Francisco Center for Health Equity recently included "access to midwifery care" as a strategy to improve person-centered care for Black birthing people.

According to the Author

California families deserve high-quality, evidence-based maternity care that improves outcomes while reducing unnecessary costs. The author states that despite leading the nation in health care innovation, we continue to see rising maternal morbidity, persistent racial disparities, and unsustainable spending. Evidence consistently shows that midwifery care improves outcomes, reduces unnecessary interventions, and lowers costs. However, outdated regulatory structures limit the ability of the health care system to fully utilize this proven model of care. The author contends that this bill addresses inconsistencies in existing law enabling a more efficient, equitable, and patient-centered maternity care system. The author concludes that by aligning policy with evidence, this bill will improve outcomes for families across California while advancing health equity and fiscal responsibility.

Arguments in Support

The California Nurse-Midwives Association (CNMA) is the sponsor of this bill and notes that Nurse-midwives are advanced practice clinicians who provide perinatal and reproductive health care. Most nurse-midwives provide direct patient care in hospital settings on labor and delivery units, evaluating and treating patients who present with a variety of pregnancy and postpartum health concerns. The triage area of a labor and delivery unit serves as an ED for pregnant and postpartum individuals. Individuals present to triage when they are experiencing contractions and want to know if they are in labor. They might also present with other urgent issues not appropriate for assessment in the clinic: severe headaches, nausea and vomiting, abdominal pain, or infection related to breastfeeding, for example. CNMA states that when nurse-midwives provide care in labor and delivery triage units, this care falls under the category of "emergency services and care" and is regulated by HSC Sections 1317-1317.10.4. This code ensures that people who need emergency services and care are not refused treatment or improperly transferred because of their ability to pay, insurance status, or other non-medical reasons. These sections are California's core patient-protection laws for emergency care, similar in purpose to the federal EMTALA law. Under Title 22 of the California Code of Regulations, "Emergency Department" means any location in a hospital licensed to provide emergency medical services where those services are provided - which includes hospital labor and delivery triage units. Pregnant and early postpartum individuals will typically be instructed to bypass the ED and go directly to labor and delivery triage units for their "emergency services and care." CNMA also notes that, currently, this code section requires that non-physicians must act under physician supervision when providing emergency services and care, including consultation and stabilization. However, the state removed the requirement of physician supervision for nurse-midwives in 2020 through SB 1237 (Dodd). This bill would update the Health and Safety Code to reflect nurse-midwives' current practice authority without physician supervision. CNMA concludes that this allows nurse-midwives and physicians to perform their work without unnecessary administrative barriers and is consistent with current California law for nurse-midwifery practice.

Arguments in Opposition

The California Chapter of the American College of Emergency Physicians (California ACEP), is opposed to this bill and states that, while it is intended to bring conformity with independent practice rights that were granted to CNMs by the passage of SB 667 (Dodd), Chapter 497, Statues of 2023, as drafted AB 1696 could have application in the ED. California ACEP notes that Section 2746.5 of the BPC as amended in 2023 by SB 667 grants independent practice to CNMs in low-risk situations. Specifically, subdivision (a) states: "the certificate to practice nurse-midwifery authorizes the holder to attend cases of low-risk pregnancy and childbirth" (emphasis added). It was not intended to grant CNMs independent practice in the ED. In fact, subdivision (h)(1) specifically states: "A certified nurse-midwife shall refer all emergencies to a physician and surgeon immediately." California ACEP contends that patients arrive at EDs with high-risk conditions. By its very definition, when a patient comes to an ED they are seeking emergency care. That care does not fall within the scope of independent practice contemplated or authorized by BPC Section 2746.5.

FISCAL COMMENTS

According to the Assembly Appropriations Committee, no state costs.

VOTES

ASM HEALTH: 15-1-0

YES: Bonta, Chen, Addis, Aguiar-Curry, Ahrens, Caloza, Carrillo, Mark González, Johnson, Patel, Patterson, Rogers, Schiavo, Sharp-Collins, Stefani

NO: Sanchez

ASM APPROPRIATIONS: 12-0-3

YES: Wicks, Hoover, Arambula, Calderon, Caloza, Fong, Mark González, Krell, Pacheco, Pellerin, Solache, Ta

ABS, ABST OR NV: Dixon, Muratsuchi, Tangipa

UPDATED

VERSION: March 16, 2026

CONSULTANT: Lara Flynn / HEALTH / (916) 319-2097 FN: 0002440

Date of Hearing: April 29, 2026

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 1696

Author:(Stefani) – As Amended Ver:March 16, 2026

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

SUMMARY:

This bill specifies that a licensed nurse-midwife does not require physician supervision when the nurse-midwife is providing emergency services and care within the scope of their licensure.

FISCAL EFFECT:

No state costs.

COMMENTS:

1. Purpose. This bill is sponsored by the California Nurse-Midwives Association. According to the author:

California families deserve high-quality, evidence-based maternity care that improves outcomes while reducing unnecessary costs. Despite leading the nation in health care innovation, we continue to see rising maternal morbidity, persistent racial disparities, and unsustainable spending. Evidence consistently shows that midwifery care improves outcomes, reduces unnecessary interventions, and lowers costs. However, outdated regulatory structures limit the ability of the health care system to fully utilize this proven model of care. [This bill] addresses inconsistencies in existing law enabling a more efficient, equitable, and patient-centered maternity care system. By aligning policy with evidence, this bill will improve outcomes for families across California while advancing health equity and fiscal responsibility.

1. Background. Certified Nurse-Midwives (CNMs) are licensed registered nurses (RNs) with additional training in obstetrics and certification by the American Midwifery Certification Board or an equivalent program. As a result of their additional training, CNMs are considered advanced practice RNs and are specifically authorized to perform midwifery services and attend cases of low-risk pregnancies and childbirth. California CNMs attend approximately 14% of births in California but could provide greater health care access with workforce expansion.
   

According to a 2019 California Health Care Foundation report, mandatory physician supervision decreases access to care by limiting the ability of licensed providers to act at the top of their license. A 2020 Legislative Analysts' Office report (LAO report) asserted that physician supervision is not well-defined—it does not mean the physician must do any of the following: be physically present; examine or ever meet the patient; sign or review any charts; or oversee patient care in any way. The LAO report concluded physician supervision is unlikely to improve quality and patient safety.

The Legislature responded by passing SB 1237 (Dodd), Chapter 88, Statutes of 2020, which established the parameters for the independent scope for CNMs and defines when a nurse-midwife may collaborate or must refer care to a physician, eliminating direct physician supervision of CNMs, with clear statutory delineation of when physician involvement is required.

1. Opposition. The California Chapter of the American College of Emergency Physicians (California ACEP) writes in opposition that the statute that grants independent practice to CNMs to attend cases of low-risk pregnancy and childbirth was not intended to grant CNMs independent practice in the emergency department. California ACEP notes the statute states “A certified nurse-midwife shall refer all emergencies to a physician and surgeon immediately.”

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: April 14, 2026

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 1696

Author:(Stefani) – As Amended Ver:March 16, 2026

SUBJECT: Emergency services and care: nurse-midwives.

SUMMARY: Clarifies that a nurse-midwife, as specified, does not require physician supervision when the nurse-midwife is providing emergency services and care within the scope of their authorized licensure. Specifically, this bill: States that consistent with 1) through 17) of existing law, below, nothing in bill is to be construed to require physician supervision of a nurse-midwife when the nurse-midwife is providing emergency services and care within the scope of their licensure.

EXISTING LAW:

1. States that the certificate to practice nurse-midwifery authorizes the holder to attend cases of low-risk pregnancy and childbirth and to provide prenatal care, intrapartum care, and postpartum care, including immediate care for the newborn, interconception care, family planning care, and care for common gynecologic conditions, consistent with the Core Competencies for Basic Midwifery Practice adopted by the American College of Nurse-Midwives, or its successor national professional organization, as approved by the board. Defines, “low-risk pregnancy” to mean a pregnancy in which all of the following conditions are met:
   1. There is a single fetus;
   2. There is a cephalic (head down) presentation at onset of labor;
   3. The gestational age of the fetus is greater than or equal to 37 weeks and zero days and less than or equal to 42 weeks and zero days at the time of delivery;
   4. Labor is spontaneous or induced; and,
   5. The patient has no preexisting disease or condition, whether arising out of the pregnancy or otherwise, that adversely affects the pregnancy and that the certified nurse-midwife is not qualified to independently address. [Business and Professions Code (BPC) § 2746.5]
2. States that the certificate to practice nurse-midwifery authorizes the holder, pursuant to policies and protocols that are mutually agreed upon by a physician and surgeon, that delineate the parameters for consultation, collaboration, referral, and transfer of a patient’s care, and that are signed by both the certified nurse-midwife and a physician and surgeon, to do any of the following:
   1. Provide a patient with care that falls outside the scope of services specified in 1) above;
   2. Provide intrapartum care to a patient who has had a prior cesarean section or surgery that interrupts the myometrium (the muscular middle layer of the uterine wall); and,
   3. Furnish or order a Schedule II or III controlled substance, including for patients that fall within the scope of services specified in 1) above. [Ibid.]
3. Authorizes, if a physician and surgeon assumes care of the patient, the certified nurse-midwife to continue to attend the birth of the newborn and participate in physical care, counseling, guidance, teaching, and support, as indicated by the mutually agreed-upon policies and protocols signed by both the certified nurse-midwife and a physician and surgeon. [Ibid.]
4. Authorizes, after a certified nurse-midwife refers a patient to a physician and surgeon, the certified nurse-midwife to continue care of the patient during a reasonable interval between the referral and the initial appointment with the physician and surgeon. [Ibid.]
5. Requires, if a nurse-midwife does not have in place mutually agreed-upon policies and protocols that delineate the parameters for consultation, collaboration, referral, and transfer of a patient’s care, signed by both the certified nurse-midwife and a physician and surgeon pursuant to 2) above, the patient to be transferred to the care of a physician and surgeon to do either or both of the following:
   1. Provide a patient with care that falls outside the scope of services specified in 1) above; and/or;
   2. Provide intrapartum care to a patient who has had a prior cesarean section or surgery that interrupts the myometrium. [Ibid.]
6. Authorizes, if after the certified nurse-midwife initiates the process of transfer pursuant to 5) above, for a patient who otherwise meets the definition of a low-risk pregnancy but no longer meets the criteria specified in 1) above, because the gestational age of the fetus is greater than 42 weeks and zero days, if there is inadequate time to effect safe transfer to a hospital prior to delivery or transfer may pose a threat to the health and safety of the patient or the fetus, the certified nurse-midwife to continue care of the patient consistent with the transfer plan described in 18) below. [Ibid.]
7. Authorizes a patient who has been transferred from the care of a certified nurse-midwife to that of a physician and surgeon to return to the care of the certified nurse-midwife after the physician and surgeon has determined that the condition or circumstance that required, or would require, the transfer from the care of the nurse-midwife pursuant to 5) above is resolved. [Ibid.]
8. States that the certificate to practice nurse-midwifery authorizes the holder to attend pregnancy and childbirth in an out-of-hospital setting if consistent with the provisions of 1) above. [Ibid.]
9. Specifies that the provision above will not be interpreted to deny a patient’s right to self-determination or informed decision-making with regard to choice of provider or birth setting. [Ibid.]
10. States that the certificate to practice nurse-midwifery does not authorize the holder of the certificate to assist childbirth by vacuum or forceps extraction, or to perform any external cephalic version. [Ibid.]
11. Requires a certified nurse-midwife to document all consultations, referrals, and transfers in the patient record. [Ibid.]
12. Requires a certified nurse-midwife to refer all emergencies to a physician and surgeon immediately. [Ibid.]
13. Authorizes a certified nurse-midwife to provide emergency care until the assistance of a physician and surgeon is obtained. [Ibid.]
14. States that the provisions above do not authorize a nurse-midwife to practice medicine or surgery. [Ibid.]
15. States that the provisions above should not be construed to require a nurse-midwife to have mutually agreed-upon, signed policies and protocols for the provision of services described in 1) above. [Ibid.]
16. Authorizes, notwithstanding any other law, subject to the discretion of a general acute care hospital (GACH), as defined in 18) below, or a special hospital specified as a maternity hospital, as defined in 19) below, and the medical staff bylaws of that facility, a hospital may grant privileges to a certified nurse-midwife, allowing them to admit and discharge patients upon their own authority, within their scope of practice, and in accordance with organized medical staff bylaws of that facility. [Ibid.]
17. Requires a certified nurse-midwife to disclose in oral and written form to a patient as part of a patient care plan, among other things:
    1. The specific arrangements for the referral of complications to a physician and surgeon for consultation. Prohibits the certified nurse-midwife from being required to identify a specific physician and surgeon;
    2. 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 recommendations for preregistration at a hospital that has obstetric emergency services and is most likely to receive the transfer; and,
    3. If, during the course of care, the patient is informed that the patient has or may have a condition indicating the need for a mandatory transfer, the certified nurse-midwife to initiate the transfer. [BPC § 2746.54]
18. Defines a GACH to mean a health facility having a duly constituted governing body with overall administrative and professional responsibility and an organized medical staff that provides 24-hour inpatient care, including the following basic services: medical, nursing, surgical, anesthesia, laboratory, radiology, pharmacy, and dietary services. [Health and Safety Code (HSC) Section § 1250 (a)]
19. Defines a “special hospital” to mean a health facility having a duly constituted governing body with overall administrative and professional responsibility and an organized medical or dental staff that provides inpatient or outpatient care in dentistry or maternity. [HSC § 120 (f)]
20. Requires, in regulations, a perinatal unit of a hospital to provide:
    1. Care for the patient during pregnancy, labor, delivery and the postpartum period;
    2. Care for the normal infant and the infant with abnormalities which usually do not impair function or threaten life;
    3. Care for mothers and infants needing emergency or immediate life support measures to sustain life up to 12 hours or to prevent major disability; and,
    4. Formal arrangements for consultation and/or transfer of an infant to an intensive care newborn nursery, or a mother to a hospital with the necessary services, for problems beyond the capability of the perinatal unit. [California Code of Regulations, Title 22, Division 5, Article 6, Section 70547)
21. Requires emergency departments (EDs), under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) and also under similar provisions of state law (state EMTALA), to provide emergency screening and stabilization services without regard to the patient’s insurance status or ability to pay. Federal EMTALA imposes this requirement on any hospital that participates in Medicare. State EMTALA imposes this requirement on any hospital that operates an ED. [42 United States Code § 1395dd; HSC § 1317]
22. Defines “emergency services and care,” under state EMTALA, as medical screening, examination, and evaluation by a physician to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person’s license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. [HSC § 1317.1 (a)(1)]
23. Defines “emergency services and care,” under state EMTALA, to also mean an additional screening, examination, and evaluation by a physician, or other personnel to the extent permitted by the scope of their licensure and clinical privileges, to determine if a psychiatric emergency medical condition exists, and the care and treatment necessary to relieve or eliminate the psychiatric emergency medical condition, within the capability of the facility. Specifies that the care and treatment necessary to relieve or eliminate a psychiatric emergency medical condition may include admission or transfer to a psychiatric unit within a GACH, or to an acute psychiatric hospital. [HSC § 1317.1 (a)(2)]
24. Defines “emergency medical condition” to mean a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

a) Placing the patient’s health in serious jeopardy;

b) Serious impairment to bodily functions; or,

c) Serious dysfunction of any bodily organ or part. [HSC § 1317.1 (b)]

FISCAL EFFECT: Unknown. This bill has not been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, California families deserve high-quality, evidence-based maternity care that improves outcomes while reducing unnecessary costs. The author states that despite leading the nation in health care innovation, we continue to see rising maternal morbidity, persistent racial disparities, and unsustainable spending. Evidence consistently shows that midwifery care improves outcomes, reduces unnecessary interventions, and lowers costs. However, outdated regulatory structures limit the ability of the health care system to fully utilize this proven model of care. The author contends that this bill addresses inconsistencies in existing law enabling a more efficient, equitable, and patient-centered maternity care system. The author concludes that by aligning policy with evidence, this bill will improve outcomes for families across California while advancing health equity and fiscal responsibility.
2. BACKGROUND. Certified Nurse-Midwives (CNMs) are licensed registered nurses (RNs) with additional training in the field of obstetrics and certification by the American Midwifery Certification Board or an equivalent program. As a result of their additional training, they are considered advanced practice RNs. As a result of that training, CNMs are also specifically authorized to perform midwifery services and attend cases of low-risk pregnancies and childbirth. CNMs provide midwifery and nursing services in many settings, including the home, birth centers, clinics, and hospitals. California CNMs currently attend approximately 14% of births in California but could provide greater health care access with workforce expansion. Nurse-midwifery is a mandated Medi-Cal benefit but access to midwifery care across the state is highly variable. They are a key component of the 2025 California Department of Health Care Services’ Birthing Care Pathway Report, a comprehensive care model road map for Medi-Cal members at a time when California is facing a worsening shortage of obstetric providers and labor and delivery units are closing around the state.

According to a 2019 California Health Care Foundation report, “California’s Midwives: How Scope of Practice Laws Impact Care,” mandatory physician supervision decreases access to care by superficially limiting the ability of licensed providers to act at the top of their license. According to a 2020 Legislative Analysts’ Office report (LAO report), “Analysis of California’s Physician-Supervision Requirement for Certified Nurse-Midwives,” physician supervision is not well-defined and “unlikely to improve patient safety and quality.” The LAO report notes that, “physician supervision” does not mean the physician must do any of the following: be physically present; examine the patient or ever meet the patient; sign or review any charts; or oversee patient care in any way.

The California state legislature responded in 2020 by passing SB 1237 (Dodd) Chapter 88, Statutes of 2020 which established the parameters for the independent scope for CNMs and defines when a nurse-midwife can collaborate or must refer care to a physician, eliminating direct physician supervision of CNMs, with clear statutory delineation of when physician involvement is required, as noted in existing law, above.

• 1. EMTALA. EMTALA was passed to address the problem of hospitals refusing to treat indigent, uninsured, or Medicaid patients, or “dumping” these patients by transferring them to county hospitals or other charity hospitals. Federal EMTALA obligates Medicare-participating hospitals that offer emergency services to provide a medical screening and treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. State EMTALA imposes its obligation on any hospital that operates an ED, and has similar requirements to federal EMTALA. Hospitals are required to provide stabilizing treatment for patients with an emergency medical condition. A patient is “stabilized” when the patient’s medical condition is such that, within reasonable medical probability, no material deterioration of the patient’s condition is likely to result from the release or transfer of the patient.

Health and Safety code (HSC § 1317, existing law 22) above) mirrors federal EMTALA requirements, stating that any patient who comes to an emergency department must receive an appropriate medical screening exam (MSE) regardless of insurance status and ability to pay, among other things. The MSE is used to determine if there is in fact a medical emergency. An MSE involves the same skills that are core to nurse-midwifery care in other settings: conducting a medical history, performing a physical exam, ordering labs or imaging, when indicated.

“Emergency services and care” (ESC) is a regulatory term indicating that hospitals are obligated to provide care when a patient presents to the ED; it is not defined by the acuity of patient status.

• 1. Nurse Assessments. Nurse-midwives currently provide ESC evaluating pregnant patients who arrive at the hospital seeking urgent care without an appointment. The patients who present for ESC fall into three buckets: emergency medical condition, non-emergency medical condition, and active labor. Existing nurse-midwife scope of practice already provides the framework to provide ESC appropriate to the skills, training and qualifications of the midwife. The physician supervision requirement in state EMTALA (HSC § 1317.1) is unnecessary because nurse-midwives already have the level of physician involvement delineated in their scope of practice: policies and protocols signed by a physician, including delineation of “the parameters for consultation, collaboration, referral, and transfer of a patient’s care.” Patients evaluated to have emergency medical conditions are required to be immediately referred to a physician by BPC § 2746.5 (h)(1).

Not every patient who comes to an ED presents with a medical emergency. If a patient presents with a medical emergency, this is not appropriate for nurse-midwifery care. For those who are not suffering a medical emergency but require care within CNM current scope of practice, the CNM serves as a critical part of the care team - allowing the physicians to focus their time on those patients whose acuity requires their care. For those patients who present with non-emergency issues, CNMs can and should provide this care as intended by SB 1237– with policies and protocols with physicians in place, but not mandatory physician supervision. This bill removes the physician supervision requirement stated in the health and safety code leaving intact the policies and procedures for physician involvement already specified in BPC § 2746.5.

• 1. Labor and Delivery and Emergency Services. According to the California Hospital Association guidance regarding whether labor and delivery is considered an ED, “When and Where Does EMTALA Begin and End?” labor and delivery service is considered by the Centers for Medicaid and Medicare Services (CMS) to be a dedicated ED. Therefore, the labor and delivery service must comply with all of the EMTALA obligations. These include signage, central log, opening of medical records and on-call coverage, as well as policies for mental status exams, necessary stabilizing treatment and an appropriate transfer (if required) for any individual who presents to the department seeking or in need of examination or treatment for any emergency medical condition.

CMS guidance (clarifying policies related to the Responsibilities of Medicare-Participating Hospitals in Treating Individual with Emergency Medical Conditions, final rule) states that, “…we note that the proposed definition would encompass not only what is generally thought of as a hospital's “emergency room” but would also include other departments of hospitals, such as labor and delivery departments and psychiatric units of hospitals, if these departments provide emergency psychiatric or labor and delivery services, or both, or other departments that are held out to the public as an appropriate place to come for medical services on an urgent, nonappointment basis.”

• 1. Access to maternity care in California. Communities around California face a severe lack of access to reproductive health and maternity care. The California Hospital Association reports that between 2014 to 2024, more than 50 maternity units closed throughout the state. The maternity workforce shortage is one of three key drivers, with a projected shortage of 1,100 OB/GYNs in California by 2030. More recent data shows that there is a projected 20% shortage of OB/GYNs in California by 2035, which is considered “severely inadequate.” Demonstrating the real-world impact, data from 2022 demonstrates that 46,000 California women age 18 to 44 lived in counties with no hospitals with obstetrics care or birth centers, and an additional 76,000 lived in counties with only one hospital with obstetrics care or a birth center. Simultaneously, maternal mortality rates in the state remain unacceptably high, with approximately 80% thought to be preventable.
  2. Disparities in maternity care. Midwives play a critical role in advancing health equity, particularly in perinatal and reproductive health. Black and Indigenous birthing people in California experience significantly higher rates of maternal morbidity and mortality compared to white patients, driven by structural racism, implicit bias, and unequal access to high-quality care. Midwifery care has been shown to reduce interventions such as cesarean birth, preterm birth, and low birth weight—outcomes that disproportionately affect these communities. By increasing access to midwives, this bill supports a model of care that improves clinical outcomes where disparities are most pronounced. Of note, the UCSF Center for Health Equity recently included “access to midwifery care” as a strategy to improve person-centered care for Black birthing people.

1. SUPPORT. The California Nurse-Midwives Association (CNMA) is the sponsor of this bill and notes that Nurse-midwives are advanced practice clinicians who provide perinatal and reproductive health care. Most nurse-midwives provide direct patient care in hospital settings on labor and delivery units, evaluating and treating patients who present with a variety of pregnancy and postpartum health concerns. The triage area of a labor and delivery unit serves as an ED for pregnant and postpartum individuals. Individuals present to triage when they are experiencing contractions and want to know if they are in labor. They might also present with other urgent issues not appropriate for assessment in the clinic: severe headaches, nausea and vomiting, abdominal pain, or infection related to breastfeeding, for example.

CNMA states that when nurse-midwives provide care in labor and delivery triage units, this care falls under the category of “emergency services and care” and is regulated by California Health and Safety Code (HSC) §§ 1317-1317.10.4. This code ensures that people who need emergency services and care are not refused treatment or improperly transferred because of their ability to pay, insurance status, or other non-medical reasons. These sections are California’s core patient-protection laws for emergency care, similar in purpose to the federal EMTALA law. Under Title 22 of the California Code of Regulations, “Emergency Department” means any location in a hospital licensed to provide emergency medical services where those services are provided - which includes hospital labor and delivery triage units. Pregnant and early postpartum individuals will typically be instructed to bypass the ED and go directly to labor and delivery triage units for their “emergency services and care.”

CNMA also notes that, currently, this code section requires that non-physicians must act under physician supervision when providing emergency services and care, including consultation and stabilization. However, the state removed the requirement of physician supervision for nurse-midwives in 2020 through SB 1237 (Dodd). This bill would update the Health and Safety Code to reflect nurse-midwives’ current practice authority without physician supervision. CNMA concludes that this allows nurse-midwives and physicians to perform their work without unnecessary administrative barriers and is consistent with current California law for nurse-midwifery practice.

1. OPPOSE UNLESS AMENDED. The California Chapter of the American College of Emergency Physicians (California ACEP) is opposed to this bill unless it is amended to not apply in the ED. California ACEP states that Section 2746.5 of BPC grants independent practice to CNMs in low-risk situations. Specifically, subdivision (a) states: “the certificate to practice nurse-midwifery authorizes the holder to attend cases of low-risk pregnancy and childbirth.” California ACEP contends that it was not intended to grant CNMs independent practice in the ED. In fact, subdivision (h)(1) specifically states: “A certified nurse-midwife shall refer all emergencies to a physician and surgeon immediately.” California ACEP argues that patients arrive at EDs with high-risk conditions. By its very definition, when a patient comes to an ED they are seeking emergency care. That care does not fall within the scope of independent practice contemplated or authorized by B&P Code Section 2746.5. California ACEP explains that there are many valuable members of the health care team in EDs and that this model delivers effective care to millions of Californians because it is team-based and physician-supervised.
2. PREVIOUS LEGISLATION.
   1. SB 667 (Dodd) Chapter 497, Statutes of 2023 clarifies a CNM’s authority to treat and provide care for common gynecologic conditions; permits a CNM to admit or discharge a patient if a CNM has privileges at a general acute care hospital, as specified; clarifies that a CNM is a practitioner for purposes of certifying disability; and includes a CNMs as a laboratory director for purposes of performing specified laboratory tests, among other technical changes.
   2. SB 1237 (Dodd) Chapter 88, Statutes of 2020 established the parameters for the independent scope for certified nurse midwives and defines when a CNM can collaborate or must refer care to a physician.
   3. SB 520 (Caballero) Chapter 601, Statutes of 2025 creates the California Nurse-Midwifery Education (CNME) Fund in the Department of Health Care Access and Information (HCAI) for the purpose of establishing California-based, master’s level nurse-midwifery education programs. Requires HCAI to administer the fund, which will receive money from the General Fund upon appropriation.

REGISTERED SUPPORT / OPPOSITION:

Support

California Association of Nurse Midwives (sponsor)
Access Reproductive Justice

American Nurses Association/California

Aria Medical

California Association of Nurse Anesthesiology (CANA)

California Clinical Nurse Specialist Association

California Women's Law Center

Gender Equity Policy Institute (UNREG)

National Health Law Program

Nurses for Sexual & Reproductive Health

Reproductive Freedom for All California

Opposition

None on file

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097