BILL NUMBER: SB 350 CHAPTERED 10/11/93
BILL TEXT
CHAPTER 1280
FILED WITH SECRETARY OF STATE OCTOBER 11, 1993
APPROVED BY GOVERNOR OCTOBER 11, 1993
PASSED THE SENATE SEPTEMBER 9, 1993
PASSED THE ASSEMBLY SEPTEMBER 8, 1993
AMENDED IN ASSEMBLY SEPTEMBER 7, 1993
AMENDED IN ASSEMBLY SEPTEMBER 3, 1993
AMENDED IN ASSEMBLY AUGUST 24, 1993
AMENDED IN ASSEMBLY AUGUST 16, 1993
AMENDED IN SENATE JULY 1, 1993
AMENDED IN SENATE JUNE 22, 1993
AMENDED IN SENATE JUNE 16, 1993
AMENDED IN SENATE JUNE 7, 1993
AMENDED IN SENATE APRIL 15, 1993
AMENDED IN SENATE APRIL 1, 1993
INTRODUCED BY Senator Killea
(Coauthor: Senator Watson)
(Coauthors: Assembly Members Eastin, Ferguson, Karnette,
Lee, Solis, and Speier)
FEBRUARY 19, 1993
An act to repeal and add Article 24 (commencing with Section
2505) of Chapter 5 of Division 2 of the Business and Professions
Code, to amend Section 11512.07 of, and to add Section 10354
to, the Insurance Code, and to add Section 14132.39 to the
Welfare and Institutions Code, relating to midwifery, and making
an appropriation therefor.
LEGISLATIVE COUNSEL'S DIGEST
SB 350, Killea. Midwifery: licensure.
(1) Existing law provides for the certification of
nurse-midwives by the Board of Registered Nursing, and the
certification of midwives by the Division of Allied Health
Professions of the Medical Board of California.
This bill would repeal those provisions related to the
certification of midwives by the division and would enact the
Licensed Midwifery Practice Act of 1993.
The bill would specify the requirements for licensure as a
midwife and the authority of a midwife with respect to the scope
of the practice of midwifery.
The bill would require the Division of Licensing of the
Medical Board of California to issue a license to practice
midwifery to all applicants who meet certain requirements and
who pay a prescribed fee.
The bill would provide for the expiration and renewal of
licenses and would authorize the board to suspend or revoke a
license for certain reasons.
The bill would require all fees prescribed by the act to be
deposited into the Licensed Midwifery Fund, which would be
established by the bill and, upon appropriation, would be
available to the board for the purposes of the act.
The bill would provide that any person who violates the act
is guilty of a misdemeanor, thereby imposing a state-mandated
local program by creating a new crime.
(2) Existing law provides for the regulation of policies of
disability insurance and nonprofit hospital service plans, and
requires those plans and policies issued, amended, or renewed
after January 1, 1992, to offer coverage and direct
reimbursement for perinatal services provided by certified
nurse-midwives and nurse practitioners.
This bill would, in addition, require every policy of
disability insurance issued, amended, or renewed on or after
January 1, 1994, that offers coverage for perinatal services, to
contain a provision for direct reimbursement to licensed
midwives for perinatal services. It would also require
reasonable consideration, as defined, to be given to licensed
midwives by disability insurers contracting for services at
alternative rates.
The bill would appropriate $70,000 from the General Fund as a
loan to the Licensed Midwifery Fund for the purposes of this
act.
(3) Existing law provides for the Medi-Cal program, pursuant
to which medical benefits are provided to public assistance
recipients and certain other persons with low income. Under
existing law, nurse-midwifery services are covered under the
Medi-Cal program.
This bill would require that midwifery services provided by a
licensed midwife also be covered to the extent federal
financial participation is available.
(4) 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.
Appropriation: yes.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. The Legislature finds and declares all of the
following:
(a) Over 40,000 babies die every year in the United States,
many of them as a result of being born severely underweight.
That rate, among the worst in the developed world, has been
condemned by health experts as a preventable tragedy and a
national disgrace.
(b) Research has shown for every dollar society might spend
to reduce the number of underweight births, three dollars ($3)
in medical-care costs could be saved.
(c) The increasing state budget deficit limits the amounts of
state funds available to subsidize public health care.
(d) It is in agreement with the principle stated by the World
Health Organization that each woman has a fundamental right to
receive proper prenatal care, that the woman has a central role
in all aspects of this care, including participation in the
planning, carrying out, and evaluation of the care, and that
social, emotional, and psychological factors are decisive in the
understanding and implementation of proper prenatal care.
(e) Prenatal care reduces the incidence of low birth weights.
(f) The number of available physicians and surgeons to serve
low-income pregnant women has sharply decreased.
(g) Five nations with the lowest prenatal mortality rates
have 70 percent of all births attended by midwives.
(h) In a 1982 report by the Department of Consumer Affairs,
recommendations were made to actively promote nurse and nonnurse
midwifery services as one means of providing cost-effective,
comprehensive perinatal services which have been shown to be
effective in lowering perinatal morbidity and mortality rates.
(i) The Office of Statewide Health Planning and Development
(OSHPD) recommended in its 1986 study of Alternative Birthing
Methods that a separate category of licensed midwives should be
established in the Department of Consumer Affairs.
(j) The OSHPD further recommended that competencies for this
new category should be comparable to those of nurse-midwives and
physician assistant-midwives, although licensure as a
registered nurse or physician assistant should not be required
to become a licensed midwife.
(k) The Legislature supports a multifaceted, cost-effective
approach which includes licensed midwives providing prenatal,
delivery and necessary followup care to families.
SEC. 2. Article 24 (commencing with Section 2505) of Chapter 5
of Division 2 of the Business and Professions Code is repealed.
SEC. 3. Article 24 (commencing with Section 2505) is added to
Chapter 5 of Division 2 of the Business and Professions Code, to
read:
Article 24. Licensed Midwives
2505. This article shall be known and may be cited as the
Licensed Midwifery Practice Act of 1993.
2506. As used in this article the following definitions
shall apply:
(a) "Board" means the Division of Licensing of the Medical
Board of California.
(b) "Licensed midwife" means an individual to whom a license
to practice midwifery has been issued pursuant to this article.
(c) "Certified nurse-midwife" means a person to whom a
certificate has been issued pursuant to Article 2.5 (commencing
with Section 2746) of Chapter 6.
(d) "Accrediting organization" means an organization
recognized by the United States Department of Education,
Division of Accreditation.
2507. (a) The license to practice midwifery authorizes the
holder, under the supervision of a licensed physician and
surgeon, to attend cases of normal childbirth and to provide
prenatal, intrapartum, and postpartum care, including
family-planning care, for the mother, and immediate care for the
newborn.
(b) As used in this article, the practice of midwifery
constitutes the furthering or undertaking by any licensed
midwife, under the supervision of a licensed physician and
surgeon who has current practice or training in obstetrics, to
assist a woman in childbirth so long as progress meets criteria
accepted as normal. All complications shall be referred to a
physician immediately. The practice of midwifery does not
include the assisting of childbirth by any artificial, forcible,
or mechanical means, nor the performance of any version.
(c) As used in this article, "supervision" shall not be
construed to require the physical presence of the supervising
physician.
(d) The ratio of licensed midwives to supervising physicians
shall not be greater than four individual licensed midwives to
one individual supervising physician.
(e) A midwife is not authorized to practice medicine and
surgery by this article.
2508. (a) If a licensed midwife does not have liability
coverage for the practice of midwifery, he or she shall disclose
to a client that fact.
(b) A licensed midwife shall disclose to a client that a
specific physician is being briefed regularly concerning the
client's pregnancy and that the physician is prepared to take
care of complications in the hospital if necessary.
2511. (a) No person, other than one who has been licensed to
practice midwifery by the board, shall hold himself or herself
out as a licensed midwife, or use any other term indicating or
implying that he or she is a licensed midwife.
(b) Nothing in this article shall be construed to limit in
any manner the practice of an individual to whom a certificate
has been issued pursuant to Article 2.5 (commencing with Section
2746) of Chapter 6, or to prevent an individual to whom a
certificate has been issued pursuant to Article 2.5 (commencing
with Section 2746) of Chapter 6 from holding himself or herself
out as a certified nurse-midwife, nurse midwife, midwife, or
from using the initials "CNM."
2512. The board shall issue a license to practice midwifery
to all applicants who meet the requirements of this article and
who pay the fee required by Section 2520.
2512.5. A person is qualified for a license to practice
midwifery when he or she satisfies one of the following
requirements:
(a) (1) Successful completion of a three-year postsecondary
midwifery education program accredited by an accrediting
organization recognized by the United States Department of
Education, Division of Accreditation. Upon successful
completion of the education requirements of this article, the
applicant shall successfully complete a comprehensive licensing
examination adopted by the board which is equivalent, but not
identical, to the examination given by the American College of
Nurse Midwives.
(2) The midwifery education program curriculum shall consist
of not less than 84 semester units or 126 quarter units. The
course of instruction shall be presented in semester or quarter
units under the following formula:
(A) One hour of instruction in the theory each week
throughout a semester or quarter equals one unit.
(B) Three hours of clinical practice each week throughout a
semester or quarter equals one unit.
(3) The midwifery education program shall provide both
academic and clinical preparation equivalent, but not identical
to that provided in programs accredited by the American College
of Nurse Midwives, which shall include, but not be limited to,
preparation in all of the following areas:
(A) The art and science of midwifery, one-half of which shall
be in theory and one-half of which shall be in clinical
practice. Theory and clinical practice shall be concurrent in
the areas of maternal and child health, including, but not
limited to, labor and delivery, neonatal well care, and
postpartum care.
(B) Communications skills that include the principles of
oral, written, and group communications.
(C) Anatomy and physiology, genetics, obstetrics and
gynecology, embryology and fetal development, neonatology,
applied microbiology, chemistry, child growth and development,
pharmacology, nutrition, laboratory diagnostic tests and
procedures, and physical assessment.
(D) Concepts in psychosocial, emotional, and cultural aspects
of maternal and child care, human sexuality, counseling and
teaching, maternal and infant and family bonding process, breast
feeding, family planning, principles of preventive health, and
community health.
(E) Aspects of the normal pregnancy, labor and delivery,
postpartum period, newborn care, family planning or routine
gynecological care in alternative birth centers, homes, and
hospitals.
(F) The following shall be integrated throughout the entire
curriculum:
(i) Midwifery process.
(ii) Basic intervention skills in preventive, remedial, and
supportive midwifery.
(iii) The knowledge and skills required to develop collegial
relationships with health care providers from other disciplines.
(iv) Related behavioral and social sciences with emphasis on
societal and cultural patterns, human development, and behavior
related to maternal and child health, illness, and wellness.
(G) Instruction shall also be given in personal hygiene,
client abuse, cultural diversity, and the legal, social, and
ethical aspects of midwifery.
(H) The program shall include the midwifery management
process, which shall include all of the following:
(i) Obtaining or updating a defined and relevant data base
for assessment of the health status of the client.
(ii) Identifying problems based upon correct interpretation
of the data base.
(iii) Preparing a defined needs or problem list, or both,
with corroboration from the client.
(iv) Consulting, collaborating with, and referring to,
appropriate members of the health care team.
(v) Providing information to enable clients to make
appropriate decisions and to assume appropriate responsibility
for their own health.
(vi) Assuming direct responsibility for the development of
comprehensive, supportive care for the client and with the
client.
(vii) Assuming direct responsibility for implementing the
plan of care.
(viii) Initiating appropriate measures for obstetrical and
neonatal emergencies.
(ix) Evaluating, with corroboration from the client, the
achievement of health care goals and modifying the plan of care
appropriately.
(b) Successful completion of an educational program that the
board has determined satisfies the criteria of subdivision (a)
and current licensure as a midwife by a state with licensing
standards that have been found by the board to be equivalent to
those adopted by the board pursuant to this article.
2513. (a) An approved midwifery education program shall
offer the opportunity for students to obtain credit by
examination for previous midwifery education and clinical
experience. The applicant shall demonstrate, by practical
examination, the clinical competencies described in Section 2514
or established by regulation pursuant to Section 2514.5. The
midwifery education program's credit by examination policy shall
be approved by the board, and shall be available to applicants
upon request. The proficiency and practical examinations shall
be approved by the board.
(b) Completion of clinical experiences shall be verified by a
licensed midwife or certified nurse-midwife, and a physician
and surgeon, all of whom shall be current in the knowledge and
practice of obstetrics and midwifery. Physicians and surgeons,
licensed midwives, and certified nurse-midwives who participate
in the verification and evaluation of an applicant's clinical
experiences shall show evidence of current practice. The method
used to verify clinical experiences shall be approved by the
board.
(c) Upon successful completion of the requirements of
paragraphs (1) and (2), the applicant shall also complete the
licensing examination described in paragraph (1) of subdivision
(a).
2514. The midwifery education program shall prepare the
midwife to practice as follows:
(a) Management of the normal pregnancy.
(b) Management of normal labor and delivery in all birth
settings, including the following, when indicated:
(1) Administration of intravenous fluids, analgesics,
postpartum oxytocics, and RhoGAM.
(2) Amniotome during labor.
(3) Application of external or internal monitoring devices.
(4) Administration of local anesthesia, paracervical blocks,
pudendal blocks, and local infiltration.
(5) Episiotomy.
(6) Repair of episiotomies and lacerations.
(7) Resuscitation of the newborn.
(c) Management of the normal postpartum period.
(d) Management of the normal newborn care, including
administration of vitamin K and eye prophylaxis.
(e) Management of family planning and routine gynecological
care including barrier methods of contraception such as
diaphragms and cervical caps.
(f) This section shall remain in effect only until January 1,
1998, and as of that date is repealed, unless a later enacted
statute, which is enacted before January 1, 1998, deletes or
extends that date.
2514.5. (a) Within 60 days following January 1, 1998, the
board shall adopt regulations setting forth educational
requirements. To develop these regulations, the board shall
update the educational requirements set forth in Sections
2512.5, 2513, and 2514. These updated sections shall reflect
national standards for the practice of midwifery and shall be
subject to public hearings prior to adoption. The board shall
review and update the regulations every two years.
(b) The board shall adopt the written examination required by
this article by July 1, 1994.
2515. The board shall approve specific educational programs
intended to meet the requirements of subdivision (a) of Section
2512.5 and Section 2514 for the course of academic study,
documentation of experience and skill, and clinical evaluation.
These programs shall also be accredited by an accrediting
organization approved by the board.
2515.5. Each applicant shall show by evidence satisfactory
to the board that he or she has met the educational standards
established by the board pursuant to this article or the
equivalent thereof.
2517. A person who has been convicted of a misdemeanor
violation of Section 2052, prior to the effective date of this
article, shall not be barred from licensure under this article
solely because of that conviction.
2518. (a) Licenses issued pursuant to this article shall be
renewable every two years upon payment of the fee prescribed by
Section 2520 and submission of documentation that the
licenseholder has completed 36 hours of continuing education in
areas that fall within the scope of the practice of midwifery,
as specified by the board.
(b) Each license not renewed shall expire, but may be
reinstated within five years from the expiration upon payment of
the prescribed fee and upon submission of proof of the
applicant's qualifications as the board may require.
2519. The board may suspend or revoke the license of a
midwife for any of the following:
(a) Unprofessional conduct, which includes, but is not
limited to, all of the following:
(1) Incompetence or gross negligence in carrying out the
usual functions of a licensed midwife.
(2) Conviction of a violation of Section 2052, in which
event, the record of the conviction shall be conclusive evidence
thereof.
(3) The use of advertising which is fraudulent or misleading.
(4) Obtaining or possessing in violation of law, or
prescribing, or except as directed by a licensed physician and
surgeon, dentist, or podiatrist administering to himself or
herself, or furnishing or administering to another, any
controlled substance as defined in Division 10 (commencing with
Section 11000) of the Health and Safety Code or any dangerous
drug as defined in Article 8 (commencing with Section 4210) of
Chapter 9 of Division 2 of the Business and Professions Code.
(5) The use of any controlled substance as defined in
Division 10 (commencing with Section 11000) of the Health and
Safety Code, or any dangerous drug as defined in Article 8
(commencing with Section 4210) of Chapter 9 of Division 2 of the
Business and Professions Code, or alcoholic beverages, to an
extent or in a manner dangerous or injurious to himself or
herself, any other person, or the public or to the extent that
such use impairs his or her ability to conduct with safety to
the public the practice authorized by his or her license.
(6) Conviction of a criminal offense involving the
prescription, consumption, or self-administration of any of the
substances described in paragraphs (4) and (5), or the
possession of, or falsification of, a record pertaining to, the
substances described in paragraph (4), in which event the record
of the conviction is conclusive evidence thereof.
(7) Commitment or confinement by a court of competent
jurisdiction for intemperate use of or addiction to the use of
any of the substances described in paragraphs (4) and (5), in
which event the court order of commitment or confinement is
prima facie evidence of such commitment or confinement.
(8) Falsifying, or making grossly incorrect, grossly
inconsistent, or unintelligible entries in any hospital,
patient, or other record pertaining to the substances described
in subdivision (a).
(b) Procuring a license by fraud or misrepresentation.
(c) Conviction of a crime substantially related to the
qualifications, functions, and duties of a midwife, as
determined by the board.
(d) Procuring, aiding, abetting, attempting, agreeing to
procure, offering to procure, or assisting at, a criminal
abortion.
(e) Violating or attempting to violate, directly or
indirectly, or assisting in or abetting the violation of, or
conspiring to violate any provision or term of this chapter.
(f) Making or giving any false statement or information in
connection with the application for issuance of a license.
(g) Impersonating any applicant or acting as proxy for an
applicant in any examination required under this chapter for the
issuance of a license or a certificate.
(h) Impersonating another licensed practitioner, or
permitting or allowing another person to use his or her license
or certificate for the purpose of providing midwifery services.
(i) Aiding or assisting, or agreeing to aid or assist any
person or persons, whether a licensed physician or not, in the
performance of or arranging for a violation of any of the
provisions of Article 12 (commencing with Section 2221) of
Chapter 5.
2520. (a) (1) The fee to be paid upon the filing of a
license application shall be fixed by the board at not less than
seventy-five dollars ($75) nor more than three hundred dollars
($300).
(2) The fee for renewal of the midwife license shall be fixed
by the board at not less than fifty dollars ($50) nor more than
two hundred dollars ($200).
(3) The delinquency fee for renewal of the midwife license
shall be 50 percent of the renewal fee in effect on the date of
the renewal of the license, but not less than twenty-five
dollars ($25) nor more than fifty dollars ($50).
(4) The fee to be paid for the licensing examination shall be
fixed by the board at not less than two hundred dollars ($200)
nor more than three hundred fifty dollars ($350).
(b) The fees prescribed by this article shall be deposited in
the Licensed Midwifery Fund, which is hereby established, and
shall be available, upon appropriation, to the board for the
purposes of this article.
2521. Any person who violates this article is guilty of a
misdemeanor.
SEC. 4. Section 10354 is added to the Insurance Code, to read:
10354. (a) (1) Every policy of disability insurance issued,
amended, or renewed on or after January 1, 1994, that offers
coverage for perinatal services shall contain a provision for
direct reimbursement to licensed midwives for perinatal services
rendered under terms and conditions as may be agreed upon
between the policyholder and the insurer.
(2) The licensed midwife may collect payment for any unpaid
portion of his or her fee, as provided under the policy for
other providers.
(3) Reasonable consideration shall be given to licensed
midwives by disability insurers contracting for services at
alternative rates. For the purposes of this section,
"reasonable consideration" shall have the meaning provided in
Section 10180.
(b) For purposes of this section, "direct reimbursement"
means that after the policyholder files a claim for the
perinatal service provided under those terms and conditions as
may be agreed upon between the policyholder and the insurer, the
insurer pays the licensed midwife directly.
SEC. 5. Section 11512.07 of the Insurance Code is amended to
read:
11512.07. (a) (1) Every nonprofit hospital service plan
contract issued, amended, or renewed on or after January 1,
1992, that offers coverage for perinatal services shall contain
a provision providing for direct reimbursement to certified
nurse-midwives and nurse practitioners for perinatal services.
(2) Every nonprofit hospital service plan contract issued,
amended, or renewed on or after January 1, 1994, that offers
coverage for perinatal services shall contain a provision
providing for direct reimbursement to licensed midwives for
perinatal services.
(3) The certified nurse-midwife, licensed midwife, or nurse
practitioner may collect payment for any unpaid portion of his
or her fee as provided for under the plan for other providers.
(b) For purposes of this section, "direct reimbursement"
means that after the enrollee files a claim for the perinatal
service provided by the certified nurse-midwife or nurse
practitioner, the plan pays the certified nurse-midwife or nurse
practitioner directly.
(c) This section shall not be construed as requiring payment
from individual recipients where prohibited by federal law or
the state Medicaid plan.
SEC. 6. Section 14132.39 is added to the Welfare and
Institutions Code, to read:
14132.39. Midwifery services provided by a licensed midwife
shall be covered under this chapter, to the extent that federal
financial participation is available, and, subject to
utilization controls.
SEC. 7. The sum of seventy thousand dollars ($70,000) is
hereby appropriated from the General Fund to the Licensed
Midwifery Fund, for the purposes of this act, which sum shall be
a loan to be repaid to the General Fund with interest at the
rate earned by moneys invested in the Pooled Money Investment
Account. The entire sum plus interest shall be repaid by
January 1, 1999.
All moneys repaid shall be from funds collected pursuant to
the Licensed Midwifery Practice Act of 1993.
SEC. 8. No reimbursement is required by this act pursuant to
Section 6 of Article XIIIB of the California Constitution
because the only costs which may be incurred by a local agency
or school district will be incurred because this act creates a
new crime or infraction, changes the definition of a crime or
infraction, changes the penalty for a crime or infraction, or
eliminates a crime or infraction. Notwithstanding Section 17580
of the Government Code, unless otherwise specified in this act,
the provisions of this act shall become operative on the same
date that the act takes effect pursuant to the California
Constitution.