SB 1237 - The Justice & Equity in Maternity Care Act (Dodd/Burke/Mitchell)

SB1237 Factsheet:

CNM Research for SB1237:

LEARN ABOUT SB1237

Read FAQ About the Bill

 

SB 1237 the Justice and Equity in Maternity Care Act will increase access to high-value, high-quality maternal health care and improve maternal and newborn health outcomes during a time in which California faces a critical obstetrician shortage and significant race-based disparities in maternal and infant outcomes.

According to the American College of Obstetricians and Gynecologist's study, at least 9 counties have no OB/GYN at all. Recent studies have also noted that large counties in Northern and Southern CA are projected to have critical shortages of maternal health care providers by 2025. Certified Nurse-midwives (CNM) are experienced women's health practitioners who are already filling this shortage gap and are poised to do much more. At the present time, CNMs attend at least 50,000 births in California annually.

 

Countless studies show that midwifery care decreases the rates of the following, thus also significantly reducing costs:

  • newborn admissions to neonatal intensive care units

  • cesarean births

  • severe perineal trauma (birth trauma)

  • severe blood loss

  • preterm births

  • newborns with low birth weight

 

SB 1237 would address these issues by updating the physician permission to practice requirement and replacing it with language that promotes collaboration and team-based care. This would allow California to join 46 other states in creating innovative strategies to improve maternal and newborn wellbeing.

Have additional questions? See our FAQ below: 

Background

Bill Sponsors:

What do Nurse-Midwives Do?

What is the Aim of This Bill?

What is Physician Supervision?

Why is Physician Supervision a Problem?

How Does this Bill Impact Access to Community birth?

What is the scope of practice outlined in the bill and how will it affect access to community birth for birthing people with common antenatal conditions like obesity,  being over 40, or who have received IVF in order to conceive?

How Does This Bill Impact Access to VBAC/TOLAC?

Is the requirement for mutually agreed upon guidelines/protocols for the care of moderate or higher risk patients the same as needing a collaborative practice agreement?

Why is this bill including scope in the statute?

What is the Data that supports this bill?

Access Data

Equity Data

Outcomes Data

Cost Savings Data

How is Midwifery Regulated in California?:

Certified-Nurse Midwives (CNMs):

Licensed Midwives (LMs):

How does this bill impact Licensed Midwives (LM) practice?

I’ve heard a lot about Doulas, are midwives and Doulas the same?

 

Background

 

Bill Sponsors:

California Nurse-Midwives Association
Black Women for Wellness Action Project

NARAL Pro-Choice California

United Nurses Association of California (UNAC)

 

What do Nurse-Midwives Do?

Nurse Midwives provide reproductive health care, prenatal, pregnancy, labor, and postpartum care, and immediate care of the newborn. Nurse-Midwives in California attend 50,000 births per year, the most of any state, and are primed to expand access to maternal health care. 

 

What is the Aim of This Bill?

The aim of this bill is to remove physician supervision for Nurse-Midwives.  

 

What is Physician Supervision? 

There is no legal definition of physician supervision! It is just physician permission to practice. Because there is a lack of legal definition, some MDs are afraid to provide “supervision” when they don’t know what this means. Others may want to provide supervision and are not allowed to by their malpractice insurance and/or their employer.

 

Why is Physician Supervision a Problem?

First, studies have shown that supervision does not improve safety of quality of care. The only thing supervision, or permission to practice, does is put CNM practices both in the hospital and in the community at risk. When friendly MDs retire or move it means CNM practice in the hospital, birth center or home are at risk of being closed. We have heard from CNMs around the state that this could happen to them at any time. This also means that new and innovative CNMs practices, in hospitals, clinics and the community setting are very difficult to open because CNM practices are restricted to places where physicians are already in practice. California has 9 counties with no maternity care provider!! We know that removing physician supervision will help increase access to midwifery care in these “maternity care deserts”. We also know that removing physician supervision will increase access to midwifery-led care in hospitals, clinics, birth centers and homes.  As things are right now, CNMs move to other states to practice because supervision prevents them practicing here, or they simply work as an RN because finding CNM opportunities are restricted. 

 

How Does this Bill Impact Access to Community birth?

 

It will increase access to community birth as more CNMs will be able to open practices in rural and health provider shortage areas, and remain in practice if they are at risk of losing physician supervision. Studies show it will also increase access to midwifery-led care in hospital settings. It will also help to create more integration between community birth settings and hospital settings because midwives will be able to help bridge these connections. 

 

What is the scope of practice outlined in the bill and how will it affect access to community birth for birthing people with common antenatal conditions like obesity,  being over 40, or who have received IVF in order to conceive? 

It will improve access to community birth for all people including people who are over 40, obese and/or who have received IVF. The language in the bill that describes almost the same as the language that LMs currently have, but slightly more flexible. LMs have told us that they are not currently excluding from their practice people who are over the age of 40, have received IVF, or are obese.

 

In fact the language in SB 1237 does more to protect people seeking out of hospital birth.

Language from LM's statute can be seen here

  • There is an absence of any preexisting maternal disease or condition likely to affect the pregnancy.

  • There is an absence of significant disease arising from the pregnancy.

  • If a potential client does not meet criteria the criteria above and still wishes to be a client of the midwife, the midwife must provide the woman with a referral for an examination by a physician trained in obstetrics and gynecology. If the physician determines that the risk factors presented by the client's disease or condition are not likely to significantly affect the course of pregnancy and childbirth, then the midwife may assist the woman in pregnancy and childbirth.

CNMA's proposed bill language (as of June 19, 2020)

The following is the scope  presented in SB 1237:

  • The certificate to practice nurse-midwifery allows the nurse-midwife to attend cases low-risk pregnancy and childbirth and to provide prenatal, intrapartum, and postpartum care, including, family-planning services, interconception care, and immediate care for the newborn, 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. Low-risk pregnancy means:

    • (1) There is a single fetus.

    • (2) There is a cephalic 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.

    • (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 pursuant to this section.

  • Additionally: the nurse-midwife may collaboratively manage (co-manage) patients with moderate and higher risk conditions with agreed upon guidelines, mutually developed by a physician and nurse-midwife that delineate the parameters for consultation, collaboration, and referral/transfer. This is in alignment with ACNM Standards for the Practice of Midwifery.

  • Furnishing: the amended bill language has removed the necessity for Standardized Procedures for furnishing of medications within our scope! This is a huge advancement in the bill! (this does not include scheduled medications, AKA narcotics; these still require standardized procedures)

  • The bill also codifies the Nurse-Midwifery Advisory Committee (the advisory committee to BRN that is already established and already advises on nurse-midwifery practice) and ensures that CNMs are the majority member of this committee 

How Does This Bill Impact Access to VBAC/TOLAC?

Evidence shows that integration of midwives improves access to VBAC. Increasing access to Nurse-Midwives throughout California will decrease our cesarean rate and increase access to VBAC/TOLAC. CNMs, in any practice setting, can still care for clients who desire TOLAC, and TOLAC can still be attempted in any setting. The bill states that CNMs can care for prenatal clients who intend to TOLAC and can do so completely independently. However, intrapartum care of these clients with previous cesarean requires mutually developed guidelines between a physician(s) and CNM.

Is the requirement for mutually agreed upon guidelines/protocols for the care of moderate or higher risk patients the same as needing a collaborative practice agreement?

Absolutely not. Collaborative practice agreements are effectively no different than supervision. We were careful to NOT include such a requirement in the bill. In states that to have collaborative practice agreements, it means that CNMs must have a signed agreement with a physician in order to practice at all, even if they are functioning completely within their scope of practice and regardless of practice setting. Written guidelines for care that are mutually developed between a physician(s) and CNM in order to guide care and co-management of moderate and higher risk patients are NOT THE SAME as a collaborative practice agreement and should not be characterized as such. The ACNM Standards of Midwifery Practice uphold mutually developed, written guidelines for care as the gold standard. 

 

If I am practicing within the delineated scope in the bill, will I need the signed guidelines or standardized procedures for furnishing. 

No. Legally, CNMs functioning within the scope described above (including for family planning care and interconception - AKA interpregnancy - care) can function with full independence, even with the ability to prescribe for conditions that fall within this scope (such as contraceptives, antibiotics for STIs, etc) WITHOUT the need for signed Standardized Procedures or collaboratively developed guidelines. Only if the CNM desires to see more moderate or higher risk clients (meaning, outside of the scope above), is it necessary to have mutually developed guidelines, and Standardized Procedures for prescribing for those co-managed conditions.

 

Why is this bill including scope in the statute? 

This is our 4th time bringing a bill. Every time we bring this bill The American College of Obstetrics and Gynecologist and the California Medical Association (CMA) fights to include this language in our bill. 


We cannot remove physician supervision without including this language. Additionally we took careful steps to make the bill effectively reflect how CNMs practice now, independently within a certain scope and then collaborate with physician if and when necessary so birthing people get the appropriate level of care when and if they need it.

What is the Data that supports this bill? 

Analysis of California's Physician Supervision Requirement for Certified Nurse-Midwives - A Report from Legislative Analyst’s Office

 

The Legislative Analyst’s Office published a report on March 11, 2020 which states that 

  • The physician supervision requirement is unlikely to significantly improve safety and quality.

  • The physician supervision requirement potentially is a factor contributing to limited access and raising costs for nurse‑midwife services. 

  • Removing the physician supervision requirement could increase access and promote cost‑effectiveness.

  • Ultimately the report recommends the legislature consider removing the physician supervision requirement, and add other safeguards (which are addressed in SB 1237)


 

Access Data

  • 9 counties have no OB/GYN at all and 19 counties have 5 or fewer OB-GYNs.

    • Modoc, Trinity, Glenn, Colusa, Sierra, Yuba, Mono, Alpine, Mariposa 

  • Physician supervision requirements concentrate nurse-midwives in geographic areas where physicians physically practice, reducing access, and worsening “maternity deserts” and health provider shortage areas. 

  • Nurse-midwives have traditionally cared for marginalized communities and go where there is greatest need - studies show that while midwives attend approximately 10% of births in CA, they  attend approximately 30% of births in rural areas.

  • States where midwives have independent practice have a higher proportion of rural hospitals with CNM-attended births.

  • There has been no increase in the number of OB-GYNs trained since 1980 despite a projected increase of 22% in California’s female population by 2030.

  • States with regulations that support independent practice have a larger CNM workforce, and a greater proportion of CNM-attended births.

  • The single best predictor of distribution of nurse-midwives in a state is the degree to which midwifery practice is restricted.

  • Specifically in California, compared to primary care physicians, nurse-midwives have a greater proportion of members in rural and health provider shortage areas.

 

Equity Data

  • Currently, the United States is the most dangerous place to give birth in the developed world. While California has made great strides to reduce maternal mortality, we still have rates of maternal and infant mortality and morbidity far higher than other countries with similar wealth. These rates are even further exacerbated for black women, who are 3 to 4 times more likely to die from pregnancy-related causes than white women, and black babies who are 4 times more likely to die before their first birthday.

  • Black Women Birthing Justice report “Battling Over Birth: Black Women & The Maternal Health Care Crisis in California” found Black women identify increased access to the midwifery care as one of the key interventions to solving the Black maternal and infant mortality and morbidity health crisis in California. 

  • Strong Start for Mothers and Newborns study found:that the Midwives’ model of care enhanced with peer counseling for additional support and referrals resulted in cost savings of Costs $2,010 lower through birth and year following for each mother-infant pair while also improving outcomes in a medicaid/CHIP beneficiary population (39.8% of women were black;29.7% were Hispanic; 25.6%were white.)  

    • Lower rates of preterm birth 

    • Lower rates of low birthweight

    • Lower rates of C-section

    • Higher rates of VBAC

    • Fewer infant emergency department visits and hospitalizations

  • Birth Place Lab: found that overall integration of midwives into maternity care is correlated with improved outcomes. They also found lack of integration of midwives in the states with the highest rates of black births and highest rates of neonatal mortality. Their analysis shows race accounts for 35% of the difference in neonatal deaths and integration of midwives almost 12%. Improving access to and integration of midwives in these states could have powerful positive benefits for African American families.

 

Outcomes Data

  • Women in states with independent nurse-midwifery practice have lower odds of cesarean delivery, preterm birth, and low birth weight infants.

  • States that promote and integrate midwives into their systems of care have:

    • significantly higher rates of spontaneous vaginal delivery, vaginalbirth after cesarean, and breastfeeding 

    • significantly lower rates of cesarean, preterm birth, low birth weight infants, and neonatal death.

  • Conversely, states with the most restrictive practice environments for nurse-midwives (e.g. less independent practice, restricted scope of practice) score worse on critical maternal and infant health indicators(cesarean, preterm birth, neonatal mortality).

 

Cost Savings Data 

  • A study supported by the California Health Care Foundation shows that increasing the percentage of low-risk pregnancies with midwife-led care from the current level of about 9 percent to 20 percent over the next 10 years could result in $4 billion in cost savings and 30,000 fewer preterm births.

  • Economic analyses demonstrate the feasibility of removal of supervision as a realistic method of reducing the maternity workforce shortage while simultaneously increasing health care savings.

  • CNMs currently do at least 50,000 births in California.  If we are able to pass SB 1237 and scale up midwifery, the results will be profound in terms of access to care, cesarean reduction, maternal morbidity and mortality, and cost savings.

 

How is Midwifery Regulated in California?:

There are currently two kinds of midwives that practice legally in California (1) Licensed Midwives and (2) Certified Nurse-Midwives. 

 

Certified-Nurse Midwives (CNMs):

Licensure & State Regulation: CNMs are regulated by the Board of Registered Nursing in California. You can see the current statute here

Physician Supervision: CNMs currently require “physician supervision” in order to practice.  

Training: CNMs train almost exclusively in the hospital-setting, although some CNM programs ensure that CNMs are able to train in the home and birth center setting, this is not always available for all CNM students. CNMs who practice in the community setting typically apprentice in home and birth centers before, after and during their CNM training. 

 

Practice Locations: 95% of CNMs in California practice in the hospital setting, a large number also provide care in community health clinics. A much smaller, but not insignificant number provide care in home and birth center settings. 

 

Licensed Midwives (LMs):

Licensure & State Regulation: LMs are regulated by the Medical Board of California. You can read an overview of the laws that pertain to LMs in the Medical Board Website Here.

 

Physician Supervision:  Until 2013 all LMs were required to have “Physician Supervision”. This was thankfully removed in 2013! In removing physician supervision the LMs that worked on that legislation accepted some language around scope of practice into their bill. 

 

Training: LMs train almost exclusively in the home and birth center setting and complete education in an accredited post-secondary midwifery education program. (There are some midwives who have been practicing since before there were specific education program requirements that may have fulfilled their education requirements in another way). Their training prepares them to be experts in community birth.

 

Practice Locations: The overwhelming majority of LMs in California practice in home and birth center settings. There are a handful of LMs that practice in community health clinics. It is legal for them to practice in hospital settings but it is uncommon.

 

How does this bill impact Licensed Midwives (LM) practice? 

It doesn’t change anything about LM practice. It doesn’t change the law that governs LMs. LM’s removed physician supervision in 2013, with their own bill (AB 1308). This bill is only focused on removing physician supervision for Nurse-Midwives, and nothing in the bill makes any changes whatsoever to how LMs practice.  It may help LMs in community practice to have better transfer agreements with hospitals that have midwifery-led practices.

 

I’ve heard a lot about Doulas, are midwives and Doulas the same? 


No. Doulas are an integral part of the care team, but not the same as midwives. A doula is trained to provide non-clinical emotional, physical, and informational support for women before, during, and after childbirth. Doulas can also provide support during miscarriages and abortions. Midwives have specialized training in the care of pregnancy, labor, postpartum and newborn care and sexual and reproductive health care. Find out more about training for midwives above.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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