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

SB1237 Factsheet:

CNM Research for SB1237:

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 racism-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:

 

FAQ

Background

Who are the Bill Sponsors?

Who supports the bill?

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?

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?

More detailed FAQs about the bill

Are “mutually agreed upon guidelines/protocols” the same as a collaborative practice agreement?

Are there data reporting requirements in this bill?

If a midwife is practicing within the delineated scope in the bill, will they need the signed guidelines or standardized procedures for furnishing?

How does this bill impact access to VBAC/TOLAC?

Does this bill change nurse-midwifery scope to include abortion?

Will the bill have a disparate impact on BIPOC, LGBTQI+, Low-Income and/or Medi-cal insured folks?

How does the bill compare to the Statute for Licensed Midwives and how does it impact practice for Licensed Midwives?

I’ve read that Californian’s for the Advancement of Midwifery has concerns about the bill, do you address them anywhere?

I’ve read that CALM has concerns about the bill, do you address them anywhere?


 

Background

Who are the Bill Sponsors?

California Nurse-Midwives Association
Black Women for Wellness Action Fund

NARAL Pro-Choice California

United Nurses Association of California (UNAC)

The Women’s Foundation of California, Women’s Policy Institute

 

Who supports the bill? 

We are incredibly proud of the amazing coalition of Reproductive Health, Rights & Justice organizations that support the effort to remove physician supervision.

 

SB1237 Supporters Include:


 

  • 2020 Moms

  • Academy of Lactation Policy and Practice INC.

  • American Association of Birth Centers

  • American Civil Liberties Union/Northern California/Southern California/San Diego and Imperial Counties

  • American College of Nurse-midwives

  • Association of Women's Health and Neonatal Nursing California Section

  • Beach Cities Midwifery & Women's Health Care

  • Best Start Birth Center

  • Black Wellness & Prosperity Center

  • Black Women for Wellness

  • California Association of Nurse Anesthetists (CANA)

  • California Black Women's Health Project

  • California Latinas for Reproductive Justice

  • California Women's Law Center

  • Center on Reproductive Rights and Justice (CRRJ)

  • Citizens for Choice

  • Every Neighborhood Partnership

  • Feminist Majority Foundation

  • Grow Midwives

  • Healthimpact

  • Healthy Children Project, INC.

  • If/When/How: Lawyering for Reproductive Justice

  • MomsRising

  • National Council of Jewish Women (NCJW) CA

  • National Council of Jewish Women Los Angeles

  • National Health Law Program New Birth Services

  • Pacific Business Group on Health 

  • The Praxis Project

  • Training in Early Abortion for Comprehensive Healthcare

  • Urge: Unite for Reproductive & Gender Equity

  • Western Center on Law & Poverty, INC.


 

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.  This bill is different from previous bills to remove physician supervision because it carefully builds in language for collaboration and team-based care. This bill creates the language of integration and sets the stage for future innovation in every care setting, where seamless movement between midwifery and medical care means diverse patient needs can be attended to a diverse team of providers. 

 

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. 

 

In California statute, supervision is NOT defined. It 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 

  • oversee patient care in any way 

 

Why is Physician Supervision a Problem?

First, studies have shown that supervision does not improve safety or quality of care. The only thing supervision (permission to practice) does is put CNM practices at risk, both in the hospital and in the community. When friendly MDs retire or move it means CNM practices in the hospital, birth center, and home setting are at risk of being closed. This could happen to any CNM at any time. This also means that new and innovative CNM practices in hospitals, clinics and the community setting are very difficult to open. Furthermore, because of the supervision law CNM practices tend to be located in places where physicians are already in practice. This is hugely problematic and creates a maldistribution of health care providers.  California has 9 counties with no OBGYN!! Removing physician supervision will help increase access to midwifery care in these “maternity care deserts”. Removing physician supervision will increase access to midwifery-led care in hospitals, clinics, birth centers, and homes. As things are right now, it is easier for CNMs to move to other states or simply work as RNs because CNM opportunities are restricted.  We have about 1100 certified CNMs in CA but only about 700 currently practicing.

 

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? 

 

If passed this bill it would allow Certified Nurse Midwives to provide completely independent practice according to our Core Competencies, based on our education and training. It even allows independent prescribing within that scope! 

 

The bill includes in statute the ability for certified nurse-midwives to provide both family planning and interconception care. This will be the first time ever that certified nurse-midwives in California will have interconception care included in our statute. This is huge! Interconception care includes basic gyn care and preventive services, and between the two services they include the time frame before, after, and between pregnancy. You can find more on what quality family planning services include here, and what interconception care includes here, if you wish 

 

The bill also protects the CNMs ability to provide care in collaborative settings. Many nurse-midwives currently care for moderate and high risk patients in collaboration with physicians, which allows us to continue to provide care even for patients who would otherwise be outside of our scope. And we won't lose that capacity with this bill! The bill requires mutually agreed upon protocols with a physician for the care of people who need medical care, but who will still benefit from the midwifery model of care. Having these guidelines is a national midwifery standard set by the American College of Nurse-Midwives (see Standard V here).

 

You can read CNMA's full proposed bill language here. The following is the scope presented in SB 1237 (as of June 19, 2020):

  • 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 the BRN that is already established and already advises on nurse-midwifery practice) and ensures that CNMs are the majority members of this committee 

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.

  • The Black Women Birthing Justice report “Battling Over Birth: Black Women & The Maternal Health Care Crisis in California” found Black women identify increased access to 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 midwifery 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, vaginal birth 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 SB1237 and scale up midwifery, the results will be profound in terms of access to care, cesarean reduction, maternal morbidity and mortality reduction, and cost savings.

How is Midwifery Regulated in California?:

There are currently two kinds of midwives that practice legally in California: (1) Licenced 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, and 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.

 

 

More detailed FAQs about the bill 

 

Are “mutually agreed upon guidelines/protocols” the same as 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  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 is 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. 

 

Are there data reporting requirements in this bill? 

CNMA is working closely with SB 1237 authors Senator Dodd, Assemblymember Burke and Senator Mitchell to ensure that the data reporting will provide useful information to show the great outcomes of Nurse-Midwives, will not have onerous reporting requirements, and will ensure patient confidentiality!  CNMs who provide care in hospital systems already have their data reported by their hospital. Reporting on births in hospitals that have integrated models with CNMs have already shown that components of the midwifery model of care, such as lower C/S rates and less use of other unnecessary medical interventions, has been a driver of quality improvement.  We are working to ensure that out of hospital CNMs have their great data reported as well! 

 

The final language is coming and will be released soon. The data collecting and reporting will be done via the birth certificate (you can see in the current placeholder bill language the required data to be reported is all data that is currently reported via the birth certificate). This has a number of benefits: 

  1. A low data burden for nurse-midwives, because there are no extra data collected for out of hospital births (bc it is collected via the birth certificate; the only extra data are for those patients transferred to the hospital setting eg reason for transfer etc),

  2. It leverages existing vital records data collection systems, instead of creating an entirely new system for data collection, which is a cost saving route! 

  3. Wraps the data collection into existing laws that protect both patient and provider confidentiality and prevents any use of the data for regulatory or investigatory reasons

  4. Is an innovative approach to data collection

 

We are confident that out of hospital birth is safe and we want the data to show that! We got great feedback from our LM colleagues that the reporting requirements for LM attended out of hospital births are onerous, difficult to validate and don’t allow them to show the great outcomes provided by out of hospital LM care! This section of the bill will allow us to accurately collect good quality data without risking the privacy of the pregnant person. We hope this innovation can be shared and used by our LM colleagues to more effectively show their great outcomes as well! 

 

Of note, when it comes to data reporting CNMA is so grateful to have Holly Smith on our team! Holly Smith, chair of our Health Policy team, is a public health nurse-midwife who has spent much of her career working on reproductive health data collection and data analysis. She has a deep understanding of the data we need and how to collect it safely. She had a big hand defining the data collection portion of SB464 California Dignity in Pregnancy and Childbirth Act. We’re thrilled she’s on our team and helping to ensure we will have good quality data showing the great outcomes of Nurse-Midwifery Care! 

 

If a midwife is practicing within the delineated scope in the bill, will they 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 high 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. 

 

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 will still be able to 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.

 

Does this bill change nurse-midwifery scope to include abortion? 

There is no language in this bill to address abortion. What CNMs can already do under existing law is unchanged by the bill. CNMs will continue to practice within the same scope they do now under current law as they will under SB 1237. The bill adds a collaborative model of care with physicians and transfer requirements when necessary, which may include abortion care in some instances. Abortion procedures will still have to be done in collaboration with a physician.

Will the bill have a disparate impact on BIPOC, LGBTQI+, Low-Income and/or Medi-cal insured folks? 

 

It will improve access to midwifery care both in the community and in hospital settings for all people including, BIPOC, LGBTQI+, low-income and Medi-Cal insured folks. It will also improve access to people who are over 40, obese, and/or who have recived IVF. The pregnancy scope language described in the bill is almost the same as the language that Licensed Midwives (LMs) currently have, but is more flexible and allows for co-management of higher risk conditions. The language also has the added benefit of the well-person gyn language, which is not included in LM scope. 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. This bill, likewise, does not exclude such people. In fact, the language in SB 1237 does more to protect people seeking out of hospital birth. Equally important, the bill will increase access to midwives for people who want or need to seek hospital-based care. 

 

How does the bill compare to the Statute for Licensed Midwives and how does it impact practice for Licensed Midwives? 

 

The bill does not change in any way the ability of Licenced Midwives to practice. You can see 

SB1237 bill language closely mirrors what LMs currently have, but is more flexible: SB1237 does more to protect people seeking out of hospital birth and those who require medical care in collaboration with midwifery care. You can compare LM statute here to the scope proposed by SB1237 (see What is the scope of practice outlined in the bill? above) 

 

Language from LM's statute You can read the full language on the medical board of california’s website here are the important parts: 

    • 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 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.

 

I’ve read that Californian’s for the Advancement of Midwifery has concerns about the bill, do you address them anywhere? 

Click this link to see our reply to the letter of opposition sent to our supporters on July 6th. 

 

I’ve read that CALM has concerns about the bill, do you address them anywhere? 

Click this link to see our reply to the letter of opposition sent to our supporters on July 15th.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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