HB344 By Representative Weaver RFD Health Rd 1 02-MAR-17

SYNOPSIS: Under existing law, nurse midwives who are licensed by the State Board of Nursing and the Board of Medical Examiners may practice nurse midwifery.

This bill would create the Safe Birth Options Act.

This bill would create a State Board of Registration for Lay Midwifery and provide for its powers and duties.

This bill would authorize lay midwives who are registered with the State Board of Registration for Lay Midwifery to assist with deliveries at birthing centers in certain circumstances.

This bill would provide training, examination, and other qualifications necessary to register as a lay midwife.

This bill would provide criminal penalties for violations.

This bill would provide civil immunity to a physician, health care practitioner, or hospital that receives or treats a mother, unborn child, or child after the use of services of a lay midwife.

Amendment 621 of the Constitution of Alabama of 1901, now appearing as Section 111.05 of the Official Recompilation of the Constitution of Alabama of 1901, as amended, prohibits a general law whose purpose or effect would be to require a new or increased expenditure of local funds from becoming effective with regard to a local governmental entity without enactment by a 2/3 vote unless: it comes within one of a number of specified exceptions; it is approved by the affected entity; or the Legislature appropriates funds, or provides a local source of revenue, to the entity for the purpose.

The purpose or effect of this bill would be to require a new or increased expenditure of local funds within the meaning of the amendment. However, the bill does not require approval of a local governmental entity or enactment by a 2/3 vote to become effective because it comes within one of the specified exceptions contained in the amendment.

A BILL TO BE ENTITLED AN ACT

Relating to lay midwives; to create the Safe Birth Options Act; to designate as Article 1 Sections 34-19-1 to 34-19-10, inclusive, Code of Alabama 1975; to add a new Article 2, consisting of Sections 19-34-30 to 19-34-40, inclusive, to Title 34, Chapter 19 of the Code of Alabama 1975; to create a State Board of Registration for Lay Midwifery and provide for its powers and duties; to authorize lay midwives who are registered with the State Board of Registration for Lay Midwifery to assist with deliveries at birthing centers in certain circumstances; to provide training, examination, and other qualifications necessary to register as a lay midwife; to provide criminal penalties for violations; to provide civil immunity to a physician, health care practitioner, or hospital that receives or treats a mother, unborn child, or child after the use of services of a lay midwife; to amend Section 22-9A-7, Code of Alabama 1975; and in connection therewith would have as its purpose or effect the requirement of a new or increased expenditure of local funds within the meaning of Amendment 621 of the Constitution of Alabama of 1901, now appearing as Section 111.05 of the Official Recompilation of the Constitution of Alabama of 1901, as amended.

BE IT ENACTED BY THE LEGISLATURE OF ALABAMA:

Section 1. Section 3 of this act shall be known and may be cited as the Safe Birth Options Act.

Section 2. An article heading is added before Section 34-19-1 of the Code of Alabama 1975, to read as follows:

ARTICLE 1. Nurse Midwives

Section 3. A new Article 2, consisting of Sections 34-19-30 to 34-19-40, inclusive, is added to Title 34, Chapter 19 of the Code of Alabama 1975, to read as follows:

ARTICLE 2. Lay Midwives

§34-19-30.

As used in this article, the following words shall have the following meanings:

(1) BIRTHING CENTER. A health facility where childbirth is planned to occur away from the client's residence and that meets all of the following criteria:

a. Is not a hospital.

b. Is not a health care facility as defined under Section 22-21-260.

c. Is licensed or otherwise approved to provide prenatal labor and delivery or postpartum care and other ambulatory services that are included in the health benefit plan.

d. Is located in close proximity to a hospital that is equipped to handle maternity care emergencies so that rapid transport is possible in an emergency situation.

e. Complies with such other requirements relating to the health and safety of individuals as required by the facility.

(2) BOARD. The State Board of Registration for Lay Midwifery.

(3) CLIENT. A woman who has secured the service of a registered lay midwife.

(4) HOSPITAL. The term as defined in Section 22-21-20.

(5) LOW RISK PREGNANCY. A pregnancy, labor, and delivery and postpartum, newborn, and interconceptional care that does not include a condition that requires a mandatory transfer pursuant to Section 34-19-35.

(6) LAY MIDWIFERY. The provision of services that is consistent with a lay midwife's training, education, and experience to women and their newborn children throughout the childbearing cycle.

(7) MIDWIFERY EDUCATION ACCREDITATION COUNCIL (MEAC). The commission recognized by the U.S. Department of Education that provides accreditation for programs and institutions that meet the national midwives alliance core competencies, the international confederation of midwives competencies, and the national registry of midwives skills and standards for basic midwifery practice.

(8) REGISTERED LAY MIDWIFE. An independent practitioner who is registered with the board to provide lay midwifery services. The term does not include a licensed nurse licensed under Sections 34-21-80 to 34-21-93, inclusive.

§34-19-31.

(a) There is created and established a State Board of Registration for Lay Midwifery to implement and administer this article.

(b) The board shall consist of five members appointed by the Governor. The composition of the board shall be as follows: Three registered lay midwives, one physician, and one certified nurse midwife. Notwithstanding the foregoing, the lay midwives initially appointed to the board need not be registered.

(c) The Governor shall strive to assure membership is inclusive and reflects the racial, gender, geographic, urban, rural, and economic diversity of the state.

(d) Members of the board shall be appointed for staggered initial terms and subsequent terms shall be for a minimum of three years or until his or her successor has been appointed and qualified.

(e) The board shall meet at least twice each year, conducting its business in person or by electronic methods, including proxy voting.

(f) The board shall elect one of its members to serve as chair for a one-year term. The chair may not serve consecutive terms.

(g) All members of the board shall be immune from individual civil liability while acting within the scope of their duties as board members.

(h) Vacancies shall be filled by the Governor in the same manner as other appointments are made. In the case of a vacancy, the new appointee shall serve for the remainder of the unexpired term.

(i) Members of the board shall serve without compensation but shall be allowed travel and per diem expenses at the same rate paid to state employees, to be paid from the funds collected for the administration of this article, as funds are available.

(j) The board may employ, subject to the state Merit System, investigators, inspectors, attorneys, and any other agents, employees, and assistants as may from time to time be necessary, and may use any other means necessary to enforce this article.

(k) The board shall be subject to the Alabama Sunset Law, Chapter 20, Title 41, as an enumerated agency as provided in Section 41-20-3, and shall have a termination date of October 1, 2021, and every four years thereafter, unless continued pursuant to the Alabama Sunset Law.

§34-19-32.

All funds received by the board under this article shall be deposited in the State Treasury to the credit of the State Board of Registration for Lay Midwifery and all such funds are to be appropriated to the board to defray the expenses incurred in carrying out this article. The expenses shall include printing, stamps, stationery, clerical help, travel, and other necessary expenditures. In all cases, any fee that is received by the board shall not be refunded, and no applicant may recover any part of a fee accompanying his or her application for registration or otherwise paid to the board except on the death, disability, or retirement from providing services of any applicant or registrant between payment of any fee and the expiration of his or her current renewal or the issuance of the initial registration. The books and records of the board shall be subject to audit by the Department of Examiners of Public Accounts in the same manner and to the same extent as any other state agency. The board shall keep a true and accurate account of all funds received by the board and all expenditures made by the board.

§34-19-33.

(a) The board may do all of the following consistent with this article:

(1) Approve, renew, suspend, or revoke registrations to provide lay midwifery services.

(2) Investigate and conduct hearings regarding complaints against a registered lay midwife in order to determine if disciplinary action is warranted.

(3) Establish reasonable registration fees, including, but not limited to, initial application, renewal, and reinstatement fees.

(4) Impose, adopt, levy, and collect administrative fines not to exceed one thousand dollars ($1,000) for each violation of this article, a board rule, or condition of registration and may institute any legal proceedings necessary to effect compliance with this article against a registered lay midwife.

(b) The board shall adopt rules pursuant to the Alabama Administrative Procedure Act to carry out this article in a manner consistent with this article. The rules shall include all of the following:

(1) Registration procedures and requirements.

(2) Initial and continuing education requirements. Initial education requirements shall include common, minimum education and training requirements that all lay midwives must meet regardless of their title, professional designation, or where they provide services. Continuing education requirements for registration renewal shall include 20 accredited continuing education units every two years, four hours of peer review every two years, and submission of required annual outcomes reports.

(3) Requirements for clinical internships for individuals seeking lay midwifery training.

(4) Standards regarding professional liability insurance of no less than one million dollars ($1,000,000) and aggregate policy period limits of no less than three million dollars ($3,000,000).

(5) A requirement that the applicant pass the nurse midwifery certification examination from the American Midwifery Certification Board.

(c) The rules shall ensure independent provision of services and shall not require any agreement, written or otherwise, with any other health care professional or health care facility.

§34-19-34.

(a) An individual desiring to be registered as a lay midwife shall apply to the board on forms provided by the board. Applicants for registration shall submit evidence satisfactory to the board that he or she has met all of the following requirements:

(1) Is at least 21 years of age.

(2) Submits to a criminal history background check, to be paid by the applicant.

(3) Is a citizen of the United States or, if not a citizen of the United States, is legally present in the United States with appropriate documentation from the federal government.

(4) Has obtained a certified professional lay midwife credential through an education program accredited by the Accreditation Commission for Midwifery Education.

(5) Has proof of current professional liability insurance coverage with the occurrence limits of no less than one million dollars ($1,000,000) and aggregate policy period limits of no less than three million dollars ($3,000,000).

(6) Meets the International Confederation of Midwives baseline midwifery standards, including all of the following:

a. A curriculum with a minimum of 40 percent theory and 50 percent practice.

b. A minimum length of direct-entry education of three years.

c. A minimum length of post-nursing education of 18 months.

d. A certification with a limited duration.

e. The certifying body does not simultaneously define or validate education and develop or administer the exam.

f. Has defined continuing education requirements.

g. Has periodic external review of education program effectiveness.

(b) A lay midwife certified before January 1, 2020, whose education was accredited by the Midwifery Education Accreditation Council may obtain the U.S. Midwifery Education, Regulation, and Association midwifery bridge certification to be eligible for registration.

(c) A lay midwife who has maintained licensure or registration in another state that does not require accredited education must obtain the midwifery bridge certificate as provided in subsection (b), regardless of the date of his or her certification, to be eligible for registration.

(d) Registration shall be valid for a period of one year.

(e) Following the contested case provisions of the Alabama Administrative Procedure Act, the board may suspend or revoke a registration or may refuse to grant registration to an applicant if the registrant or applicant does any of the following:

(1) Has obtained a registration by means of fraud, misrepresentation, or concealment of material facts, including making a false statement on an application or any other document required by the board for registration.

(2) Has engaged in unprofessional conduct that endangered or was likely to endanger the health, safety, and welfare of a client.

(3) Has been convicted of a felony or any crime arising out of or connected with the provision of lay midwifery services.

(4) Has performed an act that exceeds the registration granted to the lay midwife.

(5) Has had his or her registration revoked, suspended, or denied in any other territory or jurisdiction of the United States for any act described in this subsection.

(f) The board shall maintain an up-to-date list of every individual registered to provide lay midwifery services pursuant to this article and individuals whose registrations have been suspended, revoked, or denied. The information on the list shall be available for public inspection during reasonable business hours and the information may be shared with others as deemed necessary and acceptable by the board. The list shall include the name of the individual, the date and the cause of action, the penalty incurred, and the length of the penalty.

(g) The board shall grant continuing education credit for available educational opportunities, or make available quality continuing education programs, seminars, and workshops to acquaint and educate registered lay midwives in the most current evidence-based practices with respect to lay midwifery, women's health, or the evaluation and care of the newborn.

§34-19-35.

(a) A registered lay midwife may not provide any of the following services:

(1) Pharmacological induction or augmentation of labor or artificial rupture of membranes prior to the onset of labor.

(2) Surgical delivery or any surgery except an emergency episiotomy.

(3) Use of forceps or vacuum extractor.

(4) Except for the administration of a local anesthetic, administration of an anesthetic.

(5) Administration of any kind of narcotic analgesic.

(6) Administration of any prescription medication in a manner that violates the Alabama Uniform Controlled Substances Act.

(7) Any delivery that is not planned to be performed at a birthing center.

(b) A registered lay midwife may not assume or continue to take responsibility for a client's pregnancy and birth care and shall arrange for the orderly transfer and care to a health care practitioner for a client who is already under the care of the registered lay midwife, if a history of any of the following disorders or situations is found to be present at the initial interview or if any of the following disorders or situations becomes apparent through a client history, an examination, or in a laboratory report as prenatal care proceeds:

(1) Any previous caesarean section or previous uterine surgery such as myomectomy or uterine reconstruction.

(2) Hyperthyroidism treated with medication.

(3) Uncontrolled hypothyroidism.

(4) Epilepsy with seizures or antiepileptic drug use during the previous 12 months.

(5) Coagulation disorders.

(6) Chronic pulmonary disease.

(7) Heart disease in which there are arrhythmias or murmurs.

(8) Hypertension, including pregnancy induced hypertension.

(9) Renal disease.

(10) Sensitization with positive antibody titer.

(11) Diabetes mellitus, including gestational diabetes.

(12) Indications that the fetus has died in utero.

(13) Premature labor, defined as less than 37 weeks.

(14) Multiple gestation.

(15) Noncephalic presentation at or after 37 weeks.

(16) Placenta previa or abruption.

(17) Preeclampsia.

(18) Anemia, defined as hemoglobin less than 10 G/DL.

(19) Uncommon diseases and disorders, including Addison's Disease, Cushing's Disease, Systemic Lupus Erythematosus, Antiphospholipid Syndrome, Scleroderma, Rheumatoid Arthritis, Periarteritis Nodosa, Marfan's Syndrome, and other systemic and rare diseases and disorders.

(20) Aids/HIV.

(21) Hepatitis A through G and non-A through G.

(22) Acute toxoplasmosis infection if the client is symptomatic.

(23) Acute rubella infection during pregnancy.

(24) Acute cytomegalovirus infection if the client is symptomatic.

(25) Acute parvovirus infection if the client is symptomatic.

(26) Alcohol abuse, substance abuse, or prescription abuse during pregnancy.

(27) Continued daily tobacco use into the second trimester.

(28) Thrombosis.

(29) Inflammatory bowel disease.

(30) Herpes simplex virus, primary infection or active infection at time of delivery.

(31) Significant fetal congenital anomaly.

(32) Ectopic pregnancy, or possible ectopic pregnancy.

(33) Prepregnancy body mass index (BMI) of less than 18.5 or 35 or more.

(34) Significant mental disease, including depression, bipolar disorder, schizophrenia, and other conditions that impair the ability of the client to participate effectively in the client's care or that require the use of psychotropic drugs to control the condition.

(35) Second or third trimester bleeding.

(36) Asthma.

(37) History of genetic problems, intrauterine death after 20 weeks gestation, or stillbirth.

(38) Tuberculosis.

(39) RH sensitization with positive antibody titer.

(40) Premature rupture of membranes at 37 weeks or less.

(41) Small for gestational age or large for gestational age fetus.

(42) Polyhydramnios or oligohydramnios.

(43) Previous LEEP procedure or cone biopsy.

(44) Previous obstetrical problems, including uterine abnormalities, placental abruption, placenta accreta, obstetric hemorrhage, incompetent cervix, or preterm delivery for any reason.

(45) Postterm maturity, defined as 41 0/7 weeks or beyond.

(c) A registered lay midwife may provide lay midwifery care only in a birthing center and may not attend home births.

(d) A registered lay midwife shall ensure that the client has signed an informed consent to care form. The consent form shall include information to inform the client of the qualifications of the registered lay midwife. In a format accepted by the board, a registered lay midwife attending a birth at a birthing center shall provide each client with and maintain a record of a signed informed consent form that describes the lay midwife's education and credentials, written practice guidelines, services provided, a statement of the lay midwife's professional liability insurance coverage, procedures and risks of birth in the client's chosen environment, components of the emergency plan, and the address and telephone number of the board where complaints may be filed. The board, by rule, shall establish a form for this purpose.

(e) For screening purposes only, a registered lay midwife may order routine antepartum and postpartum laboratory analyses to be performed by a licensed laboratory.

(f) A registered lay midwife may not perform or interpret ultrasounds and may only order and use an ultrasound report provided by qualified providers managing clients.

(g) After a client has secured the services of a registered lay midwife, a lay midwife shall document an emergency care plan particular to each client, which shall include referral and transfer plans in the event of an emergency.

(h) A registered lay midwife shall determine the progress of labor and document dilation, effacement, and station at timely intervals, and when delivery is imminent shall be present until delivery is accomplished and the client is stable postpartum.

(i) A registered lay midwife shall remain with the client during the postpartum period until the conditions of the client and newborn are stabilized.

(j) A registered lay midwife shall instruct the client regarding the requirements of the administration of eye ointment required by the Department of Public Health pursuant to Section 22-20-2.

(k) A registered lay midwife shall instruct the client regarding the requirements of administration of newborn health screening ordered by the Department of Public Health pursuant to Section 22-20-3.

(l) A registered lay midwife shall file a birth certificate for each birth in accordance with the requirements of Section 22-9A-7.

(m) A registered lay midwife shall have the same authority and responsibility as other licensed health care providers regarding reporting and ordering tests, but not reading or interpreting tests, concerning public health laws, reportable disease and conditions, communicable disease control and prevention, and recording of vital statistics, except that this authority is limited to activity consistent with the registration authorized in this article.

§34-19-36.

(a) Except as provided in this section, it shall be unlawful for an individual other than a registered lay midwife to provide lay midwifery services in this state for economic remuneration or to hold himself or herself out to be a registered lay midwife unless he or she is a registered lay midwife. An individual violating this section shall be guilty of a Class C felony.

(b) An individual does not violate subsection (a) in any of the following circumstances:

(1) The individual is a certified nurse midwife acting in accordance with Sections 34-21-80 to 34-21-93, inclusive.

(2) The individual is a licensed health care practitioner, including a licensed physician, acting within the scope of his or her practice. Nothing in this article shall be construed as expanding the scope of practice of any other health care practitioner.

(c) Nothing in this section shall be construed to repeal, abridge, or modify Section 6-5-332, or any other good samaritan law.

§34-19-37.

Nothing in this article shall be construed to establish a standard of care for physicians or otherwise modify, amend, or supersede any provision of the Alabama Medical Liability Act of 1987, or the Alabama Medical Liability Act of 1996, commencing with Section 6-5-540, Code of Alabama 1975, or any amendment thereto, or any judicial interpretation thereof.

§34-19-38.

Individuals registered as midwives pursuant to this article shall be designated registered Lay Midwives (LM).

§34-19-39.

(a) Except as required under federal law, a physician, health care practitioner, or hospital, including agents and employees of a physician, health care practitioner, or hospital, that receives or treats a client, a client's unborn child, or a client's child after the use of services of a registered lay midwife, shall be immune from any civil or criminal liability for any subsequent examination, treatment, or care provided to a client, a client's unborn child, or a client's child, associated with the care of someone holding himself or herself out as a registered lay midwife. No physician, health care practitioner, or hospital, including agents and employees of a physician, health care practitioner, or hospital shall be liable for any act or omission resulting from a woman's decision to have a physiologic childbirth outside of a hospital or medical facility. Any physician, health care practitioner, or hospital, including agents and employees of a physician, health care practitioner, or hospital who attends to the client or the client's child in circumstances arising out of or related in to the client's pregnancy or delivery, following the creation of the lay registered lay midwife-client relationship, is immune from civil or criminal liability for any act or omission occurring in connection therewith. Furthermore, no physician, health care practitioner, or hospital, including agents and employees of a physician, health care practitioner, or hospital shall be liable for civil damages for any act or omission resulting from the administration of services or advice given to a client by a registered lay midwife.

(b) In any civil action against a registered lay midwife based upon any negligent act or omission of the lay midwife, proof of such act or omission shall not create or establish the responsibility of any health care provider, under the doctrine of respondeat superior.

(c) It is the express intent of this section that no physician, health care practitioner, or hospital, including agents and employees of a physician, health care practitioner, or hospital, shall be liable for damages as the result of any advice given by a registered lay midwife to a client or any care or services provided to a client or services from the registered lay midwife.

§34-19-40.

A certified nurse midwife and a licensed physician may treat clients at a birthing center established under this article. Section 4. Section 22-9A-7, Code of Alabama 1975, is amended to read as follows:

§22-9A-7.

"(a) A certificate of birth for each live birth which occurs in this state shall be filed with the Office of Vital Statistics, or as otherwise directed by the State Registrar, within five days after the birth and shall be registered if it has been completed and filed in accordance with this section.

"(b)(1) When a birth occurs in an institution or en route to the institution, the person in charge of the institution or his or her designated representative shall obtain the personal data, prepare the certificate, secure the signatures required, and file the certificate as directed in subsection (a) or as directed by the State Registrar within the required five days. The physician or other person in attendance shall provide the medical information required by the certificate and certify to the facts of birth within 72 hours after the birth. If the physician, or other person in attendance, does not certify to the facts of birth within the 72-hour period, the person in charge of the institution or his or her designee shall complete and sign the certificate.

"(2) In all cases where a birth occurs in an institution, the person in charge of the institution shall provide a procedure for collection of the normal fee for a certified copy of the birth certificate from the mother or father. The fee shall be forwarded to the State Registrar when a complete record of the birth is obtained, and the State Registrar shall issue a certified copy of the birth certificate to the mother or father of the child. The issuance of a certified copy of the birth certificate by the State Registrar shall not apply to births where the death of the infant occurred a short time following the birth, unless the certificate is requested by the father or mother, or where adoption is indicated.

"(c) When a birth occurs outside an institution, the certificate shall be prepared and filed by one of the following in the indicated order of priority:

"(1) The physician or registered lay midwife in attendance at the birth or who sees the child within three days after the birth.

"(2) Any other person in attendance at or immediately after the birth.

"(3) The father, the mother, or in the absence of the father and the inability of the mother, the person in charge of the premises where the birth occurred.

"(d) When a birth occurs in a moving conveyance within the United States and the child is first removed from the conveyance in this state, the birth shall be registered in this state and the place where it is first removed shall be considered the place of birth. When a birth occurs on a moving conveyance while in international waters or air space or in a foreign country or its air space and the child is first removed from the conveyance in this state, the birth shall be registered in this state, but the certificate shall show the actual place of birth as can be determined.

"(e) For the purposes of birth registration, the mother is deemed to be the woman who gives birth to the child, unless otherwise determined by law.

"(f)(1) If the mother was married at the time of either conception or birth, or between conception and birth, the name of the husband shall be entered on the certificate as the father of the child, unless it is established by law that he is not the father of the child.

"(2) If the mother was not married at the time of either conception or birth or between conception and birth, the name of the father shall not be entered on the certificate unless paternity has been determined by a court of competent jurisdiction or unless the legitimation process specified in Sections 26-11-1 through 26-11-3, inclusive, or otherwise provided by law has been completed.

"(3) If the father is not named on the certificate of birth, no other information about the father shall be entered on the certificate.

"(g) The birth certificate of a child born to a married woman as a result of artificial insemination, with consent of her husband, shall be completed in accordance with subdivision (1) of subsection (f).

"(h) Either of the parents of the child shall attest to the accuracy of the personal data entered on the certificate in time to permit the filing of the certificate within the five days prescribed in subsection (a)."

Section 5. Although this bill would have as its purpose or effect the requirement of a new or increased expenditure of local funds, the bill is excluded from further requirements and application under Amendment 621 because the bill defines a new crime or amends the definition of an existing crime.

Section 6. This act shall become effective on the first day of the third month following its passage and approval by the Governor, or its otherwise becoming law.

Midwives

Physicians

Health Care

Health Care Practioners

Hospitals

Licenses and Licensing

Code Added

Code Amended