Message from the chair: Changes to legal status of home birth
Laurie C. Gregg, MD
Since 1993, California has licensed midwives to deliver at home under the supervision of a physician. The Medical Board of California requires submission of statistics by midwives to renew licensure. From those statistics, we know that in 2012, 2,316 women delivered at home under the care of a licensed midwife. There were 118 vaginal births after cesarean delivery, 13 breeches, and four sets of twins delivered at home. According to the report submitted to the state, even one set of triplets came into this world at home. Of those women who started labor at home, 16% required intrapartum transfer. Forty-four women required urgent or emergency transfer to the hospital.
Home births in California do not always go smoothly when a transfer of care is necessary. ACOG consistently hears this from members at its meetings. One challenge is how difficult it is for a midwife to obtain a physician supervisor. Most physicians do not have liability coverage that will allow them to act in this capacity. In 1999, an administrative law judge recognized this difficulty and allowed midwives to go without supervision in a precedent-making ruling. In 2012, only 7% of home births had physician supervision.
This year, it appeared likely that the California Medical Board’s sunset review would remove the physician supervision requirement from the law, considering the clause had not been enforced since 1999. On October 9, Gov. Jerry Brown signed Assembly Bill 1308, which encourages better selection of home birth candidates. The law requires a verbal handoff of care and prenatal records when a woman is transferred to the hospital. It encourages women to preregister at a hospital given the 16% chance they will need to go to one while in labor.
The law also removes the requirement for physician supervision and replaces it with face-to-face physician consultation whenever a pregnancy falls outside of the bill’s definition of “normal.” It better delineates who truly is responsible for care and includes a clearer definition of legal boundaries should such a case result in medical liability litigation. Finally, the law mandates transfer of care reporting so better data can be collected and trends can be recognized.
ACOG believes that the safest place for a birth is in the hospital or a birthing center, but it respects the patient’s right to make an informed decision about where she would like to give birth. We believe this new law will allow patients to make better informed choices and enable a smoother transfer of care should “home sweet home” become “not so ideal.”
From the editor
John P. McHugh, MD, District IX newsletter editor
Thank you, dear reader! With this issue, District IX News is poised to break a new readership record, with more than 1,000 readers. These readers, like you, play an active role in setting the standards for women’s health in our state.
When you stop to think about it, California is an amazing place. It is home to many of the top centers for women’s health and academic superstars who regularly advance the standards for patient care. More than 500,000 babies are delivered in California every year, which is more than many large nations. California often adopts public health measures that are copied throughout the US.
With practice standards advancing every day, our goal is to provide you with the news you need to stay on top. Increasingly, statewide public health organizations look to District IX News as a vital way to reach you with updates on issues such as vaccination, preterm labor, and more. Our legislative advocacy team understands the need to provide essential information on statewide issues that affect your practice and your patients.
The key here is you. Your interest in staying on top of important issues and your commitment to spreading the word to others are critical to our efforts. What can you do in addition to reading every issue?
Send a copy to your colleagues when you read an article of interest
Keep your email address updated with ACOG. Click on “My ACOG” at the top of this webpage, and then click on “Update Contact Information”
Print and post this newsletter in your physicians’ lounge
Most importantly, share your ideas and concerns with your ACOG section chairs
ACOG is you, and the more you can be involved, the better off our patients will be.
District IX Fellows lead California Medical Association
Kelly A. McCue, MD, California Medical Association specialty delegation vice chair
District IX leadership works tirelessly to advocate for your ability to provide care for your patients. Still, it’s not always good news in Sacramento.
In 1975, Gov. Jerry Brown signed the Medical Injury Compensation Reform Act (MICRA) into law, reforming the insurance industry and providing essential protections to the care physicians provide. For the last 38 years, trial lawyers have been fighting MICRA. This time around, they are spending heavily, hiring an experienced political operative to lead their attack. If the changes to MICRA trial lawyers are seeking are made, they will increase barriers between physicians and patients.
ACOG Fellows assembled at the California Medical Association (CMA) House of Delegates Annual Meeting to discuss the trial lawyers’ strategy. Until their initiative is soundly defeated, we are all cognizant that our work may be taken out of context and our views may be misrepresented in the media. District IX delegates worked from dawn until dusk advocating for CMA policy to:
Support reimbursement for phone and electronic patient management
Require retro-authorization processes for tests and procedures
Protect sexually exploited minors from prosecution
Support transparency in labeling nanoparticles in food
Regulate chemicals involved in hydraulic fracturing
Oppose restrictions on patient and physician free speech
CMA recognizes the vital role ACOG Fellows play in advocating for women’s health. District IX delegates continue to move up the ranks of leadership within CMA. I now serve as specialty delegation vice chair; Mibhali M. Bhalala, MD, was elected delegation secretary; and Ruth E. Haskins, MD, was elected to the Board of Trustees, a coveted position.
Dr. Haskins presented a seconding speech to the House of Delegates that was so well received she is now giving strong consideration to running for CMA president in the near future. We’ll keep you informed.
Joanne L. Perron, MD, District IX Committee on Physician Work-Life Balance co-chair
“Pain is inevitable. Suffering is optional.” – Buddhist proverb
Mindfulness is a state of being more fully present in everyday situations. Thus, multitasking and general busyness work against mindfulness. The District IX Committee on Physician Work-Life Balance recommends reading a recent article by Joan Borysenko, PhD, “Are You Hiding Behind Your Busy Schedule?”
The article addresses busyness and gives advice toward being more mindful. Dr. Borysenko states, “The most common feelings that busyness evoked were anxiety, fear, sadness, grief, loneliness, and anger.” The article goes into depth about busyness and gives advice on how to combat these feelings. It's a great read!
Disaster planning for obstetric units
Kay I. Daniels, MD, clinical professor of ob-gyn, Stanford University School of Medicine
Medical facilities are often at the center of disasters. The majority of hospital disaster protocols have been developed to address a mass casualty event that occurs outside of the hospital. In this commonly cited scenario, the hospital will receive a large influx of injured people in a short period of time.
What have not been fully developed are plans if the hospital itself is severely damaged, either from a natural disaster, such as an earthquake or a tornado, or a massive electrical failure. Planning for that scenario is daunting. Now consider disaster planning for a hospital that has an active maternity ward.
Obstetrics is unique
Obstetric units have unique needs in the world of disaster planning. In these units you’ll find healthy women prepared for rapid discharge in addition to women who are medically fragile and require close monitoring and treatment.
Equally important are labor and delivery units. Throughout the nation, these units operate as an emergency department, operating room, post-operative unit, and acute care center for pregnant patients. Nowhere else in the hospital are this many layers of patient care housed within the same unit. In addition, obstetric units have the task of caring for two patients—mother and fetus or mother and newborn.
The job of ensuring that mothers and their newborns are evacuated together during a time of chaos is neither trivial nor simple. During Hurricane Katrina, reports identified 125 critically ill newborn babies and 154 pregnant women who were evacuated to Woman’s Hospital in Baton Rouge. Some of the newborns arrived without their mothers. It took 10 days for some of these infants and mothers to be reunited. Obstetric staff must play an integral part in disaster planning in any hospital with a maternity unit.
Disaster planning overview
It is easiest to envision three approaches to disaster planning:
- Rapid evacuation: Creating a plan for evacuation of your patients because the hospital is damaged
- Surge planning: Accepting a sudden influx of patients because a neighboring hospital is damaged, thereby stretching your abilities to provide care
- Shelter in place: Caring for patients in your hospital despite limited resources because you are unable to transfer them
Obstetric triage and collaborative networks
Stanford Hospital is developing an evacuation triage system considering the specific needs of obstetric patients. This system can be used to proceed with a rapid and safe evacuation of an individual facility. In addition, if it is used regionally, it will create a universal language that allows collaboration among local facilities and the transportation of patients to hospitals that can properly care for them.
Advancing the ideas of an obstetric-specific triage system and developing a collaborative network of obstetric units are crucial steps toward a regional, and ultimately national, disaster plan for obstetric units.
For more information on disaster planning, please contact me at email@example.com.