SB 192-BOARD OF LICENSED MIDWIVES  2:31:16 PM CHAIR WILSON reconvened the meeting and announced the consideration of SENATE BILL NO. 192 "An Act relating to midwives and the practice of midwifery; relating to apprentice midwives; relating to the licensing of midwives; relating to insurance requirements for the practice of midwifery; and providing for an effective date." 2:31:49 PM JOE HAYS, Staff, Senator Scott Kawasaki, Alaska State Legislature, Juneau, Alaska, paraphrased the sponsor statement for SB 192: [Original punctuation provided.] Senate Bill 192 would establish licensing of certified professional midwives in Alaska and create a governing board to develop licensing procedures and review licensing applications and renewals. Currently Alaska only has legislation regarding the certification of direct-entry midwives. This bill would institute licensing requirements and regulations for certified professional midwives to be formed in conjunction with a nationally recognized midwife organization. The bill also requires that licensed midwives have basic life support certification for health care providers and certification in neonatal resuscitation, and knowledge of and experience with non-hospital-based births. These requirements would be in addition to a required background in a health- related field other than nursing and graduation from a master's level midwifery education program. 2:33:18 PM This bill would also create a Board of Licensed Midwives from the current Board of Certified Direct- Entry Midwives. The new Board will adopt standards and regulations for licensed midwives that are in the public interest and in compliance with the Administrative Procedure Act. The Board will review license applications and renewals for midwives in the State of Alaska and establish insurance provisions. The Board will help to develop future legislation specific to licensed midwives that will clarify these standards and regulations. SB 192 is important for ensuring safer at-home births and improving prepartum and postpartum care for mothers and infants. I ask for your consideration and support of Senate Bill 192 to allow the State licensing of certified professional midwives and the formation of a governing board to oversee the standards and regulations for licensed midwives. 2:34:15 PM CHERIE BOWMAN, Intern, Senator Scott Kawasaki, Alaska State Legislature, Juneau, Alaska, read the sectional analysis for SB 192: [Original punctuation provided.] Section 1. Uncodified law providing legislative Intent to preserve right of women to deliver children at home with licensed midwives. Section 2. Amends AS 08.01.017(17) to change board name form (certified direct - entry) to licensed midwives. Section 3. Amends AS 08.02.010(a) to explain who can practice and what type of professional letters or title shall appear on. Section 4. Amends AS 08.03.010(c)(8) to change the name certified direct entry to licensed midwives and adds an effective date of June 30, 2023. 2:35:20 PM Section 5. Amends AS 08.64.370 to explain how licensed midwives are recognized with or without compensation and how licensed midwives are defined in AS 08.65.190 Section 6. Amends AS 08.65.010(a) to establish the board of licensed midwives. Section 7. Amends AS 08.65.010(b) to define who can be members of the licensed midwife board. Section 8. Amends AS 08.065.030 to address the powers and duties of the board of midwives Section 9. Amends AS 08.065.040 to add a new subsection on activities the board cannot adopt by regulations to include: (b) and (c). Subsection B includes 1. Requires a person to have a nursing degree or diploma to be licensed under this chapter 2. Requires a licensed midwife to practice midwifery under the supervision of or collaboration with another health care provider or a health care facility 3. Requires a licensed midwife to enter into an agreement, whether written, oral, or in another form, with another health care provider or a health care facility. 4. Limits the location where a licensed midwife may practice midwifery. 2:36:43 PM Subsection C. adds definitions of health care facility and health care provider as identified in AS 18.35.399 and AS 09.65.300 respectively. Section 10. Amends AS 08.65.050 to address the qualifications needed to be a licensed midwife in Alaska. 1. Line 1 reads "holds a valid certified professional midwife certificate, if the certificate is issued by a nationally recognized midwife organization recognized by the board and the requirements for the certificate are consistent with this chapter." 2. Line 2 is added and reads "applies on a form provided by the board". 3. Lines 2 and 3 are renumbered as 3 and 4. 4. Line 4 is renumbered as line 5 and adds "is a certified in basic life support for health care provider" and adds the word "and". 5. Line 5 is renumbered as line 6 and adds "is certified in the interventions used at the time of birth to support the establishment of breathing and circulation of the newborn." Section 11. Amends AS 08.65.080 to explain procedures for renewal of midwifery license. 2:38:08 PM Section 12. Amends AS 08.65.090(a) to allow the midwifery board to issue permits to midwife apprentices who have satisfied the education, training and apprenticeship that is deemed by the board to be in the public interest and recognized by a nationally commissioner to adopt regulations to implement and interpret the Act. Section 13. Amends AS 08.65.110 to address grounds of discipline, suspension or revocation of certification for licensed midwives. Section 14. Amends AS 08.65.120(a) to give the board the authority to impose discipline to include revocation or suspension of midwives' licenses for those who broke any code of conduct. Section 15. Amends AS 08.65.120(d) to give the board the ability to reinstate a licensed after appeal if a person proves to able to practice with reasonable skill and safety. Section 16. Amends AS 08.65.140 to allow the board to adopt regulations to licensed midwives after consultation with a nationally recognized midwife organization. The regulations would have to conform to the public interest. Section 17. Amends AS 08.08.65.150 to add a new subsection to read: (b) A licensed midwife may practice midwifery without being under the supervision of, or collaborating with, another health care provider or a health care facility. 2:39:50 PM (c) A licensed midwife may practice midwifery without entering into a written or other form of agreement with another health care provider or a health care facility. (d) A licensed midwife may provide services using audio, video, or other electronic media for the purpose of diagnosis, consultation or treatment. Section 18: Amends AS 08.65.150 to give specification that a non-licensed midwife recognized under AS 08.65.150 cannot receive compensation. Section 19: Amends AS 08.65.160 to address who can be called a licensed midwife and the penalties established for a person who uses the title illegally. Section 20: Amends AS 08.65.170 to exclude licensed physicians and advanced practiced registered nurses. Section 21: Amends AS 08.65.180 to explain the responsibility of care is not transferred from a licensed midwife to a licensed physician until the patient is physically within the physician's care. Section 22: Amends AS 08.65.190(1) to explain what board is being discussed licensed midwives. Section 23: Amends AS 08.65.190(3) to define the practice of midwifery to include preconception pregnancy, the first postpartum year and well-baby care for the infant through the age of six weeks. 2:41:41 PM Section 24: Amends AS 08.65.190 by adding a new paragraph to read: 1. "licensed midwife" means a midwife who is licensed under this chapter to practice midwifery. 2. "midwife" means a person who practices midwifery. Section 25: Amends AS 09.65.300(c)(1) to add licensed midwives as a health care provider. Section 26: Amends AS11.42.470(1) to add licensed midwives as a health care worker. Section 27: Amends AS 18.20.095(e)(2) to add licensed midwives as a licensed staff member under AS 08.64. Section 28: Amends AS 18.50.165(b) to add licensed midwives to the responsibilities of the registrar to distribute information to. Section 29: Amends AS 21.36.090(d) to add licensed midwives as a person who cannot practice or permit unfair discrimination against a person who provides services covered under a group health insurance that extends coverage on an expense incurred basis. 2:43:12 PM Section 30: Amends AS 21.42.355 by adding a new subsection that reads: (c) If a health care insurance plan or an excepted benefits policy or contract provides indemnity for the cost of services of a physician provided to women during preconception, pregnancy, childbirth and the period after childbirth up to one year, indemnity in a reasonable amount shall also be provided for the cost of a midwife licensed in AS 08.65 who provides the same services. Indemnity may be provided under this subsection only if the licensed midwife is practicing as a licensed midwife within the scope of the license. (d) If a health care insurance plan or an excepted benefits policy or contract provides for furnishing those services required of a physician in the care of women during preconception, pregnancy childbirth and the period after childbirth, and the period after childbirth up to one year, the contract shall also provide that a midwife licensed under AS 08.65 may furnish those same services instead of a physician. Services may be provided under this subsection only if the licensed midwife is practicing as a licensed midwife as a licensed midwife in accordance with the regulations adopted under AS 08.65.030(a)(7), and the services provided within the scope of practice of the license. 2:44:57 PM At ease 2:45:50 PM CHAIR WILSON reconvened the meeting. 2:45:52 PM MS. BOWMAN continued reading the sectional analysis for SB 192: Section 31: Amends AS 21.84.335(b)(15) to add AS 21.42.355(a) and (b). Section 32: Amends AS 25.20.055(a) to add licensed midwives to the protocol that hospitals must follow to assist a single parent and coupled parents regarding their rights and responsibilities and the forms and statements that must be filled out. Section 33: Amends AS 25.20.055(b) to add licensed midwives to the list of medical professionals who must adhere to the same duties described in (a)(2) (6) of this section or ensure that an agent performs those duties. Section 34: Amends AS 44.62.330(a)(36) to rename board of certified direct entry to licensed midwives. Section 35: Amends AS 47.07.900 to explain what midwife services are for a licensed midwife. Section 36: Amends AS 47.20.320(d) to add licensed midwives in this section explaining who shall not be criminally or civilly liable for providing information in good faith to the department or its designee. Section 37: Repeals AS 08.65.060, 08.65.070 and 08.65.090(b). 2:47:36 PM Section 38: Amends uncodified law by adding a new section that reads: Transition: Continuation of Board. (a) Notwithstanding AS 08.65.030, as amended by sec 8 of this Act, the members of the Board of Certified Direct-Entry Midwives, as that board is constituted under AS 08.65.030 as that section reads on December 31, 2022, shall operate as the Board of Licensed Midwives from January 1, 2023, until the new members of the Board of the Licensed Midwives are appointed by the governor un sec 39of this Act and confirmed by the legislature under AS 08.65.010, as amended by secs. 6 and 7 of this Act. (b) in this section, "Board of Licensed Midwives" means the Board of Licensed Midwives established by AS 08.65.010 as amended by secs 6 and 7 of this Act. Section 39: Amends uncodified law by adding a new section that reads: Transition: Current Direct Entry Midwives and Apprentice Midwives. (a) Notwithstanding AS 08.65.050, as amended by sec 10 of this Act, a person who holds on December 31, 2022, an unexpired certificate to practice direct-entry midwifery issued under AS 08.65.050, as that section reads on December 31, 2022, is licensed on the effective date of secs. 1 40 of this Act to practice midwifery under AS 08.65, as amended by secs. 6 24 of this Act, for a two - year period. (b) Notwithstanding AS 08.65.090, as amended by sec 12 of this Act, a person who holds on December 31, 2022, an unexpired permit to practice as an apprentice direct-entry midwife issued under AS 08.65.090, as that section reads on December 31, 2022, is permitted on the effective date of secs. 1 40 of this Act to practice as an apprentice midwife under AS 08.65.090, as amended by sec. 12 of this Act, for a two-year period. 2:50:21 PM Section 40. The uncodified law of the State of Alaska is amended by adding a new section that reads: TRANSITION: NEW BOARD MEMBERS. (a) Within 60 days after the effective date of secs. 1 40 of this Act, the governor shall appoint an advanced practice registered nurse licensed under AS 08.68 to be a member of the board to replace the physician member of the board for the remainder of the term of the physician member. 2:50:53 PM (b) Within 60 days after the effective date of secs. 1 40 of this Act, the governor shall appoint an advanced practice registered nurse licensed under AS 08.68 to be a member of the board to replace the certified nurse midwife member of the board for the remainder of the term of the certified nurse midwife member. (c) The board, as constituted under (a) and (b) of this section, shall begin operating as the board when the legislature has confirmed the members appointed under (a) and (b) of this section. (d) In this section, "board" means the Board of Licensed Midwives established by AS 08.65.010, as amended by secs. 6 and 7 of this Act. 2:51:49 PM Section 41. The uncodified law of the State of Alaska is amended by adding a new section to read: TRANSITION: REGULATIONS. The Board of Direct-Entry Midwives established by AS 08.65.010, as that section reads on December 31, 2022, shall adopt, repeal, or amend regulations as necessary to implement the changes made by secs. 1 40 of this Act. The regulations take effect under AS 44.62 (Administrative Procedure Act), but not before January 1, 2023. Section 42. Reads "Section 41 of this Act takes effect immediately under AS 01.10.070(c)." Section 43. Reads "Except as provided in sec. 42 of this Act, this Act takes effect January 1, 2023." 2:52:53 PM CHAIR WILSON opened invited testimony on SB 192. He stated that public testimony would be heard at a later date. 2:53:45 PM RACHEL PUGH, Member, Board of Certified Direct-Entry Midwives, Department of Commerce, Community and Economic Development, Eagle River, Alaska, stated she strongly supports SB 192. She said she was directly involved in writing the proposed statute changes for over a year. The changes are necessary to comply with state audit recommendations and eliminate many outdated statutes that make it challenging to access midwifery care in Alaska. MS. PUGH related one issue: the lack of legal recognition and insurance coverage for certified direct-entry midwives (CDMs) and certified professional midwives (CPMs), based on current statutes, is creating insurmountable financial barriers for many. MS. PUGH reported that a nationwide study revealed that only 3.4 percent of hospital births were paid out of pocket. In contrast, 67.9 percent of planned out-of-hospital births and 32.3 percent of birth center births were self-pay. Seven and nine-tenths percent of all births in Alaska are planned out of hospital births, whereas the national average is 1.6 percent. MS. PUGH stated that SB 192 would provide greater access to midwifery. It would allow midwives to practice to the full extent of their competencies and education and ensure that Alaska midwives have nationally recognized credentials. They would be paid the same rate as certified nurse midwives and physicians for identical procedures. She said studies provide clear evidence that midwifery care, birth center, and home birth settings provide improved birth outcomes and are highly effective at improving maternal and infant health. MS. PUGH said not passing SB 192 limits freedom of medical choice and available medical options to families in more than 35 states. 2:55:42 PM MS. PUGH offered her view that the changes in SB 192 do not endanger the health and safety of a single woman in Alaska. SB 192 would not affect how a midwife currently practices or the type of care they provide. It would not limit or restrict women from choosing their providers or where to give birth. MS. PUGH emphasized that she was fighting for the rights of women and families in Alaska to have more options and better access to the type of maternity care that they deserve, not less. She stated that witnessing women being denied medical coverage for home births was frustrating. She said she was tired of explaining to women that bureaucracy dictates their limited maternity care in Alaska, but if they lived in many other states, they would have more freedom in their medical choices. 2:56:36 PM MS. PUGH said she was also tired of providing medical care for free, such as postpartum care beyond six weeks, which she is trained and licensed to provide. She highlighted that other medical providers are reimbursed when providing these services. However, due to the current statute, she cannot do so. MS. PUGH highlighted another issue in Alaska: some women choose to have an unassisted birth because Alaska's current statutes and regulations prevent them from hiring a licensed midwife, most often due to insurance coverage and financial barriers. She stated SB 192 addresses a human rights issue. She urged members to pass the bill as written. 2:57:56 PM BETHEL BELISLE, Chair, Board of Certified Midwives, Department of Commerce, Community and Economic Development, Anchorage, Alaska, stated that she is a certified direct-entry midwife in Alaska and a professional midwife, a nationally recognized designation. She has been a midwife since 1999, with a home and birth center practice. She related that she has served on the board since 2020. MS. BELISLE thanked Senator Kawasaki for introducing the bill to preserve the rights of Alaska women to have access to safe, out- of-hospital providers, high-quality care, and guaranteed insurance coverage. MS. BELISLE indicated that SB 192 resulted from a legislative audit that began in 2016. The audit recommended that the Board of Certified Direct-Entry Midwives pursue statutory changes that benefit the public. However, due to a perceived financial concern, the previous board did not make the recommended changes. She said the 2020 audit noted, "The board identified a need to change certification statutes to align Alaska's midwifery laws with national standards." 2:59:24 PM MS. BELISLE stated that the first legislative audit recommendation indicated that the board identified a need to change certification statutes to align Alaska's midwifery laws with national standards. However, due to the legal costs involved with the project, the board did not recommend statutory changes. MS. BELISLE stated she joined the board and became chair in 2020, and the board worked on that recommendation. The board also reviewed the peer review process and fiscal responsibility. The legislature passed a peer review bill in 2021. The board now operates "in the black." MS. BELISLE stated that SB 192 provides the final piece to complete the 2020 audit recommendations because the bill would align Alaska's law with national standards, which are currently the Certified Professional Midwife Standards. SB 192 would increase fiscal responsibility by requiring applicants to be vetted by a national organization, thereby streamlining the licensure process in Alaska. MS. BELISLE listed numerous ways SB 192 will benefit midwives and patient health. It would extend well-baby visits from four weeks to six weeks, thus helping to reduce neonatal morbidity. It would extend postpartum care to one year, reducing maternal morbidity and mortality by having a trusted provider helping with maternal mental health concerns and providing referrals as needed. It would allow for preconception counseling, which could increase the health of the next generation of Alaskans. She offered her view that this bill would stand for women's rights to choose where and with whom they feel most comfortable birthing, knowing that their midwifery providers are trained to national standards. She related that the bill would complete the legislative audit and provide lower costs, including that midwifery births have a 40 percent lower cesarean rate, fewer low birthweight babies, and babies were 26 percent less likely to be born prematurely. At a recent board meeting, the board gave unanimous approval for SB 192. The board acknowledges that change is hard but emphasizes the importance of protecting public safety and abiding by the legislative audit. She urged members to support SB 192. 3:01:27 PM CHAIR WILSON held SB 192 in committee.