** UPDATE 03/23/2021 for the latest wording click here to be directed to AB387 on the NELIS website. (it is not viewable on mobile devices) **
An ANNOTATED VERSION with friendly suggestions by some parents, friends, and midwives from Nevada Friends of Midwives is attached below in both PDF and DOCX format. You can find us and join the conversation here on NFoM.org or facebook.com/nevadafriendsofmidwives.
** for the latest wording and for public meeting info, please go to the Nevada Legislature website. https://www.leg.state.nv.us/Session/81st2021/ **
BDR 225 is requested by assemblywoman Daniele Monroe-Moreno
AN ACT relating to licensed midwives.
(1) "Licensed Midwifery"
(a) Means the provision of care to a person during healthy pregnancy, childbirth, and the postpartum period, and the care of a normal newborn immediately following birth
(b) Includes co-management with other appropriate licensed health care providers as specified by the board by administrative regulation or when otherwise indicated; and
(c) is distinct from the practice of medicine or nursing.
(2) "Co-management" means the process by which a licensed midwife and a physician or other appropriate healthcare provider jointly manage the care of a client, the requirements for which shall be defined by the board;
(3) "Consultation" means the process by which a licensed midwife directs the client to a physician or other appropriate licensed healthcare provider to render an opinion regarding the management of a specific problem or condition, the requirements for which shall be defined by DHHS;
(4) "Board" means the Licensed Midwives Advisory Board created in Section 2 of this Act;
(5) "Licensed midwife" means a person who is certified by the North American Registry of Midwives and issued a license by DHHS to provide licensed midwifery services in the State of Nevada. Licensed midwives are autonomous providers able to practice to the full extent of their scope without physician oversight in both home and birth center settings.
(6) "Referral" means the process by which a licensed midwife arranges for an accepting physician or other appropriate licensed healthcare provider to assume primary management responsibility for the condition requiring referral, which shall not preclude the licensed midwife from continuing in the provision of care as mutually agreed upon with the accepting provider, as regulated by the board; and
(7) "Transfer" means the act of transporting a client to a licensed healthcare facility providing a higher level of care.
(8) “Birth Assistant/Midwife Assistant”- A person, who may be unlicensed, who performs non-clinical and basic clinical services for a licensed midwife or certified nursemidwife and has had at least the minimum amount of hours of appropriate training pursuant to standards established as set forth in this bill. The midwife assistant shall be issued a certificate by the training institution or instructor indicating satisfactory completion of the required training.
(9) “Direct Supervision”- means observation and evaluation of an apprentice/student midwife’s practical performance. The supervising midwife must be physically present on the premises and available to intervene when an apprentice/student midwife or birth assistant/midwife assistant performs any clinical task at births and prenatal and postpartum care exams. Must have a formal relationship defined in writing.
(10) "Birth center"- Community-based freestanding center for childbirth, owned and/or operated by certified professional midwives licensed in the State of Nevada where care is provided in the midwifery and wellness model of care. Birth centers are not required to adhere to the requirements set forth in the 'Guidelines for Design and Construction of Hospital and Outpatient Facilities' as required for obstetric centers.
(11) “Certified Professional Midwife (CPM)” An autonomous independent practitioner who holds valid a certification from the North American Registry of Midwives (NARM) or its successor organization.
(12)"Apprentice/Student Midwife" must be currently enrolled in a midwifery educational program consistent with United States educational accreditation standards and the United States Midwifery Education, Regulation, and Association statement on the licensure of certified professional midwives under the direct supervision of a licensed midwifery preceptor and holding a current apprentice permit issued by the Board. May not practice or represent themself as any other type of midwife.
2. A NEW SECTION OF ___________ IS CREATED TO READ AS FOLLOWS:
(1) The Licensed Midwives Advisory Board is hereby created, under DHHS. The Board shall at regular intervals and guided by newly available evidence in peer-reviewed medical literature, advise the board on promulgating administrative regulations regarding qualifications, standards for training, competency determination of licensed midwives, any necessary statutory changes, and all other matters relating to licensed midwives.
(2) The Board shall be appointed by DHHS and shall consist of:
(a) One (1) member of the board, who shall be a nonvoting, ex officio member and serve as the liaison between the chair of the council Board and DHHS;
(b) Four (4) certified professional midwives who shall be licensed certified professional midwives within six (6) months of the license availability;
(c) One (1) certified nurse-midwife licensed in Nevada;
(d)One (1) obstetrician licensed in Nevada;
(e) One (1) practicing neonatal health care provider licensed in Nevada; and
(f) One (1) member of the general public. The chair of the Board shall be elected annually by members of the Board.
(3) DHHS may solicit nominations for the board from interested parties or organizations and shall give consideration to nominees who have experience collaborating with providers of, providing, or utilizing out-of-hospital midwifery services.
(4) DHHS shall specify the terms for the Board members, not to exceed four (4) years. Members shall serve at the discretion of DHHS, may be reappointed at the end of their terms. The board will determine if compensation is available.
(5) A licensed midwife has the same authority and responsibility as appropriate licensed health care providers regarding following public health laws, reporting reportable diseases and conditions, controlling and preventing communicable diseases, recording of vital statistics, obtaining health histories, and performing physical examinations, except that this authority is limited to activity consistent with provision of services authorized by Sections 1 to 8 of this Act.
(6) A licensed midwife shall keep appropriate medical records regarding treatment and outcomes as required by the board by administrative regulation.
SECTION 3. A NEW SECTION OF ________ IS CREATED TO READ AS FOLLOWS:
DHHS shall promulgate administrative regulations, according to recommendations of the Board, in accordance with ________ to:
(1) Establish required standards for training programs for licensed midwives;
(2) Establish licensing requirements for licensed midwives, including but not limited to:
(a) Educational requirements that are consistent with United States educational accreditation standards and the United States Midwifery Education, Regulation, and Association statement on the licensure of certified professional midwives;
Provision of Temporary PEP Licensure Route: Completion of the North American Registry of Midwives Portfolio Education Process with mandatory completion of Midwifery Bridge certificate will be accepted as a route to licensure until January 1, 2023.
(b) Competency validation ferried by a national organization or agency that meets United States accreditation standards and recognized DHHS; and
(c) Anti-racism, anti-bias, and/or cultural humility training for recertification
(d) CPMs who have maintained licensure in another state that does not require accredited education must obtain the midwifery bridge certificate to be eligible for licensure in Nevada regardless of their date of certification
(3) Establish statewide requirements for licensed midwives and hospitals regarding the transfer of care from a licensed midwife to a hospital as developed by the Transfer Guidelines Work Group established in Section 8 of this Act;
(4) Establish provisions for disciplinary actions for licensed midwives;
(5) Establish fees for the initial license not to exceed one thousand dollars ($1,000), renewal of a license, reinstatement of a license, and other fees as may be necessary, for licensed certified professional midwives;
(6) Establish requirements for informed consent by individuals receiving services from a licensed midwife, which shall include:
(a) A description of the licensed midwife's education and credentials;
(b) A description of the scope of practice of licensed midwifery permitted under Sections
1 to 8 of this Act, including a summary of the limitations of the skills and practices of a licensed midwife;
(c) Instructions for obtaining a copy of the administrative regulations promulgated by the board pursuant to this section;
(d) Instructions for filing complaints with the board;
(e) A written protocol for emergencies, including transfer to a higher level of care;
(f) A description of the procedures, benefits, and risks of birth in the client's chosen environment, primarily those conditions that may arise during delivery;
(g) Disclosure of professional liability insurance if held by the licensed midwife;
(h) A summary of the requirements for consultation, referral or transfer of care as promulgated by administrative regulation by the board under this section;
(i) Procedures established by the licensed midwife for referral or transfer of care of a client to a physician or other appropriate healthcare providers;
(j) Procedures established by the licensed midwife for consultation or co-management; and
(k) Any other information deemed necessary by DHHS for the patient to provide informed consent for care by a licensed midwife;
(7) Establish regulations pertaining to certified professional midwives owning and/or operating freestanding birth centers in the state of Nevada as defined in this Act.
(8) Establish a formulary of legend medications that a licensed midwife may obtain, transport, and administer when providing licensed midwifery services including but not limited to the formulary provided in this act and those those medications and devices that are indicated and approved by DHHS for the safe conduct of pregnancy, labor and birth, and immediate care of the newborn, immediate management of obstetrical emergencies, or performance of routine prophylactic measures, and that the licensed midwife is approved to administer and monitor. This subsection shall not be interpreted to bestow prescriptive authority, and the formulary shall not include Schedule II, III, IV, or V drugs as defined in the Controlled Substances Act, 21 U.S.C. secs. 812 et seq.;
(9) Further regulate, as necessary, the provision of licensed midwifery services;
(10) Require licensed midwives to report to DHHS annually as specified by DHHS the following information regarding cases in which the licensed midwife provided services when the intended place of birth at the onset of care was in an out-of-hospital setting:
(a) The total number of clients provided licensed midwife services at the onset of care;
(b) The number of live births attended as a licensed midwife;
(c) The number of cases of fetal demise, newborn deaths, and maternal deaths attended as a licensed midwife at the discovery of the demise or death;
(d) The number, reason for, and outcome of each transport of a client in the antepartum,
intrapartum, or immediate postpartum periods;
(e) A brief description of any complications resulting in the morbidity or mortality of a mother or a newborn;
(f) Planned location of delivery and the actual location of delivery; and
(g) Any other information deemed necessary by DHHS;
(11) Require licensed midwives to report to the board, within thirty (30) days of the occurrence, a case of newborn or maternal death attended by a licensed midwife at the discovery of the death; and
(12) Define a list of conditions requiring co-management, consultation, or referral of a client to a physician or other appropriate licensed health care provider, and the process for such co-management, consultation, or referral.
(13)Establish requirements for Birth Assistant/Midwife Assistant
A. Criteria for Birth Assistants
This bill authorizes a midwife assistant to perform certain assistive activities under the supervision of a licensed midwife or certified nurse-midwife or certified midwife, including the administration of medicine, and technical support services.
1. The following criteria must be met:
a. Is at least 18 years of age
b. Has had minimum appropriate training by course or trainer approved by the Board. Certificate of completion required.
c. Anti-racism and anti-bias training
d. Must maintain current training in Neonatal Resuscitation from a certified instructor through American Academy of Pediatrics
e. Must maintain Basic Life Support (CPR)
B. Scope of a Birth Assistant
Birth assistants may perform simple routine medical tasks and procedures that can be safely performed by a midwife assistant who has limited training and who functions under the direct supervision of a licensed midwife on premise with ability to intervene. A birth assistant will not assess clinical information or make clinical decisions. Midwife assistants are permitted to perform the following technical support services:
1. Administer medications- intradermal, subcutaneous, IM and perform skin tests and additional technical support services.
2. Administer meds orally, sublingually, topically or rectally or by providing a dose to a patient for immediate self-administration.
3. Administer O2 at the direction of the supervising licensed midwife.
4. Assist in immediate newborn care
5. Placement of the device used for auscultation of fetal heart tones
6. Assist patient activities of daily living and transfer to bed and bathroom.
7. CPR/neonatal resuscitation
C. Required Training for Midwife Assistants: Training must be provided by a DHHS approved program or curriculum submitted to the DHHS for approval. Nurses or other midwives acting in the role of birth assistant must also complete this training that specifically addresses birth assisting in the home setting.
SECTION 4. A NEW SECTION OF ________ IS CREATED TO READ AS FOLLOWS: DHHS may require a criminal background investigation of an applicant for a license as a licensed midwife by means of a fingerprint check by the Department of Nevada State Police and the Federal Bureau of Investigation.
SECTION 5. A NEW SECTION OF _________ IS CREATED TO READ AS FOLLOWS:
(1) It shall be unlawful for any person to provide licensed midwifery services as defined in Section 1 of this Act unless that person is a licensed midwife currently issued a license by DHHS in accordance with Sections 1 to 8 of this Act or is an appropriate licensed health care provider providing services that are within his or her scope of practice.
(2) It shall be unlawful for any person to operate or to offer to operate or to represent or advertise the operation of a school or program of midwifery unless the school or program has been approved by DHHS to do so and are consistent with United States educational accreditation standards.
(3) Nothing in Sections 1 to 8 of this Act shall prohibit other midwives from providing midwifery services without a license if the other midwife has cultural, philosophical, or religious traditions that include the attendance of other midwives at birth, or a member of an American Indian community who provides midwifery services to the member's community. The other midwife must disclose to each client on a form provided by
DHHS:
1. That the person does not possess a professional midwifery license issued by the state.
2. That the person’s education and qualification have not been reviewed by the state.
3. The client will not have recourse through a formal complaint process through the state.
4. Must be signed and dated by both client and other midwife and kept on record for 5 years
(4) Nothing in Sections 1 to 8 of this Act shall prohibit an appropriate licensed healthcare provider or other person from providing emergency care, including care of a precipitous delivery.
(5) Nothing in Sections 1 to 8 of this Act shall prohibit a person from providing self-care, or uncompensated care to a friend or family member. Nothing in this chapter abridges, limits, or changes in any way the right of parents to deliver their baby where, when, how, and with whom they choose, regardless of licensure under this chapter.
(6) Nothing in Sections 1 to 8 of this Act shall prohibit an individual from performing activities or functions that are delegated by the licensed midwife if that individual is a student of midwifery in a training program operating as authorized by the board, and is under the direct supervision of a qualified preceptor as authorized by the board.
Apprentice/Student Midwives
A. General Provisions
1. An apprentice/student midwife may provide any care or service allowed by these regulations only set out under the direct supervision of a preceptor on premise and able to intervene. The preceptor reviews and evaluates all care provided by and attends every clinical task managed by the apprentice. The preceptor retains the responsibility for clients seen by apprentices/student midwives.
2. Preceptors must disclose to each client on a form provided by DHHS that an apprentice/student midwife may be involved in their care and the scope of that apprentice/student midwife under direct supervision.
3. Apprentice/student midwife may not represent themselves or practice as any other type of midwife while holding an active Apprentice/student midwife permit.
B. Apprentice/Student Midwife Permits:
1. Application for apprentice midwife permit must include all of the following:
a. a completed agreement with the preceptor
b. a completed apprentice application
c. payment of $100 to division
2. Upon proof of successful completion of application, DHHS will supply to the qualifying apprentice applicants an apprentice midwife permit and regulatory information applicable to apprenticeship.
4. Renewal of Permits: An apprentice midwifery permit may be renewed once q two years permit period. An applicant for renewal shall submit to
DHHS:
a. A completed renewal application
b. Renewal payment of $100
SECTION 6. A NEW SECTION OF ________ IS CREATED TO READ AS FOLLOWS:
(1) Within one (1) year of the effective date of this Act, the council shall make recommendations to DHHS for the promulgation of administrative regulations by DHHS regarding requirements for the management of clients who may have a condition that precludes the clients from being considered at lower risk of an adverse outcome for the mother, her fetus, or her newborn. These recommendations shall include:
(a) A regulatory framework to support consultation and co-management between licensed midwives and other appropriate licensed health care providers with expertise in obstetrical and neonatal care, in order to optimize obstetrical and neonatal outcomes in whatever setting a client chooses for birth. The regulatory framework shall specify:
1. Processes and infrastructure to facilitate co-management and consultation with other licensed healthcare providers who possess the appropriate medical expertise;
2. Processes and infrastructure to facilitate co-management with, or transfer of primary management responsibility to, other licensed healthcare providers who possess the appropriate medical expertise;
3. Processes and infrastructure for transfer of clients to facilities with a higher level of care, as developed by the Transfer Guidelines Work Group established in Section 8 of this Act, and as updated by the Board;
4. Processes for the provision of required or routinely recommended screening and disease prevention measures, if not provided directly by the licensed midwife; and
5. Other collaborative processes deemed necessary by the Board or DHHS to optimize obstetrical and neonatal outcomes;
(a) A list of conditions or symptoms associated with a risk of death or serious permanent harm affecting a mother, fetus, or newborn, as assessed by a licensed midwife exercising reasonable skill and knowledge, and:
1. Requirements for co-management with, or referral of primary management responsibility to, a physician or other appropriate licensed healthcare provider, of a client with conditions or symptoms specified under this paragraph, to protect the health and safety of a mother, fetus or newborn. Separate regulatory requirements shall be developed for each or any condition on the list, if clinically appropriate. If every effort is made to consult, co-manage and/or refer, and it is documented in client records, and no physician or other appropriate licensed healthcare provider is able or willing to consult, co-manage, and/or accept referral, this requirement will be considered met by the licensed midwife and the licensed midwife may continue to assume primary management responsibility for the client.:and
2. Requirements for management of a client with conditions or symptoms specified under this paragraph who refuses to consent to recommendations intended to prevent death or serious permanent harm, including requirements for informed refusal by the client. The requirements for informed refusal shall be tailored to the specific condition or symptom, and shall reflect maximal effort to protect the life and health of the mother, her fetus, and her newborn; and
(b) A list of conditions or symptoms associated with a more than minimal risk of adversely affecting a mother, fetus, or newborn, but not a significant risk of death or serious permanent harm, as assessed by a licensed midwife exercising reasonable skill and knowledge, and:
1. Requirements for consultation, co-management, or referral of primary management responsibility of a client with conditions or symptoms specified under this paragraph, for each condition or symptom on the list, to ensure the health and safety of a mother, fetus, or newborn; and
2. Requirements for documentation of an informed refusal by a client with conditions or symptoms specified under this paragraph of recommended consultation, referral of care, or other management, including the information to be provided to a client that is necessary to enable informed refusal of recommended care.
(2) The board's recommendations shall be accepted by DHHS to form the basis for any requirements or restrictions imposed by the board on the provision of licensed midwifery services to a client whose condition is not classified as healthy. The recommendations shall be based on evolving medical evidence published in peer-reviewed medical literature and with consideration to the likelihood of serious harm or death to the mother or newborn.
(3) Until such time as the Board has conveyed superseding recommendations to DHHS and DHHS has promulgated superseding administrative regulations, the following shall be enforced by DHHS:
(a) If on initial or subsequent assessment, one (1) of the following conditions exists, the licensed midwife shall arrange for consultation, co-management or referral in accordance with Sections 1 to 8 of this Act, and document that recommendation in the licensed midwife's record:
1. Complete placenta previa, or partial placenta previa persisting after twenty eight (28) weeks;
2. HIV infection;
3. Cardiovascular disease, including hypertension;
4. Severe psychiatric illness that may result in self-harm or harm to others;
5. History of cervical incompetence;
6. Pre-eclampsia or eclampsia;
7. Fetal growth restriction, oligohydramnios or moderate or severe polyhydramnios in the current pregnancy;
8. Known potentially serious anatomic fetal abnormalities;
9. Any type of diabetes requiring insulin or other medication for management;
10. Gestational age greater than forty-three (43) weeks; or
11. Any other condition or symptom which could threaten the life of the mother or fetus, as assessed by a licensed midwife exercising reasonable skill and knowledge;
(b) The licensed midwife may continue to participate in the care of a client requiring transfer, in a collaborative fashion and as mutually agreed upon with the accepting physician, to the extent permitted by hospital regulations and if it is beneficial to the client. If a client with a condition listed in paragraph (a) of this subsection declines to accept a medically indicated consultation or referral, the licensed midwife shall document such refusal in writing and shall endeavor to transition the client to an appropriate higher level of care. If the condition mandating transfer occurs during labor or delivery, or the client is otherwise acutely in jeopardy but refuses transfer, then the midwife shall call 911 and provide care at least until relieved by another appropriate licensed health care provider; and
(c) If on initial or subsequent assessment, one (1) of the following conditions exists, the midwife shall arrange for consultation and either co-management or referral in accordance with Sections 1 to 8 of this Act, and document that recommendation in the midwifery record:
1. Prior cesarean section or other surgery resulting in a uterine scar;
2. Multifetal gestation;
3. Non-cephalic presentation after thirty-six (36) weeks gestation; and
4. History of severe shoulder dystocia as documented by objective findings.
(4) DHHS shall, at the earliest opportunity, promulgate administrative regulations specific to the conditions listed in paragraph (c) of subsection (3) of this section, including the minimum requirements for informed refusal by the client of otherwise mandatory consultation and either co-management or referral.
(5) If the client has complied with administrative regulations promulgated by DHHS for informed refusal, then the licensed midwife may pursuant to subsection
(4) of this section, continue to assume primary management responsibility for the client unless and until the client subsequently consents to co-managed care or referral.
SECTION 7. A NEW SECTION OF _______ IS CREATED TO READ AS FOLLOWS:
Nothing in Sections 1 to 8 of this Act is intended to expand liability. In the event of an action for injury or death due to any act or omission of a licensed midwife licensed pursuant to Sections 1 to 8 of this Act, the liability of any other licensed healthcare provider shall be limited to their negligent acts and omissions that violate their standards of care according to existing law.
SECTION 8. A NEW SECTION OF _______ IS CREATED TO READ AS FOLLOWS:
The Transfer Guidelines Work Group is hereby established as an independent entity to develop statewide requirements for licensed midwives and hospitals which shall be based upon evidence in peer-reviewed medical literature and accepted best practice standards, regarding the process of transfer of care from a licensed midwife to a hospi-tal. The scope of the Transfer Guidelines Work Group shall include procedures that promote the safe and timely transfer of mothers or newborns to facilities that can pro-vide a higher level of care when needed, and to ensure the complete and timely trans-mission of all necessary information required to satisfactorily care for a mother or new-born requiring transfer. The work group shall select a chair from among the members.
The work group shall meet as necessary and submit the developed statewide require-ments agreed to by the majority after every attempt to satisfy all parties in the work group by the work group to the board within one (1) year of the effective date of this Act. The board shall promul-gate administrative regulations to implement the requirements developed by the work group. The work group shall cease to exist after the developed requirements have been submitted to DHHS unless DHHS directs its continuance. The members of the work group shall not be paid or reimbursed for travel or other expenses. The work group shall consist of the following members:
(1) Two (2) licensed healthcare providers- CNM, APRN, or OB/Gyn- one from Northern Nevada and one from Southern Nevada, responsible for accepting transfers from the home or birth center setting to hospital.
(2) Four (4) individuals appointed by the Nevada Chapter of the National Association of Certified Professional Midwives,-2 Northern and 2 Southern licensed midwives. If the regional position is unable to be filled by a licensed midwife in that region, it may be filled by a licensed midwife from another region.
(3) 2 Nurse Managers or similar job responsibilities, one from Northern Nevada and one from Southern Nevada, responsible for helping coordinate transfer from the home or birth center setting to hospital.
(4) Two (2) individuals appointed by Emergency Medical Services- one from Northern Nevada, one from Southern Nevada,
(5) One (1) member of the DHHS who shall be a nonvoting, ex officio member and whoshall serve as the liaison between the work group chair and DHHS.
(6) Additionally, a member of the Nevada Hospital Association is optional, but not re-quired in the Work Group
