California College of Midwives
State chapter ~ American College of Community Midwives

Section One

Client Disclosure Form ~ Required by the LMPA
Midwifery Scope of Practice, Medical Interface, Emergency Arrangements, Malpractice Insurance Disclosure, Reporting Unsatisfactory Care to MBC


Informed Consent for Community-based Midwifery Care

e The Licensed Midwifery Practice Act (LMPA) requires that each Licensed Midwife provide information on the scope of licensed midwifery practice in California to clients seeking community-based midwifery care.

The LMPA also requires that LMs identify appropriate arrangements for medical consultation and transfer of care during the prenatal period, hospital transfer during labor, birth and immediate postpartum and how to obtain appropriate emergency medical services for mother and baby when necessary.

Medical arrangements must be specific to each client's circumstance, discussed with her, documented in writing and retained on her chart.

In addition, Licensed Midwives are legally responsible for registering the births of all babies born under their care.  

Midwifery Scope of Practice as defined by the LMPA, Sec 2507: 

(a) The license to practice midwifery authorizes the holder, under the supervision of a licensed physician and surgeon, to attend cases of normal childbirth and to provide prenatal, intrapartum, and postpartum care, including family-planning care, for the mother, and immediate care for the newborn.

(b) As used in this article, the practice of midwifery constitutes the furthering or undertaking by any licensed midwife, under the supervision of a licensed physician and surgeon who has current practice or training in obstetrics, to assist a woman in childbirth so long as progress meets criteria accepted as normal. All complications shall be referred to a physician immediately. The practice of midwifery does not include the assisting of childbirth by any artificial, forcible, or mechanical means, nor the performance of any version.

(c) As used in this article, "supervision" shall not be construed to require the physical presence of the supervising physician.

(d) The ratio of licensed midwives to supervising physicians shall not be greater than four individual licensed midwives to one individual supervising physician.

(e) A midwife is not authorized to practice medicine and surgery by this article.

Note regarding physician supervision as referenced above ~ Currently the malpractice carriers who provide professional liability insurance to California obstetricians will not permit physicians to have a supervisory relationship with professional midwives who provide community-based birth services. 

Specific Arrangements for Medical Care are as follows:

Licensed Midwife _____________________________________  License #_____

Client Name   ___________________________________________ Date _______

(1) Medical/Obstetrical Consultation and Transfer of Care during your pregnancy: __________________________________________________________________

(2) Hospital-based physician care during your labor, birth and the immediate postpartum: __________________________________________________________________

(3) Emergency Care for you or your newborn baby during or after the birth:  __________________________________________________________________

As a consumer of healthcare services you have the right to check on the licensure status of any health care practitioner licensed in California. Physicians, Licensed Midwives and 18 allied health professions are licensed and regulated by the Medical Board of California (MBC). For information on Medical Board licentiates call 1- 916 / 263-2382 or visit their web site at You also have the right to report any complaints about care received to the MBC by calling 1- 800 / 633-2322. Instructions and a complaint form are available on-line by visiting the MBC Internet site @

If the above named licensed midwife does not carry professional liability (i.e. malpractice) insurance, I have been so informed of that fact. Initials ______


Client Signature _____________________________________  Date ________

Partners Signature ___________________________________ Date ________

Witness Signature ____________________________________  Date________