HB 4553

relating to the mandatory reporting of birth outcomes by licensed
midwives in the State of Texas.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1.  This Act may be cited as Malik's Law.
SECTION 2.  Section 203.154(b), Occupations Code, is amended
SUBCHAPTER H.  PRACTICE BY MIDWIFE
Sec. 203.351.  INFORMED CHOICE AND DISCLOSURE REQUIREMENTS.
(a)  A midwife shall disclose in oral and written form to a
prospective client the limitations of the skills and practices of a
(b)  The department shall prescribe the form of the informed
choice and disclosure statement required to be used by a midwife
under this chapter.  The form must include:
(1)  statistics of the midwife's experience as a
(2)  the date of the midwife's original licensure and
(3)  the date the midwife's cardiopulmonary
resuscitation certification expires;
(4)  the midwife's compliance with continuing education
(5)  intermittent auscultation certification if
(6)  a description of medical backup arrangements; and
(7)  the legal responsibilities of a midwife, including
statements concerning newborn blood screening, ophthalmia
neonatorum prevention, and prohibited acts under Sections
(c)  The informed choice statement must include a statement
that state law requires a newborn child to be tested for certain
heritable diseases and hypothyroidism.  The midwife shall disclose
to a client whether the midwife is approved to collect blood
specimens to be used to perform the tests.  If the midwife is not
approved to collect the blood specimens, the disclosure must inform
the client of the midwife's duty to refer the client to an
appropriate health care facility or physician for the collection of
(d)  The disclosure of legal requirements required by this
section may not exceed 500 words and must be in English and Spanish.
(e)  A midwife shall disclose to a prospective or actual
client the procedure for reporting complaints to the department.
(f) a midwife shall disclose if they are under active
investigation by the department before client consents to care.
Acts 1999, 76th Leg., ch. 388, Sec. 1, eff. Sept. 1, 1999. Amended
Acts 2005, 79th Leg., Ch. 1240 (H.B. 1535), Sec. 40, eff.
Acts 2015, 84th Leg., R.S., Ch. 838 (S.B. 202), Sec. 1.027,
Sec. 203.352.  PRENATAL AND CERTAIN MEDICAL CARE ENCOURAGED.
A midwife shall encourage a client to seek:
(2)  medical care through consultation or referral, as
specified by commission rules, if the midwife determines that the
pregnancy, labor, delivery, postpartum period, or newborn period of
a woman or newborn may not be classified as normal for purposes of
(3) Medical terms and practices addressed in this
chapter pertaining to maternal and neonatal health will reflect
definitions and practice standards as defined by the American
College of Obstetrics and Gynecology as well as the International
Confederation of Midwives, the American Academy of Pediatrics and
Acts 1999, 76th Leg., ch. 388, Sec. 1, eff. Sept. 1, 1999.
Acts 2015, 84th Leg., R.S., Ch. 838 (S.B. 202), Sec. 1.028,
Sec. 203.353.  PREVENTION OF OPHTHALMIA NEONATORUM.  (a)
Subject to Subsection (b), unless the newborn child is immediately
transferred to a hospital because of an emergency, a midwife who
attends the birth of the child shall comply with Section 81.091,
(b)  A midwife in attendance at childbirth who is unable to
apply prophylaxis as required by Section 81.091, Health and Safety
Code, due to the objection of the parent, managing conservator, or
guardian of the newborn child does not commit an offense under that
section and is not subject to any criminal, civil, or
administrative liability or any professional disciplinary action
for failure to administer the prophylaxis.  The midwife in
attendance at childbirth shall ensure that the objection of the
parent, managing conservator, or guardian is entered into the
Acts 1999, 76th Leg., ch. 388, Sec. 1, eff. Sept. 1, 1999.
Acts 2017, 85th Leg., R.S., Ch. 1105 (H.B. 4007), Sec. 1.002,
Sec. 203.354.  NEWBORN SCREENING.  (a)  Each midwife who
attends the birth of a child shall cause the newborn screening tests
to be performed on blood specimens taken from the child as required
by Chapter 33, Health and Safety Code.
(b)  A midwife may collect blood specimens for the newborn
screening tests if the midwife has been approved by the department
to collect the specimen.  The commission shall adopt rules
establishing the standards for approval.  The standards must
recognize completion of a course of instruction that includes the
blood specimen collection procedure or verification by
appropriately trained health care providers that the midwife has
been instructed in the blood collection procedures.
(c)  A midwife who is not approved to collect blood specimens
for newborn screening tests shall refer a client and her newborn to
an appropriate health care facility or physician for the collection
of the blood specimen and submission of the specimen to the
(d)  If the midwife has been approved by the department to
collect blood specimens under this section, the collection by the
midwife of blood specimens for the required newborn screening tests
does not constitute the practice of medicine as defined by
Acts 1999, 76th Leg., ch. 388, Sec. 1, eff. Sept. 1, 1999.
Acts 2005, 79th Leg., Ch. 1240 (H.B. 1535), Sec. 41, eff.
Acts 2015, 84th Leg., R.S., Ch. 838 (S.B. 202), Sec. 1.029,
Sec. 203.355.  SUPPORT SERVICES.  (a)  In this section:
(1)  "Clinical services" include prenatal, postpartum,
child health, and family planning services.
(2)  "Local health unit" means a division of a
municipal or county government that provides limited public health
services under Section 121.004, Health and Safety Code.
(3)  "Public health district" means a district created
under Subchapter E, Chapter 121, Health and Safety Code.
(b)  The Department of State Health Services and a local
health department, a public health district, or a local health unit
shall provide clinical and laboratory support services to a
pregnant woman or a newborn who is a client of a midwife if the
midwife is required to provide the services under this chapter.
(c)  The laboratory services must include the performance of
the standard serological tests for syphilis and the collection of
blood specimens for newborn screening tests for phenylketonuria,
hypothyroidism, and other heritable diseases as required by law.
(d)  The provider may charge a reasonable fee for the
services.  A person may not be denied the services because of
(e)  If available, appropriately trained personnel from
local health departments, public health districts, and local health
units shall instruct licensed midwives in the approved techniques
for collecting blood specimens to be used to perform newborn
Acts 1999, 76th Leg., ch. 388, Sec. 1, eff. Sept. 1, 1999.
Acts 2005, 79th Leg., Ch. 1240 (H.B. 1535), Sec. 42, eff.
Acts 2015, 84th Leg., R.S., Ch. 838 (S.B. 202), Sec. 1.030,
Sec. 203.356.  IMMUNITY.  (a)  A physician, a registered
nurse, or other person who, on the order of a physician, instructs a
midwife in the approved techniques for collecting blood specimens
to be used for newborn screening tests is immune from liability
arising out of the failure or refusal of the midwife to:
(1)  collect the specimens in the approved manner; or
(2)  submit the specimens to the Department of State
Health Services in a timely manner.
(b)  A physician who issues an order directing or instructing
a midwife is immune from liability arising out of the failure or
refusal of the midwife to comply with the order if, before the
issuance of the order, the midwife provided the physician with
evidence satisfactory to the department of compliance with this
Acts 1999, 76th Leg., ch. 388, Sec. 1, eff. Sept. 1, 1999.
Acts 2005, 79th Leg., Ch. 1240 (H.B. 1535), Sec. 43, eff.
Acts 2015, 84th Leg., R.S., Ch. 838 (S.B. 202), Sec. 1.031,
Sec. 203.357.  ADDITIONAL INFORMATION REQUIRED.  (a)  The
department may require information in addition to that required by
Section 203.253 if it determines the additional information is
necessary and appropriate to ascertain the nature and extent of
midwifery in this state.  The department may not require
information regarding any act that is prohibited under this
(b)  The department shall prescribe forms for the additional
information and shall distribute those forms directly to each
midwife.  Each midwife must complete and return the forms to the
(c)  Information received under this section may not be made
public in a manner that discloses the identity of any person to whom
the information relates.  The information is not public information
as defined by Chapter 552, Government Code.
Acts 1999, 76th Leg., ch. 388, Sec. 1, eff. Sept. 1, 1999.
Acts 2015, 84th Leg., R.S., Ch. 838 (S.B. 202), Sec. 1.032,
Sec. 203.358.  MANDATORY REPORTING OF BIRTH OUTCOMES.
(1)  A licensed midwife shall submit a Birth & Outcomes Report to
the Department of State Health Services (DSHS) Vital Statistics
and Texas Department of Licensing and Regulation within 10 days of
attending any birth in a home, birthing center, or other
(2)  The report shall be mandatory for every birth attended by a
midwife, regardless of whether:
a. The newborn or mother survives;
b. The newborn or mother is transferred to a hospital;
c. The midwife was the primary or assisting provider
e. The complications leading to a poor outcome were deemed
"unforeseen medical circumstances."
(3)  If a midwife is involved in a birth, but another midwife  files
the report, all midwives present must co-sign and verify the
report.  A failure to do so constitutes a violation under this
(b)  Required Report Contents. Each report must include:
a. Full name and Texas midwifery license number of the
a. The planned and actual location of the birth,
b. The gestational age at birth,
c. The type of birth vaginal, assisted vaginal, cesarean
d. The APGAR scores at one, five, and ten minutes,
f. Whether the birth was an attempted vaginal delivery
after cesarean, including how many previous
cesareans the client had prior to attempting VBAC and
g. How many gestation single, twin, or multiples, and
3. Complications & Interventions:
a. Any neonatal resuscitation performed, and fetal
2. Ruptured membranes up to and including five hours,
more than 10 hours and more than 20hrs,
3.Length of time and number of any fetal
decelerations incidents occurring less than 110
4. History of decreased growth during pregnancy,
6. Meconium Aspiration Syndrome,
7. Hypoxic-Ischemic Encephalopathy, and
b. Any maternal complications, including:
1. Postpartum hemorrhage (>1,000 mL),
2. Hypertensive crisis/eclampsia,
6. Abnormal labor patterns/stalling of labor, or
7. Any other significant maternal morbidities.
a. If the mother or newborn was transferred to a
1. The time elapsed from birth to transfer,
2. The name of the receiving hospital, and
Status shall be reported regardless of where the demise
occurred and shall include intrapartum death
a. Whether the newborn survived, and if not, the date of
b. Whether the mother survived, and if not, the date  of
6. Verification & Accountability:
a. If more than one midwife attended, all must sign and
(c) Data Verification and Audits.
(1) Texas Department of Licensing and Regulation shall conduct
random audits of Birth & Outcomes Reports to ensure compliance  and
(2) Hospitals shall be required to report all deaths and
morbidities linked to midwife-attended births to DSHS Vital
Statistics, which shall cross-check the data with
midwife-submitted reports. Any missing reports will trigger an
(3) A failure to report a transfer resulting in death or severe
morbidity shall be treated as a violation under this section.
A midwife who fails to submit a report within the required 10-day
a. First offense:  Written warning and remedial training in
reporting and medical recording provided by Texas
Department of Licensing and Regulation.
b. Second offense:  A fine of up to $1,000 per day for each day
the report is overdue enforced by Texas Department of
c. Third offense:  License suspension to be enforced by Texas
Department of Licensing and Regulation.
(2) False or Incomplete Reporting:
A midwife who knowingly submits false or incomplete information
a. A fine of up to $5,000 per violation.
b. A mandatory review of all past reports submitted by the
c. License revocation for repeated violations without
(3) Avoidance of Accountability:
a. If a midwife surrenders their license while under
investigation, they shall remain subject to enforcement
actions, including fines, civil, and criminal penalties,
for two years following license surrender.
The Executive Commissioner of Texas Department of Licensing and
Regulation and the Department of State Health Services Vital
Statistics shall adopt rules necessary to implement this  section,
a. Including data of out of hospital Birth & Outcomes Reports
with yearly infant and maternal mortality  statistics
separate from hospital statistics.
b. Defining protocols for investigating noncompliance with
c. Publicly displaying de-identified statistics on maternal
and neonatal outcomes from midwife-attended births in
SECTION 3.  This Act takes effect September 1, 2025.