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Legislation would decriminalize some midwifery practices

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Audrey Trepiccione is a Certified Professional Midwife, a specialist in delivering babies for women at their homes. But Trepiccione could incur a Class 1 misdemeanor if she is found to be practicing her line of work in North Carolina, her home state.

"Women appreciate that individualized care," she says. "It's so efficient and so economical and so satisfying. But no one's going do it if it's illegal. It's not worth the midwife getting arrested."

Soon, that all might change.

Senate Bills 106 and 107—The Homebirth Freedom Act and Decriminalize Direct-Entry Midwifery—sponsored by state Sen. Thom Goolsby, R-New Hanover, would license Certified Professional Midwives (CPMs) to practice.

CPMs don't have the same formal education as Certified Nurse-Midwives, who can practice legally in North Carolina under a physician's supervision. Certified Nurse-Midwives are registered nurses with further training in midwifery. Most hold master's degrees in nursing or public health; they have been practicing legally in the state since 1983, when the Midwifery Practice Act became law. In North Carolina, Certified Nurse-Midwives practice mostly in hospitals, but, unlike CPMs, it is legal for them to deliver babies at private homes and at birthing centers as well.

Alexander Miller, a lobbyist for the North Carolina Affiliate of the American College of Midwives, says there is some confusion about what Goolsby's bills would actually do if they become law. "Senate Bills 106 and 107 deal with Certified Professional Midwives only," he wrote in an email, "and would not affect the continuing licensure, practice or oversight of Certified Nurse-Midwives."

According to Miller, the American College of Midwives has not taken a position on the bills. "The organization has a clear position on minimum training in midwifery that is acceptable," he says, "and we are determining whether the bills would require a sufficient level of training."

But he says his organization agrees with the findings laid out in Goolsby's Homebirth Freedom Act. "Women in North Carolina experience serious problems in accessing health care during and after pregnancy, and in giving birth," Miller says.

A 2011 report from the University of North Carolina's Sheps Center for Health Services Research found that 31 of North Carolina's 100 counties have no practicing obstetricians/ gynecologists. More than half of all practicing ob/ gyns in the state are concentrated in just seven counties. North Carolina ranks 44th in the nation in infant mortality, according to a 2012 National Vital Statistics Report from the U.S. Department of Health and Human Services; lack of access to qualified care has been cited as the main reason.

North Carolina Friends of Midwives, a consumer advocacy group for midwives and for families who choose homebirth, supports Sen. Goolsby's bills, according to the group's president, Russ Fawcett. Since 2007, Friends of Midwives has been working to license CPMs in the state. "Rates of homebirth are accelerating in our state and all over the U.S.," Fawcett says. "All of our neighbor states do the best job they can by licensing Certified Professional Midwives. Any state that does not manage homebirth inevitably mismanages it, and we know that the only way to achieve a truly safe environment is to address and enable CPMs in a framework that promotes success."

The N.C. Coalition To Protect Patients—ostensibly a group of North Carolina physicians and lobbyists—set up a website sometime this year, criticizing Senate bills 106 and 107 for promoting unsafe practices. According to the website, "SB 106 lowers safety standards where they are needed most—during planned home births. Under current law, midwives can only practice with a nursing degree and with physician supervision. CPMs do not meet these minimum standards and are not licensed to practice in North Carolina."

As for Senate Bill 107, the coalition says, "This bill would protect from criminal prosecution midwives who deliver children independently and without the supervision of a trained physician. Midwives have very little training and no formal education requirements."

Jenny Cox, the legislative chair for the North Carolina affiliate of the American College of Nurse-Midwives, said this is not true. "One of the misnomers, and the NC Friends of Midwives are pointing this out left and right, people keep mistaking it as lay midwifery. Lay would imply that you are not trained, you've had no training to be a midwife."

Cox, a Certified Nurse-Midwife herself, does not take a position on Goolsby's bills, but she said there are two ways to receive CPM credentials. Schools of midwifery are accredited by the Midwifery Education Accreditation Council, she says, "and then there's something called the portfolio evaluation process, essentially what people refer to as an apprenticeship. So even if you apprentice, you're not a lay person. But [some people], that's what they think."

The American College of Nurse-Midwives will file its own bill to eliminate the requirement of a physician's supervision for practicing Certified Nurse-Midwives. They deem the supervisory agreement an unnecessary barrier to their practice which, according to Miller, "inappropriately exposes the signing physician to vicarious liability for the actions of another professional."

Trepiccione, whose CPM license was granted in Virginia, became a childbirth instructor in 1989. She apprenticed over four years with two midwives. After taking the American Midwifery Certification Board exams in 1997, she registered with the North American Registry of Midwives and has to recertify as a CPM every three to five years. Trepiccione has 10 children, seven of which she had at home. "It was a conviction for us, it was not a preference," she says of her homebirths. "It was a solid, spiritual decision. Some people are just cut out for this."

Trepiccione estimates that she has delivered hundreds of babies over the course of her career, including two of her grandchildren. If these bills become law, Trepiccione wants to open her own practice where she would provide expectant mothers the full range of maternity care, including pre- and post-partum services, homebirths and physician consultation and referrals.

"Women are demanding this service," she says. "It's proven to be a safe alternative to giving birth at the hospital. We think maybe, finally, having a homebirth dad in the Senate will be what's gonna do it. It's finally gotten big. It's widespread enough that it's accepted. Reasonable, educated people do it. It's a natural, low-tech, touchy-feely alternative."

Correction: Certified-Nurse Midwives can practice legally in all 50 states. In six states, North Carolina included, CNMs must practice under the supervision of a physician.

This article appeared in print with the headline "Birth of a movement."

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