North Carolina's high rate of combined fetal and neonatal mortality rank it in the bottom sixth of the nation. The state is also one of only 11 in the country where the practice of midwifery outside the supervision of physicians is illegal.
Russ Fawcett doesn't think that's a coincidence.
Fawcett helps lead an organization committed to turning the situation around in the Tar Heel State. The North Carolina Friends of Midwives (NCFOM) was formed a decade ago to advocate for the independent licensure of midwives. Direct-entry midwifery, which operates autonomously from obstetricians, was outlawed in North Carolina 25 years ago.
In contrast to North Carolina's statistics, eight of the 10 states with the lowest fetal and neonatal mortality allow and license direct-entry midwives.
The issue of legalizing direct-entry midwifery is the subject of a study committee in the N.C. General Assembly this session. The House select committee was formed to investigate the merit of licensing independent midwives, and a report is due by the end of the year. The group has already met twice and heard from both supporters and opponents; at least two more meetings are expected by fall.
The study committee was the way birth reformists sought to get around a seeming impasse: For the better part of a decade, the leadership in the state House and Senate has agreed to pass legislation legalizing direct-entry midwives if and only if the North Carolina Medical Society would sign off.
"That is a perfectly understandable position, but it's just not going to work," Fawcett said. "They are not going to agree, and never have."
The physicians' organization is staunchly opposed to licensing independent midwives.
"The gap that we have to close is the difference in our medical society's take on things versus what the midwives are able to do," says Rep. Ty Harrell (D-Wake), who called for the study committee. The second of Harrell's two sons was born with the assistance of midwives in Washington, D.C.
Hoping to show the legislature the grassroots support behind the move to license direct-entry midwives, every week during the short session one of the five regional chapters of NCFOM will visit with lawmakers. Advocates from the Triangle chapter will meet with representatives and senators May 28 and July 16.
Midwives specialize in normal pregnancy, childbirth and postpartum care and generally strive to help women have natural birth experiences. Midwives are the primary healthcare practitioners for pregnant women in much of the world, and they are trained to recognize anomalies and often refer such cases to physicians.
By contrast, obstetricians are specialists in illness related to childbearing and surgical and other methods to treat those illnesses. In almost every other developed country, the two professions work in harmony, with the majority of normal pregnancies attended by midwives while difficult pregnancies are handed off to obstetricians.
In the United States, however, it is much more common for the two professions to be at odds with each other due to different philosophies about birth. Although there is wide variation among practitioners in each profession, generally obstetricians are taught to actively manage birth, whereas midwives are taught birth is a normal event for a healthy woman and not to interfere unless necessary.
At least one obstetrician in the state supports legalizing direct-entry midwifery.
"I think midwives actually do a better job of taking care of healthy women and also women with social needs than obstetricians do," says Dr. Henry Dorn, who practices in High Point. Last year, Dorn founded the North Carolina Physicians for Midwives, a community of health care providers and researchers who support the midwifery model of care.
"If a patient is going to have a normal delivery with minimal interventions—which has been proven to have improved outcomes—midwives do that better than obstetricians," Dorn adds.
Dorn also notes that what makes midwifery particularly safe is obstetrical backup, meaning that midwives refer complications both before and during birth to physicians. But that kind of "coordinated care" is rare in North Carolina because the prohibition of direct-entry midwifery makes communication between doctor and independent midwives impossible. Most obstetricians turn away women who are working with such midwives who need or desire parallel care. Dorn is one of the only obstetricians around who will see such patients.
"Someone shouldn't have to drive from Charlotte or Hickory or Wilmington simply because they cannot get someone to do an ultrasound," Dorn says.
The chasm is primarily over the practice of birthing at home, where most independent midwives attend laboring women. The N.C. Medical Society, as well as the American College of Obstetricians and Gynecologists, is adamantly against homebirth, maintaining that monitoring of women and fetuses in a hospital or affiliated birth center is necessary in the event of unexpected complications.
The state medical society declined comment other than to refer to its 2006 statement opposing direct-entry midwives and homebirth. In a PowerPoint presentation on its mission, available on the organization's Web site, the society lauds its efforts to stop legislation to license independent midwives in 2001 as one of its legislative accomplishments.
Fawcett points out that this opposition comes in the face of a study published in the British Medical Journal showing planned homebirths to have at least as good outcomes for both mothers and babies as planned hospital births, with drastically lower rates of cesarean sections (4 percent versus 19 percent) and episiotomy (2 percent versus 84 percent). The statistics were compiled from all planned homebirths in the United States in 2000 and included 5,418 women.
Becky Bagley, the director of the nurse-midwifery education program at East Carolina University, explains that the disconnect stems from the assumption by obstetricians that a homebirth is just like a hospital birth without all of the equipment.
"They don't know because they have never been to or seen one," Bagley says.
Nothing could be further from the truth, Bagley explains. Women who birth at home don't have epidurals, maintain much more autonomy over their own movement, and play a far more active role in the management of their own labor. "Physicians are not taught that; they are taught to intervene," Bagley says, adding that the interventions themselves are associated with higher risks of complications.
Bagley is a Certified Nurse Midwife (CNM), the only type of midwifery certification accepted by the state. Certified Professional Midwives (CPMs), the national standard for credentialed direct-entry midwives, cannot legally practice in North Carolina.
Although all midwives practice within what is known as the midwifery model of care, the primary distinction is that CNMs are registered nurses and mostly operate in hospitals. CNMs then have to operate within those institutions' protocols, which often require IVs, fetal heart monitors, prohibit eating and drinking and limit the birthing woman's movement. A small percentage of CNMs practice in birthing centers, where the rules are usually more relaxed.
Certified Professional Midwives practice autonomously from obstetricians and mostly serve those seeking birth outside of a hospital, either in birth centers (in states where they are allowed) or at home.
One of the main arguments for licensing CPMs is that they are trained in the skills necessary to help women deliver their babies comfortably and safely at home and primarily serve that community. Only four CNMs in the state aid families planning homebirths. CNMs in North Carolina have to find a physician sponsor—a considerable challenge considering the stance of both the local and national medical societies on the practice of homebirth.
There are approximately 1,300 CPMs nationwide; only 15 of those are in North Carolina. CPMs are eligible for licensure in South Carolina, Tennessee and Virginia. Women in North Carolina are often attended by midwives licensed in surrounding states but who live and practice here.
"That is something these physicians cannot seem to get through their heads: Women are going to have homebirths regardless," Bagley says.
Although the law against direct-entry midwifery in North Carolina has only been enforced once in 25 years, and the charges brought against the midwife were dropped, midwifery advocates say no one is served by having the judicial system regulate midwives.
"If [women] are going to deliver at home, let's provide them with someone who is licensed or legal and is trained," Bagley says. "Physicians are not going to go and sit with a woman at home while she labors. Most Certified Nurse Midwives aren't going to do that either."
Bagley serves on the legislative study committee as an expert adviser. Thus far, she has advised the committee on the difference in education and certification requirements of CNMs and CPMs. Although Certified Professional Midwives are not required to have nursing degrees, a point often held against them by physicians, their clinical requirements are double those of nurse-midwives.
"The training that Certified Nurse Midwives get in the home setting is zero," Bagley points out. "Certified Professional Midwives are better trained in home birth than either Certified Nurse Midwives or physicians."
In addition to the independent licensure of CPMs in the state, advocates also want CNMs to be eligible for licensure without doctor supervision.
"That is the key thing," Fawcett says. "Even if physicians support the idea [of licensing midwives], they will not sign for homebirth midwives."
Of the 24 states that license direct-entry midwives, or CPMs, 18 of them have autonomous practice. CPMs are legal in 40 states but only regulated in half of those.
The charter for the legislative committee acknowledges there are "hundreds" of planned home births attended by CPMs in the state annually, yet the midwives are nonetheless denied a license. "Denying licensure to CPMs marginalizes this entire community and further impedes progress toward addressing North Carolina's poor access to maternity care," the committee charter states.
Midwifery advocates point out that all but five of North Carolina's 100 counties are designated by the U.S. Department of Health and Human Services as "medically underserved areas," in many cases meaning families do not have access to prenatal care or affordable birth services.
More than 30 percent of families birth in rural areas that usually have no access to hospital maternity care. Most of those counties are served by CPMs.
Futhermore, the cost of a planned home birth is around $2,500, while a normal birth in a hospital costs at least double that, and cesarian sections can cost upward of $20,000. More than half of the families served by CPMs are uninsured.
Despite these statistics, it's normal, healthy women who comprise 90 percent of obstetrical practice income, according to Dorn, and it's those patients OBs are afraid of losing. At the same time, he says, "It's not like the vast majority of women are clamoring for homebirth and midwifery," meaning that current obstetricians are unlikely to be financially threatened.
Economics aside, Dorn said, if more women with normal pregnancies had their prenatal care attended by midwives, rates of pre-eclampsia (high blood pressure in pregnant women), low-birth-weight babies, and complications during labor would fall. He says that's because obstetricians have very little training in nutrition and social issues that are crucial to healthy pregnancies.
"Having an OB attend a normal delivery is like hiring a pediatrician for a babysitter," Dorn concluded. "It's total overkill to have a surgeon attend a normal delivery. It just doesn't make sense."