For the past 25 years, women in North Carolina who wanted to deliver their babies at home have had very little choice in health care practitioners. Because independent midwifery is illegal here, with few exceptions, families are primarily served by practitioners licensed in other states or not licensed at all.
A bill pending in the N.C. General Assembly aims to change that, allowing for the first time in a quarter-century for midwives who operate independently from physicians to practice legally and seek licensure.
While the legislation as currently drafted is unlikely to provide women with any more choice in practitioners, the bill's very existence represents a significant step toward normalizing midwifery care in the state, as it recognizes there is a large underserved population—as well as the fact that many midwives are meeting that need by practicing illegally.
Last year, a House select panel was formed to make recommendations on the merits of legalizing independent, or "direct-entry," midwives. By successfully calling for the formation of a study committee, midwifery supporters aimed to get around longtime opposition by physician's groups, which have for years thwarted the legalization of independent midwifery.
The strategy apparently worked, as the North Carolina Medical Society has now accepted as inevitable the licensure of midwives outside of the purview of physicians in some form. The bill is expected to get a hearing in the House Health Committee within the next week.
"We did not ask for a change in the law. The folks who did ask for a change in the law are going to get some change," says Steve Keene, general counsel to the N.C. Medical Society. "It is a significant step to allow other midwives to practice in North Carolina who are not Certified Nurse Midwives."
Although all midwives practice within what is known as the midwifery model of care, the primary distinction is that Certified Nurse Midwives (CNMs) are registered nurses and mostly operate in hospitals. CNMs then have to operate within those institutions' protocols, which often require IVs and fetal heart monitors, prohibit eating and drinking, and limit the birthing woman's movement—restrictions that many women desire to avoid, prompting them to seek out independent midwives.
Certified Professional Midwives (CPMs), the national standard for credentialed direct-entry midwives, practice autonomously from obstetricians and mostly serve those seeking birth outside of a hospital. In other states, that includes birth centers, but the single birth center in North Carolina are staffed exclusively with CNMs.
North Carolina currently stands alone among its neighbors in outlawing independent midwifery and not licensing CPMs, which are licensed in South Carolina, Virginia and Tennessee.
"We stand out in the region," says North Carolina Friends of Midwives legislative co-chairman Russ Fawcett. Of CPMs in surrounding states: "They are in the Yellow Pages and they are held accountable for their practice and maintaining their standard of care," he told the Indy.
One of the main arguments for licensing CPMs is that they are trained in the skills necessary to help women birth their babies comfortably and safely at home.
The legislation that came out of the study committee in the House wouldn't allow for the licensure of CPMs, however. As currently drafted, it specifies that in order to obtain licensure, midwives would have to have a master's degree.
"That just doesn't make sense for CPMs," says Fawcett, "because it doesn't improve the quality of care and it doesn't improve outcomes. It only adds additional requirements, which is an obstacle to producing the number of midwives we need."
Although CPMs are not required to have master's or nursing degrees, a point often held against them by physicians, their clinical requirements are double those of nurse-midwives and they are trained extensively in out-of-hospital settings.
"If we require graduate degrees along with the CPM credentials, we will change nothing in our state," Fawcett added. "We don't produce midwives who are trained to attend women who birth at home in our brick and mortar universities where CNMs acquire their graduate degrees."
Nonetheless, the medical society doesn't believe the standards set forth by the North American Registry of Midwives, the organization that certifies CPMs, are stringent enough.
Despite this, Keene says: "I want to be clear that we don't have any disdain or animosity for the midwifery profession. The track record of our organization on this issue has been one of great interest and support of the standards and the deployment of midwives to deliver babies."
The medical society, which supports the current legislation, for years has diligently opposed legislation legalizing independent midwives. The organization's Web site lauds the group's efforts in 2001 to stop legislation to license "lay midwives," a term often used pejoratively by physicians, as one of its accomplishments.
North Carolina Friends of Midwives is aiming to amend the legislation to give midwifery groups some voice in drafting regulatory standards. As currently written, the bill only would name physician's groups to the licensing panel.
Midwifery supporters also hope to remove provisions requiring midwives to carry liability insurance, an expensive burden not even required by law of doctors.
"Homebirth midwives, be they CPMs or CNMs, the vast majority of the time do not carry liability insurance because their clients cannot afford it," Fawcett says.
Even as efforts are under way to legalize independent midwifery, language in two unrelated pieces of legislation introduced this session would make felons out of the dozen or more direct-entry midwives currently practicing in the state.
The bills would raise the practice of medicine without a license to a felony from a misdemeanor. Under a statute signed into law in 2007, midwifery is considered the practice of medicine.
Sen. James Forrester (R-Gaston), who sponsored one of the pieces of legislation, says his intension was not to go after midwives and that he has received "a number of phone calls" from midwifery supporters who oppose it.
Forrester says it's common sense to make the practice of medicine without a license a felony.
"Right now it's just a misdemeanor, a slap on a wrist," Forrester says. "If you sell hay without a permit in North Carolina, it's a felony."
If direct-entry midwives were legalized and licensed in North Carolina, Forrester's legislation would not apply.
"Licensing is fine," Forrester says. "If they are licensed, they are controlled and supervised."