Nurse-midwives wishing to facilitate home births in North Carolina are dependent on physicians to “supervise” their practice, but when two doctors pulled out from their supervision agreements with eight midwives this summer, it was patients who had to scramble.

By Stephanie Soucheray

Dozens of pregnant North Carolina women hoping to give birth in their homes this fall are finding themselves instead planning hospital-based births, as eight midwives and the doctors supervising them failed to reach accord over supervision of the women’s care.

Now, an emergency rule the state’s board of nursing hoped would alleviate the problem has now been ruled out after a board governing midwifery practice met to discuss emergency measures put in place for the certified nurse midwives (CNMs) who lost  supervision. In the end, the midwives – and the families they served – found themselves unsatisfied.

And most of the midwives are without jobs as a result of the conflict, that has pitted nurse midwives in a turf battle against doctors in the state.

Now, North Carolina is one of the last in the nation to allow midwives to perform their duties more independently. The state’s stance stands in contrast to other states, which have adopted policies to broaden the practices of advanced practice nurses and physician assistants to help cover the many new patients who will enter the healthcare system as a result of national health reform.

Midwives’ practice governed by doctors

The problem erupted in May when Henry Dorn, MD, a High Point-based obstetrician, informed seven midwives he supervised that he could no longer serve as their licensed physician. Around the same time, another doctor supervising an eighth midwife told her that he could no longer afford the insurance costs.

Dorn, who did not respond to multiple requests for interviews, has not explained why he reneged his supervision of the CNMs, all of whom facilitated home births in the state. According to other published reports, he initially said the NC Medical Board told him to stop supervising the nurses. A spokeswoman for the Medical Board has said that was not the case.

By law, midwives need physician supervision in order to practice, even if that supervision consists of only a few meetings per year between the supervising doctor and a midwife. Without supervision, the midwives cannot legally provide care.

North Carolina is now only one of five states which requires CNMs to act under a supervising physician.

In May, the Joint Midwifery Committee of the NC Board of Nursing adopted an emergency rule allowing the midwives  additional time to care for their patients while a compromise was hammered out – otherwise, the midwives and their patients had until August 31 to find new providers. But the midwives and the doctors couldn’t come to any settlement.

Late last month, the committee – which also includes members of the North Carolina  Medical Board – met to discuss the temporary measures.

“There was a coverage lurch and we realized there was nothing in law that allowed these CNMs to practice, so we talked about some type of emergency measures,” said David Kallbacker, the public information officer for the state board of nursing.

The committee considered adopting a temporary rule that would have allowed the CNMs to continuing practicing without a doctor’s supervision.

And according to the legal counsel for the Joint Midwifery Committee, the rule would go against the state law, which has been in place since 1983.

So the midwives will find themselves at large at the end of August.

CNMs in a “sticky state”

Suzanne Wertman, the vice president of the North Carolina affiliate of the American College of Nurse Midwives, is a CNM in Wilmington. She knows firsthand the precarious status of  midwives in North Carolina.

“It was three years ago this week that my physician’s practice told another midwife and I that they were shutting us down,” said Wertman. She had been practicing midwifery in a private practice and was facilitating hospital births. She said she was given no reason by her supervising physicians for their decision. Within a day, she was out of a job and lost the ability to practice.

“CNMs are professionals,” said Wertman. “We’re licensed professionals but we must have this physician oversight. It’s an unusual situation for health care professionals.”

Wertman called North Carolina “sticky state,” for being one of the only states in the nation to require physician supervision.

“Our midwife practice act was created in 1983 and has not been updated,” said Wertman, who now works as a midwife in a Planned Parenthood.  “We were doing something 30 years ago, it’s easy to keep the status quo. A lot of people feel like it’s working just fine for them.”

Wertman emphasized that only 11 out of the more than 250 CNMs in the state do home births, and it’s professional midwives who most often advocate for home birth rights. She maintained that for CNMs to be punished for doing their work is wrong.

“I can’t comment on professional midwives,” said Wertman. “But a planned home birth with a low-risk women in a setting that provides access to care if needed is safe, bottom line.”

Leaving home

Dorn’s decision this spring left dozens of pregnant women across the Piedmont – and their families – in a pickle. Many obstetrical and midwifery groups do not take transfer patients after 36 weeks gestation, and for the women planning home births, Dorn supervised seven of the 11 CNMs who are licensed to perform the procedure in the state.

“I’m disappointed and shocked that policies are not in place for professional midwives and CNMs who lose their physician supervision,” said Durham resident Bradley Yoder.  He and his wife Beth, who is due in December, have had two other children at home and were looking forward to having this one there as well, with multiple family members in attendance.

The Yoders had been cared for by Nancy Harman, one of the midwives supervised by Dorn, to facilitate their planned home birth. Yoder said he told Harman he would support her in any way he could, and went to Board of Nursing meeting prepared to testify about the importance of home birth in his family’s life.

“With a home birth I got to be a partner with my wife in childbirth, and I probably won’t get that this time,” said Yoder, who talked about having his parents and in-laws present at their two home births. “They were in the room there, or right nearby in the doorway and that changes their relationship with their grandchildren in a big way. That is a value that you can’t out a price on.”

Yoder said he and his family understood any risks of having their babies at home. “We are all here as the result of normal homebirth and it feels like people who are afraid of that are trying to take that away when it really ought to be my wife’s and my choice.”

Home births are the real issue

Alex Miller, a lobbyist for the North Carolina affiliate of the American College of Nurse Midwives, said that this latest situation highlights a flawed policy at the state level.

But Miller also said it’s actually part of a bigger story that began in 2011. That’s when the state legislature’s licensure committee heard a proposal from certified professional midwives (see sidebar) who wanted to legalize their supervision home births. That legislation didn’t pass, but Miller said it triggered the NC Obstetrical and Gynecological  Society to examine all the state’s midwives – conflating CNMs and CPMs.

“The top brass started looking for evidence to show home birth is unsafe,” said Miller, who does not represent professional midwives, only nurse midwives. “That led to a level of scrutiny, that led to increased review of our folks.”

Miller pointed to a letter dated May 30 of this year by Alan Skipper, the executive director of the NC ObGyn Society, sent to hundreds of physicians throughout the state – obstetricians and other specialists in unrelated fields – asking them to report any negative outcomes they’d heard about home birth and midwifery.  LINK

“The reasons for this scrutiny has not been made public,” said Miller.

“This letter was sent in an effort to gain information about what may be going on across the state relative to home births,” said Skipper, in an email response to questions.  “There have been some unfortunate, preventable home birth outcomes in recent months and the intent of the letter was to try to help get a better understanding of those occurrences.”

But some speculate that what’s really at issue is a turf war with the medical community urging obstetricians not to support midwives who perform home births. In part that’s because in an adverse event, a supervising physician or hospital (if mother or infant were brought to a nearby hospital) could be held accountable for a bad outcome.

Miller said the NC ObGyn society ignored repeated requests, including letters sent by certified mail, for a meeting by the leadership of his organization to discuss the issue and assist the nurse-midwives who had lost supervision to find alternative care for the roughly 100 affected patients.

As a result, Miller said many of the women are finding themselves heading to the Chapel Hill Birth Center, for their care and for births, even though it means a significant drive for many.

“These families have heartfelt reasons for not choosing a hospital,” Miller said. “Many would be willing to endure the inconvenience of having to drive than going to a hospital and having a medical-model birth experience.”

Maureen Darcy, a member of the joint midwifery board and the head of the Chapel Hill Birth Center said she has had patients drive from the Outer Banks to give birth at her facility in Chapel Hill.

“They come from Rocky Mount, they come from Fayettevile, they come from Winston-Salem, Mt Airy, Charlotte, they’ve come from Danville Virginia,” Darcy said. “People are willing to drive the distance for the type of birth they want.”

Darcy said she knew of five or six bad outcomes from home births in the last two years, with babies hospitalized in a NICU or dying. But Darcy said she didn’t know of any litigation that arose form these cases.

She also said nobody knows of how many good home births are happening in the state, and she fears that instead people will “go underground.”

“We need, as a state to do something about this,” said Darcy. “Folks feel like if they won’t allow it it won’t happen, but that’s not true. We need to recognize that women will keep having their babies at home.”

“They gave us the ability to do this back in the 1980s. But when the law came up that we had to have supervision, and physicians were concerned they would be held liable for our actions, we have gone no where with it,” Darcy said. “For the nurse-midwives, it’s a fact that we have a law that says we can do it, but we’re being restrained from doing it.”

Russ Fawcett, a representative from NC Friends of the Midwives (representing certified professional midwives, but not certified nurse midwives), said there are plenty of reasons midwives don’t face the same threat of malpractice as obstetricians.

“Malpractice cases against midwives as a whole are exceedingly rare,” said Fawcett, “because of the shared decision making model between families and midwives.”

Fawcett said recent incidents are an overall reflection of the hostile environment midwives face in the state.

Darcy agrees.

“Our practice should not be tied to a physician supervising us,” said Darcy. “Right now we’re going to find midwives to back them up, and then come January we’re going to be working with the legislature to bring about some change in North Carolina.”

National standards different from NC’s

Even though North Carolina maintains physician supervision insures patient safety, both American College of Nurse Midwives and the American College of Obstetrics and Gynecology have jointly stated that nurse midwives can be independent providers of care.

Most states have signaled agreement by allowing nurse-midwives to practice without physician supervision.

But despite official pronouncements, Jean Conry, the president of ACOG, said she believes the best birth outcomes come from hospital, not home, births.

“The bottom line is patient safety,” said Conry. “There should be no blame. Pull the emotions out of it and put the woman as focus on care and work with her. And in the end we want the best outcomes. I support a women’s right to choose to do what she desires, but I feel very strongly that a hospital birth is the safest mode of delivery.”

Conry emphasized that birth location and style, however, should ultimately be a woman’s choice.

Rose Hoban did additional reporting for this story.