By Rose Hoban
Becky Yates loves catching babies. She’s been working as a certified nurse-midwife for close to 30 years, and has delivered more than 3,000 babies in and around the Piedmont.
But these days, Yates is back in school, looking for certification as a breastfeeding coach, unable to work as a midwife because of the way North Carolina licenses the practice.
She’s hoping that a bill making its way through the General Assembly will help her.
“My patients were so upset when I had to quit,” Yates said. “I still get phone calls and emails from patients, asking, ‘Where are you?’”
Yates had a midwifery practice in the southern Piedmont, where she worked along with a two-doctor practice, backing them up on weekends, taking calls and getting a salary from them for her services.
After two years of uneventful collaboration, she got an email from the hospital where the doctors admitted their patients for births. Attached to the email was a new contract that she needed to agree to in order to retain physician supervision.
Physician coverage is key for Yates, and for all CNMs in North Carolina. By law, she and other CNMs can’t practice without having an physician supervisor. That supervision doesn’t mean the doctor is standing by as a midwife delivers babies; instead, the supervision consists of a few meetings per year between the supervising doctor and a midwife.
But without it, a CNM cannot legally provide care and is out of business – literally. Without it, a nurse-midwife can’t keep her license to practice midwifery.
It’s not an uncommon problem for CNMs. Eight practitioners lost their ability to practice last summer when the physicians who backed them withdrew their support.
“The contract terms were much less favorable,” Yates said. “I would have to start paying for the doctors as my backup – about $12,000 a year. They also told me that they could randomly pull patients’ charts and see them, and I thought that would be a violation of their privacy.”
Yates met with a lawyer, she met with the hospital, but wasn’t able to resolve the contract issues. She was out of business, and she couldn’t even travel out of state to do some temporary work because her licensure was tied to the doctors’ supervision agreement.
“I was due to leave the next day for a job in South Dakota to work on an Indian reservation when I got a call from the recruiter: My license was inactive because I did not have a supervising doctor in North Carolina to keep the license active,” Yates said.
Supervision vs. collaboration
North Carolina is one of only six states that require that a CNM obtain this type agreement in order to practice, said Becky Bagley, director of the nurse-midwifery education program at the East Carolina University College of Nursing. Hers is the only midwifery training program in North Carolina.
Bagley explained that the law also requires that doctors carry medical malpractice insurance for the CNM, even though the midwife carries her own insurance, and even if the doctor never encountered a patient who might sue.
“The regulation inappropriately exposes the signing physician to vicarious liability for the actions of the CNM and to higher medical malpractice premiums as a result,” Bagley said. “The bill would replace that requirement.”
Bagley said some physicians worry about having CNMs practicing under them, and that keeps them from agreeing to a supervision arrangement.
“Some read that supervision literally – that they need to be in the hospital, literally – but no one does that, they’re not hanging over our shoulders, that’s not in the language of the law now,” Bagley said. “Those docs who do take that literally say, ‘Why should I be there with a midwife when I could do it myself?’”
Nurse-midwives argue they’re in constant collaboration with doctors about their patients, and the supervisory language in the law now only serves to restrict them from practicing.
For a long time, CNMs met their strongest opposition from the state’s physicians, but that’s started to change.
“I think [the bill] would reflect how the rest of the country regulates nurse midwifery; it’d increase the ability and likelihood of CNMs to practice in underserved and rural areas where there’s not readily available physician coverage,” said John Thorp, professor of obstetrics and gynecology, and director of Women’s Primary Healthcare at the UNC-Chapel Hill School of Medicine.
Thorp points out that the American College of Obstetricians and Gynecologists recently signed a joint statement with the American College of Nurse Midwives to support “collaborative” practice over the supervisory language.
The North Carolina Obstetrical and Gynecological Society has not taken a position on the bill, while a spokeswoman for the NC Medical Society said her organization’s objections to the bill come from a concern for patient safety.
Thorp said some of the historical opposition by the state’s OB/GYNs has probably come more from battles over turf.
“It overall increases the net pie as opposed to splitting up the pie further. I see fear of competition as a rather short-sighted view,” Thorp said. “The CNMs I know and practice with are very careful and cautious and, if anything, will err on the side of over-asking for help.
I don’t think that’s a function of them being supervised; it’s a function of being good clinicians and recognizing their limitations.”
With one of the worst infant-mortality rates in the nation, Thorp said having more CNMs in rural and underserved counties could help North Carolina’s rate improve.
“The move in that direction will improve the health of women and children in North Carolina,” he said.
And research indicates using nurse-midwives costs the healthcare system less: A study in the Journal of Midwifery & Women’s Health found using CNMs for uncomplicated, low risk births saved about $1900 per patient.
Rural counties with unmet need
Bagley finds the current licensure scheme frustrating for another reason: Her program trains CNMs with an emphasis on providing practitioners for those underserved rural counties. But they can’t find supervision under the current regimen.
She said that she had a student from Dare County and another from Hertford County who began the program but then realized they couldn’t get a supervising doctor in their home counties, so they quit.
Thirty counties in North Carolina have no obstetrician/gynecologists to deliver babies and another 36 have fewer than five practicing OB/GYNs. In better-served counties, midwives collaborate happily with physicians, but many say they’d like to hang out a shingle in an underserved area.
But because of the limitations on their licenses, that’s not possible.
Laura Rosenthall-Schultz drives through Pender County several times a week from her home in Wilmington to work as a CNM on Camp Lejeune. Pender County is one of those counties with no OB/GYN, and the hospital there stopped doing deliveries. Four of six counties bordering Pender each have fewer than five doctors who deliver babies. (Not every OB/GYN does deliveries.)
“I think about all the women who must need care in all these rural counties near my home, and I think, I could provide that service and improve access to care, decrease unwanted outcomes, screen for cancer,” Rosenthall-Schultz said.
But she’s caught in the same bind as Yates: The doctors in her home county, New Hanover, stopped backing midwives from the practice she helped start.
Rosenthall-Schultz is a retired commander from the Naval Reserve. Since her retirement, she’s been able to deliver babies at the Naval Hospital on Camp Lejeune, where some of the licensure issues don’t exist.
The catch? She has to drive an hour and a half each way in order to work.
“If we could replace that supervision language, it takes that vicarious language out,” Bagley said. “The doctors would then be seen as collaborative and consulting docs, which is what we do now. But that consultation wouldn’t keep CNMs from practicing.”
Correction: The article originally stated Laura Rosenthall-Schultz is currently in the Naval Reserve.