By Rose Hoban
Lawmakers are taking another look at a proposal to loosen the practice restrictions on nurse-midwives.
A bill proposed in committee would allow nurse-midwives to practice without contractual supervisory arrangements with physicians, instead mandating that they “collaborate, consult with or refer to other providers … if indicated by the health status of the patient.”
A similar bill was passed by several committees during the 2013 legislative session after a heavy lobbying effort by nurse-midwives, with doctors lobbying against the measure. An 11th-hour procedural move killed the amended bill on the House floor.
A proposal to study the nurse-midwife issue resurfaced in the final budget bill last summer. That study began last week in a subcommittee of the Joint Legislative Oversight Committee on Health and Human Services.
At issue for nurse-midwives is the requirement that they contract with physicians who “supervise” their practice. Nurse-midwives point to the fact that physician supervisors don’t directly oversee their work and are sometimes even located several counties away. They also say it can be difficult to convince an obstetrician/gynecologist to sign supervisory agreements.
Physicians, on the other hand, argue that having the supervisory agreements ensures patient safety.
Rep. Sarah Stevens (R-Mt. Airy), the subcommittee co-chair, said both sides are entrenched in their positions.
“I think it is a territorial-type issue. I think physicians want to maintain control,” Stevens said after the committee meeting. She said she’s been meeting with both nurse-midwives and physicians over the issue. “I’m not clear I’ve got enough reason why they need to maintain control.”
Supervision vs collaboration
In North Carolina, a certified nurse-midwife (CNM) requires three things in order to practice: they need to be a registered nurse, they need to complete a master’s or doctoral degree program in midwifery and they need to enter into a supervisory contract with a physician.
“The requirement to have a signed supervisory agreement filed does not require that the supervising physician literally supervise the practice of nurse-midwives, it does not require that they work in the same setting, in the same county, even in the same part of the state,” said Alex Miller, a lobbyist for the North Carolina affiliate of the American College of Nurse-Midwives.
Miller explained that even though nurse-midwives carry their own malpractice liability insurance, the agreements can increase malpractice insurance rates for supervising physicians.
Without the supervisory agreements, North Carolina CNMs are unable to practice, even if they’ve completed training.
In several recent high-profile instances, physicians have withdrawn their supervision, putting midwives out of practice.
According to the American College of Nurse-Midwives, only six states require such supervisory agreements (see map).
“Increasingly, it is difficult for nurse-midwives to find supervising physicians to sign these agreements and accept legal liability,” Miller said.
“There is no grace period. If a supervising physician who signed an agreement withdraws that agreement for any reason – God forbid, if the supervising physician drops dead – there’s no grace period and no recourse for nurse-midwife other than to find other physician to take on that liability,” explained Miller, who said that if a CNM is not able to find another supervising physician she would be forced to abandon her patients.
In many states, CNMs work “collaboratively” with physicians – collaborating as needed when problems arise or when something is out of their “scope of practice” – but they don’t need to contract with a physician in order to practice. That standard was affirmed in a 2011 joint statement by the American College of Nurse-Midwives and the American College of Obstetrics and Gynecologist.
But because of North Carolina’s supervision requirement, Miller pointed to the fact that there are only two birthing centers in the state, whereas there are about 350 in the rest of the United States.
“There was a [birthing center] in Siler City in 1991.… The signing supervising physician moved from Siler City to Raleigh, and withdrew his supervisory agreement as a result,” Miller said. “That birth center was forced to close, so the women and families were forced to lose those services, including women who were very close to being ready to deliver.”
Miller was followed by Haywood Brown, head of obstetrics and gynecology at Duke University School of Medicine and former head of the N.C. Society of Obstetricians and Gynecologists.
“Obstetricians support certified nurse-midwives practicing to the full extent of their training and licensure. Let me be clear,” said Brown. “When they’re out of their realm, we’re there to collaborate and supervise as we need to.”
But in an at times rambling statement, he went on to say that the current system is not broken and that physician supervision ensures patient safety. At one point, Rep. Marilyn Avila (R-Raleigh) asked him if he was for or against the changes.
“I’m against,” Brown said, emphasizing that he opposed changing from supervision to collaboration.
Brown asserted that 20 of the states noted by the American College of Nurse-Midwives as requiring collaboration “require a detailed written agreement.”
He claimed that many states define collaboration in the same manner that North Carolina currently defines supervision. “Signing something in a collaborative state is not that different than signing something in a supervisory state,” Brown said.
He also said that family-medicine physicians who do obstetrics could also supervise nurse-midwives.
“In ratings for an insurance premium, isn’t it a fact that premiums for a family physician are lower than an OB/GYN?” Avila asked. “There’s not a doctor on God’s green earth who’s going to sign to raise his insurance premium.”
“Well, if you are assuming that if they are supervising a person who stays in that scope of practice and doesn’t get into trouble, then I would say there are many physicians who would sign it,” Brown said. “I sign. All the time.”
He went on to assert that two states, Maine and Oregon, were looking to roll back legislation allowing nurse-midwives more freedom.
According to Cara Kinzelman, state government affairs manager for the American College of Nurse-Midwives said she is not aware of any legislative actions to repeal independent practice.
Collaboration a necessity
The nurse-midwives at the hearing said they could not imagine practicing without collaborating with physician colleagues.
“I would consider it highly deviant to practice without it,” said Suzanne Wertman, a nurse-midwife from Wilmington who lost her supervising physician in 2009. It took her close to a year to find a job.
“How can I do my job without collaboration?” she said. “I don’t know the answers to all of the things that my patients come to me with. If I’ve got a patient who comes to me with depression, I have to send them to a specialist who can handle their medical needs.”
But Wertman said that adding language about collaboration in the nurse-practice act would ensure CNMs do work with physicians. She argued that loosening restrictions on CNMs would increase access to care for patients, in particular in rural communities.
Currently, North Carolina has 31 counties without an OB/GYN and 50 counties with fewer than three OB/GYNs.
“I have students on a regular basis who have difficulty finding jobs in rural areas because of the ‘supervising’ language in our bill,” wrote Becky Bagley in an email to legislators.
Bagley runs the CNM training program at East Carolina University, which was established in 1991 in response to a workforce shortage in many rural counties.
“If there is no obstetrician there to ‘supervise’ them, they are unemployable which creates an access to care problem for the women of those counties,” she wrote.
After Friday’s meeting, Bagley said she had several students from the northeastern part of the state who dropped out of her program once they realized they would not be able to find supervising physicians.
“I’m from one of those areas that doesn’t have a lot of obstetricians,” said Rep. Stevens after the meeting.
“I represent Allegheny County, that doesn’t have anybody. Those people get in the car and drive to Winston or somewhere else to have their baby, and what if it is an emergency? I mean, do we not want someone to at least have some training and expertise in that to be there?”
Correction: The story originally stated Suzanne Wertman lost her physician supervision in 2012.