A bill in Congress would encourage more providers to practice in rural areas.
By Thomas Goldsmith
Marieta Rangel, who lives in Dudley, a community in rural Wayne County, came to Goldsboro the other day for a pregnancy checkup with Jennifer Perry-Hidalgo, a certified nurse midwife.
Perry-Hidalgo got Rangel’s daughter, Ariana, 6, involved in the visit at Wayne Women’s Clinic. She invited Ariana to hold the transducer used to perform an ultrasound scan. Like old friends, midwife, mom and Ariana discussed the recent devastation brought by Hurricane Matthew.
“I live up on the hill, but my friends lost their house,” Rangel said.
Perry-Hidalgo told Rangel, a quality manager at a Goldsboro tortilla factory, that her baby’s heartbeat was an appropriate 150 beats per minute. After a few more minutes of consultation, the brief but unhurried visit was complete and Rangel went on her way, with a night-time shift at the factory ahead of her.
Next, Perry-Hidalgo saw regular patient Claire Ida Jean Charles, a native of Haiti who’s lived and worked in North Carolina for the past four years. While in Haiti, Charles lost a baby as a result of a premature birth. Under Perry-Hidalgo’s supervision, she’s receiving regular shots of the medication called 17P, or 17 alpha-hydroxyprogesterone caproate, administered to prevent premature births in women who have histories of the problem.
Extending this sort of care, as well as that of OB-GYNs, to more women in underserved areas nationally is the goal of legislation that won the recommendation of a U.S. House committee this fall and awaits Congress upon its post-election return. The bill, “Improving Access to Maternity Care Act of 2015 (H.R.1209/S. 628),” calls for the assessment of gaps in OB-GYN and midwifery care in rural areas.
The resulting data could put the spotlight back on North Carolina’s requirement for midwives to have a contract to work under physician supervision. That requirement that has ended up limiting midwives’ ability to establish and run practices in many underserved areas.
Legislation proposed at state, federal levels
A legislative interim committee recommended in 2014 to remove the remove the restriction, but lawmakers in the North Carolina General Assembly declined to move on the measure during the recently completed legislative biennium.
Suzanne Wertman, president of the North Carolina Affiliate of the American College of Nurse-Midwives, said her group is working with legislators who will reintroduce state legislation on the requirement during the new General Assembly session that begins in January.
“We know empirically that we have 31 counties with no maternity-care providers,” Wertman said. “We’ve got these outcomes that could be greatly improved.”
North Carolina is one of a half-dozen states where advanced practice registered nurses, or APRNs, including certified nurse midwives, are required to work under a physician’s supervision.
If state and federal legislative actions prove successful, North Carolina rural counties without maternity care could benefit from a federal assessment that showed these gaps. That designation would mean the state’s certified nurse midwives could set up practice with support from the National Health Service Corps, which provides scholarships, loan repayment and other services to primary care providers in eligible areas.
The North Carolina Medical Association supports continuing the supervision requirement, citing physicians’ higher level of training and their role in the growing trend of team practices. In addition, organization president Dr. Docia Hickey said, nurse midwives tend to move to the same areas as OB-GYNs, a trend that wouldn’t alleviate gaps in maternity care.
“The political fear is that we could be out practicing in a vacuum, in our home,” Wertman said. “In other states, we like working in an integrated systems” that include OB-GYNs, she said.
Data also contradict the Medical Society’s argument, showing that when nurse-midwifery is uncoupled from medical practice, they actually do tend to practice in rural settings.
Proponents of maternity care by nurse-midwives agree that some pregnant women require treatment by an OB-GYN, and say that those patients are referred to a physician. Becky Bagley, director of the nurse midwifery program at East Carolina University, has worked with lawmakers on legislation to remove or modify the requirement for physician supervision of certified nurse midwives.
“It’s preventing APRNs from going to many of these rural areas,” Bagley said. “Physicians don’t want to supervise from a distance.”
Natural methods preferred
Pregnant women such as Jessica Thomas, from Duplin County, go out of their way to receive care by a nurse midwife, as she did in the births of two older children, Everton, 4, and John Maxon, 2.
Thomas is a patient of Perry-Hidalgo, who works under the supervision of Dr. Peter Roethling, an OB-GYN.
Roethling said he’d want to peruse the wording of legislation before supporting a revisIon of the supervision requirement for certified nurse midwives. But he firmly believes in a team system for providing care, the approach used at Wayne Women’s Clinic.
“You do have to have someone overseeing the system and seeing how needs are met, and seeing what every member’s strengths,” Roethling said.
Perry-Hidalgo describes the relationship between nurse midwives and physicians as a “cool marriage.”
“The way we are set up, it allows us more time with patients,” she said. “He can say, ‘It sounds like you have lactation questions, go back and see Jennifer.’”
After years of resisting increased scope of practice for midwives, the American Congress of Obstetricians and Gynecologists, OB/GYN’s national professional organization, changed its policy in 2011, and now supports a greater scope of practice for midwives with certification, a spokeswoman said. The organization went so far as to publicly reaffirm their position in 2014.
“ACOG supports full scope, autonomous practice for certified nurse midwives (CNMs) and certified midwives (CMs) as qualified, accountable providers who work collaboratively with ob-gyns in an integrated maternity care system that promotes seamless access to appropriate care,” Megan Christin, director, media relations said in an email. “We don’t believe documentation of a specific relationship with a physician should be a requirements for CNM/CM licensure.”
ACOG leaders have expressed support of the bill.
“You pick up the phone”
The ending of a legal requirement wouldn’t signal the end of a working relationship between a doctor and nurse midwife, Bagley said.
“She would have to establish a relationship with an OB-GYN who is in active practice whom she could call,” she said. “You pick up the phone and have them on speed dial.”
Thomas has elected to seek care at Wayne’s Women Clinic instead of a facility nearer her home, about 35 miles away in Kenansville. She cited better response at the clinic to her preference for natural birth.
“It’s really awesome to have someone who knows what your body is capable of as a woman,” Thomas said. “I knew I would be able to have freedom of how he was born.”
Some of the professionals she’s encountered in Duplin County seem less than comfortable with the idea of a more natural approach to childbirth, she said.
“Even with breastfeeding in our county, that’s taboo,” Thomas said. “Most everyone I know goes out of the county to have babies.
“With a midwife, it’s coming into an appointment and sitting down with someone who wants to get to know you, who hears your questions and answers your questions and can joke with your husband. That makes the person more comfortable.”