Bill would remove doctor supervision requirement for nurse midwives

by Michelle Saxton
Wednesday, March 13, 2013

North Carolina would no longer require certified nurse midwives to have a doctor’s supervision to practice, under a bill being considered in the General Assembly.

House Bill 204 would remove the doctor supervision requirement, allowing for CNMs to practice “within a health care system that provides for consultation, collaborative management, or referral as indicated by the health status of the patient.”

Care would be consistent with American College of Nurse-Midwives standards, the bill stated.

“We may be able to better serve areas that are more rural in nature and have less access to health care,” Rep. Susi Hamilton, D-Brunswick and New Hanover, a primary sponsor of the bill, said in a phone interview Monday, March 11.

North Carolina has about 243 certified nurse midwives, North Carolina Medical Society communications director Elaine Ellis Stone said Tuesday, March 12, citing information from a 2011 study by the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill.

The report found six counties with certified nurse midwives but no OB-GYNs and 25 counties with neither, Ellis Stone said. 

Licensed CNMs are Advanced Practice Registered Nurses required to earn master’s or doctoral degrees and American Midwifery Certification Board certification, Suzanne Wertman, president of ACNM’s North Carolina affiliate, said in a March 11 email.

“When more midwives are working and working in full-scope practice, more women and babies will benefit from our safe, high-value care and we’ll be effective in improving health outcomes for North Carolina families,” Wertman wrote.  

North Carolina ranked 45th in the nation for infant mortality, information from the Kaiser Family Foundation and U.S. Centers for Disease Control and Prevention showed.

Olivia Marshburn, a CNM and owner of Midwifery Services in Hampstead, provides home birth care for low-risk pregnancies and said she knows of just six home birth midwives licensed in North Carolina. She and two other nurse midwives collectively interviewed more than 500 doctors to supervise them.

“It’s very difficult to find a physician who’s willing to supervise and support home birth,” said Marshburn, who works with an OB-GYN.

Pregnant women in Pender County must go to New Hanover County for care, Marshburn said.

“That’s fine for the women who have transportation and have access and health insurance,” Marshburn said. “But it’s not fine for those migrant workers or people who don’t have transportation.”

But Ellis Stone questioned whether the bill would improve access to rural areas, saying the Sheps report showed about 79 percent of both CNMs and OB-GYNs practiced in metro areas.

The North Carolina Medical Society opposed removing the doctor supervision requirement, Ellis Stone said.

“It’s a patient safety issue,” Ellis Stone said. She added if the supervisory role were removed the legislature would, in effect, be the supervising entity, and that if lawmakers had to make a list of procedures CNMs could do that might actually lessen their broad scope of practice.

Nurse midwives still would collaborate with doctors without the supervision requirement, Marshburn said. 

“That part actually wouldn’t change,” Marshburn said. “I would continue to consult with and refer to physicians.”

CNMs are licensed to practice in all 50 states.

Cara Kinzelman, an ACNM health policy researcher, said North Carolina is among six states requiring physician supervision for nurse midwives.

Fifteen states have collaborative requirements with physicians, seven states have supervisory or collaborative requirements for prescriptive authority and 22 states have no supervision requirement, Kinzelman said.

Hospitals were the setting for nearly 99 percent of U.S. births during 2010, with CNMs attending about 7.6 percent of hospital births, National Vital Statistics Reports show. 

Certified Professional Midwives

Meanwhile, legislation has been filed to allow certified professional midwives to practice in North Carolina. 

CPMs require no university or medical training and are not licensed to practice in North Carolina. Their education may involve a formal apprentice training or graduation from a Midwifery Education and Accreditation Council school.

Sen. Thom Goolsby, R-New Hanover, was among primary sponsors of Senate Bills 106 and 107 to establish the Certified Professional Midwives Licensing Act and decriminalize direct entry midwifery.

Senate Bill 106, the Home Birth Freedom Act, aims to address limited access to prenatal care and delivery services and reduce a shortage of midwives. No physician supervision would be required.

“Midwifery is a profession in its own right, and it is not the practice of medicine,” the bill stated.

The bill would create a North Carolina Council of Certified Professional Midwives, which would include CPMs, a licensed physician knowledgeable in midwifery care, a home birth consumer and a CNM who practices home birth. 

The North Carolina Medical Society opposed the CPM bill.

“The minimum requirements for education and clinical experience are just not conducive to a safe birth and delivery,” Ellis Stone said.

CPMs would need North American Registry of Midwives certification and could provide care for healthy women expected to have a normal pregnancy and birth, the Goolsby bill stated.

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