North Carolina is one of the most restrictive states in the country for midwifery care. But in the face of bad birthing outcomes, spreading women’s health care deserts and the increasing popularity of home birth, the state is considering lifting some restrictions on who can provide care to pregnant women.
Nicole Havelka is a midwife living in Wilmington. Thanks to state laws, she cannot legally practice. But as president of the North Carolina Association of Certified Professional Midwives, she is leading the fight to change that.
Two main types of midwives exist: certified nurse midwives and certified professional midwives, or CPMs. Nurse midwives are allowed in NC: they attend nursing school and typically work in traditional health care facilities. CPMs, on the other hand, learn through apprenticeship, rather than nursing school, and operate in community settings like birth centers or homes.
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Thirty-eight states allow CPMs to care for patients through their pregnancy, birth and postpartum period. Not in NC. It’s one of a small number of states where that would not only be forbidden, but considered a criminal act.
According to Havelka, however, there are those who break the law.
“There are certified professional midwives [in NC] who are serving people in their communities,” Havelka told Carolina Public Press. “They have the nursing skills necessary to execute care and provide appropriate guidance to their clients. But they are hindered by lack of licensure and access to lab work like ultrasounds.”
Licensure for CPMs, in Havelka’s view, would simply bring accountability and increased safety to a type of care that’s already happening across the state. That once-fringe viewpoint appears to be gaining momentum in official channels.
In the years since COVID hit, many North Carolina women have turned to home birth as a way to avoid the traditional medical environment and receive more personalized care. Nearly 2% of all NC births took place at home in 2021. According to anecdotal reports, that number has grown in the years since.
“We do not have enough midwives to provide care to the number of people that are interested in this model,” Havelka said. “So many of our counties are maternity deserts. Oftentimes folks who do not have a midwife available to them feel pushed into the idea of free birth, or unassisted home birth, which is not as safe as having a trained attendant with you.”
A new March of Dimes report underscores the urgency of increased care for NC women. They gave the state a D+ for maternal and infant health, citing an infant mortality rate higher than the national average and inadequate prenatal care. Plus, last month, the Perinatal Quality Collaborative of North Carolina closed its doors after budget cuts at the state Department of Health and Human Services.
In a recent investigation, Carolina Public Press found that 10 mostly rural NC hospitals eliminated maternity services over the last decade, and at least 10 more reduced their capacities for maternity care. About 40% of NC counties have no hospital that provides labor and delivery care.
Against this backdrop, alternative models begin to look more and more attractive.
In states where CPMs can legally practice, their role is to support healthy moms and babies, and escalate things to more traditional, medicalized forms of care when dangerous situations arise.
But opposition is steep. Groups like the NC Medical Society are particularly stalwart in their resistance to licensure for CPMs. CPP reached out to the Medical Society for comment, but they did not respond in time for publication.
The primary argument against licensure is safety concerns, Havelka said. People in the medical establishment worry that women don’t receive adequate care from CPMs: conditions would go undetected and irreversible emergencies would arise. They want to keep births in hospitals.
“There’s a comfort level that the medical system holds with the way that they do things, and it can be a very uncomfortable prospect to lose control and not be able to directly dictate how providers practice,” Havelka said.
There’s also a perception problem. The medical system usually only crosses paths with CPMs when emergencies are occurring and the midwife must escalate the level of care.
“They’re not seeing the home birth where their support was not needed at all,” Havelka said. “They’re seeing when we need to move into the system, and because there’s not a seamless process for that, it can be tumultuous even when it’s not an emergency.”
But Havelka also sees less savory underpinnings to the opposition to licensure for CPMs.
“When hospitals were being built, there was this drive to bring the community into the hospital setting,” Havelka said. “Over time, we saw what started out as a public health model develop into a business model.”
Havelka’s colleague, Meredith Bowen, emphasized that CPMs aren’t trying to compete for cash. They want to supplement the existing system, not take business away from it.
As of late, there have been indications that the state may be softening its stance, and that Havelka and Bowen’s fight may not be unwinnable.
State agency takes notice of midwives issue
Belinda Pettiford, chief of the Women, Infant and Community Wellness Section of the Division of Public Health at DHHS, is aware that CPMs are practicing in NC, with or without licensure.
“They exist in North Carolina,” Pettiford told CPP. “They exist in our border states, which means they’re very close by already. We know our home birth numbers are slowly creeping up, so we expect that that means someone is assisting individuals with home births. It would be really good to know if they are practicing, where they are, and the level of certification and training they receive.”
In response, she is leading the Perinatal Child Fatality Task Force in an active dialogue about what licensure could look like in NC. Over the past year, they’ve heard from CPMs, certified nurse midwives, the NC Medical Society, emergency providers, primary care physicians and pediatricians.
Now, the task force is bringing in representatives from bordering states that already license CPMs, like Virginia, Tennessee and South Carolina.
“Why would we reinvent the wheel, if they’ve already worked through some of these issues and they’re willing to share?” Pettiford said.
The outcome of the task force’s discussions remains to be seen.
Last year, a bill that would have provided a path to licensure of CPMs died in the legislature, just like many similar ones before.
Now, the NC Association for Certified Professional Midwives has hired a professional lobbyist team, which provides better access to the legislature than their volunteer board had previously.
Bowen feels like CPMs are close to a breakthrough.
“It’s on the cusp of that tipping point,” she said.
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