A History of Lay Midwifery in North Carolina (1981-2006)

North Carolina lawmakers commissioned a study in 1981 to examine the “safety and efficacy of out-of-hospital delivery and to examine the State’s role in the licensing or otherwise permitting the activities of birth attendants functioning in the non-hospital setting (HB695, 1981) in response to the applications for midwifery permits by two lay midwives. The results of the study, along with recommendations for legislation for the practice of midwifery were submitted to the 1983 legislature. Despite a large outpouring of support from homebirth families for the inclusion of lay midwives to be recognized as providers, the resultant legislation limited the provision of midwifery practice to certified nurse-midwives. The practice of lay midwifery was now legally prohibited with the exception of Lisa Goldstein. Lisa Goldstein was a practicing lay midwife in the Burnsville, NC area, who was “grandfathered” into the law under the description of “....any midwife who had already been practicing in the NC for greater than 10 years.” Lisa Goldstein was the only lay midwife who could meet that criteria in 1983.

The lay midwifery and homebirth community were devastated by this outcome since it was apparent that most certified nurse-midwives had neither the commitment to homebirth service, nor the ability to overcome the physician supervision clause. The physician supervision clause required a nurse-midwife to operate under the supervision of a physician, including a signature on the nurse-midwife’s license. Since it was rare to encounter a physician who was willing to extend this supervision to a midwife who attended homebirths, the number of CNM homebirth practices is limited. Sadly, this legislation further complicated the ability of families to locate a legal homebirth attendant. Homebirth was forced more underground as access to the medical community for things like labs and consultation was largely dependant upon the geographical location of the pregnant woman. Options for access were much more available in the western part of the state where numerous physicians were willing to see homebirth clients for labs and parallel prenatal care in addition for emergency transports. Lay midwives worked quietly but openly in western NC. Many built relationships with various physicians which allowed them to share prenatal records, obtain consultation and referral when necessary, and openly accompany clients into the hospital during transports.

Despite the outcry from the homebirth community, lay and certified nurse-midwives agreed to work towards creating more options for birthing families in NC. The certified nurse-midwives suggested that all midwives work to help establish the CNM

credential as a quality health care provider and in return promised to assist in future legislation that would legitimize lay midwifery. Midwives joined with consumers to promote family-friendly birthing options under the umbrella organization of the

Carolina Association for the Advancement of Midwifery (CAAM). CAAM, which was based in the Raleigh/Chapel Hill area, organized fund raisers to support a new freestanding birth center and a homebirth support network. They sponsored conferences and childbirth education opportunities. Midwives from all over the state began to network with each other for support and professional development. In 1993, lay midwives in the western part of the state formed the North Carolina Midwifery Alliance (NCMA). The goal was to establish a sister organization of the Midwifery Alliance of North America (MANA) that would be a support network for all types of midwives, provide opportunities for continuing education, and be a vehicle for communication between the medical and midwifery communities. Quickly requests for membership came in from midwives from all over the state, and it was not long before NCMA became a statewide midwifery organization.

Nationally, the North American Registry of Midwives (NARM) began the development of the Certified Professional Midwife (CPM) credential. The CPM credential is the only nationally recognized certification which requires training in out-of-hospital births. Several experienced NC lay midwives enrolled in the pilot program and became CPMs.

In 1997 an independent CNM/CPM practice was opened offering home and hospital births in Asheville, NC. This practice combined the traditional model of midwifery with access to the medical infrastructure when necessary.

In 1998, Amy Medwin, CPM, was arrested and charged with practicing midwifery without a permit. Midwives and consumers organized and protested the arrest of this midwife. Ms. Medwin was able to win her case on a technicality, and the local DA declined to retry her. NCMA members decided that it was time again to challenge the NC statute which prohibited the practice of lay midwifery.

In 1999, NCMA offered a bill which would permit CPMs to practice in NC. The bill easily found sponsors and a number of midwives were invited to speak before the Women’s Caucus. Two NCMA midwives served as lobbyists and spent a significant amount of time in Raleigh garnering support amongst legislators for the CPM bill. The bill was introduced in both the Senate and the House. In the House it was sent to the Finance Committee which required a vote in order to move forward for a vote in the House. A fierce debate in the committee hearing room ensued and the Committee voted to allow the bill to move forward without judgement. This was neither a negative or positive vote, but just a procedure that allowed it to be further debated elsewhere. Simultaneously, the bill was then sent to the Women and Children’s Committee in the Senate under the Chairmanship of Sen. William Purcell. Senator Purcell is opposed to any legislation which might be interpreted as an encouragement of homebirths. As Chair he has declined requests to allow the bill to come up for discussion within his committee. Because of Sen. Purcell’s position, the bill died in committee. Privately many legislators expressed frustration that the bill cannot be brought for debate within the Committee, but it is at the discretion of the majority chairman to schedule the bills which will be discussed within their committees.

The following year the bill was again introduced in both the House and Senate. As a compromise, the bill was recommended for study, but was not selected or financed for the proposed study and thus again, died.

NCMA and the NC Friends of Midwives organized several very visible legislative actions during these years. Midwives and homebirth supporters made several trips to Raleigh to personally discuss the issue with legislators. NCMA hosted two luncheons on the lawn of the General Assembly for the legislators with hand-outs available and conversation with homebirth constituents from all over the state. Telephone and letter writing campaigns were done periodically. However, supporters have been told over and over by all of the legislators that without Dr. Purcell’s support, this legislation will never succeed since he is considered an effective legislator.

In 2003 midwives again began to prepare for a legislative drive. NCMA members formed alliances with the NCACNM and numerous physicians to negotiate support within the medical community for a CPM bill. Meetings and dialogue have been held with

Dr. Purcell, the NC Medical Society, and representatives of the NC Division of Health and Human Services. Plans are under way now to again bring forth CPM legislation.

During the years that NC has been struggling with this issue, Tennessee and Virginia have both passed CPM legislation. Georgia has plans to consider the issue in the near future. Both SC and Florida have had successful licensing programs for years. Most of NC neighboring states have licensed midwifery legislation.

In 2005, the British Medical Journal published the CPM 2000 homebirth study which contained data from over 5400 births in North America. The results of this study again reinforced that homebirth was a safe option for low-risk women with trained attendants.

This study has been favorably reviewed, and has been in the top ten of the most frequently requested articles for the year 2005. Information about this study was widely circulated in all the major media outlets in the United States and included in many widely read professional journals in both the medical and legal community.

Homebirth is legal in NC and consumers should have access to qualified, trained, and legal attendants. The best way to preserve the safety of mother and baby during homebirths is to increase access to the medical infrastructure so that families can obtain appropriate lab tests, ultrasounds, consultations and referral when appropriate.

The certified nurse-midwife credential is not sufficient to supply the number of providers required to fill the current need.

North Carolina is only one of a handful of states that currently limit the practice of midwifery to certified nurse-midwives. There has never been any state that has licensed or certified non-nurse midwives that has repealed that legislation at a later date. Clearly, the system is working in other states.

Nancy Koerber, CPM

North Carolina Midwifery Alliance