By Renee Elder

Three bills coming before the General Assembly this session would expand the ability of midwives to care for women during pregnancy and childbirth in North Carolina, where infant mortality and maternal death rates are some of the highest in the country.

All three bills are expected to face opposition from the N.C. Medical Society, whose representatives have spoken out against previous moves to lessen restrictions on certified nurse midwives, who are required to have a supervisory agreement with a board-certified physician in order to practice under current law.

A bill to be introduced this week by Sen. Fletcher Hartsell, a Republican from Concord, and four House members would remove that requirement, saying it creates an unnecessary restriction and reduces the ability of CNMs to care for patients in rural areas.

"That provision has become an obstacle to care, especially in rural areas that have no practicing obstetricians," said Alex Miller, spokesman and lobbyist for the N.C. College of Nurse-Midwives.

About 30 rural counties in North Carolina have no local obstetricians, and 78 out of the 100 counties are considered medically underserved, according to the U.S. Department of Health and Human Services.

Miller said about 300 CNMs are practicing in the state, and 80 others are licensed but not practicing. He said the regulation requiring a supervising physician sets no specific geographic limits, but certified nurse midwives have been stopped from practicing by the state medical board on grounds that their supervisor worked a county or two away.

Liability insurance has also become a problem, with some insurance companies requiring physicians to carry liability coverage for the midwives they supervise, a cost-prohibitive requirement for most.

North Carolina ranks 44th highest in the nation for infant deaths and 37th highest for deaths to women during childbirth, factors that the American Congress of Obstetricians and Gynecologists links to shortages of physicians and other health care providers, mostly in rural areas. Women who receive no prenatal care are three to four times more likely to die of pregnancy-related complications than women who do, according to the American Congress of OB-GYNs.

Both the national American Congress of OB-GYNs and the Institute of Medicine, a part of the National Academy of Sciences, have opposed restrictions on CNMs, including supervisory agreements with obstetricians, a requirement now used only in North Carolina and five other states.

Previous bills to eliminate the requirement have been opposed by the N.C. Medical Society. Society spokeswoman Elaine Ellis Stone was not available to comment on Hartsell's bill Monday.

Last week, however, Stone said her group opposes two separate bills sponsored by Sen. Thom Goulsby, a Republican from Wilmington, that would allow non-nurse midwives to practice legally in the state. One bill would establish a licensing procedure for certified professional midwives in North Carolina and the other would remove criminal penalties for non-nurse midwives who serve patients.

Stone said the medical society is primarily concerned about patient safety.

"Certified professional midwives do not have anywhere near the educational background of a nurse midwife or doctor," she said. "If something were to happen, we question whether they would have the skill to handle an emergency."

North Carolina has about 33 certified professional midwives, about a third of whom are practicing, said Lisa Fawcett, a member of the N.C. Midwives Alliance, an advocacy group. She said they are well trained in pregnancy and childbirth issues and will refer patients to physicians or hospitals if a medical emergency arises.

"About 10 percent of the time families who are planning a home birth will for some reason need to go to the hospital for a medical reason or for pain relief," Fawcett said. "The passage of these laws will make that a lot safer, because midwives will be a part of the care system, and it will be easier to pass along information."

CPMs practiced legally in North Carolina until the early 1980s and are still credentialed to work in 26 other states, including South Carolina and Virginia, she said.

"Home birth is legal in all 50 states -- every woman has the right to choose where she has her baby and who will be her provider," said Fawcett, who along with about 50 other home-birth proponents visited Raleigh last week to show support for Goulsby's bills.

Goulsby said about 1 percent of childbirths are home births in North Carolina. He said he and his wife chose home births for their two children.

(c)2013 The News & Observer (Raleigh, N.C.)