Across rural North Carolina, women drive an hour or more for routine prenatal care and they endure long commutes when it's time to give birth.
Some midwives say that they could provide those women better access to health care if the state would ease restrictions over how they work.
A new survey by The Charlotte Observer and The (Raleigh) News and Observer finds 91 percent of nurse midwives — college-educated, advanced practice nurses — want to be licensed without the requirement that they get approval to practice from a supervising doctor. Nearly half of North Carolina's 100 counties do not have nurse-midwives and a quarter of the state's counties don't have a local OB/GYN doctor.
In western North Carolina, three labor and delivery units run by hospitals have closed in the past five years, leaving fewer options and fewer doctors.
"It's nerve-racking sometimes to make sure they get there in time," says nurse-midwife Sally Inglesby-Schaefer, who works in Sylva at Harris Regional Hospital, a Duke LifePoint hospital.
Harris is one of just four hospitals from Asheville to the Tennessee border where women can give birth.
Midwives could help fill the gap of women's health care access, particularly in rural areas, says Suzanne Wertman, president of the American College of Nurse Midwives in North Carolina.
Certified nurse midwives are professionals who deliver babies and provide primary health care for women. Increasingly, women are opting for midwifery care during their pregnancy instead of an OB/GYN doctor. Midwives care for women with low-risk pregnancies and can cost much less than a doctor for prenatal care and delivery.
But, Wertman and other midwifery advocates say, the current requirement that midwives have a supervising doctor is hurting their ability to practice. Midwives aim for the least amount of medical intervention as possible, typically delivering babies without pain killers and artificial induction, and practice on the premise that pregnancy and birth is a natural process.
Doctor trade groups, though, have pushed back against changing midwife rules and the debate appears to frozen in place at the state legislature.
The survey of North Carolina's 340 midwives this month also found a majority of respondents think:
▪ A healthy woman giving birth outside a hospital is just as safe as inside a hospital.
▪ Midwives should be allowed to attend home births. (Currently, certified nurse midwives attend home births only if their supervising doctor approves.)
▪ Government agencies should regulate and inspect non-hospital birth centers where midwives deliver babies.
North Carolina is one of just six states that require nurse midwives to have a supervising doctor and also one of the few that doesn't license or regulate birth centers outside a hospital. The majority of North Carolina's nurse midwives work in hospitals.
Midwives face home birth hurdle
Although the supervising doctor requirement doesn't mean a doctor is always in the room with a midwife, it does mean the midwife is only allowed to attend home births if her doctor approves — which is rare. In some cases, a lay midwife or non-nurse midwife will attend a home birth but this practice is illegal in North Carolina.
Women who want to give birth at home face long odds to find an experienced midwife to help, says Jani Barnes, a mom of two in Raleigh. She delivered both babies at home.
Five years ago, she looked for a midwife for a home birth with her first child.The only midwife she could find ended up being not compatible for her family, she said.
So during both births, it was just her and her husband in their bedroom while she labored and delivered. Her son and daughter were born healthy babies.
Barnes says she never considered a hospital birth because she wanted to avoid medical intervention with her pregnancy — namely the pressure of induction if she labored too long and constant medical monitoring of her and her baby.
"It can create a lot of unnecessary anxiety which can also stall and prolong labor," she said. "They follow what's in the textbook but people are not textbooks. It's kinda silly to think people will fit into this one specific guideline."
For the past three decades in the United States, the percentage of midwife-attended births has increased every year. Recent data from the American College of Nurse-Midwives shows midwives attend more than 330,000 births each year — that's about 8 percent of all babies born in the nation annually. Between 2005 and 2013, the increase of midwife births was 11 percent.
Doctors resist changes
Historically, trade groups in North Carolina representing doctors have pushed back against changing midwife rules. These groups contend that lifting the supervising doctor restriction wouldn't change rural health care access.
One of the country’s most prominent obstetricians, Haywood Brown, has been vocal in his opposition against independent midwife practice.
"Physician supervision helps ensure the training gap between physicians and nurse midwives," Brown said during a 2014 legislative hearing in Raleigh.
Brown is a past president of the American College of Obstetricians and Gynecologists, of the American Gynecological Obstetrical Society, and of the N.C. Obstetrical and Gynecological Society. He is a past chairman of the Department of Obstetrics and Gynecology at Duke University Medical Center.
"To suggest (women) are just as good in the hands of any individual is just absolutely false," he said. "Even in a normal birth, things can happen. There's a reason the textbook is this thick. It's not a pocket manual."
In some circles, though, OB/GYN mindsets are changing.
Last year, the North Carolina Obstetrical and Gynecological Society relaxed its opposition and said it would support eliminating the supervision rule in favor of "collaboration agreements" between midwives and doctors.
Rep. Nelson Dollar, a Republican from Wake County, said lawmakers are stuck at an impasse as long as the state's medical establishment wants to maintain restrictions on midwives. He thinks the legislature shouldn't referee disputes between midwives and doctors.
The N.C. Medical Society, the physicians' lobby, wants to keep the status quo. The society also opposes midwife-assisted home births.
Democratic Sen. Mike Woodard, a Duke University administrator and one of the members of the Joint Legislative Oversight Committee on Health and Human Services, noted that the state's doctors run a very powerful lobby, which influences how lawmakers perceive the midwifery issue.
"I have confidence in the work of nurse midwives but I think some of my colleagues don't," Woodard said.
Lawmakers eye birth center regulation
Soon, legislators could be faced with a new question: Should North Carolina draft new rules for birth centers — the one place outside a hospital where you're most likely to find a midwife.
The debate was jump-started earlier this year after three infant deaths in six months at Baby+Co in Cary, a non-hospital birth center.
A majority of certified nurse midwives surveyed this month — 73 percent — say they would welcome new North Carolina regulations on birth centers. This is also the preference of the birth center profession, because state licensing brings credibility, opportunity to work with more insurance plans, and public confidence.
But the midwives want birth centers to be judged differently than hospital-level facilities.
Hospitals handle high-risk pregnancies. Birth centers, on the other hand, screen pregnant women and will not take on expectant mothers who are likely to have complications, those who have previously had a C-section or those who have diseases like diabetes or heart problems.
Most certified nurse midwives who support regulations at birth centers want government officials to follow the guidelines set by their industry's top accrediting bodies, Wertman said.
Accreditation groups have helped shape state regulations in other parts of the country. For example, the birth centers say that a state license should not be contingent on having a doctor on site.
If North Carolina moves to regulate birth centers, it would allow for state safety inspections, an avenue for public complaints and investigations and could create new public records of the birth center's operations and record of violations.
Birth centers are a valuable option for women who have low-risk pregnancies, says Jackie Born, a midwife with more than 20 years of experience. She works at Cape Fear Valley Hospital in Fayetteville. Regulating birth centers through a state health agency is appropriate, she said.
Born's career in midwifery began after she gave birth to twins in a hospital in 1969. It was a rough experience that involved little consulting with her about her wants and needs and a doctor putting her under medication to induce "twilight sleep," followed by delivery by forceps, she said.
She's one of the majority of midwives in the survey who believe home births are just as safe for healthy women as hospital births and that midwives are well-qualified to deliver babies without doctor supervision.
"As a midwife, I'm taking care of your family, which is a normal process of humans," she said. "Doctors look at it the opposite way —you're an accident waiting to happen."
About The Charlotte Observer and The (Raleigh) News and Observer midwives survey:
The survey collected anonymous responses. Some participants agreed to follow-up, on-the-record interviews.
The survey was sent to 334 certified nurse midwives in North Carolina. Eighty-six midwives participated. About 80 percent said they work primarily in hospital settings, which reflects where most midwives work in the state.
Survey participants are some of North Carolina's most-experienced nurse-midwives. Collectively, they have attended nearly 91,000 births and nearly half of the midwives in the survey have 10 or more years of experience.