After a decades-long stalemate, nurse-midwives can now practice without physician “supervision”

After a decades-long stalemate, nurse-midwives can now practice without physician “supervision”

By Rachel Crumpler

Suzanne Wertman used to work as a certified nurse-midwife at a private practice in Wilmington. But in a day, that changed. 

The physicians who ran the practice abruptly decided to shut down midwifery services at the practice. There was no transition period, she said. 

When Wertman lost her job that day in 2009, she also lost the ability to practice her profession until she found another supervisor. The same thing happened to the two other midwives at the practice.

The Midwifery Practice Act, which passed the North Carolina legislature in 1983, required certified nurse-midwives to practice under the supervision of a physician who is engaged in the practice of obstetrics. But supervision doesn’t mean the doctor needs to be in the same room, or even the same county, as the midwife he or she supervises. Supervision can take many forms — sometimes meaning as few as two meetings a year, and many midwives even need to pay a fee for the supervision that allows them to work in their chosen profession.

Without a physician supervision agreement, North Carolina certified nurse-midwives were unable to practice, even if they’d completed training and had thousands of hours of experience.

When Wertman lost her supervising physician, she asked others to provide the required supervision. 

“I was so hopeful that I would be able to go someplace else in the community and be able to find someone,” she said. “I had that hope because we had such a need. I put together a business plan with a friend of mine who’s a business consultant. They were so excited. They’re like, ‘Oh my gosh, you’re going to do great if you can just find a supervising physician, and you’ll be able to take care of all your patients.’” 

But she came up empty-handed. No other physician would sign off. 

Rep. Gale Adcock, a nurse practitioner, speaks to certified nurse-midwife Suzanne Wertman, who drove up from Wilmington to advocate for advanced practice nurses at the General Assembly in 2019. Photo credit: Rose Hoban

As a result, Wertman said she wasn’t able to find another place to practice full-scope midwifery services in Wilmington, despite having the education and the skills and seeing the demand in the community. 

Wertman said her predicament illuminated the precarious position of midwives and how limiting the physician supervision requirement is. Over the years, other midwives have had similar experiences.

“It’s a permission slip,” Wertman said. “A physician has the autonomy, the control, the power to decide where midwives work.”

For years, Wertman and other midwives and advanced practice nurses have lobbied lawmakers to remove what they deem an unnecessary requirement. 

But physicians have worked to uphold the status quo, arguing that supervision improves patient safety, even though only three states still require physician supervision of certified nurse-midwife practice, according to the American College of Nurse-Midwives.

North Carolina will soon drop from that list. A provision inserted into the 47-page abortion bill that flew through the legislature last month removes the physician supervision requirement. This practice change for North Carolina’s 416 midwives will take effect in October.

a map of the United States shaded in colors of green, yellow and red depicting practice authority for nurse-midwives
Nurse-midwives across the nation are seeking full practice authority, meaning that they can practice to the full extent of their education, clinical training and certification. Currently, over half of states license and regulate nurse-midwives to practice to the full extent of their education, clinical training and certification. Three states still require physician supervision though North Carolina is dropping from that list in October. The remaining states require a signed collaborative practice agreement as a condition of licensure for a subset of nurse-midwifery services, such as the intrapartum period or for prescriptive authority. Credit: Courtesy of American College of Nurse-Midwives

Change coming

While the North Carolina Nurses Association and the North Carolina Board of Nursing have been advocating for the change for years, they say it came as a surprise to see it picked up now by lawmakers. Alex Miller, lobbyist for the N.C. Nurses Association and the North Carolina affiliate of the American College of Nurse-Midwives, said the two groups did not ask for its inclusion in Senate Bill 20

Catherine Moore, chief legislative and quality officer at the North Carolina Board of Nursing, said the board wasn’t consulted about the language in the bill, which she said lawmakers pulled directly from a 2014 bill

The new policy doesn’t let midwives work on their own from the start. Midwives with fewer than 24 months and 4,000 hours of practice will be required to have a collaborative provider agreement in place. A collaborating provider can either be a physician with a minimum of four years and 8,000 practice hours or a certified nurse-midwife meeting the same requirements. 

The provision also gives midwives 90 days to find a new collaborating provider if an agreement falls through before they have acquired the level of experience required to practice without an agreement. During that time, the midwife is allowed to continue practicing — something that’s currently not the case.

Moore said she hopes it’s just the “tip of the iceberg” for lawmakers enacting policy changes loosening restrictions on advanced practice nurses in North Carolina. If lawmakers had asked, Moore said, the Board of Nursing would have recommended the SAVE Act for the most comprehensive language and best path toward full practice authority for advanced practice nurses such as nurse-midwives, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists.

The American College of Nurse-Midwives and the American College of Obstetricians and Gynecologists have jointly stated that nurse midwives can be independent providers of care.

“It’s a feeling state that physicians should be in control,” said Ami Goldstein, president of the North Carolina affiliate of the American College of Nurse-Midwives. “That’s not an evidence-based health care state. We’ve got to move forward and use our evidence-based health care and best practices to address the maternal mortality crisis.”

New opportunities

Goldstein, who has been a nurse-midwife for 24 years, said removing the physician supervision requirement is long overdue.

Goldstein came to understand the backwardness of the policy in a new way when she entered residency education 16 years ago. In her role, she trains obstetric and family medicine resident physicians on how to attend people in the birthing process. She’s their teacher — backed by her education and years of experience delivering babies with successful outcomes. But when her residents graduate in June, they could become her physician supervisor starting on July 1.

“I feel like I have entered the world of ridiculousness when my supervising physicians actually used to be my residents at one point in time,” Goldstein said. “I don’t really know what to do with that.”

That’s not something she’ll need to deal with anymore.

Removing the physician supervision requirement will not affect the day-to-day practice of midwives, Goldstein said. 

Moore agreed, explaining that midwives will continue to collaborate with physicians when necessary to bring the best care to patients.

Five midwives pose for a picture. Three wear white coats.
Nurse-midwives Shannon Keller, Katie Calvillo, Jessica Albrecht, Suzanne Wertman and Kerry Autry at the state legislature last June advocating for looser restrictions on advanced practice nurses. Credit: Courtesy of Suzanne Wertman

Goldstein said the biggest impact of the policy change will be the new opportunities available.

“There have been many nurse-midwives who have wanted to open their own practices in rural communities but due to the restrictions have not been able to,” Goldstein said. 

She also thinks more birth centers could open in the state as experienced midwives can practice on their own without entering into agreements with physicians. The state’s only birth center is in Statesville. Several centers, mostly recently in Chapel Hill, have closed in recent years.

Wertman, now a consultant in state government affairs for the American College of Nurse-Midwives, said midwives can have an important role in improving maternal and infant health outcomes and loosening restrictions on their practice allows them to have a greater impact.

Tina Gordon, CEO of the N.C. Nurses Association, agrees.

“Decades of research shows Certified Nurse Midwives (CNMs) provide safe, quality care — often for some of the most underserved populations that lack access,” Gordon said in a statement. “North Carolina already has a shortage of providers, particularly in maternal health. With both Medicaid expansion and tighter restrictions on abortion imminent, demand for quality care is further outpacing supply.”  

Info about midwives

A certified nurse-midwife is a registered nurse who has graduated from a nurse-midwifery education program and has passed a national certification examination to receive the professional designation of certified nurse-midwife. Nurse-midwives have been practicing since the 1920s.

Twenty-seven states and the District of Columbia license and regulate CNMs to practice to the full extent of their education, clinical training and certification. Twenty states require a signed collaborative practice agreement with a supervising physician as a condition of licensure for a subset of nurse-midwifery services, such as the intrapartum period or for prescriptive authority.

A certified professional midwife is an independent midwifery practitioner who has met standards of certification set by the North American Registry of Midwives. CPMs do not have to be registered nurses before becoming midwives. CPMs have a path to licensure in 34 states and the District of Columbia. North Carolina prohibits the practice of CPMs. 

Information courtesy of the American College of Nurse-Midwives, the National Association of Certified Professional Midwives and the Midwives Alliance of North America.

Complicated feelings

While midwives welcome the change and advancement it will likely bring to their careers, they don’t necessarily like how it came packaged with restrictions on reproductive rights.

For Wertman, patients losing autonomy is counter to her being able to do her job sufficiently.

“Whenever patient autonomy is restricted, I can’t do my job fully as a nurse-midwife,” Wertman said. “I made a pledge to uphold patient autonomy, and the first half of Senate Bill 20 severely restricts that.”

For midwifery student Mariama Morray at Columbia University in New York, North Carolina’s new abortion restrictions taking effect July 1 are making her reconsider whether she wants to practice in North Carolina — the state she spent all her middle school and high school years — after graduation as she had originally planned. 

“My future practicing in North Carolina is looking very bleak,” she said. “I feel very lucky that I’m at the beginning of my journey right now because it’s going to be three years until I’ll be able to fully practice.”

Morray said a state with increased abortion restrictions isn’t appealing to her. She said abortion care will be part of her practice, and she doesn’t want to enter a restrictive legal landscape if she doesn’t have to. In her 20s, she also said it’s important for her to settle in a place that protects reproductive rights as she considers her own health and that of her future children.

While removing the physician supervision requirement made it more desirable for Morray to consider North Carolina, she said the new abortion restrictions canceled out that benefit.

“It’s hard because, especially with midwifery, the profession is so tied to the people that we serve,” Morray said. “And so if it’s not a win for the patients, how can it really be a win for us?”

Pushing for full practice authority

Removing physician supervision after 4,000 hours of practice is a step in the right direction for midwives, Wertman said. 

But she said it’s also time for other changes for midwives and the three other categories of advanced practice nurses, totaling more than 17,000 professionals practicing in the state. They are all after full practice authority, meaning advanced practice nurses can practice to the full extent of their education and training.

shows an older white woman standing behind a podium that reads, "North Carolina General Assembly" she's flanked by three other people in business clothes
Sen. Joyce Krawiec (R-Kernersville) speaks at a February press conference announcing the refiling of the SAVE Act, which would give more latitude for advanced practice nurses to work more independently. Flanking her (L to R) are Rep. Carla Cunningham (D-Charlotte), Sen. Ralph Hise (R-Spruce Pine) and Sen. Gale Adcock (D-Cary). Both Adcock and Cunningham are nurses. Credit: Rose Hoban

Lawmakers can grant this by passing the SAVE Act — legislation that has been introduced in every legislative session since 2015. Over the years, support has slowly grown as lawmakers have recognized the role advanced practice nurses can have in addressing provider shortages and coverage gaps in rural areas. This year, the bill has 59 sponsors in the House and 21 sponsors in the Senate. 

Senate leader Phil Berger (R-Eden) has vocalized his support for passage of the SAVE Act. In 2022, the Senate added language that would have given advanced practice nurses more autonomy as part of its Medicaid expansion proposal. However, that proposal stalled in the House and was ultimately left out of the milestone Medicaid expansion deal reached in March between the two chambers that is contingent on the passage of this year’s budget.

About half of states already allow advanced practice nurses to practice independently, and no state that has granted full practice authority has reversed course.

a man takes a picture of four people on his phone, they're holding a sign that says "SAVE Act"
Chris Cowperthwaite, who works with the N.C. Nurses Association, takes a photo of some of the 150-plus advanced practice nurses who came to the legislature in 2019 to talk to lawmakers about legislation to remove physician supervision from them. Photo credit: Rose Hoban

Miller, the lobbyist for the N.C. Nurses Association, is ready for North Carolina to join the ranks. 

But Miller doesn’t expect his lobbying to suddenly become easier after lawmakers have demonstrated this willingness to take a small step to loosen restrictions on midwives. He said there’s still a powerful lobby behind physicians who strongly oppose passage.

“The medical lobby has been adamantly opposed to allowing their colleagues to practice without restriction because it’s in their financial interest to maintain the status quo,” Miller said. “Nobody benefits from the existing system — except for those physicians who are paid passive income for this paper supervision, without which qualified providers are not able to practice.” 

But that incentive could be short-lived, as a provision in the Senate budget prohibits physicians from making passive income off supervision.

Chip Baggett, head of the North Carolina Medical Society, spoke against the SAVE Act last year, explaining that the group’s opposition is based on patient safety concerns and educational differences that they don’t think provide the necessary foundation for independent decision-making.

However, several decades of research bolster the nurses’ contention that their practices are safe.

“It’s definitely going to make the job of the medical lobby harder because when this change for nurse-midwives results in increased access to care, lower costs and better outcomes for mothers and babies, the lie that they have been selling to scare people into not supporting the SAVE Act will be exposed,” Miller said.

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