A growing focus on maternal health disparities prompts lawmakers to remove barriers for nurse-midwives

A few months into the COVID-19 pandemic, Nichole Wardlaw opened her own midwifery practice in Chesapeake. 

A certified nurse-midwife, or CNM, Wardlaw was taking advantage of an emergency order signed by Gov. Ralph Northam, which allowed certified-nurse midwives and nurse practitioners to treat patients without an agreement with a licensed physician — something that’s typically required in Virginia. 

But she was also trying to fill a need in her community. Wardlaw said she’s now the only Black certified nurse midwife in the Hampton Roads region to open an independent practice, spurred by concerns she heard from expecting mothers throughout the early months of the pandemic.

Even before then, Wardlaw said she was keenly aware of the maternal health disparities faced by many in her community. In Virginia, Black women are more than twice as likely to die in childbirth than White women, according to the most recently available data from the state Department of Health. A 2013 survey of mothers across the country found that Black women were more than three times as likely as White women to report that they were “always or usually” treated poorly in hospitals due to race, ethnicity, cultural background or language.

“My concern is that Black women are dying in childbirth and from childbirth-related issues,” said Wardlaw, who also serves as the legislative chair for the Virginia Affiliate of the American College of Nurse-Midwives. “And since I opened my practice, I’m getting calls from far north of here because women want someone who looks like them.”

As maternal health disparities come under increasing scrutiny in Virginia and across the country, there’s been a political push to address the problem. This session, the General Assembly unanimously passed legislation creating a taskforce to collect more maternal health data and narrowly endorsed a bill to remove some restrictions on midwives.  

Some providers and legislators see midwifery as an important tool, arguing it could increase the number of obstetric providers in underserved communities and reduce inequities in birth outcomes. In 2014, The Lancet, an international medical journal, found that midwife-led care by licensed and educated providers led to better maternal health outcomes. Another 2018 study examined the regulation of midwives in 50 states and found C-sections, premature births and infant fatalities all declined when midwives were integrated across health care settings.

“One thing we know is that the relationship between a woman and her health care provider is really key,” said Amy Paulson, director of the Consortium for Infant and Child Health in Norfolk and an instructor at Eastern Virginia Medical School’s Department of Pediatrics.

“So, if you don’t feel heard by your provider, maybe you stop going,” she added. “And if a woman feels more comfortable with a midwife, and is able to communicate more effectively, that improves the quality of care.”

Those arguments played an important role in legislation aimed at eliminating barriers for nurse-midwives to practice. Under current state law, certified nurse midwives can only treat patients if they have an agreement with a licensed doctor that outlines “the availability of the physician for routine and urgent consultation on patient care.” But on Saturday, the General Assembly narrowly passed a bill from Del. Dawn Adams, D-Richmond, removing the practice agreement requirement.

“This isn’t a safety issue — this is an access issue,” Adams, a licensed nurse practitioner, said in an interview. “We’re trying to make sure people have healthy lives with access to the providers of their choice who can give them the care they need.”

Debate over the bill, though, pushed its passage to the final day of session and triggered two votes in the Senate, where some lawmakers argued it warranted further study. Disagreement over the autonomy and scope of advanced practice nurses in Virginia is nothing new. But the historical significance of midwives in Black communities, combined with growing concern over maternal health disparities, gave the arguments a different dimension — and helped overcome opposition to the bill, Adams said.

“We have really been able to see how problematic health care is for women who are pregnant, particularly those who are Black,” she added. “And the nurse midwife is one of the oldest and most trusted health care providers in the Black community.”

‘What happens to my practice now?’

Even in Virginia, CNMs have historically been able to work more independently than other advanced practice nurses, whose additional training allows them to take on more advanced roles in the health care industry. Until 2018, nurse practitioners, for instance, could only treat patients if they had a collaborative agreement with a physician — a partnership that requires “period chart reviews” and physician input in complex clinical cases. 

After a lengthy fight in the General Assembly, nurse practitioners won the ability to practice independently, but only after five years of full-time clinical experience under a doctor’s supervision. While CNMs never had fully autonomous practice, some argued that their required practice agreement was much less restrictive than a collaborative agreement — requiring only that nurse-midwives sign on with a physician who could consult on cases if necessary.

“We believe the current law is appropriate,” said Dr. Barbara Boardman, chair of advocacy for the Virginia chapter of the American Academy of Pediatrics, who spoke against Adams’ bill in a January committee hearing. “The practice agreement must address the availability of the physician for routine and urgent patient consultation. This is to ensure the safety of the mother and the newborn.”

That’s because, opponents argue, it ensures that midwives are working collaboratively with other providers and establishes a continuum of care for complicated cases and pregnancies. Conditions such as high blood pressure and diabetes, or even getting pregnant over the age of 35, can make a pregnancy riskier. Some lawmakers raised concerns that Adams’ bill would leave few safeguards for midwives offering home births. 

“I do see a big difference between a home and a hospital birth,” Del. Karrie Delaney, D-Fairfax, said during the same committee meeting. “I think everything that’s happening in the hospital, there’s a team and collaboration already there. If there’s a crisis, there’s methods in place to quickly transition to emergency care. But I know home births are inherently riskier because of that lack of emergency access.”

Midwives, though, say practice agreements don’t make their services any safer. Katie Page, president of the Virginia affiliate of the American College of Nurse Midwives, said the vast majority of them already work in hospitals or group practices that also employ doctors. And nurse-midwives don’t need an added layer of oversight, she said, when they already have advanced training that establishes a clear scope of practice.

“We know we’re generally caring for people with less complex health needs,” she said. Many nurse midwives point out that patients are screened for risk factors and wouldn’t be approved for a home birth if they had a high-risk pregnancy. And Page said that while nurse-midwives can offer a broad continuum of care, they’re already referring patients to specialists if they have medical complications.

“If people have different health needs, then I’m going to either provide that care within my scope and my capacity or I’m going to be inviting— with their permission — other clinicians to join and be a part of their team,” she said. But often, those providers aren’t the physician listed on a practice agreement. 

“The agreement can be with any physician — it doesn’t necessarily mean that it’s an OB-GYN,” Wardlaw added. As a result, many CNMs say they’re frequently consulting with other providers to ensure their patients receive appropriate care.

“Say you’re my client and your complaint is that you’re having shortness of breath,” Wardlaw said. “Do I consult with my consulting physician, or do I consult with a cardiologist who can get you in and get you testing to figure out what’s going on?”

CNMs say practice agreements can also be a barrier to providing care. According to Page, many doctors who work for hospitals or group practices can’t enter into practice agreements, making it challenging to find a consulting physician even in areas with a robust medical workforce.

“We have a midwife in Charlottesville who took two years to sign a physician,” she said. According to Wardlaw, many doctors also charge for the service. And she said it can leave CNMs stranded if their consulting physician leaves the field.

“You’re always at the mercy of whoever you have this agreement with,” she said. “Let’s say they get COVID, have a car accident, decide to retire — they’re out of commission. Well, what happens to my practice now?

Competing bills

Adams’ said consultation requirements also imply that nurses can’t be trusted to practice to the full extent of their training. Her original bill removed the practice agreement language from state code governing CNMs and clarified that they would be required to practice under regulations established by the state Boards of Medicine and Nursing — in addition to standards of practice from the American College of Nurse-Midwives.

“There is zero expansion of practice in this bill,” she said in a committee hearing. “What we’re talking about is eliminating a piece of paper that often costs the nurse-midwives a fair amount of money.”

Some doctors — and lawmakers — disagreed. The American College of Obstetricians and Gynecologists testified that while it didn’t oppose the bill, it would seek an amendment requiring a physician or experienced nurse-midwife to oversee at least 25 births before a newly graduated nurse midwife could practice independently. 

A few weeks later, the Senate introduced a substitute bill that went even further. Amended legislation from Sen. Siobhan Dunnavant, R-Henrico, included a requirement for 25 monitored births before a CNM could practice independently. But it also added a delayed enactment clause, meaning the legislation wouldn’t go into effect until July 2022 — after the state’s Department of Health Professions studied “the impacts a certified nurse midwives’ transition to independent practice has had on patient safety” in other states.

“All I know is that this bill came to me with an enormous amount of conflict,” Dunnavant, a licensed OB-GYN, said in an interview. “Not just among stakeholders, but among senators. And I was trying to resolve it in a way where the bill would survive — with delayed enactment being one idea I had.”

Dunnavant wasn’t the only legislator with concerns over the bill. In a committee meeting before the Senate introduced a substitute, Sens. Steve Newman, R-Bedford, and George Barker, D-Fairfax, supported sending the legislation to the Department of Health Professions and reevaluating it next year. 

“The standard practice in a lot of these situations is to refer the issue to the department, which then during the year does a study of it and involves stakeholders in the process,” said Barker, who serves as chair of the Senate’s Health Professions subcommittee. Over the past decade, DHP has studied a slew of emerging providers, from genetic counselors to music therapists. Most recently, the department spent nearly a year studying the possibility of licensing naturopathic doctors in Virginia — a proposal that was ultimately voted down by the state’s full Board of Health Professions.

To CNMs, though, the Senate suggestions weren’t workable. Adams described the 25-birth requirement as arbitrary and not rooted in the reality of how nurse-midwives practice — or the extent of their training.

“They have to attend 60 births and be the lead of an additional 35 before they can even sit for their certification,” she said. “And again, their scope is not performing C-sections or any advanced obstetrics. They know that. So it’s frustrating to hear constantly that this woman-dominated profession of nursing is the only profession where when people graduate, they’re not able to practice to the fullest extent of our education.”

Supporters of the bill also took issue with the proposed DHP study, describing it as a delay tactic and redundant, given that other studies on midwives are already in the works. One is tied to a bill from Sen. Louise Lucas, D-Portsmouth, and Del. Wendy Gooditis, D-Loudoun, that passed the General Assembly unanimously this session. 

It establishes an entirely new category of midwifery for providers who are formally educated in the profession but not dually certified as nurses. The bill generated little discussion — largely because it requires those providers to maintain a practice agreement with a licensed physician.  

‘It was an issue of putting up barriers to care’

Opposition to independent practice isn’t unusual in Virginia. Nurse practitioners spent years advocating for autonomy before winning a pathway to work independently in 2018. This year, Adams unsuccessfully sponsored another bill that aimed to reduce the requirement for full-time clinical experience from five years to two.

“We already have nurse practitioners who are practicing autonomously under the current emergency order,” she said. But after bipartisan hesitation, Adams amended the bill to expire in July 2022 — enough time for NPs to transition their patients to other providers after the temporary waiver expires. 

A key difference in the CNM bill was support from two influential Black senators. Lucas, who chairs the Senate’s Education and Health committee, vocally opposed the effort to refer the bill to study in committee. 

“This would not be the direction I’d like to take,” she said. “I was delivered by a midwife, and so were all my sisters and brothers. And this is something that’s very important to a community like mine.” 

“I was also delivered by a midwife,” added Sen. Mamie Locke, D-Hampton. Both opposed a motion to table the bill and send it DHP, pushing it to the Senate floor for a full vote.

When the bill went into conference, a process to reconcile the competing House and Senate versions, Adams said their support was also fundamental in removing many of the changes that would have restricted the impact of the bill.

“They understand that it’s not an issue of safety — it was an issue of putting up barriers to care in communities where there don’t need to be barriers,” Adams said. The final version of the bill, which passed the House unanimously, requires 1,000 hours of practice in consultation with a physician or experienced nurse-midwife before CNMs gain full autonomy. But it eliminated the delayed enactment clause and required study by the DHP.

Negotiations extended to the final day of the General Assembly, where senators reconsidered the bill after it passed 20-18 with bipartisan opposition (Barker, Dunnavant and Newman all voted no). The bill passed 20-19 on the second vote.

Adams said she’s still worried the bill could be amended once it reaches Gov. Ralph Northam, a pediatric neurologist. Northam’s spokeswoman, Alena Yarmosky, said only that the governor would “closely review” the bill when it reached his desk.

But opposition to autonomy isn’t universal within the medical community. Paulson, director of the Consortium for Infant and Child Health in Norfolk, emphasized that midwives needed to be certified and licensed in their field. But she also doubted that physician oversight would make a difference in their practice.

“A certified nurse-midwife is someone who has a master’s in nursing plus this additional training,” she said. “And it would be a rare provider, just from a liability perspective, who would go outside the scope of their practice.”