When a private OB/GYN practice dissolved its midwife program, resulting in the loss of two of Wilmington’s three practicing midwives, angry patients hit the streets.

Wilmington Health Associates’ (WHA) decision to end its midwifery practice at Carolina OB/GYN certainly raised passions about the relationship between a patient and a caregiver.

A spokeswoman for WHA said that the decision to terminate the program was operational and not financial, but the resulting scramble for midwife care has highlighted the challenging economics of providing nurse-midwife services in Wilmington.

“The more medicine you do, the more you get paid,” said Russ Fawcett, legislative director, North Carolina Friends of Midwives. “Midwives tend to have lower intervention rates (cesarean and instruments). So the insurance company pays less,” he said.

“The cost of a birth is about $7,000 to $15,000,” said Caron Jones, chairwoman of the American College of Nurse Midwives’ North Carolina chapter. But a birth without a cesarean section, epidural or the latest hospital technology can cost as little as $1,500 to $3,000, she said. A stand-alone birthing center, where many North Carolina midwives deliver does not exist in Wilmington.

Health care professionals say such a stand-alone midwife practice would need to deliver at least seven to eight babies a month per midwife to remain profitable. “Generally, if you are doing eight births a month per midwife, you are profitable,” said Jones, who had to close a birth center she opened in the Outer Banks when she couldn’t reach those numbers. In Wilmington, about 160 births are performed by midwives each year.

Carolina OB/GYN, a division of WHA wouldn’t release figures on how many patients it had in the midwifery program for proprietary reasons, said Alysa Bostick, director of physician relations and marketing at WHA.

Cost differentials

Certified nurse midwives, who are registered nurses with additional specialized training and certification, traditionally use more natural birthing practices and less medication compared to physicians. As a result, about 7 percent to 10 percent of midwife births result in cesarean sections compared to the 25 percent to 33 percent rate of c-sections by physician-led births, Jones said. These figures can also be attributed to physicians taking on more complicated deliveries.

As a result, “We make about one-third to one-fourth of what physicians make, depending on geographics,” Jones said of midwife pay. In addition to performing surgery, physicians receive more education, which explains the difference in salary. New physicians earn about $150,000 a year while newly certified nurse midwives earn about $50,000. The numbers go up from there, with senior physicians earning up to $400,000 and experienced midwives earning about $80,000, she said.

Although midwives earn less and their birthing methods can cost less, a physicians group may still opt to drop midwifery services in tough economic times. “Economically, when you look at programs to cut, you have to have an OB/GYN on your staff. You do not have to have a midwife,” Jones said. The midwife services become ancillary, from a business perspective. And while preventive healthcare office visits are down, many practices are facing the challenges of this
economy, she said.

Finances were the main reason why SEAHEC, now the only local practice with a midwife on staff, hesitated to fill its second midwife position. “We had not aggressively tried to fill this position, because of concerns over financing,” said Dr. Mark Darrow, CEO of South East Area Health Education Center. But now in response to the community’s vocalized demand, he hopes to fill the position immediately.
SEAHEC’s one midwife delivers about 10 percent of the group’s births a year. The private non-profit practice had seen an increase in demand for midwife services earlier, which had prompted them to create a second position this past year.

Darrow said a decision to grow this type of practice needs to be thought through from an economics point of view.

“They’d need to look at the potential profit loss,” said Darrow. They would need to consider their mission, too. Then, start asking the hard questions. “Is there a demand for the service? What would [the physicians] pay, collect, and how would they supervise? The issue of supervision crosses a lot of these issues,” he said.

An issue of supervision

“The whole issue is supervision and that’s controversial,” said Darrow. North Carolina state law says that all certified nurse midwives must have a contractual supervisory agreement with a physician.

New Hanover Regional Medical Center has interpreted this law differently from most hospitals in the state and created a policy requiring the midwife’s supervising physician to be physically on-site during a delivery.

“The physicians, clinical team, and board of trustees feel that this policy needs to be,” said Martha Harlan, director of public relations and marketing at New Hanover Regional Medical Center.

However, for a physician who is off-duty or not on-call to be required to come to the hospital to supervise but not necessarily participate in a birth is an added responsibility taken on by the physician, experts said.

“It is our understanding that a key reason why WHA dissolved the CNM (certified nurse midwife) operation, and why there is an alarming dearth of CNMs in the area, is because of this policy that requires the supervising OB (obstetrician) to be on-site for all deliveries,” Fawcett said.

Carolina OB/GYN, in a press release, said that its decision to terminate its midwifery program was operational.

For SEAHEC, the operational aspect of the hospital’s midwife rules has not been an issue. The group’s physicians teach and support the residents at New Hanover Regional Medical Center and have offices at the hospital. This conveniently ensures that a supervising physician will be on-site when a SEAHEC midwife is delivering, Darrow said.

Not all hospitals have NHRMC’s same policy. “I’m not aware of any other hospital in the state … except for one in Winston-Salem,” with a similar policy, Jones said. Although Brunswick Community Hospital has never had a midwife on staff, they do not require supervising physicians to be on-site for their “allied health professionals” such as nurse practitioners and physicians’ assistants to practice, said a spokeswoman for Brunswick Community Hospital. However, no midwives have applied to join the hospital staff yet. 

“The practice of midwifery has been around since the beginning of time,” Jones said. And the demand for it has not gone away. But, despite the demand in Wilmington, local physicians will not necessarily jump at the opportunity to add midwives to their practices. “Like in any business, just because you can do it, doesn’t mean you ought to do it,” Darrow said.

Bostic said WHA wouldn’t rule out starting a new midwifery program in the future. She reiterated that the company was proud to have offered the program for more than five years.