ACOG's official position, reiterated in a 2017 statement, is that the risk of a baby dying during or after childbirth is more than two times higher in a home birth than in a hospital.
Thus for some North Carolina doctors, endorsing certified professional midwives is tantamount to endorsing home births.
"That's one of the concerns: If you legitimize it, home births would go up and more women may be lured into it," Allbert said. "That is the past resistance: that we don't want to validate poorly or inadequately trained individuals doing deliveries. We do not want to promote home births."
Kellett Letson, the current president of the N.C. OB-GYN Society, remains unmoved by the arguments of certified professional midwives. He said that even with the stricter training requirements, they lack the medical expertise of midwives who hold nursing degrees.
"We have a model that works," said Letson, an Asheville obstetrician. "I have seen many women shift from a low-risk to a high-risk pregnancy, and in those moments having the right kind of training and medical experience is very, very important. And it's the level of care women in North Carolina deserve."
Challenges of delivering at home Home births, of course, were once all most women in rural North Carolina knew. In 1925, North Carolina led the nation with 6,500 midwives, who delivered one-third of the babies born in the state that year; of those births, 80 percent were African-American children, according to a 1992 article by East Carolina University anthropologist Holly Matthews.
Currently there are 42 certified professional midwives with North Carolina addresses on the rolls maintained by the North American Registry of Midwives. It's not clear how many of them are illegally active in home births, because some of them could live in North Carolina and deliver babies in Virginia, Tennessee or South Carolina, said Ida Darragh, the organization's executive director, in an email. According to the national registry, seven new midwife certifications have been issued in North Carolina in the past five years.
To find a midwife who will deliver a home birth, many pregnant women turn to the tightly-knit home birth community, where the midwives are known and protected.
For, Julie Feickert, a technology entrepreneur in robotics education in Raleigh with an MBA and a masters in science and business strategy, this statewide speakeasy network involved getting vetted by email before the midwife would agree to meet with her. And Feickert, who had previously home-birthed three kids in Oregon, had to agree she would never disclose the name of the midwife who illegally delivered her son at her Raleigh home in July 2017.
"I realized I would as safe or safer by giving birth at home," Feickert said an interview. "I knew if my stress level was high, in an unfamiliar hospital environment, if I had to regularly advocate for myself and my baby, I wouldn't be able to manage my pain."
Ashley Kopp-Houston, who had used a midwife with her first pregnancy, also had trouble finding a midwife when she became pregnant with her second child.
Her original midwife had retired and because she refuses to take medication for a blood clotting disorder, Kopp-Houston had "risked out" of a home birth and could not find a certified professional midwife or a legal nurse midwife to deliver the baby anywhere -- at home, in a birth center, or in a hospital.
Her delivery did, in fact, turn into a scene of "panic and chaos," she said.
Last October, when she was 41 1/2 weeks pregnant, she went to UNC Hospitals, for a planned natural birth, without medication, and with the hope that her husband could "catch" the baby as the child emerged.
But the baby, weighing nearly 10 pounds, developed shoulder dystocia -- a complication in which the infant becomes stuck in the birth canal -- requiring emergency medical intervention. Kopp-Houston said the doctor on call was supportive and "wonderful."
"He did what he had to do," she said. "I'm completely fine with that."
Which is safer: home or hospital? In states where they're legal, certified professional midwives can assist during home births and they can also work at freestanding natural birth centers. Certified professional midwives say that home births are a cheaper, simpler -- and safer -- option than hospitals, when all factors are taken into account, a view shared by Audrey Trepiccione, a Garner certified professional midwife who is under a 2012 cease-and-desist order.
"At home, let's face it: The challenge is managing pain," Trepiccione said. "If she can relax, it will be much quicker."
Hospitals mean more intervention, more drugs, more surgery and more mistakes, Trepiccione said, echoing the belief of many certified professional midwives. Hospitals are a pathway to an unacceptably high c-section rate, said Trepiccione, who serves as vice-president of N.C. Friends of Midwives, the state advocacy group for the legalization of certified professional midwives .
Midwives frequently point to the damning statistic that in the United States, nearly 1 of 3 babies is delivered surgically, a rate deemed excessive by ACOG, the U.S. Department of Health and Human Services and the World Health Organization.
A common argument in favor of legalizing traditional midwives is that they would coordinate with doctors and hospitals if pregnancy complications arise, instead of delaying medical care for fear of getting caught.
Midwife acceptance by the health care system is seen as a proxy for newborn safety by midwife advocates. A February 2018 study in the online peer-reviewed journal PLOS One gave North Carolina the lowest score in the nation in this area, saying a low score reflects low integration of midwives and health care providers.
The question of home birth safety remains a matter of dispute, because safety is not easy to measure. Studies cited by certified professional midwives conclude that the rate of newborn deaths and complications is comparable between home births and hospital births.
But Barbara Levy, ACOG's vice president of health policy, said the comparisons can be misleading. For example, if a home birth goes awry and the newborn is transferred to a hospital emergency room and dies there, it's likely to be counted as a hospital death, not a home birth death. Additionally, newborn deaths at hospitals typically include high-risk pregnancies -- women past term, obese women, women with previous c-sections, and women with diabetes and other complications -- which are rejected as candidates for home births.
The New England Journal of Medicine ran a study in 2015 adjusting for some of those factors. That study found the death rate in an out-of-hospital birth compared to a hospital birth was 3.9 deaths per 1,000 versus 1.8 deaths per thousand, or more than twice as high. The study was based on 2012-2013 Oregon data using newly revised Oregon birth certificates that distinguished between planned hospital births and unplanned out-of-hospital births.
Raw data show that the newborn death rate is roughly twice as high in home births compared to hospital births in North Carolina. The state reported 11 fetal deaths during home deliveries in 2017, 12 in 2016 and 10 in 2015, which is more than 1.5 percent of all home births each year. In the same three years, the number of fetal deaths during delivery in hospitals was 792, 808 and 892, less than 1 percent of all hospital births, according to records at the N.C. Department of Health and Human Services.
Midwifery care can go terribly wrong, as evidenced by a 2012 murder charge against midwife Tina Louise Bailey in western North Carolina. Bailey assured the parents that the presence of meconium was nothing to fret about, just days before the baby was stillborn. Bailey pleaded to lesser charges in 2015 after spending 298 days behind bars, according to news coverage and information from the Buncombe County district attorney's office.
However, Bailey was not a certified professional midwife as recognized by the national registry; she was a graduate of The Matrona, an unaccredited school in Asheville. If certified professional midwives were legalized, midwives like Bailey would remain illegal in North Carolina, unless they obtained additional credentials.