The deaths of several newborns at a Cary birth center may complicate efforts to integrate midwives further into North Carolina’s health-care system. An investigation is underway into Baby + Co., a natural birthing center, where four newborns have died since the center opened in 2014.

As WRAL reports, Baby + Co. has directed all expectant mothers to WakeMed Cary while an investigation is conducted. The decision to send clients to the hospital came after a newborn went into distress and was taken to Duke Hospital’s neonatal intensive care unit.

“Clustering of cases in health care is difficult, but it happens in a lot of different settings. It happens in hospitals. It can happen in birth centers,” Margaret Buxton, a certified nurse midwife and clinical director for Baby+Co., told WRAL. “When it happens, it’s an opportunity for any health care agency — and we include ourselves in that — to take a step back.”

All midwives with Baby + Co. are certified to practice and have full privileges at WakeMed Cary, an investor in the company.

Anayah Sangodele-Ayoka, a midwife and consultant with MomsRising, a left-leaning grass-roots organization, says allowing midwives to practice with fewer restrictions could improve outcomes for pregnant women.

A focus on “midwife integration” — incorporating midwives of every training and certification level more completely in the prenatal health-care system — could be especially helpful to pregnant women and their children in low-income and rural counties. Specialized prenatal care there is harder to find, and obstetricians can be hours away.

“We look at women as whole people,” Sangodele-Ayoka said. “We tend to focus a lot more on psycho-social needs. We care for low-risk women, so we do a lot of screenings and things to make sure a woman is remaining low-risk, which is within the scope of our care.”

North Carolina has the lowest level of midwife integration in health care across the country. At the same time the state struggles with high infant and neonatal mortality rates. Maternal mortality rates — while lower than most U.S. states — are among the highest among developed countries.

Using data from the Centers for Disease Control and Prevention, the United Health Foundations determined North Carolina’s maternal mortality rate is 12.1 deaths per 100,000 births. The U.S. average is 19.9 per 100,000 births.

In 2016, North Carolina reported 7.2 deaths per 1,000 live births, ranking it seventh from the bottom among states. In 2015, the most recent data available, the U.S. averaged 5.9 deaths per 1,000 live births.

Sangodele-Ayoka said midwives could help address this problem.

“We really have to take a step back away from the way our health-care model has been structured to before and put the emphasis back on the people who are in need of our care,” Sangodele-Ayoka said. “We don’t have to reinvent the wheel.”

A February 2018 report published in the Public Library of Science — a nonprofit open access science, technology, and medicine publisher — mapped the integration of midwives across the country.

Researchers looked at the differences in scope of practice, autonomy, governance, perspective authority, and any restrictions that could affect patient safety, quality, and access to maternity providers. Each state was graded on a 100-point scale, with higher scores indicating greater integration of midwives.

North Carolina had the lowest score at 17 — compared to Washington, which earned the highest score, 61.

“In our study, lower MISS scores were associated with significantly higher rates of neonatal mortality among Hispanic, black, and white babies when examining race-specific outcomes,” the report reads.

States with higher MISS scores, such as Washington and New Mexico, saw higher rates of spontaneous vaginal delivery and breastfeeding, while also seeing significantly lower rates of cesarean procedures, preterm births, low birth-weight infants, and neonatal death.

“The more integrated midwives are in the state, the fewer restrictions there are to midwives practicing according to their training, the better the outcomes are,” Sangodele-Ayoka said.

Most midwives train as nurses first, Sangodele-Ayoka said, and then go on to advanced training in midwifery. They approach pregnancy differently than obstetricians and don’t treat going into labor as a medical emergency.

In North Carolina, midwives must pass a national board exam to become credentialed and then seek approval from a physician to practice. Sangodele-Ayoka said this requirement could be a conflict of interest.

“It is like having someone who is in your same industry supervising you or deciding whether or not you get to practice,” Sangodele-Ayoka said. “North Carolina and a handful of other states are the only ones that still require this archaic practice where you would require someone who is direct competition to be able to say whether or not you can practice.”

Midwives are unable to practice in 31 counties because those counties have no obstetrical care providers to take on the supervisory role.

“It’s not magic. As midwives, we tend to be more focused on the whole person,” Sangodele-Ayoka said. “Our care is really about getting to know the person, so that when you do get to know them you reduce some of those barriers and create more trust.”