AN ACT to recognize maternal health initiatives and TO support and expand licensure and recognition of midwives.

The General Assembly of North Carolina enacts:

SECTION 1.(a)  Chapter 90 of the General Statutes is amended by adding a new Article to read:

Article 10B.

Maternal Health Accountability Act.

§ 90‑178.10.  Short title.

This Article shall be cited and known as the Dr. Janell Green Smith, DNP, CNM, Maternal Health Accountability Act.

§ 90‑178.11.  Legislative findings; intent.

(a)        Findings. – The General Assembly makes the following findings:

(1)        North Carolina continues to experience unacceptable rates of maternal mortality and severe maternal morbidity, with disproportionate impact on Black, Indigenous, rural, and low‑income communities.

(2)        The American College of Nurse‑Midwives (ACNM) and the National Association of Certified Professional Midwives (NACPM) recognize Certified Nurse Midwives (CNMs), Certified Midwives (CMs), and Certified Professional Midwives (CPMs) as essential providers in a safe, evidence‑based, and equitable maternal health system.

(3)        National clinical standards and peer‑reviewed evidence demonstrate that midwifery care, when licensed, regulated, and integrated across birth settings, improves continuity of care, patient satisfaction, and maternal and neonatal outcomes.

(4)        States in the southeastern United States, including South Carolina and Virginia, have enacted laws to do all of the following:

a.         Formally integrate midwives into perinatal levels of care systems.

b.         License and regulate Certified Professional Midwives using national standards.

c.         Prohibit physician supervision or contractual gatekeeping requirements.

d.         Require equitable reimbursement for midwives providing covered maternity services.

(5)        Virginia law expressly provides for autonomous midwifery practice and reimbursement parity for licensed midwives, while South Carolina law requires the integration of midwives and community birth into statewide perinatal care planning, without restricting scope of practice or requiring hospital privileges.

(6)        A maternal health system that excludes community‑based providers, fails to ensure accountability for hospital practices, or relies on uncompensated perinatal labor undermines patient safety and worsens disparities.

(b)        Intent. – It is the intent of the General Assembly to establish a comprehensive maternal health accountability framework that promotes safety, transparency, workforce sustainability, informed consent, and equitable access to care, while honoring the legacy of Dr. Janell Green Smith, whose leadership advanced patient‑centered maternity care and system accountability.

§ 90‑178.12.  Core principles.

North Carolina's maternal health system shall be governed by the following principles:

(1)        Maternal health systems shall be accountable for patient safety, respectful care, and measurable outcomes.

(2)        Pregnant and postpartum individuals and their families shall have clear, accessible pathways for reporting harm and obtaining timely support.

(3)        Certified Nurse Midwives, Certified Midwives, and Certified Professional Midwives are essential maternal health providers and must be recognized, regulated, and supported across all birth settings.

(4)        Community‑based organizations, including midwifery practices and doula organizations, constitute essential public health infrastructure.

(5)        The maternal health workforce shall be sustainable, accessible, and fairly compensated.

(6)        Licensed midwifery care across hospital and community settings improves continuity of care, safety, and birth outcomes.

§ 90‑178.13.  Definitions.

The following definitions apply in this Article:

(1)        CM. – Certified Midwife licensed under Article 10C of this Chapter.

(2)        CNM. – Certified Nurse Midwife licensed under Article 10A of this Chapter.

(3)        CPM. – Certified Professional Midwife licensed under Article 10C of this Chapter.

(4)        Department. – The Department of Health and Human Services.

(5)        Hospital. – As defined in G.S. 131E‑214.1.

(6)        Perinatal health care provider. – A licensee under this Article and Articles 10A and 10C of this Chapter.

§ 90‑178.14.  Hospital accountability and safe discharge.

Hospitals providing maternal or emergency obstetric services shall do all of the following:

(1)        Implement and maintain a safe labor discharge plan prior to the discharge of any individual presenting in labor.

(2)        Adopt and maintain standardized maternal clinical escalation and emergency response protocols.

(3)        Require annual training in respectful maternity care and implicit bias for obstetric, emergency, and nursing staff.

(4)        Maintain formal collaboration and transfer agreements with licensed CNMs, CMs, and CPMs to ensure timely, respectful, and safe transitions of care from community‑based to hospital settings.

(5)        Prohibit denial or delay of care based solely on provider type or planned birth setting.

(6)        Allow perinatal health care providers in birthing rooms as part of the care team and not counted as a member of the family, including in the event that a birth moves from home care to hospital care.

§ 90‑178.15.  Reporting requirements; oversight.

(a)        Departmental Reporting Requirement. – On August 1 of each year, hospitals and all perinatal health care providers shall annually report to the Department of Health and Human Services all of the following:

(1)        Maternal mortality.

(2)        Severe maternal morbidity.

(3)        Emergency postpartum readmissions.

(4)        Discharges during active labor.

(5)        Cesarean delivery rates.

(6)        Labor induction rates.

(7)        Neonatal intensive care unit admissions.

(8)        Transfers between community‑based and hospital‑based care.

(b)        Data. – All data compiled for the reports under this section shall be disaggregated by race, ethnicity, payer, geography, and provider type. All reports under this section shall be made available for public access on the Department's website.

(c)        Oversight. – The Department is required to do all of the following:

(1)        Conduct compliance audits.

(2)        Require corrective action plans if a hospital covered under this Article is found to not be in compliance.

(3)        Provide technical assistance to hospitals and perinatal health care providers to comply with the provisions of this Article.

(4)        Evaluate outcomes across all birth settings, including community‑based midwifery care, consistent with perinatal integration models adopted in peer states.

(d)       Annual Report. – The Department shall annually submit a report containing (i) the data collected under subsection (a) of this section and (ii) the outcomes under subdivision (c)(4) of this section to the Joint Legislative Health and Human Services Oversight Committee by October 1 of each year.

§ 90‑178.16.  Patient advocacy and accountability.

(a)        System. – The Department shall establish a statewide maternal health reporting and navigation system to provide all of the following:

(1)        Assistance with the hospital grievance process under the North Carolina Medical Board or the Division of Health Service Regulation.

(2)        Referrals to legal resources.

(3)        Referrals to relevant occupational and State agency licensing boards.

(4)        Referrals to community health workers.

(5)        Access to trauma‑informed and perinatal mental health services.

(b)        Funding. – The Department shall provide any available funds, if practicable, to community‑based organizations to provide the services listed in subsection (a) of this section.

§ 90‑178.17.  Transfers.

Hospitals and perinatal health care providers shall participate and collaborate in standardized transfer protocols that prioritize patient safety and continuity of care while preserving professional autonomy, consistent with national standards of practice and peer state models for those providers.

§ 90‑178.18.  Midwifery education and community infrastructure.

(a)        Infrastructure Support. – The State, through this Article, shall support all of the following:

(1)        Midwifery education and apprenticeship pathways.

(2)        Scholarships and stipends for perinatal health care providers.

(3)        Continuing education and workforce development.

(b)        Funding. – The Department shall provide any available funds, if practicable, to community‑based organizations and birth centers to provide the services listed in subsection (a) of this section and care coordination, billing and compliance, and workforce supervision.

§ 90‑178.19.  Doula workforce sustainability.

The State recognizes doulas as essential members of the maternal health workforce and shall (i) establish fair reimbursement and prompt payment standards, (ii) fund doula support hubs and mentorship programs, (iii) provide operational grants to maternal health community‑based organizations, and (iv) conduct regional workforce assessments. Doula labor shall not be premised upon unpaid or volunteer models.

SECTION 1.(b)  G.S. 58‑3‑170 reads as rewritten:

§ 58‑3‑170.  Requirements for maternity coverage.

…

(c)        A health benefit plan that provides coverage for any maternity care provided by a Certified Nurse Midwife licensed under Article 10A of Chapter 90 of the General Statutes shall reimburse at the same rate, subject to the same coverage terms, equivalent services provided by a perinatal health care provider licensed under Article 10C of Chapter 90 of the General Statutes and subject to Article 10B of Chapter 90 of the General Statutes.

SECTION 1.(c)  Subsection (b) of this section is effective October 1, 2026, and applies to insurance contracts entered into, renewed, or amended on or after that date.

SECTION 1.(d)  Reimbursement Parity for Medicaid. – The Department of Health and Human Services, Division of Health Benefits (DHB), shall take all necessary actions, including any changes to applicable clinical coverage policies, to ensure that Medicaid maternity care services provided by a Certified Nurse Midwife licensed under Article 10A of Chapter 90 of the General Statutes are reimbursed at the same rate and subject to the same coverage terms as equivalent Medicaid maternity care services provided by a perinatal health care provider licensed under Article 10C of Chapter 90 of the General Statutes, as enacted by Section 2 of this act.

SECTION 1.(e)  Subsection (d) of this section is effective October 1, 2026.

SECTION 2.  Chapter 90 of the General Statutes is amended by adding a new Article to read:

Article 10C.

Certified Professional Midwives and Certified Midwives.

§ 90‑178.25.  Title.

This Article may be cited as the Accessing Midwives Act.

§ 90‑178.26.  Definitions.

The following definitions apply in this Article:

(1)        Antepartal. – Occurring during pregnancy.

(2)        Certified Midwife (CM). – A person who has obtained national certification from the American Midwifery Certification Board (AMCB).

(3)        Certified Professional Midwife (CPM). – A person who has obtained national certification from the North American Registry of Midwives (NARM).

(4)        Collaboration. – The process by which a Certified Professional Midwife and a physician or other appropriate health care provider jointly manage the care of a client, as defined by Council rule.

(5)        Consultation. – The exchange of information and advice regarding the client's condition and indicated treatment with a licensed physician or Certified Nurse Midwife.

(6)        Council. – The North Carolina Council of Certified Professional Midwives, a subcommittee of the Division of Health Service Regulation.

(7)        Department. – The North Carolina Department of Health and Human Services.

(8)        Division. – The Division of Health Service Regulation within the Department of Health and Human Services to which the North Carolina Council of Certified Professional Midwives reports.

(9)        Health care provider. – As defined in G.S. 90‑21.11.

(10)      ICM. – The International Confederation of Midwives.

(11)      Intrapartal. – Occurring during the process of giving birth.

(12)      Licensed physician. – A physician duly licensed in this State to practice medicine under Article 1 of this Chapter.

(13)      Licensee. – A Certified Professional Midwife who holds the CPM credential or a Certified Midwife who holds the CM credential and is licensed to practice midwifery under this Article.

(14)      Midwifery. – The provision of primary health or maternity care to childbearing people and infants.

(15)      NACPM. – The National Association of Certified Professional Midwives.

(16)      NARM. – The North American Registry of Midwives.

(17)      Postpartal. – Occurring subsequent to birth.

§ 90‑178.27.  License required; exemptions.

(a)        No person shall practice or offer to practice midwifery, as defined in this Article, or otherwise indicate or imply that the person is a licensed Certified Professional Midwife or Certified Midwife unless the person is currently licensed as provided in this Article.

(b)        The provisions of this Article do not apply to any of the following:

(1)        An individual approved to practice as a Certified Nurse Midwife under Article 10A of this Chapter.

(2)        A physician licensed to practice medicine under Article 1 of this Chapter when engaged in the practice of medicine as defined by law.

(3)        The performance of medical acts by a physician assistant or nurse practitioner when performed in accordance with the rules of the North Carolina Board of Nursing and the North Carolina Medical Board.

(4)        The practice of nursing by a registered nurse engaged in the practice of nursing under Article 9A of this Chapter.

(5)        The rendering of childbirth assistance in an emergency situation.

§ 90‑178.28.  The North Carolina Council of Certified Professional Midwives.

(a)        Composition and Terms. – The North Carolina Council of Certified Professional Midwives is created. The Council shall consist of seven members who shall serve staggered terms. The Council members shall be appointed by the Secretary of the Department of Health and Human Services, and the initial Council members shall be appointed on or before October 1, 2026, or within three months of this Article becoming law, whichever is later, as follows:

(1)        Four Certified Professional Midwives or Certified Midwives, one of whom shall serve for a term of four years, two of whom shall serve for terms of three years, and one of whom shall serve for a term of two years.

(2)        One licensed physician who is knowledgeable in midwifery care who shall serve for a term of four years.

(3)        Two community birth consumers who shall serve for a term of two years.

Upon the expiration of the terms of the initial Council members, members shall be appointed for terms of four years and shall serve until their successors are appointed. No member may serve more than two consecutive terms.

(b)        Qualifications. – Each Council member shall be a resident of this State. The members who are Certified Professional Midwives or Certified Midwives shall hold current licenses from the Council and remain in good standing with the Council during their terms.

(c)        Vacancies. – Any vacancy shall be filled by the Secretary of the Department of Health and Human Services. Appointees to fill vacancies shall serve the remainder of the unexpired term and until their successors have been duly appointed.

(d)       Removal. – The Council may remove any of its members for neglect of duty, incompetence, or unprofessional conduct. If a Council member is absent from three consecutive Council meetings without excuse, that member shall be removed from office and a new member shall be appointed by the Secretary of the Department of Health and Human Services. An absence shall be deemed excused if caused (i) by a health problem or condition verified in writing by a licensed health care provider or (ii) by an accident or similar unforeseeable tragedy or event, on or before the next Council meeting. A member subject to disciplinary proceedings in the member's capacity as a health care provider shall be disqualified from participating in the official business of the Council until the charges have been resolved.

(e)        Compensation. – Each member of the Council shall receive per diem and reimbursement for travel and subsistence as provided in G.S. 93B‑5.

(f)        Officers. – The officers of the Council shall be a chair, a vice‑chair, and other officers deemed necessary by the Council to carry out the purposes of this Article. All officers shall be elected annually by the Council for two‑year terms and shall serve until their successors are elected and qualified. No person may serve as chair for more than six consecutive years.

(g)        Meetings. – The Council shall hold its first meeting within 45 days after the appointment of its members and shall hold at least two meetings each year to conduct business and to review the standards and rules previously adopted by the Council. The Council shall establish the procedures for calling, holding, and conducting regular and special meetings. A majority of Council members shall constitute a quorum. The Council shall hold such meetings during the year as it deems necessary, one of which shall be an annual meeting. The Department, the chairperson, or a majority of the Council shall have the authority to call additional meetings.

(h)        Notice of Meeting; Records. – Public notice shall be given for all meetings, and all meetings are open to the public. All records are available to the public. Persons wishing to obtain copies of records may request copies, in writing, from the Council.

(i)         Rulemaking. – The Council shall adopt rules within one year of the initial meeting to implement the provisions of this Article.

§ 90‑178.29.  Powers and duties of the Council.

In consultation with the Division and with guidance from the National Association of Certified Professional Midwives Standards of Practice and standards of practice adopted by the Council for Certified Midwives, the Council shall have the following powers and duties:

(1)        Administer this Article.

(2)        Issue interpretations of this Article.

(3)        Adopt, amend, or repeal rules as may be necessary to carry out the provisions of this Article, including rules relating to the administration of medications consistent with a Certified Professional Midwife's or Certified Midwife's training and scope of practice.

(4)        Verify the credentials and qualifications of applicants for licensure, license renewal, and reciprocal licensure.

(5)        Issue, renew, deny, suspend, or revoke licensure and carry out any disciplinary actions authorized by this Article.

(6)        Set fees for licensure, license renewal, and other services deemed necessary to carry out the purposes of this Article, not to exceed five hundred dollars ($500.00) over a two‑year period.

(7)        Maintain a current list of all persons who have been licensed as Certified Professional Midwives or Certified Midwives under this Article and, using a statistically validated data collection tool, collect and review annual practice reports.

(8)        Address problems and concerns of Certified Professional Midwives or Certified Midwives in order to promote safety for the citizens of this State.

(9)        Conduct investigations for the purpose of determining whether violations of this Article or grounds for disciplining Certified Professional Midwives or Certified Midwives exist.

(10)      Maintain a record of all proceedings and make available to all Certified Professional Midwives and Certified Midwives and other concerned parties an annual report of all Council action.

(11)      Adopt a seal containing the name of the Council for use on all official documents and reports issued by the Council.

(12)      Educate the public and other providers of maternity care about the role of the Certified Professional Midwives and Certified Midwives.

§ 90‑178.30.  Requirements for licensure.

An applicant shall be licensed to practice as a Certified Professional Midwife or Certified Midwife under this Article if the applicant meets all of the following requirements:

(1)        Completes an application on a form approved by the Council.

(2)        Has completed all required educational and clinical training, including education in emergency skills for pregnancy, birth, and newborn care and other midwifery topics addressing all ICM Core Competencies, as determined by NACPM or NARM, and has earned the national Certified Professional Midwife certification credential awarded by a national midwifery certification agency accredited by the National Commission on Certifying Agencies (NCCA), the accrediting body of the Institute of Credentialing Excellence.

(3)        Submits proof to the Council of current cardiopulmonary resuscitation (CPR) certification and neonatal resuscitation program (NRP) certification.

(4)        Has read, understands, and agrees to practice under the guidelines set forth in this Article and any rules adopted pursuant to this Article.

(5)        Pays the required fees in accordance with G.S. 90‑178.34.

§ 90‑178.31.  Responsibilities of a Certified Professional Midwife; display of license.

(a)        A Certified Professional Midwife or Certified Midwife licensed under this Article shall practice according to the National Association of Certified Professional Midwives (NACPM) Standards of Practice or the standards of practice adopted by the Council for Certified Midwives, as applicable, and shall have the following responsibilities:

(1)        Provide care for the healthy client who is expected to have a normal pregnancy, labor, birth, and postpartal phase in the setting of their choice.

(2)        Ensure that the client has signed an informed consent form. This form shall include information to inform the client of the qualifications of the licensee and the process of shared decision making and refusal.

(3)        Order routine antepartal or postpartal screening or laboratory analysis to be performed by a licensed laboratory or testing facility, when necessary.

(4)        Develop an emergency plan in collaboration with the client that shall include transfer plans for the client in the event of an emergency.

(5)        Determine the progress of labor, monitor fetal and maternal status, and when labor is well‑established, be available until delivery is accomplished.

(6)        Remain with the mother during the postpartal period until the conditions of the mother and newborn are stabilized.

(7)        Instruct the parents regarding the requirements of all State‑required newborn screening.

(8)        Submit and maintain a birth certificate of live birth in accordance with the requirements of Article 4 of Chapter 130A of the General Statutes.

(9)        Practice in compliance with the requirements of this Article and any rules adopted pursuant to this Article.

(b)        A licensee licensed pursuant to this Article shall display the license at all times in a conspicuous place where the licensee is practicing, when applicable.

§ 90‑178.32.  License renewal; inactive status; lapsed license.

(a)        An initial license to practice shall be valid for two years. After the initial license expires, a license shall be renewed every two years. All applications for renewal shall be filed with the Council and shall be accompanied by the renewal fee in accordance with G.S. 90‑178.34 and proof of current certification from NARM. Compliance with NARM recertification requirements shall include (i) remaining in good standing with NARM, (ii) maintaining current cardiopulmonary resuscitation (CPR) and neonatal resuscitation program (NRP) certifications, and (iii) completing any continuing education requirements.

(b)        A license that has expired for failure to renew may be reinstated after the applicant pays any late and renewal fees as required by G.S. 90‑178.34 and complies with any other rules adopted pursuant to this Article.

(c)        Upon written request to the Council, the Council may grant a Certified Professional Midwife or Certified Midwife inactive status. While inactive, the licensee shall not practice midwifery in this State and shall not be subject to license renewal requirements established by the Council. A licensee may change the licensee's status from inactive to active by (i) submitting a written request to the Council and (ii) fulfilling the requirements for renewal described under subsection (a) of this section.

(d)       A licensee who does not seek inactive status and allows the license to expire after a 90‑day grace period shall apply for a new license as prescribed in this Article.

§ 90‑178.33.  Reciprocity.

The Council may, upon application and payment of proper fees, grant a license to an individual who resides in this State and has been licensed, certified, or registered to practice as a licensee in another jurisdiction if that jurisdiction's standards of competency are substantially equivalent to those provided in this Article in accordance with rules adopted by the Council.

§ 90‑178.34.  Fees.

(a)        All fees shall be set by the Council, in consultation with the Division, pursuant to rules adopted under this Article. All fees payable to the Council shall be deposited in the name of the Council in financial institutions designated by the Council as official depositories and shall be used to pay all expenses incurred in carrying out the purposes of this Article.

(b)        All salaries, compensation, and expenses incurred or allowed to carry out the purposes of this Article shall be paid by the Council exclusively out of the fees received by the Council as authorized by this Article or funds received from other sources.

§ 90‑178.35.  Midwifery formulary.

The Council shall establish a formulary of drugs and devices that are appropriate to Certified Professional Midwife care. Certified Professional Midwives shall dispense only those drugs and devices in accordance with the current formulary defined by the Council. Certified Professional Midwives shall comply with applicable State and federal laws and rules relating to administering of drugs. Certified Professional Midwives shall maintain proper records of obtaining, storing, and administering drugs and devices. Nothing in this section shall be construed to preclude a midwife from carrying out the prescribed medical orders of a licensed health care provider authorized to prescribe.

§ 90‑178.36.  Suspension, revocation, and refusal to renew license.

(a)        The Council may issue a letter of reprimand, deny, refuse to renew, suspend, or revoke an application for licensure or a license if the applicant or licensee does any of the following:

(1)        Gives false information or withholds material information from the Council in procuring or attempting to procure a license.

(2)        Gives false information or withholds material information from the Council during the course of an investigation conducted by the Council.

(3)        Has been convicted of or pled guilty or no contest to a crime that indicates the person is unfit or incompetent to practice midwifery, as defined in this Article, or that indicates the person has deceived, defrauded, or endangered the public.

(4)        Has a habitual substance abuse problem or mental impairment that interferes with his or her ability to provide appropriate care as established by this Article or rules adopted by the Council.

(5)        Has demonstrated gross negligence, incompetency, or misconduct in the practice of midwifery, as defined in this Article.

(6)        Has had an application for licensure or a license to practice midwifery as a Certified Professional Midwife or Certified Midwife in another jurisdiction denied, suspended, or revoked for reasons that would be grounds for similar action in this State.

(7)        Has willfully violated any provision of this Article or rules adopted by the Council.

(b)        The taking of any action authorized under subsection (a) of this section may be ordered by the Council after a hearing is held in accordance with Article 3A of Chapter 150B of the General Statutes. The Council may reinstate a revoked license if it finds that the reasons for revocation no longer exist and that the person can reasonably be expected to perform the services authorized under this Article in a safe manner.

§ 90‑178.37.  Enjoining illegal practices; vicarious liability.

(a)        The Council may apply to the superior court for an order enjoining violations of this Article. Upon a showing by the Council that any person has violated this Article, the court may grant injunctive relief.

(b)        No health care provider or medical facility shall be liable for an injury to a woman or infant arising during childbirth and resulting from an act or omission by a Certified Professional Midwife or Certified Midwife licensed under this Article, regardless of whether the health care provider has consulted with or accepted a referral from the licensee.

SECTION 3.  Except as otherwise provided, this act becomes effective October 1, 2026.