Nationally, only a small portion of women give birth outside of hospitals (around 1%) and very few of those women are low-income. In a recent piece for RH Reality Check, The Cost of Being Born at Home, I painted a grim picture of the options afforded to low-income women around the country who are considering out-of-hospital birth. Few out-of-hospital childbirth providers are registered with Medicaid. Cost and physical space available at women's homes are also significant prohibiting factors. And lack of knowledge of the practice, as well as lack of targeting from media and advocacy promoting home birth (such as the pro-home birth film The Business of Being Born), impact low-income women's decisions about where to birth.
But there's at least one exception to this national trend, brought up by the advocates I interviewed and by commenters responding to my original piece-Washington State. In fact, thanks to a history of expansive access to midwifery care and a number of big legislative gains, low-income women in Washington State now have more birthing options than most women around the country.
According to Audrey Levine, President of the Midwives Association of Washington State (MAWS), 2.3% of births statewide in 2007 were performed out-of-hospital. While still a low percentage, that's more than twice the national average of 1%. What is even more impressive is the number of those births that are reimbursed by Medicaid. According to Levine, around 45% of out-of-hospital births attended by midwives in the state are Medicaid births. That mirrors the percentage of births to women on Medicaid overall in the state-also around 46-47%. (Of the 26 states that license CPMs, only 9 allow CPMs to participate in Medicaid, so this percentage is a significant departure from the situation nationally.)
Washington State has long been at the forefront of the midwifery movement, which helps explain some of the huge leaps forward they've made in access to midwifery care. In the early 1970s, Seattle Midwifery School co-founder Suzy Myers was already practicing midwifery in Washington. She and a group of midwives were training by apprenticeship and getting clients by word of mouth in conjunction with a feminist health center in Seattle. This was not uncommon around the US, and there is a history of midwives practicing in similar fashion, quietly and under the radar. The legal status of their practices has been debated in the courts, with the overall conclusion that unless a state has a specific law on the books licensing midwives, midwives are practicing advanced nursing without a license. In the 1970s, however, this was unclear to many midwives and advocates, a number of whom believed that since midwives were not mentioned in the law in many states, they could practice as they saw fit. Some also chose to practice regardless of their legal status.
In the mid-70s, Myers and her cohort of midwives were approached by the Department of Licensing (DOL, now the Department of Health) about their practice. "We were asked to explain our illegal midwifery practice. We went to that meeting with the director of DOL and a representative of the Attorney General," Myers remembers. "We were expecting to be reprimanded and what we found instead was Roz Woodhouse, the only African American woman to be appointed a cabinet position in Washington State. The first thing she said was ‘How can I help you?'"
From that meeting, the midwives learned that there was already a law on the books in Washington that would allow them to practice midwifery with a license - all they needed was a degree from an accredited school in good standing. The law dated back to 1918, and according to Myers, was probably written to accommodate foreign-trained midwives coming to work in Japanese immigrant communities in the state.
So began the Seattle Midwifery School (SMS), co-founded by Myers and Marge Mansfield, which just celebrated its thirtieth anniversary last year. SMS trains direct-entry midwives who can practice in a number of states, depending on the licensing there. Direct-entry midwives are not nurses (the other main path to practicing midwifery in the US is as a Certified Nurse Midwife-CNM) and instead train in independent schools that develop their own curricula which are accredited by a national accrediting body, through the Midwifery Accreditation Advisory Council.
The founding of the school provided a mechanism for licensing midwives with the state. Licensing is an important step, because not only does licensure often legalize midwives' practice, it also opens up the possibility of inclusion in insurance coverage. According to Myers, Medicaid coverage had technically always been an option for midwives, but was blocked by the qualification that the birth had to take place in a licensed facility. By the 1990s legislation was passed providing that all births in Washington state, regardless of location or provider, could be covered by all insurance policies based in the state, including Medicaid.
What doesn't seem to be so different in Washington State are the demographics of the women having out-of-hospital births. Michelle Sarju, the first African-American midwife to graduate from the Seattle Midwifery School and Clinical Director at Open Arms Perinatal Services, explained that women of color are still only a small portion of her clients. "The majority of my Medicaid clients were white women who were educated. [Out-of-hospital birth] is accessible-the question is do women know about it."
Other advocates in the state readily admit this shortcoming, and point to a lack of diversity among midwives as a part of the problem. Myers, the current Midwifery Education Chair at SMS, addresses this through her work in midwifery education: "I'm trying to do everything I can to make midwifery education accessible to women from underserved communities. The best thing is to make our midwifery profession reflect the women. It doesn't right now. We don't have enough women of color in the profession."
According to Sarju, some of the same social barriers that were mentioned by midwives and doulas in my original article hold true in Washington as well. "Women of color don't know about midwives," she reiterated. "And what they do know doesn't lead them to make that decision." Sheila Capestany, a doula and home birth mom explained, "There are some cultural beliefs about home birth, [and] hospital care is equated with the gold standard of care." Despite the fact that out-of-hospital birth is more common, there are still knowledge gaps in particular communities about birth options. "There is a lot of misinformation about midwifery care," Capestany emphasized. "I had my babies out of hospital - a lot of people asked me if it was legal." The potential for this to change, however, seems ripe, as shown by Sarju's experience with the newer immigrant communities. One of her clients, a Somali woman, recently discovered that home birth was an option in Washington. "Now that she is choosing an out of hospital birth, it's spreading like wildfire," Sarju explained.
The best news for advocates of the midwifery model of care is the recent data coming from Washington State about the cost benefits of out-of-hospital birth. According to the Midwives Association of Washington State, "Washington Department of Health cost benefit analysis showed that licensed midwifery care saves the state $3.1 million per biennium in cost-offsets to Medicaid when low-risk women give birth with licensed midwives instead of in the hospital." This is probably the most compelling argument for promoting licensed midwifery practice and inclusion of LMs in public and private insurance policies. Legislators are beginning to hear this message as well, and not just in Washington State. Three weeks ago, Idaho became the 26th state to pass legislation licensing Certified Professional Midwives, and other states are considering similar legislation. The proof, however, is in the budget negotiations from this past session. Levine explained, "When we went to the legislature this year, and even though so many services are being cut, we hung on because licensed midwifery is a bargain." In a climate where cost-cutting is a top health care reform priority, this may prove the right moment for expansion of midwifery care nationwide.
Join us on Thursday, May 14th at 9am Eastern/12 noon Pacific for Making "My Birth, My Choice" A Reality For All Women - a livechat with Miriam Perez and JayVon Muhammad, certified professional midwife. Join in on a fascinating, in depth discussion about the reality of access to homebirth in the United States for all women! Ask your questions about or share your experiences with out-of-hospital birthing, midwifery and doula services for all women regardless of income level. Visit the site on Thursday, May 14th at 9am Eastern and join the conversation!
