The Midwives Association of Washington State (MAWS) was officially founded in 1983, but the story of midwives in Washington state and the midwifery movement begin long before that date. For a complete history including the role of MAWS in shaping that history, visit the following links:
- Midwifery Licensure
- Midwifery Education
- Access to Midwifery Care
- Managed-care plans
- Increasing Access to Midwifery
- Midwife-Physician Relations
- Professional Liability
- Quality Assurance
Washington State has a particularly strong history of supporting the development of the direct-entry midwifery profession as well as choice and access to care for childbearing women. The original statute regulating direct-entry midwifery was adopted in 1917 and required two years of schooling. There were no in-state training programs at that time, and most midwives were foreign-trained professionals who had immigrated to Washington from Asia and Europe. The Japanese-American midwives were particularly well-organized, serving large communities in Seattle and Tacoma and maintaining their own professional association.
However, the number of midwives in practice declined into the 1940s as birth moved into the hospital. In addition, the remaining Japanese-American midwives were removed during the Second World War with other Japanese-Americans to internment camps, where they were not allowed to practice midwifery. 1
The Resurgence of the Midwifery Movement in the ’70s
The midwifery licensing law was dormant until rediscovered in the mid-1970s with the onset of the home birth movement. Amid much controversy, the state legislature commissioned a study to determine whether or not the law should be repealed. 2 Based on the study findings, the legislature revised the statute in 1981 to incorporate contemporary international standards for midwifery education and practice. The education requirement was increased from two to three years, specific curriculum requirements were listed, the number of required birth experiences was increased, and a formulary of drugs and devices that midwives could obtain and administer was established.
In 1986, the midwifery licensing law was scheduled for sunset review. This time, both the Senate and the House of Representatives passed the law unanimously! There was one point of disagreement between the two bodies, however:
- State officials argued that the gratuitous services clause in the law should be removed in order to close a loophole that allowed birth attendance by anyone who didn’t hold themselves out as a midwife, and didn’t charge for their services; whereas
- Representatives of the Midwives’ Association of Washington State argued that removing the clause would jeopardize access to care in areas not served by LMs, and should remain until such time as education and licensure were more widely accessible.
This disagreement resulted in a last-minute addition to the law that allowed for a challenge mechanism to the education requirements. A committee appointed by the regulatory agency worked for several years to develop a mechanism that would assure educational equivalency, but the program was never implemented due to lack of funding. Since the mid-1990s, midwives who have not completed Washington State-approved programs have sought licensure through the challenge mechanism. With the establishment of the Certified Professional Midwife credential by the North American Registry of Midwives, the Midwives’ Association of Washington State saw an opportunity to create a systematic, consistent process for the review of licensing applications received from midwives who have not completed educational programs approved by Washington State based on the national competency-based standards for national certification. Several attempts have been made over the years to move that idea forward, but financial constraints in the regulatory agency, turnover in the advisory committee, and shifting priorities in the state association have hindered progress.
While the old midwifery law was still in place, state officials encouraged a group of lay midwives associated with the Fremont Women’s Clinic in Seattle to develop their study group into a school so that they could meet the requirements for licensure. The Seattle Midwifery School was subsequently founded in 1978 and approved by the state that year, with the first graduates licensed in 1979. Graduates and faculty of the Seattle Midwifery School have played significant roles in the national midwifery movement, serving as officers and board members of MANA, NARM, MEAC, and NACPM.
The next midwifery program was approved by the state in 1984. Located at Bastyr Naturopathic College, the program was designed exclusively for naturopathic students and physicians. This followed an earlier court ruling that the scope of practice of naturopathic physicians in Washington State did not include attending births, and that they would need to be licensed as midwives if they chose to do so.
In 2010, Seattle Midwifery School merged with Bastyr University to become the new Department of Midwifery in Bastyr’s College of Natural Health Arts and Sciences, and Bastyr announced its plan to bring the naturopathic midwifery program to a close. The only Washington-based midwifery education program is also the first direct-entry midwifery program to offer a master’s degree in a regionally accredited university.
Washington state law requires Licensed Midwives (LMs) to complete 3 years in a state-approved midwifery educational program, which includes participation in 100 or more births and verification of clinical skills and didactic course work. To attain licensure, all LMs must pass a national and a state examination. Midwives who did not attend a state-approved school are able to apply for licensure through a Challenge Process Mechanism through which they demonstrate that they have met “equal requirements.”
ACCESS TO MIDWIFERY CARE
The number of LMs and the percentage of midwife-attended births have both grown steadily over the years. There are now approximately 110 licensed midwives in Washington State, and in 2009 they attended 2,130 births (2.5% of all births in the state). Six counties have reported 5% or more of all births as being attended by LMs. 3
The Washington Department of Social and Health Services made the first official recommendation to increase utilization of midwives in state maternity care in 1988. The following year, the legislature added midwifery students to the state’s health professional scholarship program, and midwives were later included in the health professional loan repayment program. Scholarship recipients, who must commit to work in work in health professional shortage areas, have set up new practices and found employment in agencies that serve childbearing families. Midwives who participate in the loan repayment program are employed in qualified midwifery practices or birth centers that provide care in under-served areas.
The Washington State Medicaid program recognized licensed midwives as qualified providers in the early 1980s, but reimbursed only for prenatal and postpartum care given that Medicaid did cover home births or births in unlicensed facilities; after the birth-center licensing law was adopted in 1986, Medicaid added reimbursement for deliveries that occurred in birth centers. After years of consumer and professional pressure to expand coverage, a task force was appointed by the Department of Social and Health Services that ultimately recommended that Medicaid policies be changed to cover home birth services. A pilot project was started in 1999 and the results were so positive that the project was ended and reimbursement fully implemented.
In 1993, responding to public demand for healthcare reform, the legislature adopted a number of laws affecting the delivery of health services. Certain insurance carriers were required to provide for the inclusion of every category of licensed health professional, a mandate that includes LMs (who are considered to constitute a different category than CNMs). 4 The state insurance commissioner committed resources to assure access to the full range of healthcare services by addressing barriers to integrating every category of provider into all health plans in the state. To support insurer compliance with the law, the Insurance Commissioner invited representatives of health plans to join LMs and other healthcare providers in a Clinician Workgroup on the Integration of Complementary Medicine. The workgroup’s report was another landmark document that has been useful in establishing better communication and awareness. 5
During this same period, managed-care plans were gaining market share rapidly in the state, and Medicaid began contracting with managed-care plans for the provision of services to low-income women. Since managed-care plans typically limit the providers allowed in their networks to those with professional liability insurance, there was a real possibility that LMs who didn’t have access to insurance would be excluded from third-party payment. To address this problem, in 1993 legislation was passed to create a Joint Underwriting Association (JUA) that required all liability carriers in the state to participate in underwriting professional liability insurance for LM, CNMs and licensed birth centers. 6
Another helpful product of the health reform efforts was the publication of a comprehensive State Health Personnel Resource Plan in 1994. LMs were recognized in the plan as primary care providers for maternity care, and once again there was a recommendation to increase their utilization. 7
Finally, in 2000, the legislature took one additional step to assure that women could access midwifery care: it added licensed midwives to a Washington State law that requires private health insurers to provide direct access to health-care services for women. Women must also be allowed to choose from a network of healthcare providers, including LMs, without first having to visit a primary care doctor.
In a 1998 survey of all LMs residing in Washington State, 65% of the respondents were in clinical midwifery practice and 23% were doing related work in public health departments, physician’s offices, community clinics, or family planning organizations. The midwives reported receiving payment from all sources, including self-pay, fee-for-service insurance plans, preferred provider and managed-care organizations, and Medicaid (both fee-for-service and managed care). Most midwives reported having one or more managed-care plan contracts. The median number of contracts was three per midwife. Managed care plans, including those covering Medicaid-eligible women, accounted for 37% of all payment received. Medicaid, covering clients enrolled in managed-care plans and those in the fee-for-service group, accounted for 34% of all payment received. In a follow-up survey done in 2004, the median number of contracts reported was seven per midwife. Managed-care plans, including those covering Medicaid-eligible women, had grown to 63% of all payment received. Meanwhile, Medicaid, covering both clients enrolled in managed-care plans and those in the fee-for-service group, had expanded to 41% of all payment received. 8
Group Health Cooperative of Puget Sound was one of the first managed-care plans in Washington State to recognize the potential benefit of providing home birth and direct- entry midwifery services. Group Health has contracted with licensed midwives since 1996 to make home birth services available to all plan members. The Group Health Cooperative’s involvement with direct-entry midwives followed a 1995 survey in which they found that 8% of their members were interested in the idea of a midwife- attended home birth, and might use such a service if Group Health would provide the same benefits for a home birth that it provides for an in-hospital birth. An internal task force determined that licensed midwives were best qualified to provide home birth services and developed a framework to support integrating them into the co-op. Group Health enrollees may self-refer to a licensed midwife. The midwife provides all prenatal, labor, birth, and newborn postpartum care, and consults with Group Health physicians and nurse- midwives as needed. When home- or birth-center-to-hospital transports are indicated, they are accepted within the context of the whole system of care. CNMs employed by Group Health may also be involved in the care of women who are transferred to a Group Health Hospital from a home birth. Unfortunately, despite their early decision to include LMs, Group Health has not entered into any new contracts with midwives for many years.
INCREASING ACCESS TO MIDWIFERY
Midwives have developed a variety of strategies for increasing or improving access to their services. Certainly, the establishment of licensed birth centers has contributed to the growth in out- of-hospital birth across the state. Most owners of birth centers have created mechanisms for granting privileges to midwives who meet their criteria, thereby extending access to the facility to a broader array of practitioners. Many midwives also engage private billing services to assist with health plan contracts, claims processing, etc.
Because the midwifery profession is still relatively small in Washington State, the costs of the licensure program have been a matter of debate for many years. In 2007, the legislature commissioned a cost–benefit analysis from the Department of Health on licensed midwifery. This independent analysis found that licensed midwives directly save the state at least $473,000 per biennium in cost offsets to Medicaid when women give birth at home or in free- standing birth centers. This was a very conservative estimate considering that the figures reflect only avoided costs associated with licensed midwives’ lower Cesarean-section rates. When facility fees and other medical procedures — such as epidurals and continuous electronic fetal monitoring — are factored into the equation, the actual savings to Medicaid jumps to approximately $3.1 million per biennium. These savings occurred during a period when licensed midwives attended fewer than 2% of the births in the state. 9
With utilization and outcome data in hand, and now these cost-savings reports, the Chief Medical Officer of the Washington State Medicaid Program has taken a public stance in support of expanding the role of licensed midwives in the provision of care to women on Medicaid. He has acknowledged the significant role that licensed midwives can play in reducing the C-section rate.
LMs in Washington State have a duty to consult with licensed allopathic or osteopathic physicians whenever there are significant deviations from normal in either the mother or the infant; this is a requirement carried forward from the original 1917 licensing law that did not define or specify what conditions might be considered significant deviations from normal. When the law was revised in 1981, the Legislature, recognizing midwives as autonomous, well-educated professionals who could meet international standards for education and practice, determined that it was not necessary to provide any more specific guidelines. Washington’s position was unusual during that time period, as most states that regulated midwifery did not require formal education but clearly limited whom midwives could care for and/or specified in detail when midwives must consult or refer care. The dynamic relationship between educational requirements, autonomy, and scope of practice was explored at length in the legislative study completed in 1980, and is still a useful resource to those interested in this subject. 10
Preserving the autonomy of midwifes and avoiding legally defined limitations on the scope of practice while promoting safety and accountability, has been a priority of the Midwives’ Association of Washington State ever since. In the 1990s, as LMs were gaining ground and getting the attention of policy-makers concerned about improving access to care, the state medical association started raising concerns about the quality of care provided by midwives while objecting to the undefined scope of practice. For several years, the medical association argued in the legislature that midwives should be supervised by physicians and their practices limited, while MAWS successfully defended the opposing position. Tired of the inter-professional turf battle, the legislature asked representatives of the professional organizations to resolve their differences outside of the legislative arena. Beginning in 1995, the Midwives’ Association of Washington State, Washington State Medical Association, and Washington Obstetrical Society have held a series of meetings to exchange information, identify problem areas, and develop mutually acceptable guidelines for consultation and referral. MAWS conducted a thorough review of the best available evidence and gathered examples of guidelines from other states and countries to present at these meetings, and subsequently drafted a document titled “Practice Guidelines for Risk Screening and Indications for Consultation and Referral.” While the document never received endorsement from the physician organizations, the series of meetings did serve to address some of the previous misunderstandings.
Many LMs enjoyed very positive consulting relationships with physicians during this period. Some well-established practices had developed long-term relationships with physicians and could call on them as needed. On the other hand, physicians in some communities remained adamantly opposed to midwifery and out-of-hospital birth, and midwives found it extremely difficult to obtain the necessary consultation services. The situation began to worsen across the state for all midwives as new liability concerns among physicians and hospitals grew in the early 2000s. Not only was consultation more difficult, but transferring care to a hospital during labor was increasingly problematic.
The Midwives’ Association of Washington State, determined to frame this as a health system problem, brought the issue to the attention of the Washington State Department of Health Perinatal Advisory Committee. The committee agreed, and in 2004 it appointed a task force to study and improve the process of transferring women and their babies from a planned out-of-hospital birthing location to an acute-care hospital when a higher level of care became necessary. (The task force is a cooperative effort of obstetrician–gynecologist physician leaders and licensed midwifery leaders, as well as those with expertise in public health and policy.) The licensed midwife members, working with MAWS, developed a document titled “Planned Out-Of-Hospital Birth Transport Guidelines.” These guidelines have been reviewed and approved by members of the Statewide Perinatal Advisory Committee, the Midwives’ Association of Washington State, and the Physician-Licensed Midwife Work Group.
Since developing transport guidelines, the Physician-Licensed Midwife Work Group has concentrated its efforts on developing a quality improvement project, The Planned Out-of-Hospital Birth Transfer Quality Improvement Project. The goal of the project is to facilitate communication between midwives and hospitals in order to improve care in the event of a transfer. In some parts of the state, midwives and physicians have begun to meet and discuss implementation. Several hospitals have been identified as locations at which to begin piloting this important work. To read more about Smooth Transitions: Enhancing the Safety of Planned Out-of-Hospital Birth Transports - A Quality Improvement Initiative of the Washington State Perinatal Collaborative, Download a PDF of the Project Manual here.
Smooth Transitions: Enhancing the Safety of Planned Out-of-Hospital Birth Transports - A Quality Improvement Initiative of the Washington State Perinatal Collaborative. Download PDF.
In 1993, the legislature created a Joint Underwriting Association (JUA), requiring participation by all liability carriers in the state, to assure that LMs, CNMs and licensed birth centers could purchase malpractice insurance. 11 The board of directors of the JUA is made up of LMs and representatives from the participating insurance companies. They undertake a variety of duties:
- determine assessments;
- discuss current issues facing midwifery;
- discuss pending claims and vote on settlement offers;
- determine the rate-change proposal to file with Office of Insurance Commissioner; and
- discuss results of Professional Liability Reviews.
An administrative service (hired by the JUA) carries out the day-to-day functions, including selling the policies, providing risk-management services, and assisting midwives through the claims process when sued. 12 MAWS laid the initial groundwork for a quality assurance mechanism that was further developed by a midwife-owned private company that now provides risk-management services through contracts with the JUA. The Practice Liability Reviews (PLR) process is a central part of the risk management program mandated by the JUA statute. The review includes a self-report of practice statistics, a site visit with chart review, and evaluation of informed consents and other practice documents. 13 Professional liability insurance has opened doors for midwives who want to make their services available through private insurance plans, and is valued by many because it protects personal assets in the event of a malpractice suit. At the same time, there is the added expense of premiums and certain restrictions that apply in terms of what is covered by the insurance.
MAWS first created a quality assurance program in the 1980s in collaboration with the state chapter of the American College of Nurse-Midwives. This program included a practice review component that involved teams of midwives visiting each other’s practices, with everyone taking a turn as reviewers. The model fostered mutual understanding and support among both types of midwives and across practice settings. Unfortunately, as malpractice concerns starting heating up in the late 1980s, the organizations were advised to end the reviews out of concern that their observations were “discoverable,” i.e., midwives could be called to testify against each other on the basis of the reviews, whereas hospital-based case reviews were protected.
Once again, as part of the health reform legislation passed in the 1990s, the state allowed other facilities and organizations to create protected quality assurance programs, provided they met certain requirements for consistency, fairness, and so on. In 2004, the Quality Improvement Program (QIP) administered by MAWS was approved by the Washington State Office of Quality Assurance. 14 The QIP is now referred to as the Quality Management Program (QMP). The QMP includes both peer review and incident review mechanisms, and participation is required for membership in the association. MAWS core documents, including the “Guidelines for Consultation and Referral,” are primary references, along with other current evidence used in reviewing cases. The QMP, developed and administered by the midwifery profession, has been an important defense in maintaining professional autonomy and accountability against those who would argue that the state or other professionals should have more control over midwifery practice. In 2011, the MAWS Quality Management Program was presented as a model at a session during the 2011 International Confederation of Midwives Congress in Durban, South Africa by midwife researcher Karen Hays, CNM, PhD.
You can also read the "History of Direct-Entry Midwifery in Washington State" in the Orientation Manual for Licensed Midwives (download pdf)
The footnotes throughout this web page refer to the citations in the History section of the PDF of the Orientation Manual for LMs