Barriers to Home Birth Fall in Washington State

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
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

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!

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  • invalid-0

    Great reporting Miriam. People interested in the Midwifery Education Program or the Simkin School for Allied Birth Vocations of the Seattle Midwifery School can visit us at

  • invalid-0

    SMS just celebrated it’s 30 year anniversary not 20!

  • emily-douglas

    Corrected the error!

  • invalid-0

    Just yesterday, when I was writing a post on Obama, I was thinking, since he’s cutting this and that and trying pinch pennies, why doesn’t he make midwifery care mandatory for all low risk women? It’s the only thing that makes sense.

    I have also recently had the conversation about Black women not knowing about midwives, or either not “trusting” the profession because of the misconception about Doctor God Power and the gold standard.

    What Washington State midwives have been able to accomplish is formidable. How can we replicate this, for the benefit of all women…?

  • therealistmom

    … when I was pregnant with my first child here in Washington state and on Medicaid until my then-husband’s military coverage kicked in, I was encouraged to use a certified nurse midwife for my prenatal care and birth. Of my three birth experiences it was by far the most positive, despite being the longest (as is normal for a first birth). I used a birthing room at the local hospital and had the support of a woman who cared about including my family and making sure I and my baby got the best with the least amount of intervention. Things like walking, nice warm showers over the belly, working on breathing, helping my parents give comfort (as the husband was still off in training). I will always, always encourage women who do not need a perinatologist to monitor their pregnancies to look into all of their options, and I am glad to see my state becoming more progressive in recognizing the legitimate options available for safe, happy childbirth.

  • anna-clark

    … thanks for sharing it! If I ever have kids, I’ll consider moving to Washington first.  :)

  • invalid-0

    Two years ago, the state of New Mexico joined Washington in providing Medicaid coverage for home birth whether provided by licensed CPMs or CNMs. New Mexico Medicaid, working with the New Mexico Midwives Association and the N.M Chapter of ACNM, developed a program called Birth Options which provided accessible, straightforward information about home, birth center, and hospitals as birth sites, and CPMs, CNMs, or physicians as birthing professionals. The state developed and made widely available a brochure that explained the Birth Options program. Over 30% of babies in New Mexico are born with a midwife in attendance. Recently, a nonprofit organization of Native American women in northern New Mexico, Tewa Women United, published the results of a survey it conducted about birth practices among Native American women. The results indicated that nearly 30% would choose home birth if it were reimbursed by Medicaid, and 67% would choose a birth center, if reimbursed by Medicaid. Unfortunately, the Birth Options program had not made sufficient inroads into the Indian Health Service, which has required all women it serves to birth in hospitals.
    Also unfortunately, the federal Medicaid agency, CMS, has recently ruled that state Medicaid programs may not reimburse birth centers for their costs or expenses related to childbirth. After CMS pulled the plug in Washington State, the birth centers in the state were forced to close their doors.
    The American Association of Birth Centers hopes to correct this wrong-headed policy — left over from the Bush administration — by getting legislation introduced in teh new Congress which will guarantee that Medicaid-enrolled women will continue to have access to midwife services at freestanding birth centers. Please go to and check out the legislative alerts to sign a petition to Congress to support this bill, which will be introduced by Susan Davis (D, CA).

    • invalid-0

      Children are very sensitive, all of them feel, they perfectly know, that between the daddy and mum something not so, and very much worry it, angry and dissatisfied persons every day see, after all with the unloved person to be very difficult always in good mood.

    • invalid-0

      Very necessary bill. I from Los Angeles, therefore will sign also others I will agitate.

  • invalid-0

    We have been very blessed here in Washington, thanks to the pioneering hard work of the women mentioned in the article, to have a comparatively favorable climate for all midwives, providers who have produced the great outcomes we expect from the midwifery model of care. On the other hand, Washington was the first state that Medicaid targeted to stop paying the federal match for birth center facility fees to, and the State has further reduced its payment to under $550/birth, which is not sustainable. Of course, Medicaid still pays the much more expensive hospital facility fee! If you think this is unfair (never mind a crazy way to spend tax dollars), please sign on to our letter to Congress at:

    Thanks for your support,
    Cynthia Flynn, President
    American Association of Birth Centers

  • invalid-0

    Wow – thanks for this comprehensive reporting.

  • invalid-0

    Even though I live in a state that has a long way to go on many reproductive issues this makes me optimistic.

    As a black home birthing mom, I probably represent 1% of the 1% of the out of hospital birthing population. I try and do what I can on a personal level to dispel the misconceptions surrounding home birth but it is definitely an uphill battle. Hopefully more states will take Washington’s lead.

  • invalid-0

    from Reuter’s, article by Jill Stein

    BALTIMORE, Maryland (Reuters Health) May 05 – The risk of neonatal mortality among infants delivered by a certified nurse midwife (CNMW) in the home is considerably greater than among in-hospital CNMW deliveries, according to data released here at Pediatric Academic Societies (PAS) 2009.

    Dr. Michael H. Malloy, at the University of Texas Medical Branch in Galveston, compared a range of adverse outcomes among infants by delivery attendant type and site of delivery occurring in the U.S. over a recent 5-year period.

    “Currently, the only Western country with a substantial number of home births is the Netherlands, where 30% of births are in the home,” Dr. Malloy, professor of neonatology, pointed out. “In the U.S., less than 1% of births are in the home, and the American College of Obstetrics and Gynecology ‘does not support programs that advocate for, or individuals who provide home births.'”

    The present analysis was limited to term (37-to-42 weeks), singleton, vaginal deliveries.

    “I decided to restrict the analysis to this low-risk population because they would be the best candidates for home delivery,” Dr. Malloy said.

    During the study period, there were 10,330,214 (88.5%) hospital physician-attended births available for analysis; 1,237,129 (10.6%) hospital-CNMW births; 17,389 (0.2%) hospital-other nurse midwife births; 13,529 (0.1%) home-CNMW births; 42,375 (0.4%) home-other nurse midwife; and 25,319 (0.2%) birth center-CNMW births.

    The number of neonatal deaths for each of the categories was respectively 6,992; 614; 7; 14; 75; and 16. However, while there were only 14 neonatal deaths occurring in association with a home-CNMW assisted delivery, the risk of death was more than two-fold higher for CNMW-home deliveries and four-fold higher for deliveries by other midwives versus CNMW-hospital deliveries.

    remainder of article can be found at

  • amie-newman

    with evidence that refutes its findings:

    Research, published in the British Journal of Obstetrics and
    Gynaecology, carried out on more than 500,000 low risk mothers showed
    there was no significant difference in deaths of babies or admission to
    neonatal intensive care units whether they were delivered at home or in

    The analysis was on those who were looked after by
    midwives in the community and who gave birth between January 1, 2000
    and December 31, 2006.

    Also, Dr. Malloy’s study recorded results with certified nurse midwives,  and not CPMs (certified professional midwives) that Miriam focuses on in this article.

    In fact, his study also found that "…the safest setting for the delivery of babies is in a hospital attended by a certified nurse midwife." However, he chose to explain this  by saying that physicians work with higher risk babies which is the reason for the discrepancy. 

    Finally, the study I cite above, makes excellent points about how critical the need is for high-quality, accessible maternity services all around:

    "It must be noted that maternity services in the Netherlands are set
    up to meet the demand for home births, transport is good, and distances
    short if emergency transfer to hospital is needed.

    "The same
    advantages are not available in all places in the UK, so the safety of
    home birth has to be considered in the context of the availability of
    local services."



    Amie Newman

    Managing Editor, RH Reality Check

  • invalid-0

    Thank you Miriam for this wonderful report and for the history. I am proud to see my teachers and fellow alumae from Seattle Midwifery School quoted!

    Small correction–it is Midwifery Education Accreditation Council (MEAC).

  • invalid-0

    The British Journal of Ob-Gyn has published several recent articles about homebirths in the Netherlands, you need to present the whole debate. The Dutch have the highest newborn mortality rate in western Europe. You missed the 2008 articles about maternal transfers to hospitals. Approximately 1/3 of Dutch women trying to deliver at home end up at a the hospital because of complications. So if all the potential homebirths with complications end up being counted as hospital births, of course homebirth looks great. If you ignore all the bad things that happen, that leaves only the good outcomes.

    • invalid-0

      “Readers need to know that there is nothing “selective” about the Dutch statistics, BMJ refs nothwithstanding. The Dutch have just published this April 2009, the largest study of their home births ever published and it is based on an “intention to treat” model that includes transfers. The study finds that the outcomes of home births including transfers, were comparable to low risk hospital births. The study makes very clear that home births are not the cause of the Netherlands currently poor outcomes, and in fact makes it certain that the home birth option should be preserved. It should also be noted that the presumption — that the Netherlands has the highest newborn mortality rate in W. Europe — is also wrong. The most recent comparable data (2004) available on perinatal mortality show the Netherlands with a rate of 6.6 deaths per thousand — a figure that is similar to Greece and Belgium and exceeded by France, the UK, and the U.S. Also the Dutch maternal mortality rate is among the lowest in W. Europe.

      This study also makes it clear that, as Cochrane reviews and other studies have shown, the midwifery option should be offered to women because the benefits are unmistakable and have been verified repeatedly. It also clarifies that “planned” is the key element in understanding home birth outcomes. Malloy and others need to take this into account.

      The commentator on the Dutch figures illustrates a common US assumption that home birth must of course always be more dangerous than hospital birth and that somehow “transfers” prove this. [Therefore, home births should not be “allowed.”] This reasoning ignores the fact that hospitals and specialists exist to manage complicated births, and save lives if they can, but there is no reason why their interventions should be administered to the overwhelming majority of normal, healthy women. Several other good studies show that there is a consistent refusal on the part of many tertiary-care trained professionals to believe either of these kinds of data, even when scrupulously analyzed.

      The larger question of why the Dutch outcomes in hospitals are poor — not among the poorest — certainly deserves attention, and I for one trust that in time their researchers will get to the bottom of it.

      But I believe the Dutch have now answered two very important questions in the negative: Neither home births or midwives are the “cause” of mortality and severe morbidity in the Netherlands. Eventually I believe careful US researchers will be able to show similar results here.”

  • invalid-0

    Reference below to previous comment posted to correct misleading comments on Dutch statistics.

    [Ref.: “Perinatal mortality and morbidity in a nationwide cohort of 529688 low-risk planned home and hospital births. AdeJonge,BYvanderGoes,ACJRavelli,MPAmelink-Verburg,BWMol,bJGNijhuis,JBennebroekGravenhorst,SEBuitendijkaa
    TNO QualityofLife,Leiden,the Netherlands Department of Obstetrics and Gynaecology, Amsterdam Medical Centre,Amsterdam, the Netherlands Department of Medical Informatics, Amsterdam Medical Centre, Amsterdam, the Netherlands Health Care Inspectorate, Rijswijk, the Netherlands Department of Obstetrics and Gynaecology, Maastricht University Medical Centre,Maastricht,the Netherlands. Correspondence: DrAdeJonge,TNOQualityofLife,P.O.Box2215,2301CELeiden,the Netherlands.Email
    Accepted 26February 2009.Published Online 15 April 2009.]

  • invalid-0

    Audrey Levine was my midwife! She is such an amazing woman. Great article, I am happy to be a washingtonian for this reason. I had state health care, and I though it was funny that they will pay for a epidural, but not a birthing tub which is a small fraction of the cost! Hhhmmm.

    • invalid-0

      It is very pleasant to read you and thanks to you I hope will be less than that that listen to a today’s total preponderance of a dirt and lie about those times.

  • invalid-0

    With all of the hoopla about Medicaid coverage, has anyone seen what they are doing for facility coverage? A birth center should be able to bill for the facility, just as a hospital bills for their facilities. There are many midwives delivering in their homes (and a few free-standing birth centers!) that are being denied those fees. Their business is using that space and it should be compensated!


  • invalid-0

    Thank you Miriam! The subject of a very wonderful and distinct.
    I thank you for continuing excellence.
    Thank you!