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Overcoming Barriers to Informed Choice in Childbirth
Midwifery in North America: demise and re-emergence
Midwifery care is currently
the standard for low-risk pregnancies in much of Europe, where
childbirth outcomes and cost are more favorable than in the
United States. It was also the standard of care in the United
States until the early 1900s, but was gradually replaced by the
practice of obstetrics throughout the early part of the
century. By the early 1970s, many women were dissatisfied
with the medicalization of childbirth and a grassroots movement
to promote midwifery emerged across North America. In
the 1980s, social and biomedical researchers also began to
re-examine the appropriateness of the medical model of care for normal
pregnancy and birth. Mounting evidence demonstrates that the demonstrated
benefits of obstetric care for complicated pregnancies do
not extend to most low-risk pregnancies. The obstetrical approach
for low risk pregnancies is under new scrutiny.
The history of
Seattle Midwifery School: a grass roots accomplishment
Washington State is considered by many to be a pioneer in the adoption of public health policies that encourage access to midwifery care.
The growing availability of midwifery care in the state not only
provides residents with opportunities for better health care, but
also serves as a model for other states and localities that are currently investigating midwifery care issues. The health of the midwifery profession in Washington State is of national and international importance; for the past 23 years, Seattle Midwifery School (SMS) has had a central role in ensuring that health.
In 1978, when Seattle Midwifery School was founded, there were no licensed midwives
practicing in Washington State. Members of the Fremont Women's
Health Collective took the radical initiative to provide a means
for aspiring midwives to meet the educational requirements
prescribed in a "forgotten" 1917 law. This law
authorized the practice of midwifery by care providers who had
completed a course of study meeting prescribed requirements. The
school these women founded became Seattle Midwifery School.
Washington law
catches up
Soon after the first
graduates of Seattle Midwifery School began to practice,
Washington State law makers recognized the need for an updated
midwifery law. A 1980 legislative analysis document stated that
such a law was under consideration in large part because Seattle
Midwifery School graduates were providing maternity care under
the 1917 law. That law passed and is the basis for today's law that regulates midwifery in Washington State.
[Heany CT and Malter A.
(1980) Midwifery Outside of the Nursing Profession: the Current
Debate in Washington. Health Policy Analysis Program RD-37,
School of Public Health and Community Medicine, University of
Washington]
Thirty years
and 20,000 babies later...
Today, approximately 100
licensed midwives practice in this Washington State. Most of these midwives
received their training at Seattle Midwifery School. Practicing
in accordance with the
Midwives Model of Care, they have delivered over 20,000
Washington babies and have a record of excellent medical
outcomes, cost effectiveness and client satisfaction.
The turning point
We are now at an historically important time in the re-emergence of midwifery in Washington State and nationally. Relative to other industrialized countries, the United States ranks high in health care costs and low in terms of health outcomes. As discussed in the benefits of midwifery and doula care page, maternity costs and outcomes are a major factor in this equation and therefore offer rich opportunities for improvement in our overall performance. Public policy makers are taking note!
Major victories
Access to
midwifery care in Washington State has expanded dramatically in the
past two decades. In addition, many
national and
international developments
have expanded access to midwifery care.
Times of great change
often pose great challenges, and this time is no exception. But
the stakes are high; the health and well-being of the individuals
who would benefit from universal access to midwifery care are in
our hands. We must grapple with these challenges and build on our
success.
| LICENSED
MIDWIVES IN WASHINGTON STATE A number of recent policy changes have increased access to midwifery care in Washington State. Medicaid covers doula and midwifery care in
Washington. State law now requires that Washington
insurance companies contract with licensed midwives and
that women can have access to midwifery care without
first seeing a physician for referral. Group Health
Cooperative of Puget Sound, the oldest health management
organization in the state and a standard setter since it
was first formed in the 1950s, now incorporates the
services of licensed midwives, including coverage for
birth center and home births. Seattle Midwifery School's
program has recently undergone major revisions that open
it to a wide range of students who were previously unable
to access midwifery education.
- 1917
midwifery law adopted
- 1978
Seattle Midwifery School founded
- 1980
University of Washington Health Policy Analysis
Program publishes comprehensive and favorable
report on “Midwifery Outside of the Nursing
Profession” citing the existence of the
Seattle Midwifery School as one of the reasons an
update of the 1917 law was under consideration
- 1981
midwifery law revised, contemporary international
standards incorporated
- 1983
Midwives Association of Washington State (MAWS)
founded
- 1988
Washington Department of Social and Health
Services recommends increased utilization of
midwives in state maternity care
- 1989
Licensed midwives eligible for State Health
Professional Scholarship Program
- 1993
Legislature creates Joint Underwriting
Association to provide liability insurance
- 1993
“Every category of provider” law
requires Washington health insurance carriers to
include licensed midwives
- 1994 State
Health Personnel Resource Plan calls for
increased utilization of licensed midwives
- 1995 Office
of Insurance Commissioner invites Licensed
Midwives to join dialogue with health care plans
and participate in Clinician Workgroup on the
Integration of Complementary Medicine
- 1995
Midwives Association of Washington State,
Washington State Medical Association, and
Washington Obstetrical Society begin series of
meetings to resolve scope of practice and other
regulatory issues
- 1995 Group
Health Cooperative becomes the first managed care
plan to contract with licensed midwives
- 1996
MAWS adopts “Practice Guidelines for
Risk Screening and Indications for Consultation
and Referral”
- 1996
Quality Midwifery Associates implements quality
assurance program for midwives with liability
insurance
- 1997
Medical Assistance Administration Task Force on
Home Birth recommends Medicaid change policy to
cover home births
- 1999
licensed midwives in Washington State are
featured in PEW Health Professions Commission
Report on the Future of Midwifery, which
recommends that the midwifery model of care be
available to all families
- 1999
Students at Seattle Midwifery School are eligible
for federal financial aid programs
- 2000
Legislature includes licensed midwives in statute
guaranteeing women direct access to the
women’s health care provider of their choice
(eliminating need for gatekeeper referral)
- 2001
Medicaid launches pilot project to cover home
birth
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NATIONAL
AND INTERNATIONAL ADVANCES IN ACCESS TO MIDWIFERY CARE
A
growing body of clinical research
demonstrates that midwifery care is as
safe or safer than obstetric care for low
risk pregnancies, that it is preferred by
mothers, and that it results in
significantly lower costs to the consumer
and the public
See Current
Research on Midwifery and Doula Care
Public
policy makers on all levels are increasingly
recognizing the individual and public health benefits
of midwifery care
World
Health Organization
"The
most appropriate person to care for pregnant
women is someone with midwifery skills who lives
close to the community. People trained in
midwifery are qualified to provide preventive
care to pregnant women, detect abnormal
conditions in mothers and infants, assist women
through labour and delivery and prescribe
essential drugs. When delivery complications
arise, those providing midwifery care
especially at the community level need to be
able to carry out emergency measures if medical
help is absent, and get medical assistance or
refer women to an appropriate health
facility."
"Governments
need to promote the training of more
personnel with midwifery skills, and
launch comprehensive training programmes
if such programmes do not already exist.
Existing programmes may need to be
upgraded in alliance with midwives in
order to better meet women's
needs."
[World
Health Organization. Ensure Skilled
Attendance At Delivery, WHD 98.6.
Accessed on 7/24/01 at
www.who.int/archives/whday/en/pages1998/whd98_06.html.]
American
Public Health Association
"The
American Public Health Association takes
a position in support of midwifery as a
key strategy for improving access to care
for childbearing families. In terms of
quality, satisfaction, and costs, the
midwifery model for pregnancy and
maternity care has been found to be
beneficial to women and families,
resulting in good outcomes and cost
savings." [American Public
Health Association (2001) 20004:
Supporting Access to Midwifery Services
in the United States (Position Paper).
American Journal of Public Health. 91(3):
7-10.]
PEW Health
Professions Commission
A
recent report of the Pew Health
Professions Commission identified the
midwifery model of care as an essential
element of comprehensive health care for
women and their families that should be
embraced by the health-care system and
made available to all women. They further
identified the midwifery model of care as
responding strongly to the three values
of the emerging managed care system:
lowering or controlling costs, enhancing
patient satisfaction, and improving the
overall quality of care. [Charting
a Course for the 21st Century: The Future
of Midwifery. San Francisco, CA: Pew
Health Professions Commission and the
University of California San Francisco
Center for the Health Professions. April
1999.]
State
of Washington Department of Licensing
"Certified
nurse midwives and licensed
midwives have a lower rate
of negative outcomes than physicians and
osteopaths, which indicates provision of
services within the scope of practice and
appropriate referral of potential
problems to the medical community."
[State of Washington Department of
Licensing. (1988) An assessment of
childbirth outcomes in Washington SSB
5163 Report to the Legislature. ]
Public
awareness and use of midwifery are increasing
- Use of
midwifery is
on the rise in the United
States. The percentage of
midwife-attended births has
increased from 1% in
1975 to 7.7% in
1999.
[Ventura SJ, Martin JA, Curtin SC Menacker F, Hamilton BE. (2001) Births: Final data for 1999. National Vital Statistics Reports 49(1). Hyattsville, Maryland: National Center for Health Statistics.]
- Citizens
for Midwifery
was founded by mothers in
1996. It promotes the
Midwives
Model of Care
and supports legislative and
other advocacy work in numerous
states.
- In 1996, the Coalition to Improve Maternity Services, which represents over 30 national groups of childbirth educators, midwives, doulas, nurses, and physicians, created the Mother-Friendly Childbirth Initiative. The Initiative is an evidence-based document which provides guidelines for identifying and designating mother-friendly birth sites including hospitals, birth centers, and home-birth services. Their model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs.
- Mainstream media attention to the benefits of midwifery is on the increase. From The
New York Times to People
Magazine and Mother Jones, articles on midwifery and midwife-assisted births
are becoming more common.
- In 1999
the National Organization for
Women resolved to include
references to birthing choices
and midwifery in all policy
statements, brochures, and fact
sheets on reproductive freedom
and to work in cooperation with
state and national midwifery
organizations to increase women's
limited access to midwifery.
An
infrastructure of professional organizations has
been established to support and further develop
midwifery and promote high standards of
professional care
Midwives
Alliance of North America (MANA)
Founded
in 1982, MANA is a professional
organization for all midwives in Canada
and the United States. MANA sets
standards for midwifery practice,
core competencies, and ethics. It
encourages communication among midwives,
sets educational standards, promotes
research, public education, and midwifery
advocacy.
North
American Registry of Midwives (NARM)
Founded
in 1987 by the Midwives Alliance of North
America, NARM is an international
certification agency whose mission is to
establish and administer certification
for the credential "Certified
Professional Midwife" (CPM). CPM
certification validates entry-level
knowledge, skills, and experience vital
to responsible midwifery practice.
Midwifery
Education Accreditation Council (MEAC)
The
Council, founded in 1991, accredits
direct-entry (non-nursing) midwifery
education programs and institutions under
the rules of the U.S. Department of
Education which has approved MEAC as a
federally recognized accrediting agency.
Midwifery
Association of Washington State (MAWS)
MAWS
was formed to unite and organize the two
groups of midwives in Washington state,
licensed midwives and certified nurse
midwives, and to promote public and
professional recognition of midwifery.
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SEATTLE MIDWIFERY SCHOOL'S INVESTMENT: Overcoming Barriers
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