The state of midwifery

Midwifery care is holistic, focusing on each birthing person and family as biopsychosocial people. The goal of midwifery care is to provide a safe and rewarding experience, while never compromising safety.

A huge body of research supports the safety and satisfaction with midwifery care. An analysis of 23,000 low-risk women who birthed in the hospital—cared for by midwives in the Northwest—were 30-40 percent less likely to have C-sections, compared to low-risk women cared for by obstetricians. They were also less likely to have episiotomies, epidurals, and induction of labor, which reduced costs. Researchers estimated that increasing midwife-attended hospital births to 20 percent by 2027 could save $4 billion (Soutter et al., 2019).

The following paragraphs describe some of the major changes in midwifery in the past 50 years:

Education

In the United States, nurse-midwifery education has always been competency-based. Over the years, academic packages have become more robust to meet the increasing complexity of an often-dysfunctional healthcare system. Currently, Certified Nurse Midwifery (CNM) and Certified Midwifery (CM) education must include postgraduate education (master’s or doctoral level). In addition, all CNM and CM education programs must be pre-accredited or fully accredited by the Accreditation Commission for Midwifery Education (ACME), whose stringent criteria are approved by the U.S. Department of Education. In Washington state, we have two ACME-accredited nurse-midwifery education programs (Seattle University College of Nursing and University of Washington School of Nursing) and one midwifery education program accredited by the Midwifery Education Accreditation Council (Bastyr University).

Regulation/legislation

Washington state was among the first states to license midwives in 1917. That law was in effect in 1977 when I arrived in Washington. CNMs practicing in the ’70s and early ’80s initially practiced under one registered nurse license, with or without an endorsement or additional notation as a certified registered nurse. Currently, most CNMs (~85%) are in states where boards of nursing and boards of nursing and medicine license nurse-midwives under the nurse practitioner umbrella. Only two states (New York and Utah) currently recognize separate boards of midwifery or nurse-midwifery. However, CMs are yet to be licensed in many states, despite meeting the same educational requirements and attending ACME-accredited education programs.

Initially, CNMs did not have prescriptive authority but could follow standing orders from physicians, the same as any licensed RN. Now, advanced practice nurse practitioner midwives in Washington can obtain and maintain prescriptive privileges. CNMs can also register with the federal Drug Enforcement Administration to administer, prescribe, or dispense controlled substances.

Insurance reimbursement was limited to physicians. Today, CNMs and other advanced practice nurse practitioners in Washington state are now able to bill insurance, as well as federal programs (Medicare and Medicaid). Some companies, however, reimburse CNMs and other nurse practitioners at a lower rate for the same work. Global billing for pregnancy care, labor, and birth also presents problems for CNM billing, particularly when physicians take over the care of complicated patients, making it difficult to split out the care of each provider.

Clinical practice

Although it is still the status quo to go to an obstetrician when you are having a baby, Washington state midwives attend about 12 percent of births in the state annually. Most CNMs attend births in the hospital, although a few attend births in freestanding birth centers or homes, along with a cadre of licensed midwives.

Midwives originally only provided pregnancy-related care, but CNMs are now prepared to provide primary women’s healthcare across the lifespan. Midwives work collaboratively with physicians. They consult with obstetricians or maternal-fetal medicine specialists, and sometimes transfer the care of their patients to specialists.

Clinical practice is based on standards of practice and a code of ethics set by the American College of Nurse-Midwives. Recertification is required every five years to maintain clinical competency. Midwives are practicing across the state, and our numbers are continuing to increase.