Jo Anne Myers-Ciecko, MPH, Seattle Midwifery School, 2807 32nd Avenue South, Seattle, WA 98144, 206 723 1618, jciecko@seattlemidwifery.org

The American Public Health Association resolved in 2001 to support efforts to increase access to out-of-hospital maternity care services, based on the mounting evidence that these cost-effective services could benefit women and babies. The resolution adopted by APHA’s Governing Council called for state licensing of nationally-certified direct-entry midwives, expanding access for rural and underserved populations, and eliminating barriers to the reimbursement of direct-entry midwifery services. This paper will examine trends in midwife-attended births in Washington State, public policies and private payment systems that support increased access to out-of-hospital services, and the barriers to practice reported by Licensed (direct-entry) Midwives. The results of a 2004 survey of midwives will be compared to a 1998 study, which found that most midwives were in active practice or doing related work in community, were receiving payment from Medicaid and had established managed care contracts. Nevertheless, survey respondents in 1998 identified difficulty obtaining third-party reimbursement, inadequate compensation per episode of care, and difficulty obtaining contracts with managed care plans as the most significant barriers to practice. At the time, most midwives did not consider physician consultation relationships to be a serious barrier to practice. Changes in the medical, legal and political environment are likely to produce quite different results in the 2004 follow-up survey.

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