WASHINGTON IS A midwife-friendly state, but there’s still a lot of confusion about midwives, what they do and how they’re trained. It doesn’t help that there are two distinct educational and professional tracks and that midwives can practice in multiple settings: Hospitals, homes and free-standing birth centers. All midwives specialize in helping low-risk women with uncomplicated pregnancies give birth, though they can provide prenatal care for high-risk women. Here’s some information on the two types of midwives that practice in Washington and how to vet them, along with information on free-standing birth centers.

Cover story: The case for midwives: Washington leads the nation in midwifery care, giving women another childbirth option

The Backstory: Photographing a story about childbirth made me more confident as I prepared to give birth to my first child

Certified nurse-midwives: A CNM is a registered nurse with a graduate degree — either a master’s or doctorate — in midwifery. CNMs can be licensed in every state. In Washington, they are licensed as Advanced Registered Nurse Practitioners. CNMs must pass a certifying exam administered by the American Midwifery Certification Board. They are regulated by the Nursing Care Quality Assurance Commission, part of the Department of Health.

CNMs in Washington are independent practitioners, which means they do not have to be supervised by physicians. They have full prescribing authority and can provide gynecological and primary care for women throughout their lives, not just in pregnancy. CNMs can care for newborns through the first six weeks of life. Most CNMs practice in hospitals, but they can also attend births at home and in free-standing birth centers. There are about 400 CNMs in the state.

Hospital CNMs oversee labor and birth and supervise nurses. They have access to a full range of medical technology, including ultrasound, continuous fetal monitoring and induction of labor. They can order epidurals, which are administered by anesthesiologists. When things go wrong, hospital midwives can call in obstetricians to consult.

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A review of disciplinary records from 2016 to 2019 shows action against one CNM, who was placed on probation.

To check out a CNM’s record, search here by name, selecting “Advanced Registered Nurse Practitioner Midwife License — AP” as the credential.

Licensed Midwife/Certified Professional Midwife: Washington has some of the country’s strictest requirements for licensed midwives, who are not trained as nurses. The most common path to licensure is via a three-year program accredited by the Midwifery Education Accreditation Council. The programs require attendance at at least 100 births during training. LMs must also pass a state exam and the certifying exam of the North American Registry of Midwives (NARM). Passing the NARM test qualifies a midwife for the Certified Professional Midwife credential, but the state does not require it.

An alternative route to becoming an LM doesn’t require an accredited education, but it’s becoming increasingly rare. Midwives can gain CPM status by what’s called a portfolio evaluation process, which involves apprenticeship with an experienced midwife. Midwives with a CPM credential but no accredited education must attend at least 100 births, pass the state exam and take accredited courses in epidemiology and obstetric pharmacology before being licensed in Washington.

There are about 175 LMs in Washington, about 80 percent of whom have an accredited education. Nationwide, LMs/CPMs can be licensed in 33 states.

LMs/CPMs provide prenatal and postnatal care, attend births at home and in free-standing birth centers, and provide up to six weeks of care for newborns. They do not have hospital privileges and cannot prescribe drugs, administer anesthesia — except nitrous oxide gas — or provide primary care outside of pregnancy. They can draw blood for routine testing, fit and prescribe diaphragms and surgical caps, and perform Pap smears. They are authorized to administer a wide range of medications during and after birth, including IV fluids, antibiotics, drugs to control bleeding, and newborn immunizations.

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If serious complications arise, LMs/CPMs transfer their patients to a nearby hospital.

LMs in Washington are regulated by the Midwifery Advisory Committee. A review of health department records for several years shows about 14 percent of complaints result in disciplinary action. For comparison, the rate for paramedics is 28 percent.

To check out an LM’s record, search here by name, selecting “Licensed Midwife” as the credential.

Free-standing Birth Centers

Free-standing birth centers are not associated with hospitals. They are licensed by the Washington State Department of Health, which conducts regular inspections. About a third of birth centers nationwide are accredited by the Commission for the Accreditation of Birth Centers, but Washington does not require it. There are 21 birth centers in the state with active licenses.

Birth centers generally feature large birthing tubs. LMs and CNMs can deliver babies in birth centers. In the birth-center setting, they have access to the same tools as home-birth midwives: Basic resuscitation equipment, IVs, antibiotics, medications for bleeding, and nitrous oxide for pain relief. Birth centers do not offer epidurals and don’t have the same advanced resuscitation capabilities as hospitals. They do have good working relationships with local hospitals and are easily able to transfer clients when complications arise.

Inspection results and enforcement actions against birth centers are not available online. They can be obtained by filing a public records request with the Department of Health. State records from 2017 and 2018 show five complaints filed against birth centers, three of which were substantiated and resulted in statements of deficiencies or citations.