Forces promoting health insurance coverage of homebirth: a case study in Washington State

The movement of childbirth to the hospital in the early 1900s and the eventual establishments of health insurance reimbursement for hospital birth--but not for homebirth--solidified and reflected physician dominance in the area of obstetrics. Until recently, it was rare that a health insurer or a health maintenance organization (HMO) would cover a homebirth. However, in Washington State the majority of health insurance groups cover homebirths, which are generally attended by licensed midwives. In this context, our research is a case study focused on answering the question: What are the forces promoting the extensive coverage of homebirth by health insurers in Washington State? Data were gathered primarily through fourteen (14) in-depth, audiotaped interviews with key informants in relevant agencies and organizations in the state (i.e., state offices; midwife and other professional associations; and health insurance groups). Results suggest that consumer demand was an important precipitating factor without which changes to health insurance coverage would likely not have been made. Additionally, changes in state policies and professional mobilization on the part of licensed midwives were critical factors facilitating the widespread reimbursement for homebirth. Health care organizations' concerns for cost containment had little impact on this health insurance trend. Our study concludes that jurisdictional openings in the system of professions can be facilitated by a small number of strategically positioned individuals.