SEATTLE - Deep in the throes of labor, Amie-June Brumble is still able to crack a joke.

"I forgot why this was a good idea," the Seattle woman gasps between contractions. Brumble is curled on a hospital bed where she will soon give birth to her second son without benefit of painkillers and with minimal medical intervention. There's no doctor, either.

The health care professional in charge is a midwife - who responds in kind to her patient's wry comment.

"Because babies are so cute and cuddly," says Mary Lou Kopas, holding a cold washcloth on Brumble's neck. "And when they come, labor is over."

Kopas leads a group of six certified nurse-midwives who deliver a third of the babies at UW Medical Center-Northwest, formerly Northwest Hospital. Two-thirds are delivered by physicians, mostly obstetricians. If Kopas and other women's health advocates had their way, those fractions would be flipped. Midwives would oversee all low-risk pregnancies, like Brumble's. Obstetricians would handle only the complicated cases.

It sounds revolutionary in a country where physicians preside over 90% of births. But that's the division of labor in many other developed countries - where women and babies fare much better. Half the babies in the U.K. are delivered by midwives, including Kate Middleton's royal offspring. In Norway, Denmark, France and Sweden, midwives supervise most births. There's ample evidence midwifery offers a partial solution to some of the thorniest problems in American health care: The worst maternal and infant mortality rates of any wealthy nation, with risks up to three times higher for black and Native American women; rising levels of complications and premature birth; C-section rates more than twice the recommended level; a looming shortage of obstetricians; and sky-high spending.

"For women who are low-risk, costs would be lower, and outcomes would be better if midwives were managing the majority of births," Kopas says - a conclusion backed by a mountain of research, including some of her own.

A recent study that found lower rates of C-sections, prematurity and infant mortality in states where midwives are well-integrated with the medical system also ranked Washington best in the nation for midwife-friendly policies. Certified nurse-midwives (CNMs), like Kopas, don't have to be supervised by physicians, and practice in most major hospitals. And while many people assume giving birth with a midwife means doing it like Brumble, with no pain relief, hospital midwives have access to a full range of medical technology and drugs - including epidurals.

For women who want to give birth in a cozier setting, licensed midwives (and a few CNMs) oversee deliveries at home or in free-standing birth centers. Most insurance policies cover midwifery - and the field has passionate supporters statewide. When the UW School of Nursing considered closing its midwife training program in 2012, the deluge of legislator mail rivaled the number of comments on same-sex marriage. The proposal was dropped.

Yet even in Washington, midwives attend only about 11% of births, slightly more than the national average of 10%. "People aren't even aware the option exists," Kopas says. "The status quo is that when you get pregnant, you go to an obstetrician."

Brumble, 37, chose the UW midwives for both her deliveries because she likes the profession's approach to birth as a natural process - not a medical disaster waiting to happen. She didn't want to be hustled through a system that can feel impersonal, or have her baby delivered by an obstetrician she might never have met. But she also liked being in a fully-staffed hospital - just in case.

"One of the things I appreciated about Mary Lou is that she was 100% present for me ... the whole time," Brumble, a law firm supervisor, said a few weeks after her son's birth. "If I needed anything, she was there. If I had a question, she answered it. I think if I'd asked for an iced latte, she would have had it in my hand before I finished the sentence."

Midwifery care is holistic, focusing on each woman as person. Labor is allowed to unfold on its own time frame, with no pressure to speed things up. The goal is to give the woman a rewarding experience while never compromising safety.

"I used to tell the ladies that I worked with that I have two pairs of eyes," says Ceci Cordova, a CNM and lactation consultant at Rainier Valley Midwives in South Seattle. "I have eyes that look at you with love and just rejoice with you and celebrate, and I have another pair of eyes that's evaluating and making sure everything's OK."

While Brumble labored in her hospital room, Kopas kept a close watch. Earlier, the pregnant woman paced the room and leaned against her husband as her contractions intensified. Now, as she enters the final stage, she hefts herself onto her hands and knees and begins to push.

We're getting so close now," Kopas says. "Just listen to your body." The midwife presses on Brumble's back to relieve pressure. Brumble's water breaks with a gush. She howls and pushes, then does it again and again. In less than 10 minutes, her newborn son slides into Kopas' hands, crying like he's always known how. The midwife immediately passes him to his mother, who gazes into his eyes and welcomes him into the world.

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It's no accident midwifery is marginalized in the United States. The profession was nearly eradicated beginning in the early 1900s with the rise of physicians and hospitals. The fledgling field of obstetrics and its allies waged a propaganda campaign that portrayed traditional midwives - who were mostly black and immigrant women - as dirty, ignorant and dangerous. In fact, midwives at the time had lower rates of maternal and infant mortality than most physicians.

Midwifery has changed dramatically since then, but misconceptions endure. Many people think midwives are uneducated. They're often confused with doulas - who support pregnant women but don't provide medical care. Organizations working to expand midwifery spend a lot of time educating lawmakers about a profession many have never heard of.

This year, the Midwives Association of Washington State is requesting a legislative review they hope will lead to greater authority, including the ability to prescribe some common drugs, for the state's licensed midwives. At the federal level, the American College of Nurse-Midwives is promoting the Midwives for MOMS Act, which would boost student funding and increase diversity in a field that is overwhelmingly white.

Washington was one of the first states to license midwives with a 1917 law that allowed Japanese and other immigrant women trained abroad to practice their craft. State standards remain among the country's highest. Most licensed midwives graduate from three-year accredited programs. Nurse-midwives are registered nurses with graduate degrees in midwifery.

But midwives are also mavericks, standing in opposition to the traditional American way of birth, which is the world's costliest but often leaves women and their families feeling powerless. Even seemingly normal pregnancies can spiral into a cycle of interventions that culminates in cesarean sections. More than a quarter of women in one survey said they were yelled at, ignored or otherwise mistreated during hospital births, with higher percentages among women of color.

Faisa Farole, a licensed midwife at Rainier Valley Midwives, was shocked by the treatment she saw many pregnant Somali women receive. "These are women who may not have gone to school, but they are leading a whole family. Then they go to a hospital and they are treated like they don't know anything," Farole says. "One of my biggest goals is to empower women by giving them information."

While the average obstetrician appointment lasts nine minutes, midwives spend 20 minutes to an hour with every patient. They listen and encourage women to talk about anything on their minds. Midwives also advocate for healthy habits, knowing women in the midst of a major life transformation are open to change. A federal study found women covered by Medicaid - the low-income insurance that pays for nearly half of births - had healthier babies and saved the system more than $2,000 per birth when they received prenatal care from birth-center midwives, even if they delivered in a hospital.

Women cared for by midwives in the Northwest were 30 to 40% less likely to have C-sections than women cared for by obstetricians, according to an analysis of 23,000 low-risk hospital births Kopas co-authored. They were also less likely to have episiotomies, epidurals and drug-induced labor - which reduces costs. Researchers estimate that increasing midwife-attended hospital births to 20% by 2027 could save $4 billion.

Midwives' patients breastfeed at higher rates, are less likely to have low-birthweight babies, and their experiences as joyful and positive. Cochrane, a consortium that identifies best health care practices, reviewed the data and concluded: "Most women should be offered midwife-led continuity of care."

Women who seek out midwives generally hope to give birth with the least medical meddling possible, but, as Kopas warns her patients: You never know what kind of labor the universe will give you. Jessica Jones' first birth with the UW midwives was physiologic, a less-judgmental term for what some call "natural birth." The 39-year-old archivist's second delivery is a more complex affair, with a serious complication. The common denominator is the midwife's mantra of putting the woman and her family at the center and giving them the information and power to call the shots.

Almost two weeks past her due date, Jones and her husband consult with Kopas and opt to induce labor for the baby's safety. But induced labor can be more painful. Several hours in, Jones - who has barely slept in four days - requests an epidural to help her endure the lengthy process. By the time she's ready to push, Jones has been in the hospital more than 14 hours. Kopas coaches her through another 40 minutes of pushing before her second son is out - healthy, pink and barely crying.

All seems fine until an hour later, when Jones begins to bleed heavily. Postpartum hemorrhage is the leading cause of maternal death, and Kopas acts quickly, barraging Jones with anti-hemorrhagic drugs. The bleeding stops, then starts again. The midwife summons the on-call obstetrician, but the medications eventually take hold and surgery is averted. From an abundance of caution, Kopas also orders a blood transfusion.

It was scary, Jones said later, but would have been more traumatic without the midwife at her side. "Mary Lou was such a calming presence," she said. "Despite the complication, the whole thing was really satisfying."

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The analysis that ranked Washington best for midwives found some of the worst outcomes in states like Alabama and Mississippi, where more black women live, and midwives are highly restricted. Midwifery doesn't account for all the variation, but expanding midwives' roles could make a significant difference - particularly in high-risk communities, says study leader Saraswathi Vedam, of the Birth Place Lab at the University of British Columbia.

That's what executive director Tara Lawal had in mind when she co-founded the Rainier Valley Midwives clinic. Lawal's group is pioneering ways to combine the benefits of traditional midwifery and conventional medicine with the goal of improving the health of all mothers and babies and reducing racial disparities, which exist even in a state with some of the most outstanding maternal outcomes.

Lawal developed what she calls the "Birth Bundle" for women who want to deliver with a doctor, but still get personalized prenatal and follow-up care from midwives and doulas who look like them. Residents in the family medicine program at Swedish Cherry Hill rotate through the clinic, learning how midwives work and getting to know patients. When it's time for birth, midwives often accompany women to the hospital for support.

For the Somali women she often works with, having a caregiver from the same culture makes a huge difference, says Farole, herself an immigrant. "It just melts the tension. The mom knows I am looking out for her good, that I am on her side."

Farole specializes in home and birth-center deliveries, and her clientele includes a growing number of women of color. Some distrust the medical system or reject a medicalized approach to birth. "For me, it was mostly that I wanted to be in control," says Angelica Grunewald, who delivered her first two children in hospitals but chose home birth with Farole for her third. A Latina, Grunewald also wanted a midwife of color. "With Faisa, I never once felt pressured, I felt 100% informed," she says. "Faisa answered every question I had, she listened to my partner, she didn't mind my kids running around."

The mechanics might be the same, but the trappings of modern home birth bear little resemblance to our great-great-grandmothers' era. Licensed midwives in Washington carry IVs, resuscitation gear and an array of drugs to stop bleeding and prevent infection. Many LMs collaborate with hospitals through a program called Smooth Transitions that makes it easier to transfer clients if complications arise.

About 2% of babies in Washington are born at home - twice the national average. Another 1.5% are born in free-standing birth centers across the state.

While birth centers are endorsed by obstetrician groups as safe alternatives to hospitals, home birth remains hotly debated. Several studies suggest a higher, though still very low, risk of neonatal death. Others find no difference, particularly in countries where midwifery is more common.

Grunewald, 31, is a birth educator, and she and her husband did their homework. With Farole, they discussed situations that could require a transfer, like a spike in blood pressure or fetal distress. They mapped out routes to the closest hospitals. Grunewald's labor went on so long that Farole spent the night, dozing on a futon and slipping quietly into the master bedroom every 30 minutes to check the baby's heart rate with a handheld ultrasound.

When Grunewald finally gives birth, she's on the floor, clutching the bed leg for leverage and crying out at the top of her lungs. "Here's your baby!" Farole exclaims, catching the wrinkled, streaked newborn and placing her on her mother's chest. Grunewald sobs with relief and joy - surrounded by family, just as she wanted.

After Grunewald's husband cuts the cord, Farole helps her into bed. "We had a baby at home," Grunewald says, in a voice tinged with amazement.

Meanwhile, the midwife is busy, following postpartum procedures nearly identical to hospital routine. Farole monitors the baby's breathing and heart rate and gives Grunewald a dose of anti-hemorrhagic medication. She keeps a close eye on the new mom's blood pressure, temperature and pulse and logs the data on her laptop. She weighs the newborn, strokes the bottom of her feet to test reflexes and gives her a vitamin K shot to promote blood clotting.

Farole works calmly in the midst of the excited hubbub. Grunewald's other two children clamber onto the bed to meet their sister while her mother snaps pictures. Her husband takes a turn cradling his new daughter. Soon, they'll order pizza before settling in for the night. About five hours after the birth - and more than 36 hours since she arrived - Farole packs up her gear. She'll return tomorrow, then several times over the next few weeks, to check on mother and child.

"Let people help you," Farole advises her patient before she leaves. "Stay in bed. Boss people around."

Grunewald can't stop smiling, her newborn at her breast.

"That was amazing," she says to the midwife. "Thank you."

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