Midwives, Birth Centers Improve Maternal Health Outcomes in Medicaid

Midwives and birth centers have been associated with improved maternal health outcomes at lower costs to Medicaid, but payment policies and other challenges pose barriers to expanding access to these services, according to an issue brief from the Medicaid and CHIP Payment and Access Commission (MACPAC).

Medicaid covered 42 percent of births in 2020 and pays for a greater share of births for women who are more likely to face care disparities. The public program is required to cover certified nurse-midwife (CNM) services, and states can choose to cover services provided by certified midwives (CMs) and certified professional midwives (CPMs).

In 2019, 9 percent of the 6.5 million people whose birth was covered by Medicaid had their birth attended by a CNM. In 23 states, more than 10 percent of Medicaid births were attended by a CNM. CNMs typically provide care for low-risk pregnancies due to scope of practice and supervision requirements.

Mothers with CNM present during birth were more likely to receive prenatal care and see positive birth outcomes. For example, 77.2 percent of people who gave birth attended by a CNM had nine or more prenatal care visits, compared to 75.9 percent of people who gave birth with a doctor. People with Medicaid who had a CNM present at birth had lower rates of preterm (5.1 percent) and low birthweight infants (4.5 percent) compared to those who gave birth with a doctor (11.7 percent and 10.2 percent).

Birth centers are designed specifically for childbirth and often are predominantly staffed by midwives. In states that license the facilities, Medicare is required to cover care at birth centers, but coverage is not required in CHIP.

Most Medicaid-financed births occurred in hospitals, with less than 1 percent occurring in a freestanding birth center. Still, mothers who gave birth in a birth center had more prenatal care visits and lower rates of preterm and low birthweight infants compared to those who gave birth in a hospital.

In addition to improving maternal and infant health, using midwives and birth centers led to cost savings for Medicaid. Overall childbirth costs for low-risk women with midwife-led care were $2,421 less than births for women cared for by obstetricians. The average Medicaid cost of care at a birth center was lower by $1,163 per delivery.

These cost savings are likely due to fewer medical interventions under the midwifery model of care, including less common use of epidurals, pain medication, and electronic fetal monitoring. Women who gave birth at a midwifery-led birth center also had higher rates of spontaneous vaginal births, better initiation of breastfeeding, and higher satisfaction levels with their care.

State Medicaid programs that want to add or expand coverage for midwives and birth centers face several barriers.

States determine payment rates for midwifery services and birth centers, leading to variation in how facilities are paid for the services. For example, midwives can be paid through maternity care bundle payments or via a specific fee schedule. Similarly, birth centers are paid via fee-for-service payments, global professional fees, or facility fees.

A lack of payment parity between provider or setting types may also deter access to midwives and birth centers, the brief noted.

Birth centers and midwives may face challenges contracting with managed care organizations (MCOs), creating additional access barriers. State Medicaid agencies do not require MCOs to include birth centers in networks. In addition, administrative staff at birth centers and midwives may be unable to contract with individual MCOs, submit claims and prior authorizations, and track reimbursements.

The scope of practice for midwives differs across states. In 44 states, CNMs are regulated by a board of nursing, while other boards of midwifery, medicine, or public health regulate CNMs, CMs, and CPMs in the remaining states. Some states require physician supervision for CMs, while others require a collaborative agreement from a partnering physician. The differing scope of practice regulations can limit midwives’ abilities to practice in birth centers or attend home births.

Simultaneously, there is a limited supply of midwives and birth centers to serve Medicaid beneficiaries; more than half of US counties lack a nurse-midwife.