In the wake of the Supreme Court overturning Roe v. Wade, maternal mortality is on the minds of many Americans. The United States has long been worst-in-class among developed nations in maternal mortality, and maternal care access keeps getting worse. There’s never been a better time to act. The first step is empowering the professionals who can help change this situation, which some simple federal rule changes can help accomplish.
A whopping 42 percent of births (over 1.5 million annually) are covered by Medicaid. Medicaid’s reimbursement rates for health care providers are notoriously low, which influences the rates paid by private insurers as well. This translates into many providers opting out of the program.
That’s a problem when provider shortages are pervasive, especially in rural areas, to which doctors saddled with med-school debt and trained in complex specialties are loath to relocate. It’s even more acute when we know 98 percent of women give birth in hospitals still overwhelmed by a pandemic and other fiscal challenges. In fact, the March of Dimes estimates some 7 million American women live in areas with low or no access to maternity care. Troublingly, access is steadily decreasing, not increasing, in part because of low provider pay and unnecessary restrictions on where and how non-physician providers can practice.
Birthing women, their babies and the medical system need options. America is historically reluctant to allow non-physicians to take the lead on caring for patients. But today, we don’t have that luxury. There just aren’t enough doctors.
Fortunately, a host of medical professionals are qualified and waiting to step into the breach. Midwives have all the skills needed to safely deliver babies and to assess when complications require physician or hospital care. Research consistently demonstrates the safety for low-risk women. Countries such as the United Kingdom and Canada already use midwives extensively as frontline providers.
But in many states, midwifery practice is either seriously restricted or midwives face a tangle of complex regulations that prevent access. At least 23 limit midwives’ ability to practice autonomously, requiring costly and unnecessary transfer agreements with physicians and hospitals, undermining midwives’ potential to bring care where it’s most needed. Such regulations also essentially require midwives to rely on their direct competitors to operate.
Even some states allowing autonomous practice often limit where midwives provide care, or set reimbursement rates for birth center care so low that midwives can’t afford to stay in practice.
While states should expand access to midwifery-led maternity care, the federal government has an important role to play.
First, the Centers for Medicare and Medicaid Services (CMS) could make it easier for multiple providers to split Medicaid reimbursement for birthing care. Right now, it’s difficult to separate prenatal care reimbursement from labor and delivery reimbursement. Midwives provide excellent prenatal care at home, in birth centers or in community clinics. However, midwives who practice at home or in birth centers often can’t be compensated for nine months of prenatal care and hours of support during labor if delivery ends up taking place at a hospital.
Second, Medicaid reimbursement rules need to make it easier for providers to cooperate, such as when midwives consult with obstetricians or maternal fetal specialists. Such cooperation is the norm in other systems, but our model forces women into a binary and more expensive choice.
Third, CMS could tie Medicaid monies to the rollback of certificate-of-need (CON) laws. In several states, these force licensed, would-be providers to first get a sort of permission slip to begin providing maternity (or other) care. CON laws can limit the number of birth centers or make opening one so onerous and expensive that most midwives cannot afford it. New York, for example, has only two birth centers in a state with over 200,000 annual births due to its restrictive CON process. Maternal health outcomes are all the worse for it.
Fourth, CMS could require that states allow autonomous practice for certified nurse midwives and certified professional midwives — when they meet national standard accreditation requirements. This would go a long way to meeting the Social Security Act of 1935’s goal that payment and provider rules are “sufficient to enlist enough providers.”
To recruit these providers, CMS should also demand pay parity for midwives receiving Medicaid payments. Right now, the Affordable Care Act requires that certified nurse midwives be reimbursed by Medicare at the same rate as physicians for identical care, but paradoxically does not require states to do the same with Medicaid. The vast majority of recipients who use midwives use Medicaid. Some 22 states still pay midwives between 75 percent and 90 percent of the physician rate for the same care.
Every American woman deserves convenient access to top-quality maternal care. That includes qualified midwives, who have the training and skills to make that objective a reality.
Lauren K. Hall is chair of the Department of Political Science at Rochester Institute of Technology and the author of “Midwifery Licensing: Medicalization of Birth and Special Interests.” Elise Amez-Droz is a program manager for the Open Health program at the Mercatus Center at George Mason University.