Barriers to Medicaid Participation for Community Midwives in California

Abstract

Introduction:

The United States faces persistent perinatal health inequities, and there is growing recognition that midwifery care, including community-based care offered outside of hospital settings, could address these challenges. Medicaid finances half of births in the United States, but state policies notably limit access to community midwifery care for people insured through Medicaid.

Methods:

To understand barriers to Medicaid participation and how community midwives navigate these barriers in practice, we conducted a qualitative, interview-based study with midwives (n=62) and non-midwife birth center administrators (n=2) in independent homebirth practices and free-standing birth centers in California (CA); data were collected between 2022 and 2025.

Results:

The main barriers community midwives face to becoming Medicaid providers in CA include (1) extremely low reimbursement rates for the extensive continuity of care community midwives provide, (2) liability insurance and birth center licensing requirements that are unaffordable and not reflective of community birth settings, and (3) complex administrative bureaucracy that places undue burden on these independent clinicians. Midwives expressed a commitment to be accessible within their communities, striving to provide care to people across the socioeconomic spectrum. Due to the numerous barriers to being Medicaid providers, midwives employed various workarounds to increase access to midwifery care.

Discussion:

The expansion of midwifery care is a critical intervention to improve perinatal health in the United States, though access to the midwifery model of care remains suppressed by a fragmented approach to insurance and longstanding marginalization of US midwives. In CA, structural barriers make Medicaid participation administratively inaccessible and financially unsustainable for most community midwives. These findings have national implications for improving state Medicaid policies, such as by reducing administrative burdens, improving reimbursement rates, and restructuring the payment model; doing so could increase access to community midwifery care and improve perinatal health outcomes.

Précis

Expanding community midwifery care in the United States requires fair compensation from Medicaid, with streamlined contracting, value-based payment, and improved systems coordination.

INTRODUCTION

The United States faces persistent perinatal health crises, including striking racial and socioeconomic inequities.^1,2 There is growing recognition that greater utilization of midwifery care could play a key role in reducing pregnancy-related deaths and otherwise improving perinatal health.^3–6 In the United States, there are three national midwifery credentials⁷: Certified Professional Midwife (CPM) (licensed in 36 states)⁸; Certified Nurse-Midwife (CNM) (licensed in 50 states); and Certified Midwife (CM) (licensed in 13 states).⁹ In California, “licensed midwives” (LMs) often concurrently hold the national CPM license and are regulated by the Medical Board of California.^7,10 All three credentials include community-based care outside of hospital settings in their scope of practice. Community midwifery care is provided during pregnancy, childbirth, and postpartum in freestanding birth centers (non-hospital facilities) and home settings¹¹; community midwives also provide sexual and reproductive healthcare. The community midwifery model of care encompasses physical, psychological, and social well-being, and is distinctive from the dominant model of hospital-based care in the United States.¹² (see Table 1). Perinatal care in community settings is demonstrated to be high quality and safe, leading to high rates of physiologic birth and positive health outcomes for birthing people and their infants,^11,13 including people insured through Medicaid.^3,4

Table 1.

Comparison of Community (Out of Hospital) Midwifery Model and Dominant (Hospital-Based) Model of Care in Low-Risk Birth^a

	Community Midwifery Model	Dominant Model
Prenatal Care	• 4 to 10 hours total face-to-face time • 8–10 visits, 30–60 min each • Between visits: midwife available via phone/text/email • Integrated services: doula, childbirth & breastfeeding education • Referrals as needed	• 50 min to 2.5 hours total face-to-face time, 8–10 visits, 15 min each (6–10 min with provider) • After-hours support varies; often urgent care or ER • Supplemental services referred out (e.g., Comprehensive Perinatal Services Program52 in CA) • Referrals as needed
Labor & Delivery	• Typically planned at home or birth center • Known midwife present throughout labor • Continuous labor support by midwife & often a doula • Emergencies managed on-site or transferred to the hospital if needed • 2+ trained providers present at birth • Pain relief: massage, water, nitrous oxide, doula support	• In-hospital birth • Provider may be unknown until delivery • Providers often enter the room only for delivery • Team: 2–4 registered nurses + 1 medical doctor or certified nurse-midwife, often unfamiliar • Emergency services available on-site (varies by hospital) • Pain relief: epidural, fentanyl, spinal anesthesia; nitrous/water rare
Immediate Postpartum (First 24 hrs)	• Home or birth center discharge 4–6 hours post-birth • Focused support for rest & breastfeeding • Newborn care: exam, meds (Vit K, Hep B, erythromycin), breastfeeding support	• Hospital stay 24–48 hours • Check-ins often disrupt rest • Prioritization of staff schedules over recovery • Newborn care: same as midwifery model
Postpartum Care (First 6 Weeks)	• 2–8 hours total face-to-face time • 3–8 visits, 30–60 min each • Dyad care (parent + newborn) at each visit • Maternal & infant assessments + mental health, birth control, breastfeeding • Whole-family support, social needs addressed	• 24–48 minutes total face-to-face time • Parent: 1 visit at 3–6 weeks (15 min, 6–10 min face time) • Newborn: 2–3 separate visits (15 min each) • Separate providers, limited time for full assessment • Social needs may not be integrated
Comprehensive, Whole-Person Care	• Integrated care: includes ACEs, mental health, nutrition, lactation, childbirth ed. • Closed-loop referrals (midwife ensures follow-up) • Culturally relevant nutrition & education • Continuous support in labor & postpartum • Designed to reduce maternal mortality & address health disparities • Midwifery model shows better outcomes for low-risk Medicaid enrollees	• Fragmented care: supplemental services require separate visits • External referrals often needed • Brief appointments limit holistic assessment • Risk of compartmentalizing care

^aAdapted with permission from Midwifery Access California

Although midwifery-led perinatal care is a global norm, only 14% of US births are attended by midwives,¹⁴ and 2% of births take place in community settings (i.e., freestanding birth centers and homes).^15–17 Systemic racism and gender-based oppression led to the professionalization of obstetrics in the early 20th century when midwifery care—predominantly provided by Black, Indigenous, and immigrant women—was maligned, criminalized, and nearly eliminated.^18–20 Today, obstetric norms pervade US perinatal care, which is plagued by the poorest and most inequitable health outcomes among high-income countries.¹⁵ Expanding midwifery care is one evidence-based response to this problem, as states with higher midwife integration have better perinatal health outcomes.¹¹ Birth center care has been associated with lower rates of preterm and cesarean birth among Medicaid recipients,^3,4 and demand for community midwifery care is growing, especially among Black women and people insured through Medicaid.²¹

Despite rising interest in midwifery care, access is limited by a profit-oriented approach to US healthcare, combined with the sociocultural and systemic marginalization of the midwifery profession and a patchwork of often-restrictive regulation across states.⁵ Medicaid, which pays for approximately 50% of US births, reimburses less for perinatal care than most other types of healthcare; in many states, reimbursement is lower for midwives than physicians.^22–24 Low Medicaid reimbursement has contributed to the closure of hospital labor and delivery services, including birth centers, leaving greater than 35% of US counties without these services.^25,26 Medicaid covers midwifery care provided by CNMs in all 50 states, CPMs in 18 states,²⁷ and CMs in five states and Washington DC.²⁸ This disparity illustrates the systemic favoring of CNMs (who primarily provide hospital-based care) over other community midwives. Even when midwifery care is covered by Medicaid, community midwives face barriers to participating in Medicaid and are frequently excluded from Medicaid managed care contracts.²⁹ In CA, midwives were not included in the design of state midwifery Medicaid benefits despite being recognized as independent clinicians. Midwives are required to use billing practices that do not reflect the nature of the care they provide, including bundled payments for perinatal care (a fixed global payment regardless of the number of services provided) and ineligibility for “top off” payments to cover the cost of care provided.²¹

These inequities are especially untenable for community midwives who typically provide more comprehensive care than their hospital-based colleagues, such as 60-minute prenatal appointments and 5 or more postpartum visits, compared to 15 to 30-minute prenatal appointments and a single postpartum visit in hospital-based settings.¹² As a result, community midwives are frequently unpaid or underpaid by both public and private insurance. Efforts to improve Medicaid coverage for midwifery care are ongoing. In CA, all managed care plans are required to contract with at least one birth center, one CNM, and one LM, and Medicaid coverage lasts 12 months postpartum.³⁰ However, community midwifery care continues to exist at the margins, remaining largely inaccessible to CA Medicaid recipients.^31,32 This qualitative study examines barriers to Medicaid participation among community midwives in CA and how they navigate these barriers in practice.

STUDY DATA AND METHODS

Data Collection

This qualitative study included interviews with midwives and non-midwife administrators providing perinatal care in home birth practices and freestanding birth centers in CA. Our initial study aim was to understand and document the community midwifery model of postpartum care.¹² One section of our interview guide addressed payment models and midwives’ perspectives on the financial sustainability of their work and its accessibility to people in their communities; these data led us to focus on Medicaid and community midwifery care.

We recruited study participants via email from professional networks, such as midwife colleagues and acquaintances in midwifery advocacy organizations, and via snowball sampling. Participants were eligible for this study if they could speak English or Spanish during the interview, were at least 18 years old, and had experience providing community midwifery care in CA. In addition to this comprehensive recruitment criteria, we used purposive sampling to identify community midwives of color and community midwives with experience as Medicaid providers.³³ We reached out to prospective participants up to 3 times, and we offered each participant a $50 gift card following their interview. Authors JMH, CW, MP, and ATL conducted semi-structured, 45 to 90-minute interviews in-person or via teleconferencing between January 2022 and August 2025. Interviews focused on midwives’ current practice model, including barriers and facilitators to serving families insured through Medicaid. Verbal consent was recorded, and participants chose whether to use pseudonyms. Interviews were fully recorded and transcribed, and the data transcriptions were cleaned and anonymized. This study was approved by the University of California San Francisco IRB.

Data Analysis

We analyzed data using reflexive thematic analysis.³⁴ After reviewing transcripts for accuracy, we wrote memos on initial impressions, generating 30 data-driven codes (e.g., “model of care;” “barriers to care”). At least 2 authors coded each transcript using qualitative data analysis software Dedoose. Discrepancies in coding were resolved through group discussion by the first three authors. In the next phase of analysis, we met as a group to sort coded data into themes by reviewing the research questions and discussing interacting codes and the intended impact of this study. Finally, we invited feedback on preliminary findings during two member-checking events, one virtual and one in person, with study participants.

Seven study participants attended member checking events, and one participant shared their feedback via email. The researchers who conducted the interviews co-facilitated member-checking events. We first provided a handout with preliminary findings and shared our intention to present community midwifery care with dignity and integrity to researchers, multidisciplinary clinicians, and policymakers; we then gave them time to review the handout and consider what felt accurate or different from how they want their work presented. Next, we invited discussion using the following guiding questions: Is this a true story about Medicaid from your perspective? Should we present the community midwifery model of care and challenges of midwife sustainability together or separately? What stories do you want us to tell to elevate and amplify your work? Insights from member checking events primarily validated our findings; they also underscored the importance of addressing structural and systemic issues with thoughtfulness and precision, given the protracted marginalization of community midwifery care in the United States.

Researcher Reflexivity

Consistent with COREQ guidelines,³⁵ we reflected on our positionality and all aspects of the research process.³⁴ We prioritized racial concordance between the interviewer and the midwife when possible and shared with study participants that the interviewers were parents who received community midwifery care. These approaches were particularly important to develop rapport in the context of interviewing professionals with experiences of systemic marginalization and interpersonal discrimination in the healthcare workforce. We intentionally assembled a multiracial research team with diverse professional training (sociology, public health, epidemiology, medicine, somatic psychology, law, and midwifery, including LMs and CPMs). This interdisciplinarity is crucial for addressing the myriad clinical, sociopolitical, and population health considerations related to this topic.

One primary researcher of this study attended monthly meetings of Midwifery Access California (MACa), a statewide coalition focused on Medicaid midwifery care access. Two authors of this manuscript are co-directors of MACa, and their involvement supported recruitment and data interpretation. Compared to authors of other disciplines, they are uniquely sensitized to the issues addressed in this manuscript, which allowed them to provide important context and specificity. The study’s primary investigator presented preliminary findings at two MACa events.

RESULTS

Our sample included 62 midwives and two non-midwife birth center administrators serving 38 counties in CA. The two non-midwife birth center administrators were not the only birth center administrators in our sample; they were the only ones who were not midwives by profession. More typical in our sample of midwives in freestanding birth centers were midwives concurrently running birth centers and providing midwifery care. Most of our participants spoke multiple languages, 72% identified as White, 61% practiced in home birth, while the remainder practiced in freestanding birth centers, and 84% were Certified Professional Midwives or Licensed Midwives. Only 22% of midwives in the study were registered as Medicaid providers (see Table 2).

Table 2.

Participant Characteristics (n=64)

Characteristic	n	(%)
Midwife Type
Certified Professional Midwife and/or Licensed Midwife (CPM, LM)	54	(84)
Certified Nurse-Midwife (CNM)	8	(13)
Non-Midwife Birth Center Administrator	2	(3)
Practice Setting
Home birth	39	(61)
Freestanding birth center	25	(39)
Race and Ethnicity a
American Indian, Alaska Native or other Indigenous	8	(13)
Asian or Pacific Islander	5	(8)
Black or African-American	7	(11)
Latina or Chicana	11	(17)
White	46	(72)
Languages Spoken a
English only	33	(52)
English & Spanish	24	(38)
English & another language	9	(14)
Forms of Payment Accepted a
Medicaid + private insurance + self-pay	17	(27)
Private insurance + self-pay	23	(36)
Self-pay only	24	(38)
Sliding scale/discounted fee	48	(75)
Geographic Setting a
Rural	18	(28)
Suburban	26	(41)
Urban	35	(55)

^aTotal is more than 100%; participants could select more than one option.

Our analysis identified three main barriers that preclude community midwives from being Medicaid providers: 1) low reimbursement rates and delayed reimbursement; 2) birth center licensing and liability requirements; and 3) administrative burdens (see Figure 1). We also detail workarounds that midwives employ to increase access to care for low-income families. Notably, there are some key differences between home birth and freestanding birth centers. Birth centers can generally bill Medicaid for a facility fee, whereas home birth midwives cannot. This results in different reimbursement rates. Birth centers face additional regulatory burdens, such as the infrastructure required to operate a licensed facility. These nuances notwithstanding, the structural challenges facing community midwifery care in CA are broadly characteristic of the field across practice settings.

Figure 1.

Barriers to Medicaid in Community Midwifery: “In trying to give a discount, we end up short.”

Structural Exclusion: Bureaucratic and Financial Barriers in Community Midwifery

The most common barrier to community midwives being Medicaid providers is reimbursement. Midwife Cindy explained, “None of the midwives in our area are taking [Medicaid] because it doesn’t pay enough.” Depending on location, most midwives charge between $7,000-$10,000 for perinatal services, which include 30 to 90-minute prenatal visits, being on call 24 hours a day, and 5 to 8 early postpartum visits. Midwives reported that Medicaid typically paid $0-$2800 for their services, depending on the managed care plan (counties may have numerous managed care plans; rates vary widely). Study participants explained that the only way to cover their costs with Medicaid reimbursement would be to drastically reduce the time they spend with patients. “Getting to the bare minimum,” as midwife Sarah described most other perinatal care settings, was an unacceptable deviation from the community midwifery model of care.

For hospitals, the facility fee (payment for the service location) is typically the largest sum reimbursed by public or private insurance. Midwives in birth centers are eligible to bill for facility fees, but they explained that Medicaid did not consistently reimburse for this. Midwives who attend births in homes are not eligible for facility fees. Without facility fees, many midwives found Medicaid reimbursement so low that it was not worth the process of seeking reimbursement. Several midwives asserted, “I’m losing money” by providing care to people insured through Medicaid, saying they were not paid for their time or supplies.

Many community midwives do not carry malpractice insurance, largely because it is cost-prohibitive for independent clinicians. Midwives reported that premiums could cost $30,000 per year for a single midwife, and few malpractice companies would cover CPMs. Teri explained, “Malpractice insurance is so expensive [and the pay from Medicaid] isn’t enough to support my practice.” A midwife must show proof of malpractice insurance before applying for Medicaid and must maintain this insurance until the state approves them as a Medicaid provider, sometimes for up to a year. Given midwives’ relatively low patient volume, most reported that paying for malpractice insurance was not a viable option, precluding them from becoming Medicaid providers.

Midwives practicing in birth centers face specific complications related to state licensing. California law permits midwives to deliver care in birth centers under their own clinical license, without requiring additional licensure of the building. However, many midwives were told that licensing from the California Department of Public Health was a prerequisite for contracts with Medicaid managed care plans and private insurance companies. For some study participants, state facility licensing requirements complicated, delayed, or completely shut down their plans to serve families using Medicaid. For example, one group of community midwives built their birth center planning to be Medicaid providers, but the state Department of Public Health would not approve their heating, ventilation, and air conditioning (HVAC) system. The HVAC changes required for facility licensure were based on the needs of a hospital and were cost-prohibitive. This stopped their plans to become a licensed birth center, leaving families insured through Medicaid in their region without access to birth center care. At least three midwives in our study closed their birth centers during the study period: two had been Medicaid providers, and one had been excluded by facility licensing requirements.

Midwives often described Medicaid as an impenetrable bureaucracy, referring to it as “complicated,” “an endless loop,” and “like unravel[ing] a ball of yarn.” Independent midwifery practices are small, typically run by one or two midwives, and do not have the extensive billing support available to clinics and hospitals. Many midwives found it impossible to manage the complex administrative burdens imposed by Medicaid while constantly on-call for their patients. Midwife Francine said, “there’s no conceivable way that I can do that because it’s just too much work for a single practice midwife.” From navigating provider application processes to dealing with claim denials, midwives in our study described numerous administrative hurdles they lacked the time, support, or expertise to navigate.

Each managed care plan interprets state guidance and administers its own contracting processes, and midwives described how many plans do not follow state guidance on contracting with midwives. Midwives said the variations in managed care make navigating Medicaid cumbersome and unclear. As midwife Jessica said, “What [Medicaid] will reimburse changes by the day, because we have nine managed care plans [in our county].” Other midwives were unable to distinguish among plans’ billing procedures, contracting rules, and reimbursement rates.

Midwives in our study who were Medicaid providers described wait times of up to a year for reimbursement, though Medicaid is required by law to reimburse providers within 45 days. In some cases, midwives said they never received payment for services billed to Medicaid. Filing complaints about the reimbursement problems requires yet more administrative labor from independent midwives, without the guarantee of eventual reimbursement. The nature of Medicaid bureaucracy, combined with low reimbursement rates and costly liability and licensing requirements, makes it virtually impossible for most community midwives to sustain a practice as Medicaid providers, whether they practice independently or operate a birth center.

Midwives Responding to Barriers: Community Access and Unsustainable Workarounds

Facing numerous barriers to becoming Medicaid providers was a disappointment for many community midwives. Across our sample, the midwives expressed a desire to “make [themselves] accessible to anyone,” with interest in caring for families insured through Medicaid. Madeleine, a midwife contracted with Medicaid, explained, “the best way we can have an impact on health equity in California is to address all Medicaid clients…and to give really good clinical care.” They expressed a commitment to be accessible within their communities, striving to provide care to people regardless of whether they could afford a midwife’s full out-of-pocket rate. Midwife Maya, not a Medicaid provider, explained, “I do want my care [to be available] …I’ve incorporated all these other ways of making my care accessible.” Midwives described various strategies to serve clients across the socioeconomic spectrum. Some midwives arrange single-case agreements with managed care plans, though these are idiosyncratic and time-consuming. Most offer sliding-scale or pro bono care to people without insurance who cannot afford the full fee. Midwife Michelle explained, “I’ve decided that I would rather offer a sliding scale…than deal with being a [Medicaid] provider.” Midwives offer payment plans spread out over a year or more, or make barter arrangements in exchange for care.

Some midwives spoke specifically about the importance of community midwifery access for families of color, particularly those with lower incomes. Midwife Francine explained,

A lot of our work in midwifery care is undoing the harmful things that have been said and done to [parents]. Many of them are people [who] had their first babies as teen moms and then had that double impact of being a Black or brown woman, being poor…so they sadly are happy to pay [for an alternative to hospital-based care].

Multiple birth centers have “birth equity funds,” raising money specifically for Black women seeking their care.

Despite study participants’ efforts to make care accessible, these workarounds are taxing and often unsustainable. Midwife Kendra said, “In trying to give a discount, we are the ones who end up short. I can’t subsidize what the government is unwilling to subsidize.” When asked about Medicaid and the cost of providing care, midwives expressed disappointment, frustration, and sadness; they often sounded resigned, lamenting their eventual plans to leave the profession. One midwife left a community setting to serve Medicaid patients in a hospital, but felt she compromised quality of care.

Midwives felt conflicted about taking payment from financially strained people, such as those who make slightly too much to qualify for Medicaid but also do not have private insurance coverage for community midwifery care. As midwife Margaret said, “We donť have a whole system behind us…[if] you're not turning away people based on finances, then a lot of what you're doing is either uncompensated or extremely undercompensated.” Neither Medicaid nor financial workarounds to care for low-income families provide security for midwives or their clients.

DISCUSSION

There is widespread agreement that US maternal health is in crisis, exemplified by poor maternal and infant outcomes, persistent inequities, and decreasing numbers of hospitals offering perinatal services.^1,2 The expansion of midwifery care has been documented as a critical intervention,^36,37 though access to the midwifery model of care remains suppressed by a fragmented approach to insurance and longstanding marginalization of US midwives. In California, all midwives are eligible to be Medicaid providers, but structural barriers make Medicaid participation administratively inaccessible and financially unsustainable for nearly all community midwives. There are no accurate numbers accounting for overall community midwifery participation in Medicaid in CA, making direct verification of representativeness in our sample impossible. However, there is credibility for the broader relevance of our finding that only 22% of participants had experience as Medicaid providers. Across extensive engagement with community midwifery communities, including attendance at legislative hearings, conferences, and advocacy meetings, we consistently encountered the characterization that Medicaid participation is not meaningfully available in community midwifery care.

The benefits of community midwifery care are well-substantiated: it is safe,³⁸ less expensive than hospital-based care,^4,39,40 and has comparable or better outcomes than hospital-based care, including for people insured through Medicaid. ^3,4,13,38,41 Community midwifery care aligns with the World Health Organization's practice guidelines.⁴² Yet despite evidence supporting this high-value model of care and the sustained advocacy of professional organizations, public health stakeholders, and policymakers, access remains notably limited. Our research shows that community midwives are eager to contribute to perinatal health equity and are dedicated to the communities they serve. Many provide uncompensated care to low-income families when contracting with Medicaid is not functionally possible.^21,41

As labor and delivery units continue to close throughout the United States,⁴³ smoothing pathways for community midwifery care could improve access to care, especially in rural areas.⁴⁴ However, birth centers are closing rapidly as well. From 2020 to 2025, 40% of CA birth centers closed completely, leaving only 4 licensed and 32 unlicensed birth centers in the state as of April 2025.⁴⁵ The greatest obstacle for community midwives contracting with Medicaid is the low reimbursement rates, worsened by substantial administrative burdens. Community midwives are not alone in their struggle to serve low-income families. This challenge, faced by safety-net clinics and hospitals, is particularly acute in CA. However, as independent clinicians, community midwives face specific challenges navigating a system that increasingly caters to large hospitals and clinic networks.⁴⁶ The consequences of hospital consolidation have included dramatic reductions in access to perinatal care in rural communities: in CA, half of rural hospitals no longer offer labor and delivery services.⁴⁷ Currently, Medicaid in CA and many other states is physician-centered and hospital-oriented, failing to leverage the high-value care that community midwives offer.

There is growing national attention to the role of midwives in Medicaid.^3,27,48 In CA, this is reflected in several places: (1) new Transforming Maternal Health funding from Centers for Medicaid and Medicare (CMS) that acknowledges the importance of midwives;⁴⁹ (2) explicit inclusion of midwifery in the Department of Health Care Services Birthing Care Pathway efforts, funded by a Medicaid 1115 waiver;³² (3) new legislation to ease the birth center licensing process;⁵⁰ and 4) advocacy from organizations such as Midwifery Access California, a coalition that includes community midwives, representatives from multiple state agencies, and Medicaid managed care plans. Notably, these advocacy efforts produced tangible policy changes during our data collection period, which shaped our analysis. The dynamic relationship between advocacy and policy, along with ongoing shifts in national healthcare systems, has the potential to further transform community midwifery practice in ways that will be important to account for in future research. As the national healthcare landscape continues to shift, sustained attention to community midwifery in research, practice, and policy is warranted.

This study has several strengths. A substantial response rate to email recruitment (42%) and robust participant engagement, including member checking and ongoing researcher participation in a statewide coalition focused on midwifery access, support the credibility of the findings. Qualitative methods facilitated a detailed understanding of barriers to providing community midwifery care. Further research could extend this work nationally to capture the impact of state-level Medicaid policy variation, while follow-up research in CA could account for subsequent policy and practice changes.

Midwifery Access California’s key recommendations to support midwifery care in Medicaid include simplifying Medicaid contracting procedures to reduce administrative burdens and delays, testing a value-based payment model for community midwifery care that would accurately reflect the comprehensive care midwives provide, ensuring fair compensation for their work that includes extended appointment times, newborn care, and extensive postpartum care, and improving Medicaid coordination and transparency to ensure managed care plans maintain adequate access to midwives.⁵¹ These recommendations align with Medicaid programs in other states, such as Washington, that have developed programs to improve Medicaid payment for community midwifery care,⁴³ resulting in improved outcomes and cost savings. Because Medicaid is the predominant payer of pregnancy-related health services across the United States, its reform is paramount for improving the lives of birthing people and their families and establishing precedent for commercial payers. Expanding access to community midwifery care is essential to advancing perinatal health equity.

Quick Points:

• Expanding midwifery care is a critical intervention to address persistent US perinatal health crises.

• As hospital-based labor and delivery units close throughout the United States, smoothing pathways to community midwifery care could improve access to perinatal healthcare and promote better outcomes.

• Improving Medicaid processes for community midwifery care is necessary. This includes refining contracting procedures to reduce administrative burdens and delays; testing value-based payment models for community midwifery care that reflect the care midwives provide; ensuring fair compensation for extended appointment times, newborn care, and postpartum care; and improving coordination to ensure managed care plans provide access to midwives.