Midwives are recognized worldwide as an evidence-based approach to reducing maternal mortality.[1] Evidence shows that states integrating midwives into their health care systems have better indicators of maternal and neonatal wellbeing.[2] States are increasing access to midwifery care to expand the maternal health workforce, which has suffered provider shortages due to the COVID-19 pandemic.[3] State licensure and Medicaid reimbursement of services provided by midwives who do not have a nursing degree is an important consideration for this provider type. Minnesota and Washington State are among a growing number of states that provide Medicaid reimbursement to midwives without a nursing degree as a tool to improve health outcomes and expand the maternal health workforce.

Background

Midwives can increase access to maternity care providers in areas experiencing a shortage of obstetricians.[4] As of 2020, there was a shortage of 9,000 obstetrician-gynecologists (OB-GYNs) in the U.S., which is projected to increase to 22,000 by 2050.[5] Fifty percent of U.S. counties do not have a practicing OB-GYN and 56 percent of U.S. counties do not have a certified nurse-midwife (CNM).[6] In addition to there being a lack of practicing OB-GYNS, rural areas are facing a decline in available obstetric services in hospitals.[7] Midwives can fill gaps in these underserved areas where they attend over 30 percent of deliveries in rural hospitals.[8] Integrating midwives without nursing degrees into the health care workforce can help address the shortage of OB-GYNs and CNMs and ultimately improve health outcomes.

There are several licensure pathways states utilize for the midwifery profession. Certified nurse-midwives (CNMs) must meet a state’s nursing licensure requirements in addition to the midwife licensing requirements. In some states, midwives also can pursue licensure pathways that do not require a nursing degree. States have different titles for this licensure pathway including certified midwives (CMs), certified professional midwives (CPMs), licensed midwives (LM), direct entry midwives (DEMs), and traditional midwives. From 2004 to 2017, 50.7 percent of planned home births and 36.7 percent of birth center births in the United States were delivered by midwives without a nursing degree.[9] Reimbursing these types of midwives creates opportunities to improve access to maternity care for pregnant people who may want to give birth outside of the hospital setting.

As of April 2022, 36 states and Washington, DC offer a path of licensure for midwives who do not have a nursing degree. Minnesota and Washington State are among the 18 states that also provide Medicaid reimbursement for these midwives.[10] States operationalize this coverage differently in terms of licensure requirements and allowable scope of care and practice settings, but all reflect a growing trend to leverage Medicaid reimbursement of midwifery services to improve access to quality care and maternal health outcomes.

Minnesota

In Minnesota, midwives who do not have a nursing degree are called “traditional midwives.”[11] To gain licensure, a requirement for Medicaid reimbursement, traditional midwives must be certified by a Midwifery Educational Accreditation Council (MEAC) accredited program and provide a notarized copy of a midwifery diploma or written verification of a completed apprenticeship.[12] Another key aspect of Minnesota’s traditional midwifery licensure is maintaining an active North American Registry of Midwives (NARM) credential as a certified professional midwife (CPM).

Traditional midwifery services in Minnesota include the assessment and care of a person and newborn during pregnancy, labor, birth, and six weeks postpartum outside of a hospital.[13] The traditional midwife scope of practice includes prenatal education and coordination with other licensed health care professionals to provide services such as prenatal laboratory testing, monitoring of fetal development, and the provision of physical, nutritional, and emotional support to the patient and their family.[14] Traditional midwives in the state also may provide community resources on childbirth preparation, breastfeeding, exercise, and nutrition, among other key areas of maternal health and wellbeing.[15]

Most Medicaid beneficiaries in Minnesota receive their benefits through one of the state’s nine Medicaid managed care organizations (MCOs).[16] Traditional midwives are reimbursed by MCOs for services provided in freestanding birth centers. Covered services include prenatal visits, routine lab services, ultrasounds, low-risk labor and delivery, an initial postpartum visit, newborn care services, and labor care prior to an emergency hospital transfer.[17]

Washington State

In Washington State, midwives who do not have a nursing degree are called “licensed midwives.” [18] Licensed midwives must be a Medicaid agency-approved provider to participate in home births and in birthing centers.[19] Qualifications for midwifery licensure, a requirement for Medicaid reimbursement, include completion of at least three academic years of approved midwifery education, the care for at least 50 pregnant people through various stages of the perinatal period, observation of an additional 50 pregnant people in the intrapartum (labor) period, and successful completion of the national and state midwifery licensure examinations.[20]

Licensed midwives in Washington State can provide a variety of services such as prenatal care including lab work and referral for ultrasound, pregnancy, and birth counseling, infant care, labor and delivery, newborn care for the first two weeks of life, and postpartum care for up to eight weeks.[21] Licensed midwives may also prescribe cervical caps and diaphragms.[22] As of October 2022, implementation is underway to add limited prescriptive authority to the scope of practice for licensed midwives.[23] Licensed midwives are permitted to practice independently in the state and provide care in a variety of settings including patients’ homes and birth centers.[24] Licensed midwives are also able to conduct deliveries in hospitals after receiving privileges.[25]

Like Minnesota, most Medicaid beneficiaries in Washington State receive their benefits through MCOs, which include licensed midwives in their provider networks.[26] In addition to maternity care services, such as perinatal risk screening and prenatal care along with labor and delivery, licensed midwives can bill Medicaid for substance use disorder (SUD) screening and mental health screening as part of the risk assessment process before and during care under the global obstetrical care bundled payment. Additional reimbursable services include screening the postpartum birthing parent for depression at the newborn’s checkup (under the infant’s Medicaid ID), limited family planning services, and providing tobacco and nicotine cessation counseling during pregnancy.

Washington State also reimburses for home births, which are overwhelmingly performed by licensed midwives.[27] The state administers these services through its Planned Home Births and Births in Birth Centers program, which provides the option for an alternative delivery setting for pregnant Medicaid beneficiaries at low risk for adverse birth outcomes.[28] Under this program, licensed midwives may bill for home birth supplies and newborn assessments that occur in a home birth setting along with additional labor and delivery services.[29] In addition to Medicaid reimbursement for perinatal health services, licensed midwives are also included in the Bree Collaborative maternity bundle, which aims to promote and incentivize quality care.[30] Licensed midwives will also be included in Washington’s upcoming maternal care model which aims to incentivize high-quality, high-value care that improves perinatal health and addresses racial and ethnic disparities.

Conclusion

State policies aimed at enhancing access to midwifery care include expanding the scope of practice for midwives who do not have a nursing degree, allowing midwives to have privileges to continue supporting patients after transferring them from birth centers to hospitals when needed, and providing Medicaid reimbursement for midwifery services.[31] States such as Minnesota and Washington are increasingly pursuing Medicaid reimbursement of services provided by midwives who pursue a variety of licensure and training pathways. By including and reimbursing midwives who do not have a nursing degree in Medicaid payment reform efforts, states can expand the maternity health care workforce and improve maternal and infant health outcomes. For more information on similar policies across the country, explore NASHP’s 50-state research findings, Midwife Medicaid Reimbursement Policies by State.