State policymakers are addressing high rates of maternal mortality in the U.S. by expanding the maternal health workforce through Medicaid payment initiatives and other policies to increase access to certified nurse-midwives (CNMs) and midwives.
A NASHP 50-state in-depth analysis of state midwifery policies shows a varied state landscape for Medicaid reimbursement of midwifery services and policies related to licensure and scope of practice. Findings from this analysis indicate that Medicaid payment initiatives such as those that incorporate midwives into primary behavioral health care settings are a critical component of many states’ efforts to improve maternal health outcomes.
In a systemic review of studies comparing nurse-midwifery care to physician care, women who received nurse-midwifery care had lower rates of Cesarean birth, labor induction and augmentation, and third- and fourth-degree perineal tears; lower use of regional anesthesia; and higher rates of breastfeeding.
Midwifery has been practiced for centuries, including among American Indian and Black communities. Many states are seeking to expand access to midwifery care as part of broader maternity initiatives to improve outcomes and address disparities for pregnant and parenting individuals.[1]
American Indian and Black midwives have passed on traditions and knowledge in holistic health care for generations. Indigenous midwives from the Navajo Nation guide families through ceremonial birthing processes. “Granny midwives” were highly respected traditional Black midwives in the South from the late 1800s to the mid-1900s and were the primary maternity and reproductive care providers for Black and white women. As states began regulating the practice of midwifery from the late 1800s to the mid-1900s, midwives of color increasingly lost access to opportunities for licensure.
To learn more about Medicaid reimbursement of midwifery services, NASHP analyzed Medicaid managed care contracts, provider manuals, state plan amendments, and other public health policies from all states and Washington, DC. An overview of state licensure approaches, including those related to scope of practice, for both midwives and CNMs, that intersect closely with Medicaid reimbursement policy was included in this analysis.
Providers, Services, and Practice Settings
All states and Washington, DC, reimburse CNMs under Medicaid, and 18 states and Washington, DC, allow for Medicaid reimbursement of services performed by midwives who do not have a nursing degree. States have varying approaches across their Medicaid service delivery systems for how they finance and operationalize these services.
For the purposes of this brief, certified nurse-midwives (CNMs) are midwives with a nursing degree. States use a variety of terms to refer to midwives without a nursing degree, including licensed midwife, direct-entry midwife, licensed lay midwife, certified midwife (CM), certified professional midwife (CPM), traditional midwife, and verifiable midwife. In this brief, to best encompass the diversity of the terms leveraged by states, midwives without a nursing degree will be referred to as “midwives.”
Midwives may practice in hospitals under physician supervision, or independently in a home setting or in freestanding birth centers. Depending on certification and licensure, midwives can provide an array of services, including gynecological examinations, contraceptive counseling, and labor and delivery care.[2] All states and Washington, DC, allow CNMs to provide reproductive health services in addition to labor and delivery care to pregnant and postpartum people. For example, California allows CNMs to be reimbursed for medication abortion care services. Other states, such as Oregon, allow midwives without a nursing degree to be reimbursed for family planning services, including intrauterine device placement.
Over two-thirds of states (36 states) allow CNMs to be reimbursed for services beyond traditional maternity care, as allowable under their state licensure requirements, to include services such as care coordination, substance use disorder (SUD) screening, behavioral health screening, well-woman exams, and smoking cessation.[3] Thirty-one states include CNMs as primary care providers in state Medicaid reimbursement policies. For example, Missouri allows CNMs to be reimbursed for care of newborns up to two years old.[4] Other states, such as Mississippi, allow reimbursement for home visiting services provided by CNMs.
Integration of midwifery care with the provision of behavioral health and substance use treatment services is another trend some states are pursuing to support pregnant and parenting people. For example, Michigan allows CNMs to be reimbursed for providing medication assisted treatment (MAT). Indiana and Michigan allow CNMs to provide and be reimbursed for SUD screening and treatment and other needed behavioral health screening and treatment.[5]
Medicaid Practice Settings
The settings in which CNMs and midwives are permitted to practice are also an important policy consideration for Medicaid reimbursement. Some states identify a specific place of service (POS) where this provider type can be reimbursed for care. Freestanding birth centers are a primary setting across states in which midwives practice. Minnesota provides reimbursement for traditional midwives — which is the state’s licensure category for midwives without a nursing degree — in freestanding birth centers. Often states will require care provided by a midwife without a nursing degree to be conducted in the home or in a freestanding birth center as a billable POS. Some states limit the settings in which midwives can be reimbursed and practice. For example, certified professional midwives (CPMs) in Delaware are only permitted to provide care in outpatient settings. CNMs are generally permitted to practice and be reimbursed in a variety of settings, including hospitals and outpatient clinics.
Medicaid Payment Reform and Innovation
While all states reimburse for CNMs, and many are moving toward reimbursement of midwives without a nursing degree, there are varying approaches to further enhancing payment reform. Sixteen states have developed specific fee schedules for CNMs and/or midwives. Washington state covers behavioral health screenings and other services, such as care coordination, under the state’s global obstetric payment or as part of standard care.[6] Other states, such as Virginia, allow for reimbursement of midwives without a nursing degree only via their fee-for-service payment delivery system because Medicaid managed care organizations (MCOs) currently do not contract with this provider type.
Another key element of Medicaid reimbursement policies that vary across states for both CNMs and midwives is their reimbursement rate. About half of states reimburse CNMs at 100 percent of the rate of physicians providing the same service. Twenty states reimburse CNMs at 75 percent to 98 percent of the rate paid to physicians. States operating with a Medicaid managed care model such as Tennessee note that the reimbursement rate for CNMs varies by Medicaid MCO.
States with diverse Medicaid service delivery systems are also considering opportunities to include CNMs and midwives in additional Medicaid program goals. Half of all states include CNMs in state Medicaid maternity payment reform initiatives, indicating midwifery care as a potential priority area for states. In Maryland, CNMs are eligible providers for value-based payment metrics related to timeliness of prenatal and postpartum care. These metrics can result in incentive payments to high-performing MCOs. In Connecticut, CNMs play a role in obstetric pay-for-performance initiatives, and the state plans to include CNMs in a future maternity bundle. In Idaho, CNMs who provide birthing support in a hospital setting are included in the state’s hospital and primary care value-based care initiatives. Other states, such as Mississippi and Texas, reported that MCOs in their states have varying value-based payment initiatives that include CNMs.
Bundled maternity payments occur when a payer, including a state Medicaid program and/or its contracted managed care entities, provides reimbursement for prenatal care, labor and delivery, and/or postpartum care under a single procedure code. Codes for bundled payment traditionally include the labor and postpartum care services either with or without prenatal care.
State Midwifery Licensure and Impact on Medicaid Reimbursement
State Medicaid reimbursement policies are linked to other fundamental provider requirements such as scope of practice and licensure. To understand the impact of licensure on Medicaid reimbursement, NASHP included in its analysis state licensure and national certification policies. Among key findings, states determine licensure requirements for all types of midwives and often do so before allowing services to be reimbursed as a Medicaid provider. Licensure requirements for CNMs vary by state but generally include an active registered nurse license, master’s degree or higher degree in nursing, and certification as a CNM from the American Midwifery Certification Board (AMCB).
The majority of states require CNMs to mirror the scope of practice for advanced practice registered nurses (APRNs), who are registered nurses who often hold a master’s or post-master’s-level degree and have a specific skill set to support a certain patient population.[7] CNMs also have additional licensure requirements that generally follow APRN guidelines.[8] Some states require completion of courses in pharmacology for CNMs to obtain prescriptive authority; lab interpretation of pregnancy, antepartum, intrapartum, and postpartum complications; and neonatal care. Licensure requirements vary across states for midwives without a nursing degree, but in general midwives are required to complete an accredited midwifery program.
Aside from specific educational requirements, states also have additional requirements for CNM and midwifery practice that affect Medicaid reimbursement. NASHP found that 22 states use a collaborative model for CNM scope of practice, which requires care to be provided under the supervision of a physician. Twenty-five states and Washington, DC, allow CNMs to practice independent of physicians. Florida and Virginia operate hybrid models in which CNMs are granted a certain level of autonomy in their practice.
Some states, including Maine, New Mexico, New York, and Rhode Island, allow midwives without a nursing degree to practice independently, often with low-risk pregnancies. Maine, New York, and Rhode Island also require midwives to have the authority to write prescriptions. States such as New Mexico allow licensed midwives to order lab work, ultrasounds, non-stress tests, and newborn screenings, among other key aspects of antepartum, intrapartum, and postpartum care.[9]
NASHP’s case study highlights New Mexico’s Medicaid midwifery benefit under the state’s Birthing Options Program, which has strengthened access to high-quality midwifery care among pregnant people. New Mexico’s Medicaid midwifery benefit has been in effect for over 15 years, building on a key partnership between traditional Latina midwives and the New Mexico Department of Health.
National Certification Practices
NASHP’s analysis also found that national midwifery certification policies play a role in how states structure Medicaid reimbursement policies, including scope of practice. The three types of midwives credentialed in the U.S. are certified nurse-midwives (CNMs), certified midwives (CMs), and certified professional midwives (CPMs). Many states consider CNMs to be a separate provider type to midwives without a nursing degree who pursue the CM or CPM certification. Studies show that integration of all types of midwives into state health care systems have significantly better outcomes for birthing people and babies.[10] States often require midwives without a nursing degree to hold certification from the appropriate credentialing organization (e.g., NARM, AMCB), complete an application, and submit required documents to obtain licensure. CPMs are currently legally recognized to practice in at least 37 states and Washington, DC, while CMs are currently legally recognized to practice in at least nine states and Washington, DC.
The table below highlights certification information of CNMs, CMs, and CPMs, as well as the number of states that license each type of midwife.
Certification of Midwives and Certified Nurse-Midwives in the United States
| Type of Midwife | Number of Licensing States | Credentialing Organization | Education |
| Certified Nurse-Midwife (CNM) | 50 states and Washington, DC | American Midwifery Certification Board (AMCB) | Completion of graduate-level midwifery program accredited by the Accreditation Commission for Midwifery Education (ACME) and licensure as a registered nurse |
| Certified Midwife (CM) | 9 states and Washington, DC | American Midwifery Certification Board (AMCB) | Completion of graduate-level midwifery program accredited by ACME |
| Certified Professional Midwife (CPM) | 37 states and Washington, DC | North American Registry of Midwives (NARM) | Completion of an approved midwifery education accreditation council (MEAC) program |
Key Considerations
As states continue to advance policies that expand Medicaid reimbursement of midwifery services, they can consider opportunities to support CNMs and midwives as an integral part of the maternal health workforce. There is strong evidence that midwifery care for people with low-risk pregnancies improves health outcomes.[11] As states continue to increase access to midwifery care to support pregnant and postpartum people (and even those seeking reproductive care outside of pregnancy), they can consider policies to expand their workforce while improving outcomes and advancing equity.
Prioritize Policies to Increase Access to Midwifery care
Increasing access to midwifery services can help address the shortage in obstetric care across the U.S. and improve health outcomes. Nearly 50 percent of U.S. counties do not have a single practicing OB-GYN, and in rural areas, from 2004 to 2014, the number of hospitals offering obstetric services fell more than 16 percent.[12] In addition, at least 25 rural hospitals have closed since January 2020, further limiting access to obstetric services .[13] Nurse-midwifery-led care has been proven to yield overwhelmingly positive health outcomes for birthing people.[14] Establishing licensure for midwives who do not hold a nursing degree (e.g., certified midwives and certified professional midwives) can help expand the maternal health workforce, increase the ability for midwives to be included as a participating Medicaid provider, and increase access to health services for pregnant people.
Reimburse Midwives without a Nursing Degree
States can consider licensing midwives without a nursing degree and reimbursing them for services under Medicaid to fill gaps in the workforce, especially in areas experiencing a maternity workforce shortage. In recent years, many states, such as Idaho and Indiana, have established licensure of midwives without a nursing degree and providing Medicaid reimbursement for the care they provide.[15]
States are increasingly pursuing Medicaid reimbursement of services provided by midwives who pursue a variety of licensure and training pathways. NASHP published a case study highlighting policy levers Washington state and Minnesota have taken to operationalize Medicaid reimbursement for midwives without a nursing degree.
Medicaid reimbursement of this provider type can also help improve care and outcomes for pregnant people of color seeking a holistic birth experience outside a hospital. Due to experiences of structural racism in traditional health care settings, people of color are increasingly choosing to give birth at home or in birthing centers, the primary location where midwives without a nursing degree practice.[16] Allowing midwives without a nursing degree to be eligible for Medicaid reimbursement can help establish a sustainable, diverse maternity care workforce and support opportunities for patients to have more options for their birthing experience.
Integrate CNMs and Midwives into Holistic Primary and Reproductive Health Care Settings
Depending on certification and licensure, midwives can provide an array of services, including gynecological examinations, contraceptive counseling, and labor and delivery care.[17] States can also consider enhancing their reimbursement infrastructure to embed CNMs and midwives into services that affect people across the reproductive life course and improve early identification of holistic behavioral health and other medical needs. This approach can support continuous preconception, postpartum, and interconception care for people who wish to continue building relationships with a single provider. These efforts can also be particularly impactful for people who face persistent health disparities.
Leverage Midwifery Care to Advance Community Maternal Health Provider Availability
States can consider leveraging both CNMs and midwives without a nursing degree to advance larger maternal health equity initiatives geared toward increasing provider access for people of color and those living in rural communities. Although people of color have traditionally practiced midwifery for centuries, they have also heavily relied on midwifery services due to structural barriers in the health care system. Increased access to midwives, especially those with similar lived experiences, can support larger state efforts to enhance maternity care. These activities can also support efforts to address maternity care deserts in rural areas, a concern many states are grappling with. Recent studies show that more than half of counties in the U.S. do not have rural hospitals providing obstetric services.[18] Increased access to midwives can also help address these shortages and provide care to people living in remote areas.
Conclusion
NASHP’s 50-state analysis of state midwifery policies shows a varied landscape with opportunities to improve access to midwifery care that can improve the maternal and reproductive health care infrastructure. Medicaid midwifery reimbursement trends, including payment reform initiatives and efforts to operationalize reimbursement within diverse Medicaid payment delivery systems, demonstrate the potential to enhance the maternity workforce and elevate the impact Medicaid can have on care as the largest single payer of maternity care in the country.[19] These policies intersect closely with state efforts to license CNMs and midwives while refining their scope of practice. These collective efforts across states play a vital role in expanding the maternity care workforce and increasing access to essential health interventions among pregnant people and those seeking reproductive or postpartum care.
Endnotes
- FACNM, Joyce E. Thompson, DrPH, RN, CNM, FAAN, and Helen Varney Burst FACNM RN, CNM, MSN, DHL (Hon). 2015. A History of Midwifery in the United States: The Midwife Said Fear Not. Google Books. Springer Publishing Company. https://books.google.com/books?hl=en&lr=&id=79zhCgAAQBAJ&oi=fnd&pg=PP1&dq=history+of+midwifery&ots=jS-c58CXTX&sig=ui4xrXvyfWusSHJH2KxaEuaM6A0#v=onepage&q&f=false.
“The Benefits of Midwives.” 2017. American Pregnancy Association. April 26, 2017. https://americanpregnancy.org/healthy-pregnancy/labor-and-birth/midwives/.
NASHP. 2022. “Midwife Medicaid Reimbursement Policies by State.” The National Academy for State Health Policy. April 15, 2022. www.nashp.org/midwife-medicaid-reimbursement-policies-by-state/.
NASHP. 2022. “Midwife Medicaid Reimbursement Policies by State.” The National Academy for State Health Policy. April 15, 2022. www.nashp.org/midwife-medicaid-reimbursement-policies-by-state/.
NASHP. 2022. “Midwife Medicaid Reimbursement Policies by State.” The National Academy for State Health Policy. April 15, 2022. www.nashp.org/midwife-medicaid-reimbursement-policies-by-state/.
- Hasan, Anoosha; Creveling, Emily. “Medicaid Reimbursement of Midwifery Services in Minnesota and Washington State Supports Diverse Pathways to Care.” www.nashp.org/medicaid-reimbursement-of-midwifery-services-in-minnesota-and-washington-state-supports-diverse-pathways-to-care/.
NCSBN. 2019. “APRNS in the U.S | NCSBN.” NCSBN. 2019. www.ncsbn.org/aprn.htm.
NCSBN. 2019. “APRNS in the U.S | NCSBN.” NCSBN. 2019. www.ncsbn.org/aprn.htm.
- New Mexico Department of Health. n.d. Review of Department of Health Practice Guidelines for New Mexico Licensed Midwives. Accessed December 16, 2022. www.nmhealth.org/publication/view/guide/7062/.
- Vedam, Saraswathi, Kathrin Stoll, Marian MacDorman, Eugene Declercq, Renee Cramer, Melissa Cheyney, Timothy Fisher, Emma Butt, Y. Tony Yang, and Holly Powell Kennedy. 2018. “Mapping Integration of Midwives across the United States: Impact on Access, Equity, and Outcomes.” Edited by Dongmei Li. PLOS ONE 13 (2): e0192523. https://doi.org/10.1371/journal.pone.0192523.
Souter V; Nethery E; Kopas ML; Wurz H; Sitcov K; Caughey AB; “Comparison of Midwifery and Obstetric Care in Low-Risk Hospital Births.” Obstetrics and gynecology. U.S. National Library of Medicine. Accessed February 21, 2023. https://pubmed.ncbi.nlm.nih.gov/31599830/.
Martin, Nina. 2018. “A Larger Role for Midwives Could Improve Deficient U.S. Care for Mothers and Babies.” ProPublica. February 22, 2018. https://www.propublica.org/article/midwives-study-maternal-neonatal-care.
The Cecil G. Sheps Center for Health Services Research. n.d. Review of Rural Hospital Closures. Shepscenter. The University of North Carolina at Chapel Hill. Accessed May 3, 2023. https://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/.
Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife‐led continuity models versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub5. Accessed 16 December 2022.
“New Law Allows Non-Nurse Midwives to Practice in Indiana.” n.d. The Statehouse File. Accessed December 16, 2022. www.thestatehousefile.com/politics/new-law-allows-non-nurse-midwives-to-practice-in-indiana/article_c1ba5042-1106-525f-814d-eefe5b77d405.html.
- “Improving Our Maternity Care Now through Community Birth Settings.” 2022. www.nationalpartnership.org/our-work/resources/health-care/maternity/improving-maternity-community-birth-settings.pdf.
“The Benefits of Midwives.” 2017. American Pregnancy Association. April 26, 2017. https://americanpregnancy.org/healthy-pregnancy/labor-and-birth/midwives/.
“Maternal Health” Availability of Hospital-Based Obstetric Care in Rural Areas. October 2022. United States Government Accountability Office. www.gao.gov/assets/gao-23-105515.pdf.
- Gomez, Ivette, Usha Ranji, Brittni Frederiksen Published: Feb 17, and 2022. 2022. “Medicaid Coverage for Women.” KFF. February 17, 2022. www.kff.org/womens-health-policy/issue-brief/medicaid-coverage-for-women/#:~:text=Medicaid%20is%20the%20largest%20single.
Acknowledgements
This policy brief was written by Emily Creveling and Anoosha Hasan. Carrie Hanlon and Karen VanLandeghem also contributed to this brief through guidance and review. NASHP thanks the state Medicaid officials, as well as officials at the Health Resources and Services Administration, Maternal and Child Health Bureau, for their review.
This brief is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services HHS under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, content, and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred, by HRSA, HHS, or the U.S. government.
