Barriers to Medicaid Participation for Community Midwives in California.

Abstract

Introduction: The United States faces persistent perinatal health care 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 the 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 nonmidwife birth center administrators (n = 2) in independent home birth practices and freestanding birth centers in California; data were collected between 2022 and 2025.

Results: The main barriers community midwives face to becoming Medicaid providers in California 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 being accessible within their communities and striving to provide care to people across the socioeconomic spectrum. Because of 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 care in the United States, although access to the midwifery model of care remains suppressed by a fragmented approach to insurance and long-standing marginalization of US midwives. In California, 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 care outcomes.