Recommendations
Improving Our Maternity Care Now – Recommendations

September 2020
Maternal Health

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The ongoing maternal health crisis, compounded by the current COVID pandemic, underscores the urgency of taking concrete action now to improve birth outcomes for women and their families. Click below to see our complete recommendations for federal, state and territorial policymakers, as well as private sector decisionmakers.


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Increase Access to Midwifery Care

Midwives have a distinctive, dignifying, person-centered, skilled model of care and an exemplary track record. They are an important part of the solution to the nation’s shortage of maternity care providers. However, there are barriers to meeting this need and enabling more childbearing people and families to experience benefits of midwifery care.

Congress and federal policymakers should:

  • Enact the Midwives for Maximizing Optimal Maternity Services (Midwives for MOMS) Act (H.R. 3849 in the 116th Congress). This bipartisan bill would increase the supply of midwives with nationally recognized credentials (CNMs, CMs, CPMs) by supporting students, preceptors, and schools and programs. It would give funding preference to supporting students who would diversify the profession and who intend to practice in underserved areas.
  • Mandate payment for services of CMs and CPMs recognized in their jurisdiction by Medicaid, the Child Health Insurance Program (CHIP), TRICARE (the military health care program), the Veterans Health Administration (VHA), the Indian Health Service (IHS), and Commissioned Corps of the U.S. Public Health Service.
  • Mandate that hospitals cannot deny privileges to midwives as a class.
  • Require the collection and public reporting of data related to health inequities, such as racial, ethnic, socioeconomic, sex, gender, language, and disability disparities in critical indicators of maternal and infant health, including, but not limited to, maternal mortality, severe maternal morbidity, preterm birth, low birth weight, cesarean birth, and breastfeeding.

State and territorial policymakers should:

  • In jurisdictions that currently fail to recognize them, enact CM and CPM licensure. For CMs, these include all of the territories, the District of Columbia, and all states except Delaware, Hawaii, Maine, New Jersey, New York, Oklahoma, and Rhode Island. Jurisdictions that have yet to recognize CPMs through licensure are: Connecticut, Georgia, Iowa, Illinois, Kansas, Massachusetts, Missouri, Mississippi, North Dakota, Nebraska, North Carolina, New York, Nevada, Ohio, Pennsylvania, West Virginia, and all U.S. territories.
  • Amend unnecessarily restrictive midwifery practice acts to enable midwives to practice “at the top of their license” in line with their full competencies and education as independent providers who collaborate with others according to the health needs of their clients.
  • Mandate reimbursement of midwives with nationally recognized credentials at 100 percent of physician payment levels for the same service in states without payment parity.
  • In states where Medicaid agencies do not currently pay for services of CMs and CPMs licensed in their jurisdiction, mandate payment at 100 percent of physician payment levels for the same services. Currently, Delaware, Hawaii, Maine, New Jersey, Oklahoma, and Rhode Island recognize CMs but do not pay for their services through Medicaid. States that regulate CPMs yet fail to pay for their services through Medicaid are: Alabama, Arkansas, Colorado, Delaware, Hawaii, Kentucky, Louisiana, Maryland, Maine, Michigan, Minnesota (does not pay for home birth services), Montana, New Jersey, Oklahoma, Rhode Island, South Dakota, Tennessee, Utah, and Wyoming.

Private sector decisionmakers, including purchasers and health plans, should:

  • Incorporate clear expectations into service contracts about access to and sustainable payment for midwifery services offered by providers that hold nationally recognized credentials.
  • Educate employees and beneficiaries about the benefits of midwives with nationally recognized credentials.
  • Mandate that plan directories maintain up-to-date listings for available midwives.

Increase Access to Community Birth

For many pregnant people, community birth options offer better care, more positive experiences, improved health outcomes, and potential cost benefits. The differences in care, experiences, outcomes, and costs are so striking that a leading international maternity care researcher has recently asked, “Is it time to ask whether facility-based birth is safe for low-risk women and their babies?” Given this track record and the increasing use of, and unmet need for, these types of care, decisionmakers should act to make them more available to low-risk pregnant people who desire them.

Federal policymakers should:

  • Mandate payment by Medicaid, CHIP, TRICARE, VHA, IHS, and the Commissioned Corps of the U.S. Public Health Service for care in licensed birth centers and midwife providers in birth centers who hold nationally recognized credentials and are recognized in their jurisdiction.
  • Mandate payment by Medicaid, CHIP, TRICARE, VHA, IHS, and Commissioned Corps of the U.S. Public Health Service for home births attended by midwives with nationally recognized credentials who are recognized in their jurisdiction.
  • Enact the Birth Access Benefitting Improved Essential Facility Services (BABIES) Act (H.R. 5189 n the 116th Congress). This bipartisan bill would fund demonstrations of birth center models for improved maternity care access and quality for Medicaid beneficiaries with low-risk pregnancies in underserved areas, and develop sustainable approaches to payment for birth center care.
  • Require the collection and public reporting of data related to health inequities, such racial, ethnic, socioeconomic, sex, gender, language, and disability disparities in critical indicators of maternal and infant health, including, but not limited to, maternal mortality, severe maternal morbidity, preterm birth, low birth weight, cesarean birth, and breastfeeding.

State and territorial policymakers should:

  • Enact birth center licensure in the 10 states that do not currently regulate birth centers: Alabama, Idaho, Louisiana, Maine, Michigan, North Carolina, North Dakota, Vermont, Virginia, Wisconsin, and in the U.S. territories.
  • Mandate payment by Medicaid and CHIP programs for care in licensed birth centers, for services provided by midwife birth center providers with nationally recognized credentials who are recognized in their jurisdiction, and for home birth with midwives with nationally recognized credentials who are recognized in their jurisdiction.

Private sector decisionmakers, including health care purchasers and health plans, should:

  • Incorporate clear expectations into purchaser-payer contracts about access to and sustainable payment for community birth (birth center and home) settings and for services of midwives with nationally recognized credentials.
  • Educate employees and beneficiaries about the benefits of community birth settings and midwifery care.
  • Mandate that plans contract with birth centers and midwives with nationally recognized credentials in their service area and pay for care in all settings provided by midwives recognized in the jurisdiction.
  • Mandate that plan directories maintain up-to-date listings for available birth centers and midwives.
  • Educate maternity care providers and hospitals about the safety of integrated maternity care with consultation, shared care, and seamless transfer from community birth settings as needed, and encourage adoption of “Best Practice Guidelines: Transfer from Planned Home Birth to Hospital,” and accompanying Model Transfer Forms.

Increase Access to Doula Support

There is a strong evidence base to support the wider availability of doula services, particularly for women of color. Yet doula services are often out of reach for many pregnant people because insurance coverage for these services is rare. Given the ongoing maternal health crisis, especially in communities of color, doula care must be financially supported as a public policy.

Federal policymakers should:

  • Mandate that all federally funded health insurance programs cover payment for doula support, including the extended model with prenatal and postpartum support, and for support for specific segments (e.g., birth doula) as desired by women, including Medicaid, CHIP, TRICARE, and IHS.
  • Support research to more fully understand variations on this model, including effect
    • of community-based and led doula training and support programs for low-income, marginalized communities of color.
  • Require the collection and public reporting of data related to health inequities, such as racial, ethnic, socioeconomic, sex, gender, language, and disability disparities in critical indicators of maternal and infant health, including, but not limited to, maternal mortality, severe maternal morbidity, preterm birth, low birth weight, cesarean birth, and breastfeeding.

State policymakers should:

  • Mandate payment for extended model doula support, and for support for specific segments (e.g., birth doula) as desired by women, in Medicaid and CHIP.
  • Ensure that doula training is tailored to the specific to needs of the Medicaid population (including trauma-informed care, maternal mood disorders, intimate partner violence, and systemic racism).
  • Promote racial, ethnic, and language diversity in the doula workforce that better aligns with the childbearing population covered by Medicaid and CHIP.
  • Provide payment for extended doula support at a level that sustainably provides them with a living wage, and can help attract and retain these critically important birth workers.

Private sector decisionmakers, including health care purchasers and health plans, should:

  • Incorporate clear expectations into purchaser-payer contracts about sustainable plan payment for extended model doula services.
  • Educate employees and beneficiaries about the benefits of doula support.
  • Include doula support, including extended model with prenatal and postpartum support, as a covered benefit in health plans, ensure reimbursement levels that are able to sustain and expand the doula workforce, and promote this benefit among eligible beneficiaries.
  • Ensure that plan directories maintain up-to-date listings for available doulas or doula agencies.

Increase Support for Community-Led and Based Perinatal Health Worker Groups and for Evaluations of This Model

Given the extremely promising early evidence, community-led perinatal health worker groups have great potential for reducing racial and ethnic health inequities. Their frequent use of proven maternal care and support models is a strong asset. Decisionmakers should target support for and ongoing evaluation of these innovative, community-centered and -led groups.

Federal policymakers should:

  • Create programs to support and evaluate new and existing community-led and -based multifunctional programs, including quality of services, health outcomes, women’s experiences, and impact on equity, in comparison with similar women without access to such programs. One mechanism would be through a major program at the Centers for Medicare and Medicaid Services Center for Medicare and Medicaid Innovation.
  • Enact the Kira Johnson Act (H.R. 6144 and S. 3424 Title II in the 116th Congress) to provide funding for community-based perinatal health worker organizations, especially those led by Black women, to improve Black maternal health; to address racism and bias in all maternal health settings; and to support hospital Respectful Maternity Care Compliance Offices.
  • Enact the Perinatal Workforce Act (H.R. 6164 and S. 3424 Title IV in the 116th Congress) to provide guidance to states for promoting diverse maternity care teams and the role of culturally congruent care in improving outcomes, especially for minority women; establish and scale programs to grow the maternal health workforce (including doulas, community health workers, and peer supporters); and study barriers to entry for low-income and minority women into maternity care professions.
  • Require the collection and public reporting of data related to health inequities, such as racial, ethnic, socioeconomic, sex, gender, language, and disability disparities in critical indicators of maternal and infant health, including, but not limited to, maternal mortality, severe maternal morbidity, preterm birth, low birth weight, cesarean birth, and breastfeeding.

State policymakers should:

  • Pursue partnerships with community-based perinatal health groups, using Medicaid levers such as value-based contracts, managed care organization regulations, and state plan amendments, to support partnership efforts.
  • Work to identify and establish inventories of community-based perinatal health groups, and support efforts to evaluate them.

Private sector decisionmakers, including health care purchasers and health plans, should:

  • Incorporate clear expectations into purchaser-payer contracts about access to, and sustainable payment for, community-led perinatal health worker groups offering services of midwives with nationally recognized credentials, community birth, and/or doula services.
  • Educate employees and beneficiaries about the benefits of midwifery care, community birth, and doula services.
  • Make services of community-led perinatal health workers incorporating midwifery care, community birth, and/or doula services available to beneficiaries, and evaluate the overall multifunction model and return on investment, including implications of quality of care, health outcomes, and women’s experiences, and possible synergistic effects.
  • Mandate that plan directories maintain up-to-date listings for available community-led perinatal health worker groups whose services are paid for by plans.



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