Doulas have been a popular topic in the maternal health space as one means of improving birthing outcomes, especially for Black women and other communities of color that have been historically marginalized from the traditional health system. It can be confusing to differentiate between the different support persons and clinicians that may assist expecting or postpartum parents. While an important resource, doulas are just one among many possible opportunities for Medicaid to improve care. Doulas do not have formal clinical and/or obstetrical training. They can provide support to their clients physically, emotionally, and by educating them about different topics like childbirth and breastfeeding. States have begun reimbursement for doulas through Medicaid, but rates oftentimes are low.
A recent report by the National Academy of State Health Policy (NASHP) details the opportunity to respond to the maternal health crisis by expanding Medicaid payment initiatives to include a full range of midwifery care. Midwifery care has been shown to improve health outcomes for low-risk pregnancies. Midwives are clinicians that can help women deliver their babies and so much more. Historically, American Indian and Black women used indigenous and cultural practices to deliver babies in the United States. As the field of midwifery began to become more regulated in the late 1800s to the mid 1900s, midwives of color essentially became pushed aside due to a lot of red tape and systemic racism. The impact can still be felt today, as people of color constitute less than 5% of the midwifery workforce.
In the United States, there are three recognized different types of midwives; certified nurse-midwives (CNMs), certified midwives (CM), and certified professional midwives (CPMs). The table below briefly describes some key differences between them. Unlike CNMs, CMs and CPMs are not required to have nursing degrees.
Apart from assisting in childbirth, CNMs also usually are advanced practice registered nurses (APRNs) and some even are women’s health nurse practitioners where they have prescriptive authority and can treat women throughout the perinatal period. In addition to CNMs, CPMs, and CMs, there are other definitions of midwives such as Licensed Midwives (LMs), Direct Entry Midwives, and traditional midwives. Different states may define midwives differently in terms of their scope of practice. The differences can be seen in NASHP’s Midwife Licensing and State Medicaid Reimbursement Policies table.
Policy recommendations from NASHP’s analysis include:
- Prioritize policies to increase access to midwifery care
- Reimburse midwives without a nursing degree
- Integrate CNMs and midwives into holistic primary and reproductive health care settings
- Leverage midwifery care to advance community maternal health provider availability
As the U.S. faces a maternal mortality and morbidity crisis, midwives need to be a part of the conversation along with other clinicians and community-based supports like doulas. All can work together to ensure the maternal care workforce has the community reach and wide range of providers to serve the unique and varied needs of perinatal women.
Editor’s note: To maintain accuracy, Georgetown CCF uses the term “women” when referencing statute, regulations, research, or other data sources that use the term “women” to define or count people who are pregnant or give birth. Where possible, we use more inclusive terms in recognition that not all individuals who become pregnant and give birth identify as women.