Association for Public Policy Analysis & Management

The birth center model of care is one of three approaches for testing prenatal care enhancements under the national Strong Start for Mothers and Newborns initiative for Medicaid and CHIP beneficiaries. The model involves comprehensive prenatal care in freestanding birth centers, typically provided by midwives who take a holistic and wellness approach to pregnancy and birth. We use Strong Start evaluation data to describe birth centers’ experiences participating in Medicaid and identify policies that hinder or facilitate Medicaid beneficiaries’ access to midwifery care in birth centers.

We analyzed qualitative data from birth centers, including over 200 key informant interviews and 40 focus groups conducted during four annual case study rounds, a telephone survey of Medicaid officials in Strong Start states, and an internet survey of participating birth centers. We identified themes related to policies influencing Medicaid participants’ access to birth center and midwifery care.

Awardee and site-level program staff and prenatal providers from more than three dozen birth centers operating in over 20 states and D.C. participated in interviews and a survey. Focus group participants included 199 of the pregnant or postpartum birth center patients who participated in Strong Start. Medicaid officials from 20 states responded to a survey.

Strong Start participants often chose birth center care because they preferred midwife providers, wanted natural birth experiences, or were seeking pain relief methods or birth procedures not available at hospitals (e.g., water birth, nitrous oxide, vaginal birth after a previous c-section). However, some birth centers limit Medicaid business because of low reimbursement rates. Around 20 percent of birth center survey respondents said inadequate Medicaid reimbursement prompted them to restrict the volume of, or even cease serving, Medicaid patients, and others enrolled Medicaid participants at a financial loss as a community service. Several reported challenges contracting with MCOs limited their ability to participate in Medicaid, though experiences varied.

Birth center interviewees reported that Medicaid reimbursement does not adequately cover costs of providing more time-intensive care (e.g., longer visits, supplementary classes). Medicaid survey findings indicate large payment differentials for uncomplicated vaginal deliveries at birth centers versus hospitals, with birth centers paid as little as 15 percent of hospital rates for the same delivery, and differentials between obstetricians and midwives’ reimbursement, with midwives paid 70 to 92 percent of physician rates for the same service.

Medicaid beneficiaries do not currently have access to the same range of maternity providers and birth settings as their privately-insured counterparts. Medicaid policies present barriers to serving Medicaid patients at some birth centers. For instance, while birth center reimbursement is required under the Affordable Care Act, not all MCOs include birth centers in their networks. Furthermore, state licensing restrictions can hinder birth center access for Medicaid beneficiaries.

Ensuring beneficiary access to a range of maternity providers promotes patient choice and individualized care. Birth centers can incorporate promising practices for participating in Medicaid as identified by Strong Start sites, such as outreach and partnerships with Medicaid MCOs or increasing patient volume to mitigate effects of lower Medicaid reimbursement.