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Insurance Coverage of Midwife Services

Written by Dr. Rieka Yu
Published on December 18, 2023
Research Highlights

Midwife attendance can reduce physician intervention and birth costs. 

There are three different midwife certifications. 

Only Certified Nurse-Midwives are covered by Medicaid in MO. 

Midwife attendance improves birth outcomes. 

National data shows a positive correlation between midwife attendance and the number of non-induced vaginal births. Midwife attendance integration into the health care system is correlated with decreases in low birth weight, newborn mortality rate, and physician intervention (e.g., inducing labor, Cesarian sections) (Vedam et al. 2018). 

Communication with physicians improves when women are attended by a midwife (Kozhimannil et al. 2015).

  • More women understood medical terms and were encouraged to discuss questions and concerns, and fewer women held back questions. 

Midwife attendance of low-risk births is associated with a $2,421 decrease in cost (Attanasio et al. 2019).

  • If midwives attend 20% of births by 2027, there would be $4 billion in savings due to fewer unnecessary obstetric procedures (Kozhimannil et al. 2019). 

Different midwives have different scopes of practice and usage. 

There are three types of midwives: Certified Nurse-Midwife (CNM), Certified Midwife (CM), Certified Professional Midwife (CPM). Before certification, CNMs must have their Registered Nurse (RN) License. In MO CNMs are also licensed as an Advanced Practice Registered Nurse (APRN) (MO State Board of Nursing 2010). Before beginning midwife certification, CMs must take certain science and health courses while CPMs do not have specific licensing or education requirements  (American College of Nurse-Midwives (ACNM) 2022). MO does not recognize CPMs (Jefferson et al. 2021).

CNMs and CMs are responsible for care during pregnancy, childbirth, and the postpartum period. Their services also include sexual and reproductive health, gynecologic health, and family planning services, including preconception care (ACNM 2022).

  • CPMs provide care, education, and counseling to women and families throughout the pregnancy, birth, and postpartum period (ACNM 2022). See Table 1 for specific midwife responsibilities. 

In 2021, 7% of births in MO were attended by a midwife. Nationally, CNM-attended births were more likely to occur in hospitals and paid for by private insurance or Medicaid. Births attended by other types of midwives were more likely to occur at home or at a freestanding birth center and paid out-of-pocket (GAO 2023).

All types of midwives attend births from white women the most often (GAO 2023). A mother’s race does not make her more or less likely to utilize a midwife. However, white mothers were more likely to be attended to by other types of midwives compared to CNMs or CMs.

In MO, 1 in 10 of babies were born to women living in rural counties (March of Dimes 2023).

  • Only 4% of MO maternity care providers practice in rural counties.
  • Women in MO travel up to 43 miles to reach the nearest birthing hospital.
  • Nationally, women are attended by a CNM or CM in rural areas less often than in urban areas (March of Dimes 2022).

Insurance coverage of midwife services differs by state.

CNMs are covered by most private insurance, Medicare, and are mandatorily covered by Medicaid. CMs are covered by most private insurance but not by Medicaid in MO. CPM insurance coverage varies by state but is not covered by Medicaid in MO (ACNM 2022).

CNMs must be certified by ACNM in MO (Mo. 20 C.S.R. § 2200-4) and must have a current MO RN License to have services reimbursed by MO HealthNet (MO Department of Social Services (DSS) 2023). In MO, APRNs and therefore CNMs are required to work collaboratively with physicians (RSMo 334.104). In collaboration with physicians, APRNs can use telehealth to serve people outside of their geographic proximity (RSMo 335.175). MO HealthNet reimburses CNM services on a fee-for-service basis (MO DSS 2023).
See our APRN Scope of Practice Science Note for the effects of restricted practice.

Under MO Health Net, CNMs can provide care at a(n) office, home (delivery and newborn care only), off-campus outpatient hospital, inpatient hospital, and birth center (MO DSS 2023). Covered CNM services include pre-birth and postpartum care, risk appraisal, delivery, Healthy Children and Youth Program

Table 1. The scope of practice for midwives. This table shows specific responsibilities of CNMs, CMs, and CPMs according to ACNM.

References

American College of Nurse-Midwives. (2022). Comparison of Certified Nurse Midwives, Certified Midwives, and Certified Professional Midwives. https://www.midwife.org/acnm/files/cclibraryfiles/filename/000000008494/20220418_CNM-CM-CPM%20Comparison%20Chart_FINAL.pdf.

Attanasio L.B., Alarid-Escudero F., Kozhimannil K.B. (2019). Midwife-led care and obstetrician-led care for low-risk pregnancies: A cost comparison. Birth. 47(1), 57-66. https://onlinelibrary.wiley.com/doi/10.1111/birt.12464.

Jefferson K., Bouchard M.E., & Summers L. (2021). The Regulation of Professional Midwifery in the United States. Journal of Nursing Regulation. 11(4), 26-38. https://www.midwife.org/.

Kozhimannil K.B., Attanasio L.B., Yang Y.T., Avery M.D., & Declercq E. (2015). Midwifery Care and Patient-Provider Communication in Maternity Decisions in the United States. Maternal and Child Health Journal. 19: 1608-1615. https://link.springer.com/article/10.1007/s10995-015-1671-8.

Kozhimannil K.B., Attanasio L., & Alarid-Escudero F. (2019). More midwife-led care could generate cost savings and health improvements. University of Minnesota School of Public Health. https://www.sph.umn.edu/sph/wp-content/uploads/docs/policy-brief-midwife-led-care-nov-2019.pdf.

March of Dimes. (2022). Nowhere to go: Maternity care deserts across the U.S. https://www.marchofdimes.org/sites/default/files/2022-10/2022_Maternity_Care_Report.pdf.

March of Dimes. (2023). Where you live matters: Maternity care in Missouri. https://www.marchofdimes.org/peristats/assets/s3/reports/mcd/Maternity-Care-Report-Missouri.pdf.

Missouri Department of Social Services. (2023). MO HealthNet Nurse Midwife Manual. https://mydss.mo.gov/media/pdf/nurse-midwife-manual.

Missouri State Board of Nursing. (2010). APRN Recognized Specialties. https://pr.mo.gov/boards/nursing/APRN%20RECOGNIZED%20SPECILITIES.pdf.

Mo. Revisor § 334.104. (2023). https://revisor.mo.gov/main/OneSection.aspx?section=334.104.

Mo. Revisor § 335.175. (2023). https://revisor.mo.gov/main/OneSection.aspx?section=335.175&bid=54245&hl=.

Mo. 20 C.S.R. § 2200-4. (2021). https://www.sos.mo.gov/cmsimages/adrules/csr/current/20csr/20c2200-4.pdf.

United States Government Accountability Office. (2023). Information on Births, Workforce, and Midwifery Education. https://www.gao.gov/assets/gao-23-105861.pdf.

Vedam S., Stoll K., MacDorman M., Declercq E., Cramer R., Cheyney M., Fisher T., Butt E., Yang Y.T., & Kennedy H.P. (2018). Mapping integration of midwives across the United States: Impact on access, equity, and outcomes. PLoS ONE. 3(12), e0192523. https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0192523&type=printable.

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