California Community Midwives Face Medicaid Barriers That Limit Perinatal Care Access

Why California's Community Midwives Stay Outside Medicaid

A peer-reviewed study from the University of California, San Francisco has documented why most community midwives in California do not participate in Medicaid, even though Medicaid pays for roughly half of births in the United States and community-based midwifery is widely discussed as a way to reduce persistent perinatal health inequities.

Researchers interviewed 62 midwives and two non-midwife birth center administrators working in independent home birth practices and freestanding birth centers between 2022 and 2025. They identified three main barriers to becoming Medicaid providers: extremely low reimbursement rates for the continuous care midwives provide; liability insurance and birth center licensing requirements that are unaffordable and not designed for community birth settings; and administrative bureaucracy that places a heavy burden on independent clinicians.

Published in the Journal of Midwifery & Women’s Health, the study found that midwives often use informal workarounds to serve lower-income clients despite these barriers. The authors conclude that California’s current structure makes Medicaid participation administratively inaccessible and financially unsustainable for most community midwives, and they argue the findings carry national lessons for state Medicaid policy.

Inside the Three Barriers Blocking Medicaid Midwifery Access

Reimbursement Rates Do Not Match the Care Model

The financial barrier is central: the study reports that Medicaid rates are extremely low relative to the extended, continuous care community midwives provide. That matters because community midwifery typically spans prenatal visits, labor and birth support, and postpartum care, not a single reimbursable episode. When payment does not account for that time commitment, independent practices can struggle to justify formal Medicaid participation. The paper does not publish a specific dollar rate, but the barrier appeared consistently across interviews.

Insurance and Licensing Rules Were Built for Hospitals

Authors describe liability insurance and birth center licensing requirements as both unaffordable and not reflective of community birth settings. That mismatch is important because treating freestanding birth centers and home birth practices as if they were hospital-based facilities can price out smaller independent providers, reducing the supply of community midwifery care for Medicaid beneficiaries.

National Implications Are a Policy Prescription, Not a Proven Outcome

The study concludes that reducing administrative burdens, improving reimbursement rates, and restructuring the payment model could increase access to community midwifery care and improve perinatal health outcomes. That conclusion is a policy argument grounded in interviews, not a controlled effectiveness study. Because Medicaid finances half of US births, the California findings may be a useful reference for other states, but each Medicaid program would need to test which changes work locally.

State and Payer Reforms to Expand Community Midwifery

• For state Medicaid directors: Use the study’s finding on “complex administrative bureaucracy” as a reason to audit enrollment, credentialing, and revalidation steps for independent community midwives, not just institutional providers.
• For Medicaid rate-setting officials: Reassess whether current payments reflect the continuous care model the study identifies as undervalued. The authors recommend restructuring the payment model, not only raising a single rate.
• For insurers and Medicaid managed care plans: Review liability insurance and birth center licensing requirements in contracts and network standards. The study describes these as “unaffordable and not reflective of community birth settings,” suggesting that adapting them could remove a documented barrier.
• For other states: Treat the California study as a benchmark for evaluating local midwifery access, since the authors argue the findings have national implications and Medicaid funds half of US births.