She opened a business to deliver babies. California policies drove her out of the country
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Madeleine Wisner dreamed of making community midwife services available to all expecting parents regardless of their income when she opened Welcome Home Community Birth Center in south Sacramento.
But 451 births and five years later, Wisner is packing up her family and moving from California to New Zealand, where government policies are far more favorable to midwifery. She closed her birth center in October.
Wisner was the only licensed community midwife who took Medi-Cal patients in the greater Sacramento region, but she’s leaving, she said, because it was impossible to sustain the birth center. Insurance refused to pay two out of every three claims she submitted for services including prenatal visits, labor and delivery, at-home postpartum check ups, and lactation consultations, Wisner said.
“The entire system is not made for us,” Wisner said. “I look at Medi-Cal as the standard of care, and midwives should be part of the standard of care.”
Her experience and decision to leave reflects larger problems for California midwives highlighted in a new study released today from UC San Francisco’s Osher Center for Integrative Health. It focuses on community midwives who work outside of hospitals but have licenses and training to perform much of the same reproductive care doctors provide to women with low-risk pregnancies.
The report warns that access to maternity care will worsen in California if the state does not increase the number of community midwives who are Medi-Cal providers at a time when hospitals are shutting down labor and delivery wards and maternal mortality is trending upwards.
Seventy-five community midwives are registered with Medi-Cal, according to data provided by the state. More than 1,000 nurse midwives are registered with Medi-Cal, but the majority of those providers work in hospitals and not in community settings, researchers said.
Outdated licensing requirements, tortuous state regulations and cumbersome insurance policies make it nearly impossible for community midwives to accept Medi-Cal patients, the UCSF report found.
Medi-Cal is the state’s health insurance program for extremely low-income residents. It pays for 40% of all births statewide, and midwife care is a guaranteed benefit for expecting mothers.
On paper, the benefit includes community midwifery, which focuses on providing care close to where people live either at a birth center or in the home. But the reality is different, researchers and providers say.
“So many people who have taken Medi-Cal in the past have had to stop or close their practices, and so many people who want to have not been able to make it happen,” said Ariana Thompson-Lastad, lead author of the study.
California’s ‘Momnibus’ Act
The UCSF findings come at a time when the state is trying to make inroads against persistent maternal and infant health disparities, particularly among Black families. Statewide surveys show Black mothers are the most interested in alternative birth support through doulas and midwives, which have been shown to improve a variety of birth outcomes.
Doulas are birth workers who provide non-medical social and emotional support during and after pregnancy while licensed midwives are clinically trained professionals who can provide a range of independent reproductive care for low-risk moms and babies.
In an effort to chip away at inequities, state lawmakers passed the “California Momnibus Act” three years ago. It required Medi-Cal to cover postpartum care for a full year after birth — the period when most maternal deaths happen — and added doula benefits. In January, rate increases for California doulas made them the highest-paid in the nation.
But state regulations simply aren’t designed to accommodate the services community midwives provide, UCSF researchers found.
For example, the Medi-Cal application until recently asked midwives to list a supervising physician even though licensed midwives are authorized to practice independently. Providers also said most community midwives conduct home visits during pregnancy and especially after birth, but Medi-Cal billing policies make it difficult to get reimbursed for services that happen outside of a clinical facility.
“The overarching policy issue for licensed midwives in California is that we continue to be regulated under a very dysfunctional arrangement,” said Rosanna Davis, president of the California Association of Licensed Midwives.
Wisner, who served mostly Medi-Cal patients, said on average insurance reimbursed just 17% of her costs — roughly $1,451 out of $8,500 for a full course of prenatal, birth and postpartum care — and frequently took months to pay her.
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