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The Alabama Department of Public Health released statistics last week that show Certified Professional Midwives have so far primarily provided services to white women with the ability to pay.
Chloe Raum, one such midwife operating in the state, told APR there are a variety of factors behind those statistics, many of which are out of CPM’s control.
The statistics show that in the four years since the Alabama Legislature created a statute to allow such midwives to practice in the state, a vast majority of the deliveries have been provided to white women, almost entirely through self-pay. In 2022, 87 percent of deliveries were performed on white mothers, while 94.5 percent were self-pay.
“I really see it as a two-fold issue of what has to be resolved to make a change,” said Raum, a Certified Professional Midwife, or “licensed midwife,” practicing as Harvest Midwifery in Harvest, Alabama.
Part of the issue is simply a lack of midwives in the state with the practice being outlawed for decades in the state before the 2019 statute.
“We need to grow the midwifery workforce. We are community-based providers; we need to have a midwife in every community or a couple in every county,” Raum said. “That’s the staffing that would have to be there to be making a big difference. The challenge with growing the midwifery workforce is it takes time to grow midwives. There’s usually going to be a 2- to 4-year training period in order to do that. Right now, we are a little bit limited by how many midwives we have, how many are being trained in the state, and how many would like to practice in Alabama.”
Raum said restrictions like those ADPH is trying to enforce are part of a restrictive practice climate that affects the potential of the midwife workforce.
There is also the matter of reimbursement for services, which Raum said is multi-faceted with some issue more complicated to resolve than others.
“In 2017, the insurance lobby demanded that the licensed midwife statute include language stating that no health or insurance plan is required to provide coverage or reimbursement for their services,” Raum said. “Insurance companies are businesses who seek to reduce their payouts to maximize their profits. Is home birth a fraction of OB/hospital costs? Yes. But why pay a fraction when you could pay nothing?”
An argument for allowing these midwives and birthing centers to operate is that they can help Alabama address a growing crisis of maternity care deserts. But the rural areas most isolated from maternity care also tend to have many women who require the help of Medicaid to afford services, and licensed midwives have not been added as Medicaid providers in the state.
“A midwife working on this issue in 2019 said that 60 percent of the rural pregnant women are on Medicaid,” Raum said. “All these women are prevented from accessing midwifery care unless they can self-pay. Many LMs offer sliding-scale payment options for Medicaid mothers, and grants may also be available to help with cost”
Even if licensed midwives were added as Medicaid providers, Raum said there’s a broader problem with Medicaid and the business model for midwives.
“Hospital providers are struggling too because Alabama Medicaid doesn’t pay well,” Raum said. “In big practices, you can see more people with insurance to make ends meet. In our model, we can’t do high-volume; we take three to four births per month. That’s what it takes for us to do our jobs and do it well, with two people. If I have somebody accepting Medicaid for $1,352 instead of $5,500, we just can’t make ends meet. We couldn’t take all Medicaid clients—that wouldn’t pay for my practice. It’s a bigger problem that I don’t know if we have the ability to change.”
Even if insurance and Medicaid coverage were available, Raum said there is yet another problem with the coverage codes that won’t allow midwives to charge a “facility fee.”
“A hospital charges for their extra staff, equipment, instruments, in addition to facility expenses and supplies,” Raum said. “There are no comparable CPT codes to cover the midwife who places “mobile birth center” resources in every client’s home by providing the extra staff, equipment, and instruments required for a safe birth.”
That inability to reach women through insurance and Medicaid also impacts the racial demographics of who midwives can help. According to March of Dimes, Medicaid coverage percent at the time of birth were highest for Hispanic women at 76 percent, and Black women at 68.3 percent on average between 2018 and 2020. During the same period, only 36.5 percent of white women were covered by Medicaid.
Despite all these challenges to providing midwifery care to the places that need it most, such as the Black Belt, Raum said it hasn’t been for lack of trying.
Raum pointed to a memorandum released by ADPH in August that specifically called out CPMs to make a significant impact in Black Belt counties, noting that each year only 3.5 percent to 6.9 percent of deliveries were performed in those counties.
Raum said those stats show that CPMs are making an effort to assist in those maternity care deserts when possible though, as those deliveries are being performed by out-of-county midwives.
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