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Outdated licensing requirements, tortuous state regulations and cumbersome insurance policies make it nearly impossible for community midwives to accept Medi-Cal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.

Midwife Madeleine Wisner measures Chloé Mick’s belly during a maternity care consultation at Mick’s home in Sacramento on Feb. 6, 2024. Photo by Miguel Gutierrez Jr., CalMatters

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.

“We’ve had people have two or three babies with us before we get paid for the first one,” Wisner said.

The state is trying to make improvements, said Holly Smith, co-lead of the California Midwifery Learning Collaborative, but the system is still “failing a lot of people.” The midwifery learning collaborative is a five-state initiative aimed at improving access to midwife care. The state agency that oversees Medi-Cal recently joined, Smith said.

In an emailed statement, the Department of Health Care Services said it is working closely with the midwifery learning collaborative to help midwives “successfully navigate and work within Medi-Cal.” The department is using a document drafted by the collaborative to “continue making program and policy improvements” on issues related to billing and applications, the statement said.

Midwives could help fill maternity gaps

Large studies of birth center and at-home birth outcomes show that when trained midwives care for low-risk patients, cesarean section and preterm birth rates decrease while breastfeeding rates and reports of satisfactory birth experiences increase. Severe outcomes and deaths of mother and baby are exceedingly rare and similar to the rates found in planned hospital births. UCSF researchers also found that community midwives see patients more frequently before and after birth and are able to catch complications early.

The majority of Medi-Cal births — more than 80% — are babies of color. They and their mothers suffer some of the worst infant and maternal health outcomes. Even though the state has made improvements overall, it has struggled to curb severe pregnancy complications and death among Black women and babies. Black women of all income levels are more than four times as likely as white women to die from pregnancy-related complications and their babies are nearly three times as likely to die within a year, according to state data.

Physicians deliver the vast majority of babies in California, and while the percentage of babies delivered by certified nurse midwives has increased slightly in the past decade most certified nurse midwives work in hospital maternity wards under doctors. Often when maternity services end, providers leave the area.

At least 46 hospitals have closed maternity wards since 2012, leaving a dozen counties without a single hospital delivering babies, a CalMatters investigation found.

Smith, with the midwifery learning collaborative, said historically state laws and policies have supported physician-only maternity care.

“It’s not safe anymore to do that,” Smith said. “We have a maternity desert situation. Literally hospitals are closing, and birth centers will be a necessary strategy for that.”

One of her last California patients

Midwife Madeleine Wisner speaks with Chloé Mick during a maternal care consultation at Mick’s home in Sacramento on Feb. 6, 2024. Photo by Miguel Gutierrez Jr., CalMatters

In a cozy house in Sacramento’s Oak Park neighborhood, Wisner has Chloé Mick lie back on her couch while her kids and husband play outside. Wisner measures the length of Mick’s uterus, feels for the baby’s position and they both listen to the baby’s heartbeat. Mick is 25 weeks pregnant and tired.

“I feel the most depleted probably just from having two other children that I hope I have the inner strength to not get a bad attitude during the process and make it through,” Mick tells Wisner.

Wisner responded, “Has it occurred to you that having a bad attitude is OK?”

Mick is planning a home birth, and Wisner assures her that going to the hospital would not be “giving up.” It would be listening to her body’s needs and responding appropriately. They make plans for what to do if the baby is breech or if Wisner’s New Zealand visa comes before Mick gives birth. When Mick’s second child was born, she was on Medi-Cal and Wisner was the only midwife who would take her.

“(The hospital) really feels like a business. You’re in and out, and you don’t have a rapport or relationship with them…It feels like your bodily autonomy is taken away,” Mick said. “And then you look back, and you wish you had done things different.”

Midwife Madeleine Wisner uses a fetal doppler on Chloé Mick’s belly during a maternal care consultation at Mick’s home in Sacramento on Feb. 6, 2024. Wisner is listening to the fetal heartbeat. Photo by Miguel Gutierrez Jr., CalMatters

Wisner wishes her birth center’s story had ended differently. Her practice finally had enough patient volume to maybe be sustainable, she said, but the other community midwives who worked with her didn’t want to argue with Medi-Cal insurers day in and day out. Over the past five years, Wisner estimates she poured $250,000 into the birth center to keep it open. It’s a big reason why she’s leaving California for another country where she’ll make $60,000 a year working four days a week with a team of other midwives.

“There was always this promise that the system would be reformed, you know, Medi-Cal is gonna get reformed,” Wisner said. “I was really let down.”

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Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

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