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Women’s rights to reproductive choice should not be limited to whether or not to continue a particular pregnancy. Their range of reproductive choice should also include the ability to choose preferred health care providers for pregnancy, birth, and well-woman health care services. Unfortunately, the right to give birth where, how, and with whom a woman chooses is, like abortion, under threat today. Federal and state policies particularly impact Medicaid recipients and other low-income women, often denying them the right to receive services from a midwife, or to give birth at home or in a free-standing birth center.
There are two types of midwives who practice today in the United States: Certified Nurse-Midwives and Direct-Entry Midwives. DEMs enter midwifery education directly, without first being required to become a registered nurse, while nurse-midwives are both R.N.s and midwives. CNMs provide well-woman gynecological care and family planning services; DEMs focus more exclusively on pregnancy and birth.
Midwives believe in the natural birthing process and in the power and innate ability of women to give birth. CNMs typically have the legal right to prescribe medication, but both DEMs and some CNMs are more apt to rely on herbs and natural remedies. Midwives attend births in freestanding birth centers or in the woman’s own home, and some CNMs also provide birthing services in hospitals, although not all hospitals have granted them the right to practice.
Out-of-hospital birth has been proven to be as safe, if not safer, than hospital birth for women who are at low risk for complications. Women who are hospitalized for childbirth have faced unnecessary interventions from the medical establishment, including a disturbing increase in Cesarean sections. Midwives, in contrast, try to help women avoid medical interventions and have very low C-section rates.
Despite the benefits midwives can offer to women, reimbursement for midwifery services in the United States is far from guaranteed. Private insurers have been slow to include midwives as participating providers. And as for government programs, the results are mixed. Federal law mandates payment under Medicare and Medicaid for CNM services in all states, but Medicare, which covers services to disabled women of reproductive age, will only pay for services provided by CNMs at a rate of 65 percent of what a physician would be paid for the same services.
Technically, state Medicaid plans are required to cover CNMs for all eligible enrollees, but not all states comply with the federal mandate. Thus, the present status of access to midwifery by Medicaid recipients varies from state to state. Some states, for example, have refused to pay for home birth or births in birthing centers, newborn care, or the full spectrum of gynecological care that CNMs are licensed to provide. Some states have also tried to require CNMs to be employed or supervised by a physician, or to submit bills through a physician in order to be paid, even though the mandate requires state Medicaid plans to pay CNMs directly.
DEMs, however, do not have a federal statutory mandate and have only been recognized as Medicaid providers so far in nine states. This lack of coverage stems in part from insufficient lobbying resources that could focus legislative attention on this issue. But it also is due to opposition from organized medicine, which continues to oppose licensure and reimbursement laws for this group of competitors, and paternalistic state policies that seek to “protect” Medicaid recipients from birth at home or in freestanding birthing centers.
The ability of female professionals to get paid for their work is certainly important, but the rights of Medicaid recipients to obtain services from the health professionals of their choice must be viewed as paramount. When state Medicaid programs deny coverage for any part of the full spectrum of birthing and reproductive health care services, they effectively restrict the reproductive choices of low-income women in that state. Moreover, they ultimately direct women toward a medical path where they could have unnecessary interventions or disincentives to obtaining care, placing themselves and their children at greater risk.
Several years ago, the primary providers of in-hospital services for low-income women in Washington, D.C. were CNMs. They staffed several local clinics and the labor and delivery unit of the city-owned hospital. Yet the managed care plans that administered the Medicaid program refused to include CNMs as participating providers. They were eventually required to do so, but had CNMs been left out of the provider roster in these plans, low-income women would not have been able to pay for the services provided in their neighborhood. Women who have to travel to receive prenatal care are more likely to skip appointments, so coverage of the CNM-staffed clinics was vital to ensuring that the women obtained proper care.
There are some states, however, that have adopted a highly progressive attitude toward midwives and place of birth services for Medicaid enrollees. New Mexico has required Medicaid to cover all midwifery services and has lifted malpractice insurance requirements if the insurance is unavailable or prohibitively expensive. It has also established a birthing-options program to educate Medicaid-enrolled women about available alternatives for pregnancy and birth.
Over 32 percent of babies born in New Mexico are born into the hands of midwives—the highest percentage in the country. Approximately half of all births in New Mexico are paid by Medicaid. In order to increase access to prenatal care and lower the rate of teenage pregnancy, New Mexico has expanded its income eligibility ranges for women so that even more will qualify.
New Mexico’s policies are in stark contrast to those of its neighbor Texas, which refuses to offer Medicaid coverage for births attended by DEMs and limits access to out-of-hospital births attended by CNMs. Texas Medicaid takes this position despite a state law that expressly recognizes the right of all parents “to give birth where and with whom the parent chooses.”
Restrictions on a woman’s reproductive choices are a slippery slope. Government agencies not only dictate whether a woman may terminate her pregnancy by withholding payment; they also use their power to deprive low-income women of the choice of giving birth where, how, and with whom they wish. We must resist these restrictions whenever they occur, all along the spectrum of reproductive choice.
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Susan Jenkins is an attorney in private practice in Washington, D.C., and the former general counsel of the American College of Nurse-Midwives, which is the national professional society for certified nurse-midwives.