When I was pregnant in 2019, I knew that I wanted to receive care from a midwife. Having advocated for health equity for more than a decade, I was aware that midwives improve outcomes for mothers and birthing people by lowering rates of preterm birth and cesarean delivery, and by emphasizing trust, respect, and shared decision-making. I also knew that midwives from diverse backgrounds reduce maternal health disparities for members of historically underserved communities. As a Black woman and expectant first-time mother, I wanted access to culturally relevant care rooted in the community.
But finding that care was surprisingly hard. In Los Angeles, the state’s largest metropolitan area, I struggled to find a Black midwife who lived close by. When I expanded my search to other parts of LA, the midwife I found was in such high demand that she didn’t have the capacity to take me on as a patient. In the end, I chose a provider based on proximity, a physician at a practice where I was one of a handful of Black patients. While the prenatal care I received was competent, it wasn’t delivered by the culturally representative maternity care team I had hoped for.
Since then, California and the nation have plunged into a worsening maternity care crisis that was exacerbated by the COVID-19 pandemic. Since 2020, OB-GYNs and labor and delivery nurses have left the field at alarming rates. Fewer physicians are accepting Medi-Cal, and half of California’s birth centers have shuttered. In the past decade, more than 50 hospitals statewide stopped delivering babies, turning entire regions into maternity care deserts. The crisis is most acute in Black and Latino/x communities, which face more barriers to access and higher rates of pregnancy-related death.
It doesn’t need to be this way.
California’s Skilled Midwifery Workforce
California has a highly skilled midwifery workforce waiting in the wings, ready to plug care gaps and improve access to high-quality, patient-centered care. In fact, midwifery services have long been covered for pregnant people enrolled in Medi-Cal. Since the 1970s, care from certified nurse-midwives (CNMs), who mostly practice in clinics and hospitals, has been reimbursable under Medi-Cal. And in 2016, the California Department of Health Care Services allowed licensed midwives (LMs), who mostly practice in homes and birth centers, to be compensated by Medi-Cal for their services.
And yet, only 8.4% of LM patients’ care is paid for by Medi-Cal, compared with 41% of CNM patients’ care. The top reasons cited by LMs for not accepting Medi-Cal patients are inadequate reimbursement rates and bureaucratic authorization processes.
We know that mothers and birthing people, especially in the Black community, want midwifery care, so why is this benefit not more widely used? Why are midwives struggling to find work while women and birthing people struggle to get care?
I am perplexed by the fact that the potential of this cost-effective, high-impact workforce is not being realized. Yet I feel hopeful. I believe the solutions to the nation’s maternity care and health workforce challenges are to expand the midwifery workforce, to better integrate midwives into health systems and care teams, and to ensure that policies meet their needs. Policymakers and health leaders need to understand the opportunities that midwives represent. To give more families a fair shot at a healthy start, here are the goals I would pursue:
1. Develop the Workforce
California’s midwifery workforce is not representative of the populations it serves: In 2023, 2% of California licensed midwives were Black compared to 6% of the birthing population. Only 12% of the state’s LMs were Latino/x compared to 45% of people of childbearing age. California has only two programs to train certified nurse-midwives and no operational LM programs.
We should increase the number of midwifery practitioners, especially those from historically underserved communities, such as rural areas. Angela Sojobi, PhD, DNP, CNM, is a midwifery educator and lead midwife at Martin Luther King Jr. Community Hospital in Los Angeles. She is only able to graduate eight to 12 midwives per year. “The training of midwifery students is difficult,” Sojobi said. “The number is constrained because we have to pair our students with practicing midwives in the community, and there aren’t enough people for students to pair with.”
Important steps are being taken to move the needle. The California Department of Health Care Access and Information is funding two LM programs through the Song-Brown Program. The training will be housed at Cerro Coso Community College, the first LM program created within California and located about 80 miles east of Bakersfield; and in the hybrid Commonsense Childbirth School of Midwifery, which officially opens to students in fall 2026 and will feature a strong focus on Black maternal care. These will enable more students from marginalized communities to join the profession, but more investments are needed. Only by developing a diverse midwifery workforce can we achieve equitable access to maternal health care.
2. Integrate Care
If the midwifery workforce remains siloed from the larger health care system and remains unable to practice with full autonomy, investments in education and training can go only so far. Few Medi-Cal clinics and hospitals keep midwives on staff or extend practice privileges to midwives, making it difficult for them to build sustainable careers. The challenge is complicated by the fact that services provided at birth centers are reimbursed at a lower rate than at hospitals, making it hard for birth centers to stay in business.
Maximizing the potential of the midwifery workforce requires better integration of midwives into our care delivery and payment systems. This means having midwives on hospital staffs or giving community-based midwives hospital privileges. Midwives’ track record of limiting medical interventions and preventing stays in newborn intensive care units will “save hospitals money in the long run,” Sojobi said.
Medi-Cal should strive for parity in reimbursement for midwife services provided at both birth centers and hospitals. It should also streamline payment processes so birth centers, which are typically small businesses operating on tight budgets, don’t get overextended covering overhead costs while awaiting reimbursement. CHCF has reported that 85% of licensed midwives do not contract with Medi-Cal because billing processes are complicated and reimbursement rates inadequate.
Allegra Hill, LM, who runs Kindred Space Los Angeles birth center, intended to accept Medi-Cal payments when the South LA business opened in 2020, but low reimbursement rates and delayed payments made it impossible to operate as a Medi-Cal provider. “It became clear that if we succeeded in accepting Medi-Cal, our business would close,” she said.
3. Shift the Culture
The state Department of Health Care Services and providers recognize midwives as essential partners in achieving the DHCS goals of equitable, accessible, and high-quality maternity care. There is more than enough maternity care work to go around. Midwives are not a threat to physicians — they are one type of provider in a multidisciplinary care team.
Moms and birthing people should have the right to choose who is on their team from a wealth of excellent options and not base the decision on workforce shortages or other hurdles to access. “People are afraid of what they don’t understand,” said Nikki Helms, LM, principal midwife at San Diego Community Birth Center. “We do all the same tests that the doctors do, but we give much more intimate, individualized, personal care.”
Getting to this point will take some legwork. Many providers, policymakers, and health care leaders don’t realize that Medi-Cal reimburses for midwifery services. Hospital leaders and plan executives are only beginning to understand that investing in a midwifery workforce saves money over time by prioritizing prevention and helping patients avoid unnecessary, expensive interventions. With better policies, health plans can more effectively deploy the state’s midwifery workforce and solve our maternity care crisis by embracing person-centered care.
Investing in Midwives
I believe the maternity care system can be repaired and its challenges overcome. To do that, we’ll have to stop missing opportunities to see, elevate, and invest in midwives. They are critical to solving the maternal health workforce crisis. I’m encouraged that Gov. Gavin Newsom recently signed into law the “Freedom to Birth Act,” authored by Assemblymember Mia Bonta, D-Oakland. The legislation modernizes the complex regulatory requirements birth centers must satisfy to obtain a license. Though birth centers don’t require a state license to operate in general, only facilities licensed by the California Department of Public Health are eligible for reimbursement from Medi-Cal and most insurers.
This legislation is a step in the right direction. I am hopeful that California will continue to update policies to meet the moment and move us closer to ending the maternal health crisis.
