2024 Iowa maternal health priorities: Birth centers, Medicaid, and midwives

Photo provided by the author, showing maternal health advocates advocating for licensure of certified professional midwives during an Iowa House Ways and Means subcommittee meeting in February 2023.

Rachel Bruns is a volunteer advocate for quality maternal health care in Iowa.

This time last year I wrote about five policies that would improve maternal health in Iowa. I’m updating the piece for the 2024 legislative session with a focus on three core priorities. 

Although access to abortion care and contraceptives are critical to maternal and infant health, I do not discuss those topics here. I want to highlight lesser-known aspects of maternal health specific to prenatal, birth, and postpartum care, which receive much less media coverage.

For the 2024 legislative session, I am focusing on three issues I raised last year, which have a strong chance to be enacted. These policies would improve maternal health in Iowa by expanding access to midwives and expanding prenatal care options. I wrote at length in 2021 about how midwives save lives, and it seems like every week a different study or article underscores how the midwifery model of care leads to better outcomes. If you’re interested in diving deeper, one of my favorite resources released in 2023 is this Issue Brief on Maternity Medicaid Strategies from the Maternal Health Hub.

It’s also important to acknowledge that infant mortality increased in 2022 for the first time in 20 years. As reported by The Associated Press, “More than 30 states saw at least slight rises in infant mortality rates in 2022, but four states had statistically significant increases — Georgia, Iowa, Missouri and Texas.” 

The two main factors contributing to the increase in infant mortality are poverty and inadequate prenatal care. Almost one-third of Iowa is classified as a maternal health desert. The solutions described below could improve access to prenatal care in rural areas by expanding low-cost and high quality prenatal care options, leading to better outcomes for moms and babies. 


As I wrote last year, Certificate of Need (CON) laws increase health care costs, make it harder for individuals like midwives to establish freestanding birth centers, and create fewer options for Iowans seeking prenatal, birth, and postpartum care. If you didn’t read my previous article, here is a quick recap of why this matters:

According to the American Association of Birth Centers, certificate of need laws are associated with fewer birth centers in a state. Research has shown birth centers improve outcomes, narrow racial disparities, enhance patient satisfaction, and reduce costs to state Medicaid programs and other payers. 

Iowa is in the minority of states that require a certificate of need for birth centers (less than 15 states). Among nearby states, Minnesota, South Dakota, Nebraska, Kansas, Missouri, and Wisconsin do not require a certificate of need for birth centers. (Side note: I’m tired of Iowa media outlets incorrectly reporting on birth center specific CON laws in other states. They often don’t do the extra work of finding that while more states have CON laws, many exempt birth centers!)

This 2019 report confirmed that birth centers deliver improved health outcomes at a lower cost, averaging 21 percent lower cost of birth and 15 percent lower cost for care for women and infants for the first year after birth.

The Institute for Medicaid Innovation’s 2020 report on Improving Maternal Health Access, Coverage, and Outcomes in Medicaid indicated that midwife-led care—including in freestanding birth centers—results in improved care, better outcomes, and costs less.

State-level developments in 2023

A few things have changed since last year. The only freestanding birth center in Iowa closed, making Iowa one of only a handful of states without any freestanding birth centers.

In addition, Pacific Legal Foundation took on a pro bono legal case on behalf of two Certified Nurse Midwives, Caitlin Hainley and Emily Zambrano-Andrews, who want to open a freestanding birth center. Hainley and Zambrano-Andrews provide primary care, gynecological, pregnancy, and lactation services in their Des Moines based clinic. They also provide home birth services, but are unable to open a freestanding birth center without going through the expensive Certified of Need process with no guarantee of success. I cannot think of any other small business having to jump through similar hoops to start a business, let alone one that would meet a pressing need. 

Last year, the Iowa Senate approved Senate File 506 by 29 votes to 21, with five Republicans and all Democrats voting against the legislation. The bill is a broad reform of Certificate of Need, which would increase the financial thresholds of health care facilities that would need to go through CON. It would also eliminate the Health Facilities Council (a state board appointed by the governor) and instead have a state agency administer the CON application process. Additionally, the bill would exempt birth centers and community mental health centers. The bill could be considered this year by the House Health and Human Services Committee.

It is unclear to me why Senate Democrats opposed this bill and want to protect the Health Facilities Council. Eliminating or improving Certificate of Need should be a bipartisan issue, even if pro-business and anti-regulation organizations are leading the charge.

I am not naive enough to assume most of those advocating for the elimination of CON are primarily concerned with health care outcomes. More likely, they are interested in making money for their mostly physician clients. That being said, maintaining CON only serves to protect hospitals as monopolies in a state with very little accountability for their outcomes. 

As this 2021 Forbes article noted, “Demonstrating the potential for bipartisan cooperation on this issue, the need to repeal or reform CON requirements was a rare instance of agreement between the Obama and Trump administrations.” 

The same Forbes article mentioned, “Controlling for other factors, researchers find that the average patient in a CON state has access to fewer hospitals, fewer hospice care facilities, fewer dialysis clinics and fewer ambulatory surgery centers (ASCs)”.

When it comes to access to health care, Iowa is already on the struggle bus. CON laws make it harder for midwives like Hainley and Zambrano-Andrews to open a birth center. As I have written before, other midwives in Iowa have tried to open a birth center and were denied through the CON process. 

While I support Senate File 506 for removing birth centers from CON, I am concerned about the amendments related to birth centers, added at the request of hospital lobbyists. The amended bill requires the Department of Inspection, Appeals, and Licensing to create a provisional birth center licensure and proposed birth center licensure legislation the following year. 

Any proposed birth center licensure should be developed with input from experts like those at the American Association of Birth Centers. While I see value in establishing standards for freestanding birth centers in Iowa, I am apprehensive about eliminating one barrier to create another, if not done properly. Just this past year, the ACLU sued the Alabama Department of Public Health due to its “defacto ban on birth centers” per their birth center licensure being unattainable. The case is ongoing, while Alabama’s first licensed birth center opened in December thanks to a preliminary injunction.

Possible change at the federal level

Some glimmers of hope from the federal government include a new model from the Centers for Medicare and Medicaid Services (CMS). Released in December, the model seeks to increase access to midwives and birth centers. States wanting to receive funding from CMS will need to be willing to make way for freestanding birth centers. For Iowa, that could mean not only exempting birth centers from CON, but also making sure Medicaid funding is accessible. As of today, the state is not in compliance with having a birth center fee schedule.

Members of Congress have proposed several bipartisan federal bills in recent years, which would uplift midwifery and birth centers. The Midwives for MOMS Act, introduced in June 2023, would provide funding for midwifery education. Its lead sponsors are Iowa’s own U.S. Representative Ashley Hinson (R, IA-02), Representative Bonnie Watson Coleman (D, NJ-12), Democratic Senator Ben Ray Luján of New Mexico, and Republican Lisa Murkowski of Alaska.

The BABIES Act, introduced in 2022, seeks to promote accessible and affordable use of freestanding birth centers by Medicaid beneficiaries. U.S. Representative Katherine Clark (D, MA-05), who was the assistant speaker at the time, was the lead sponsor in the House. Original co-sponsors included Representative Jaime Herrera Beutler (R, WA-03), Lucille Roybal-Allard (D, CA-40), and Hinson. As of October 2022, 46 House members had co-sponsored the bill. Luján was the BABIES Act’s lead sponsor in the Senate.

The Black Maternal Health Momnibus Act combines provisions from thirteen bills that would improve perinatal care and diversity in the perinatal workforce, with a focus on maternal health disparities and access to the midwifery model of care. 

Whether it is through legislation, a lawsuit, or federal funding, I hope CON will soon be one less barrier to Iowans having access to freestanding birth centers.  


Talking about improvements to Medicaid coverage may seem like a long-shot in a red state. But when Iowa Medicaid covers more than 40 percent of Iowa births, every legislator regardless of political affiliation should understand the importance Medicaid plays in maternal and infant health outcomes. 

Extending postpartum coverage

The big push in 2024 will be to extend Medicaid coverage postpartum from the 60 days Iowa currently provides to twelve months. At this writing, just three states—yes, you read that correctly—only Arkansas, Idaho, and Iowa have yet to adopt twelve months of postpartum Medicaid coverage. A broad coalition of organizations led by Iowa ACEs 360 is working to make the case for this policy.

Some of the most dangerous pregnancy-related complications (i.e., eclampsia, blood clots, cardiomyopathy, strokes) may not surface until months after delivery. Without access to health coverage, these conditions can go undetected and untreated, sometimes turning deadly. According to the 2021 Iowa Maternal Mortality Review Committee Report, 54 percent of Iowa’s pregnancy-associated deaths occurred within 43 days to one year after birth. 

Suicide and overdose are the leading causes of death in the first year postpartum, with the 3-6 month time frame as the most critical for mental health issues developing, and 6-9 months the time frame when most pregnancy related suicides occur per the Maternal Mental Health Alliance. While suicide and overdose are the leading causes of death for the majority of new mothers, when you break this down by race, it is only the leading cause for white women and Hispanic women. The leading cause of death for Black women is cardiac and coronary conditions, and the leading cause for Asian women is hemorrhage. 

Maternal mortality and morbidity from untreated pregnancy related or associated conditions affect Iowa’s economy. Maternal health issues may affect the ability to work and can create significant losses in the family’s economic productivity. A study by Commonwealth Fund found that over a five year period, maternal morbidity cost the United States $6.6 billion in lost productivity. The estimated total maternal morbidity costs for all U.S. births in 2019 is estimated to be $32.3 billion from conception through the child’s fifth birthday. This amounts to $8,624 in additional costs to society for each maternal–child pair.

In Missouri, Republican Senator Elaine Gannon sponsored the 2023 bill that extended postpartum Medicaid coverage bill to twelve months. She explained that the potential cost of the program was worth it if it meant saving lives. I agree, and while I don’t have data to support this, my strong assumption is that twelve-month postpartum Medicaid coverage will not only save lives, but will also save states money in the long run, with fewer downstream health consequences impacting an already strained health care system. 

Iowa has one thing to be proud of: the state currently provides Medicaid coverage for pregnant individuals at or below 375 percent of the Federal Poverty Level through pregnancy and currently up to 60 days postpartum. A concern is that in order to pass a bill to extend coverage to 12 months postpartum, there will be a compromise to scale back the income limits, so fewer women will be covered. While 375 percent may seem high, research shows that 15.1 percent of pregnant and 18.3 percent of postpartum people with commercial insurance face medical debt, making them effectively underinsured. 

I commend Governor Kim Reynolds for proposing to extend Medicaid to twelve months postpartum. She said in her 2024 Condition of the State Address on January 9,

To continue building a robust culture of life, we must also do everything in our power to ensure new moms and their families—especially those who are struggling—have what they need to make ends meet. Today, Medicaid only covers postpartum care for two months after birth. I’m proposing to expand that coverage to 12 months, for new moms who make less than $42,000 a year.

Unfortunately, the governor’s plan would give fewer Iowans Medicaid coverage during pregnancy. The governor’s proposed budget for fiscal year 2025 indicates that only Iowans earning up to 215 percent of the federal poverty level would be covered.

State Representative Ann Meyer, the Republican chair of the Iowa House Health and Human Services Committee, proposed House Study Bill 500 earlier this week, which would implement twelve months postpartum coverage. Meyer’s bill would not change the federal poverty level eligibility, meaning no one now eligible for Medicaid during pregnancy would lose it (in contrast to the governor’s plan).

I hope that through Meyer’s leadership, and Reynolds’ willingness to make this policy a priority, Iowa lawmakers will approve a twelve-month Medicaid postpartum bill that maintains current eligibility. In the words of the governor, that would help more “moms, babies, and their families get off to a good start.” 

Increasing Medicaid reimbursement for midwives

As I discussed last year, Iowa also needs to increase the reimbursement for Certified Nurse Midwives and OB/GYN providers for the global obstetric fee-for-service reimbursed by Medicaid in Iowa, which covers all prenatal, birth, and postpartum care.

The current reimbursement is so nominal it is hardly worth the paperwork to become a Medicaid provider. This inordinately affects Certified Nurse Midwives who provide these services for those seeking out of hospital birth. At this writing, only two out-of-hospital birth practices in the entire state accept Medicaid. 

Image Description: Map of United States showing Medicaid Fee for Service Rates for Obstetrics Services as a percent of Medicare payments

I recently learned that doulas who are part of the state’s pilot doula project receive $1,000 per client. While I think doulas deserve that fee, compare it to the $1,159.80 Iowa Medicaid pays to Certified Nurse Midwives who serve home birth clients. That fee is for the midwife’s services during the entire ten months of pregnancy, as well as the two months of postpartum care and any lactation care provided. It works out to less than $100/month for ensuring the health and safety of a mother and baby.

No wonder almost no home birth CNM providers currently accept Medicaid. The state must update its provider fee schedule to ensure home birth providers receive adequate reimbursement.

End pay disparities for midwives

One more possible Medicaid improvement should be an easy fix: end pay disparities for Iowa’s Certified Nurse Midwives, who are reimbursed at only 85 percent of the rate the state reimburses physicians when providing the same services for gynecological and obstetrical care (such as pap smears, contraceptive family planning, prenatal/postpartum care, and vaginal deliveries).

No wonder hospitals across the state devalue midwives when they are reimbursed 15 percent less by the state for the same work of physicians. Physicians are already paid more for cesareans and other services midwives don’t provide, so it is not as if they are not getting compensated adequately.   

While the gender makeup of most OB/GYNs now skews to women, the inequity of paying the profession with men in it more than women nurse-midwives (I don’t know of any male midwives in Iowa) for the same work is obvious. “Equal Pay Day” is recognized every March to recognize the gender wage gap of women working full-time earning an average of 83.7 percent as much as men. You don’t need a hypothetical “equal pay day” to demonstrate how the state of Iowa discriminates against the all-female workforce of midwives. 

When I have raised the issue of pay equity for CNMs, I’ve been told any solution requires legislative action. I would welcome a legislator to take up this issue (see sample legislation from Connecticut here).

That said, I cannot find in state law any provision requiring CNMs to be paid 85 percent of physicians for the same work. What I find related to reimbursement is in Iowa HHS Administrative Code Chapter 79, which refers to the Advanced Registered Nurse Practitioner fee schedule.

If the disparity stems from administrative code rather than statute, the Department of Health and Human Services could solve it through rulemaking. Whether in law or administrative rules, there is also an opportunity for the Managed Care Organizations (for-profit insurance companies that manage care for Iowa Medicaid recipients) to reimburse midwives at a rate higher than 85 percent of what they pay physicians.

In some states, managed care organizations reimburse for midwifery care at higher rates; one in Georgia pays midwives at 108 percent of physician pay, for “value-based care” (also known as better outcomes).

Image description: Map of United States showing CNM/CM Medicaid Reimbursement rates as of March 2022.

Iowans should not shy away from expecting better Medicaid coverage to improve care options and outcomes. Looking at other Republican-controlled states that are leading the way, we can have 100 percent or more of the global obstetric Medicaid fee for service set by CMS, 100 percent CNM reimbursement, and twelve months postpartum coverage. To increase access to care, all three pieces need to be addressed.


Some may have hoped I would quit writing about Certified Professional Midwives once Reynolds signed House File 265 into law on June 1, 2023. The bill had overwhelming bipartisan support, passing the Senate 46-2 and the House 91-2. The bill provides licensure for Certified Professional Midwives (CPMs), increasing access to quality maternal health care providers. Licensure is necessary for CPMs to obtain the life saving medications within their training and scope of practice. My comprehensive write-up “The time has come to finally license midwives in Iowa” explained why Iowa needed this policy.

Getting the bill through the upper chamber came down to the wire. The floor manager, Republican State Senator Scott Webster, offered a compromise amendment to avoid the creation of a new state board, and to keep the licensing fee low. The concept was to have the Iowa Board of Nursing administer the licensure process, and create a Midwifery Advisory Council to “advise the board regarding licensure and continuing education requirements, standards of practice, professional ethics, disciplinary actions, and other issues relating to midwifery.” 

Reynolds recently appointed the inaugural Midwifery Advisory Council members, and licensure is supposed to be available by July 1, 2024. The hiccup is the Boards and Review Committee’s Final Report, issued in September 2023, recommended eliminating that council (and more than 100 other state entities). According to the report, “The statute is highly prescriptive, and the Board of Nursing can administer licensure without the Council.” What the review committee misses is that CPMs are not nurses and those serving on the Board of Nursing, which has a significant workload as it is, will likely never have expertise in the practice of midwifery. 

The legislature created the council as an advisory group to the Board of Nursing for the express purpose of saving the state money and avoiding the need to create a new entity solely to license professional midwives. Having nurses set the rules for a different profession will create barriers for the CPM workforce and is contrary to the stated goals of the Boards and Commissions Review Committee.

The governor has asked the legislature to approve the review committee’s recommendations. Legislators will need to hear from Iowans about the value of the Midwifery Advisory Council. We should not disrupt the implementation of a new law providing oversight to a critical maternal health workforce before it has even begun to issue licenses.

Much more could be said about the historic passage of House File 265—who supported it, and who didn’t support it, despite evidence-based research and public health recommendations. Given the significant support for the licensure bill last year, I remain hopeful that lawmakers will retain the Midwifery Advisory Council. That said, I also recognize there will be a lot of competing priorities in the 2024 legislative session. Here’s hoping we can finally celebrate in July with the newly licensed midwives. 

A final request: please take a few minutes to reach out to your legislators (and for extra credit the state representatives and senators serving on the relevant committees) to ask them to help improve maternal health in Iowa. Feel free to reach out to me at rachel.m.bruns @ gmail.com to discuss these policy priorities or other topics related to maternal health in Iowa.

About the Author(s)

Rachel Bruns