Graduation Year

2014

Document Type

Dissertation

Degree

Ph.D. & M.P.A.

Degree Name

Doctor of Philosophy (Ph.D.)

Department

Anthropology

Degree Granting Department

Anthropology; Global Health

Major Professor

Nancy Romero-Daza, Ph.D.

Committee Member

Heide Castañeda, Ph.D., M.P.H.

Committee Member

Cecilia Jevitt, C.N.M., Ph.D.

Committee Member

Russell Kirby, Ph.D., M.S.

Committee Member

Rebecca Zarger, Ph.D.

Keywords

Access to Care, Autonomy, Empowerment, Informed Choice, Midwifery

Abstract

The overwhelming social norm for pregnant women in the U.S. is to receive prenatal care from an obstetrician and to give birth in a hospital setting. However, the incidence of midwifery care and out-of-hospital birth is increasing, particularly among White, non-Hispanic women. Florida has been considered a "model" state for home birth midwifery given legislative support that mandates coverage of all types of midwifery (e.g., Certified Professional Midwives and Certified Nurse-Midwives) care in all birth settings (e.g., hospital, home, birth center) and by all forms of insurance (e.g., commercial and Medicaid). Medicaid is the payer source for nearly half of the births in the United States and in Florida. However, Florida is one of only ten states where Certified Professional Midwives, who attend the vast majority of planned home births, are actively able to receive Medicaid reimbursement for home birth care. A key question then becomes, how is the system for Medicaid-funded home birth in Florida functioning?

The central aim of this research was to better understand how Medicaid impacts the practice of and access to planned home birth in Florida. This was examined through quantitative analysis of Florida birth certificates as well as through qualitative data collection and analysis that sought to describe the experiences of women who had planned home birth while on Medicaid as well as the experiences of midwives that cared for these women. Findings are presented through the lens of Critical Medical Anthropology, which helps to interpret how and why home birth is systematically supported or threatened by legislation, policy, and practice at the level of the State of Florida, the federal-state Medicaid program, and the professional organizations in the United States involved in maternity care.

Key findings demonstrate that the vast majority (87%) of planned home birth in Florida is attended by Certified Professional Midwives, and that while Florida Medicaid paid for 45% of all births between 2005 and 2010, only 31% of planned home births were paid for by Medicaid. However, after controlling for multiple factors (e.g., race/ethnicity, age, parity), in fact women who completed home (vs. hospital) birth were much more likely to be self-pay (AOR 10.1) or on Medicaid (AOR 4.6) compared to private, commercial insurance. Women interviewed for this study who received Medicaid for their home births overwhelmingly appreciated the "safety net" that Medicaid provided to them and the "relief" of knowing that if a hospital transfer was necessary it would be covered. However, they nearly universally stated that they would have found a way to pay for a home birth if they had not received Medicaid. Women felt that home birth with midwives provided them the greatest chance of having a "natural" birth in the environment most likely to maintain autonomy over decisions related to their pregnancy and birth. Several women experienced significant delays in enrolling in Medicaid, and found that the only providers who would provide care during "presumptive eligibility" were Licensed, Certified Professional Midwives. Midwives appreciated the steady, reliable payments Medicaid provided, despite that these were at about 30 to 40% of their rates charged to privately insured or self-pay clients. They felt that providing care to Medicaid funded women served as a form of social justice. They strongly disliked interfacing with Medicaid HMOs. Some midwives felt that the Florida legislation supported their practice, while others felt that it constrained their practice.

Medicaid coverage of planned home birth in Florida now stands at a crossroads, given that Florida Medicaid has recently transitioned to a 100% managed care program (i.e., HMOs). These HMOs act as intermediaries between Medicaid providers and their reimbursements, as well as between Medicaid providers and recipients. The new relationships between providers, patients and the HMOs have shifted from that with a state agency to that with a private, for-profit industry. It remains to be seen whether home birth providers will enroll with Medicaid HMOs in order to continue providing care to pregnant women receiving Medicaid.

Key policy recommendations therefore are to monitor women's access to pregnancy Medicaid, and specifically access to services mandated under Florida statute, including home birth and midwifery care. Furthermore, the creation of an integrated maternity care system that better supports transfers of care from the home to hospital setting is needed.

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