This is the second part of an ongoing series on maternal health care from Rachel Bruns.
In part 1 of this series, I discussed the impact of rising C-section rates and challenges some families face in avoiding unnecessary cesareans due to a wide range of challenges including financial pressures from hospitals and provider preferences for surgery. While providers and hospitals have an important role to play in aligning practice with evidence, state and federal leaders also have a responsibility to improve policies that impact access to evidence-based maternal health care.
The power of coalitions in maternal health reform
There have been some positive improvements at the state policy level that improve access to care in the past few years including:
- Licensure of Certified Professional Midwives (CPMs), along with maintaining a Midwifery Advisory Board. This has paved the way for more midwives to practice in the state without fear of prosecution by the state, and provide quality maternal health care to families that want to have an out-of-hospital birth with a credentialed professional.
- Removal of freestanding birth centers from the definition of Certificate of Need, paving the way for more community birth centers to open. When passed, Iowa was only one of a handful of states with zero freestanding birth centers. A new freestanding birth center is opening in Adel in 2026.
- Expansion of Medicaid coverage to one year postpartum. With most maternal mortalities happening in the postpartum period, this expansion from 60 days to one year will hopefully improve access to care and reduce mortality and morbidity issues. This law reduced income eligibility limits, which means fewer Iowa families are eligible and may be impacting access to care.
These policy improvements are a great example of the power of coalitions, like Iowa ACES 360, to advance a common goal. There are many individuals and groups that may not always agree on everything that led to one or more of these pieces of state legislation.
For licensure of CPMs, I had the opportunity to connect with individuals and groups that my political ideology does not typically align with – yet we all agreed on the importance of bodily autonomy in birth and the research showing the benefits of licensing CPMs. It is so important for people with differing viewpoints to find common ground where they can to make life better for Iowans.
What still needs to change
The recent passage of HR 1 (Big Beautiful Bill has the potential to seriously threaten maternal health in Iowa by shifting more costs and administrative burden onto the state. That pressure could force cuts to essential prenatal, postpartum and rural maternity care services at a time when Iowa already faces significant access changes. Iowans should stay vigilant to ensure legislators do not balance the budget on the backs of Iowa’s most vulnerable families.
In addition there are state policy improvements that are still needed to improve access to quality maternal health care.
Workforce support
- Pay parity for midwives. Unfortunately there has yet to be improvement on pay parity for midwives doing the same work for less pay and reimbursement for out-of-hospital birth. The reimbursement is so terrible for out-of-hospital birth providers that as of today only one group in Northwest Iowa provides homebirth services for Medicaid recipients. With 40% of all births in Iowa being covered by Medicaid, a large share of Iowans have no option but to give birth in a hospital.
- Access to doula care during prenatal, birth and postpartum. While Iowa has a doula program available for some eligible Iowans, this successful pilot should be expanded to ensure all Iowans who want a doula can access one whether through insurance or Medicaid. You can learn more about state and federal policies actions on doula reimbursement from the National Health Law Program.
- Lactation counseling and pelvic floor physical therapy. We could also benefit from improvements to both prenatal and postpartum access to lactation counseling and pelvic floor physical therapy. I’m not aware of significant state efforts in these areas — however you can follow pelvic floor policy efforts from the Academy of Pelvic Health Physical Therapy and lactation related bills with the U.S. Breastfeeding Committee.
Mental health infrastructure
- Establish a perinatal psychiatric access program. There is a gap between the demand for perinatal mental health services and the supply of professionals who can provide these services. While there is not one simple solution to this shortage, a Perinatal Psychiatric Access Program is an important tool to support the mental health of Iowa moms. More than half of states currently operate Perinatal Access Programs. Iowa ACES 360 has led a broad coalition of organizations to advocate for this resource in our state.
Family economic stability
- Paid family leave. Paid family leave would significantly improve maternal and child health outcomes in Iowa. Most notably, breastfeeding would increase with paid leave, but I also believe we would see improvements with maternal mental health and health overall. The biggest hurdle to passing a federal paid leave law, is formula companies, who benefit from mothers returning to work too soon after birth.
Iowa’s state government leaders are implementing a “hub and spoke” approach for health care, which should more intentionally incorporate both hospital and out-of-hospital midwifery-led care. While Iowa policymakers are focused on increasing access to physicians due to shortages, with limited resources we need a “both-and” approach to leverage skills, specialties and reach families where they are located.
When it comes to maternal health the research overwhelmingly points to midwifery-led care providing the best outcomes for both mothers and babies. We need physicians for the approximately 10% of those truly high-risk patients that need a higher level of care, but most Iowans could be supported in their prenatal, birth and postpartum period with midwifery care and we would see a reduction in costs and improvement in outcomes.
Congresswoman Ashley Hinson (R-IA-02) recently reintroduced the bipartisan Midwives for MOMS Act, which would expand the education and training pipeline for credentialed midwives and nurse-midwives. We need all of Iowa’s federal and state policymakers to lead and support legislation that improves training, access and reimbursement for midwifery-led care in and out of hospitals, which will bring more options to Iowans.
Evidence from states like Iowa with full practice authority for Advanced Registered Nurse Practitioners (ARNPs), which includes certified nurse midwives, shows better outcomes for Medicare patients. This calls into question claims that physician-led care is inherently safer. Medical advocacy groups should be spending their resources on initiatives to improve access to care – not those that will limit it. This is especially important as confidence in the medical system has weakened significantly in my lifetime.
Rachel Manuel Bruns is a volunteer maternal health advocate and lives in Des Moines with her partner and two children. If looking for support on pregnancy, birth and postpartum support check out her compilation ofmaternal health resources. Rachel can be reached at rachel.m.bruns@gmail.com.
