Last month, the Commonwealth Fund highlighted the importance of freestanding birth centers in Community-led approach to transforming obstetric care. Freestanding birth centers that use a midwifery and wellness model offer families the option of delivering outside of a hospital or at home. There are 415 freestanding birth centers in the United States in 40 states and Washington, DC, but a small portion—less than 5%—are led by people of color. The majority of births in the United States occur in hospitals, but more families want to deliver at home or in a birth center. The midwifery model of care has been shown to help reduce adverse birth outcomes, such as preterm births, low birth weight, cesarean sections, and NICU admissions. Approximately 20,000 births occur in birth centers, less than 0.5% of all births in the United States. Freestanding birth centers are separate facilities from hospitals, but they often partner with hospitals and provide full continuity of birth care. Typically, the midwives working there are those who are trained as certified nurse midwives (CNM) or as other types of midwives, such as certified professional midwives (CPM).
Figure 1: Chart from the American Association of Birth Centers showing the growing trend of midwife-led birth centers over time.
Birth centers emphasize a relationship-centered model that emphasizes building relationships to create trust and safety between birth attendants, pregnant women, and their families. Some midwives in birth centers build on the work of midwife Jennie Joseph, LM, CPM, who came to the U.S. from the UK to make midwifery care more accessible through her work at the Commensense Childbirth Easy Access Clinic in Winter Garden, FL. Her JJ Way® model of childbirth care is recognized as a promising practice by the Association of Maternal and Child Health Programs because it is proven to reduce disparities and improve birth outcomes.
The Commonwealth Fund article also highlights the work of socially conscious entrepreneurs like Rebecca Polston, a certified midwife who founded Roots Community Birth Center in Camden, a Minneapolis neighborhood with a high concentration of low-income black families. Her practice serves 200 patients annually, 80% of whom identify as black or Indigenous and 60% of whom are insured through Medicaid. She says:
“Health is built in the community and in your heart. It has nothing to do with biometrics. It’s something we incorporate into every single patient encounter.”
Roots Community Birth Center has many positive outcomes in its decade of operation, including a low cesarean section rate, higher than average breastfeeding rates and a low hospital transfer rate. Polston has developed relationships with two local hospitals to ensure transfers go smoothly when an emergency requires more intensive medical intervention. Because of the “impossible math” many birth centers face, her practice must raise a quarter of its annual budget from private funds.
The article also highlights efforts to build new birth centers in Detroit and Boston, as well as previous attempts among the Navajo Nation in New Mexico that were not fully implemented due to the limited fundraising capabilities of many community-based organizations seeking to interface with the health care system. Nicole Arthun, a certified nurse midwife who founded the Changing Women Initiative, said she wrote up to 10 grant applications per month but was never able to earn more than $100,000 per year. She stated that this was due to the limited funding for maternal health focused on indigenous populations. The center Arthun and her team wanted to build would have cost about $2.5 million, but they were never able to meet the goal. The article also highlights similar community-based efforts in Michigan (Birth Detroit) and Massachusetts (Neighborhood Birth Center).
Given funding challenges and the need for additional maternal health care options, some states have proactively increased birth center payments under Medicaid. In Oregon, the state Medicaid agency requested a CMS-approved state plan amendment (SPA) to increase the birth center facility fee from $1,200 to $3,700. This change will take effect July 1, 2023. Similarly, Washington state more than doubled the facility fee in 2016 for fee-for-service Medicaid births to $2,500. Washington state’s Medicaid agency pays midwives and physicians the same fee regardless of birth location and for the same level of care.
CMS’s new funding opportunity, the Transforming Maternal Health (TMaH) model, provides funding and support to states to test new approaches, including freestanding, community-based provider birth centers, that—when implemented in coordination with community involvement—promise to more effectively address health disparities. (Is your state agency applying? Applications are due by September 20.)th.)
Birth centers built by and for communities are important and successful efforts to improve maternal and child health. States can leverage the focus on maternal health to promote the work of birth centers by using Medicaid to expand the availability of birth center models through provider and payment policies.
