Birth Centers Disentangled from Regulations: A Solution to Disappearing L&D Wards

The U.S. has the highest maternal mortality rate among developed nations. And yet, since 2020, a staggering 116 rural labor and delivery (L&D) wards in America have shuttered their doors, representing an 11 percent reduction in the overall number of rural L&D wards. A result of expensive operation costs, low reimbursement rates, and difficulty in recruiting L&D staff, these closures threaten access to care for pregnant people, with many now having to drive hours to give birth at a hospital. 

And this burden is not shared equally: As Professor McGregor et al. from the Harvard T.H. Chan School of Public Health found, closures were more likely to occur in Black communities, exacerbating the existing racial disparities in maternal mortality rates. 

Birth centers — freestanding facilities operating separately from hospitals, using a midwifery model — provide an alternative to L&D wards for low-risk pregnancies. Midwives are trained providers who holistically support women through pregnancy and childbirth, whose involvement in maternal care significantly decreases the risk of mortality and reduces preterm births, cesarean sections, and the number of low-birthweight babies.

In addition to midwives, other professionals such as doulas, nurse practitioners, and lactation specialists may practice at birth centers. Patients are able to cultivate meaningful relationships with these professionals through longer appointments, in which different aspects of patients’ health is discussed. And importantly, patient care continues until well after birth, ensuring that postpartum complications are detected in both the mother and infant.

State policymakers, recognizing the imperative to expand the maternal health care workforce and address disparities, have launched Medicaid payment initiatives and other programs to finance the work of midwives and doulas. While such initiatives to finance and integrate midwives are undoubtedly valuable, they don’t solve the fundamental problem: As L&D wards close, there are simply fewer places to give birth. Birth centers seem like a workable solution to fill this gap. However, they face a myriad of regulatory barriers that often make it impossible to open or stay in operation.

For instance, onerous building regulations, often mirroring those of meant for hospitals and the like, increase startup costs for birth centers. By way of example, two California birth centers were forced to close in 2024 because their heating ducts failed to meet building codes for ventilation. This standard, which is designed to prevent the spread of illness in high-risk settings such as primary care clinics and hospitals, was applied to facilities serving only low-risk pregnancies — a requirement one midwife from a closed clinic argued was completely unnecessary for their patient population. A recent Massachusetts law, which removes the requirement for birth centers to meet these onerous outpatient surgical center building codes, offers a model for other states. Where standards are not based on evidence about care outcomes, they function as meaningless red tape that hinders access to care.

Additionally, requirements for birth centers to be located near hospitals in case of emergency may become increasingly difficult as hospitals across the country disappear. While helpful in ensuring access to care for sudden high-risk cases, proximity requirements may not be a good solution; hospitals in close proximity to a birth center may not necessarily be ready for admission and treatment upon patients’ arrival. The interest in safety might be better served by transfer agreements with hospitals, a perspective recently highlighted by the American College of Obstetricians & Gynecologists. 

California recognized this by recently enacting a law that replaced its requirement that a birth center be in near proximity to a hospital with a requirement that each birth center has a transfer agreement with a hospital. Albeit an arguably necessary improvement, this change may come with its own host of issues, as hospitals may be reluctant to take on the risk of liability accompanying such transfers. Fourteen states and the District of Columbia merely require written protocols for emergency transfers rather than formal written transfer agreements. In contrast, nineteen require formal written transfer agreements, and eleven states still have proximity requirements. There is an imperative for research to be conducted that compares maternal and neonatal outcomes in these different regimes.

A similar obstacle faced by birth centers arises from “Certificate of Need” (CON) laws, which require new health care facilities to prove to state regulators that there is an economic need for their services. While ostensibly designed to prevent the over-saturation of expensive services, CON laws may be used by established hospitals to block potential competitors. For birth centers, this process is an expensive, time-consuming legal battle that favors the “incumbent,” not the community in need of care. 

Take Katie Chubb’s effort to establish a birth center in the South for example. Not only did hospitals in her area file an opposition to her CON, alleging there was no need in the community, but they also refused to enter into written transfer agreements. Some advocates for birth centers argue that CON laws are entirely unnecessary for birth centers; their patient population is low-risk, whereas hospitals serve high-risk patients. States such as Iowa and Georgia, likely adopting this perspective, have revised their laws to relieve birth centers of this requirement.

Birth centers also face the obstacle of contracting into insurance networks and obtaining sufficient reimbursement for their midwives. Some birth centers have leveraged existing state laws to obtain initial contracts. Rebecca Polston, for instance, successfully leveraged a Minnesota law that requires insurers to contract with any providers working in underserved areas to convince insurers to contract with her center. Achieving parity for reimbursement of midwives compared to physicians is a separate battle, and one that Massachusetts state legislators wanted to address with law in 2022. However, insurers argued that the cost of increasing reimbursement rates would spill over to patients, and the bill was ultimately not passed.

The U.S. maternal mortality crisis and L&D ward shortages demand every available solution, and birth centers appear to provide one. Yet too often, their growth is stifled by a web of regulations not supported by evidence related to birth centers themselves. Outcomes in states that have begun innovating in this space should be further researched. These initiatives provide a vital opportunity to gather evidence on which reforms are most effective in reducing maternal and infant mortality.