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Sarah Simmons, a midwife and co-owner of Maple Street Birth Center in rural Okanogan County, Wash., holds a newborn. Freestanding birth centers can address maternal health inequities, but many are facing mounting financial and regulatory pressures. (Photo courtesy of Sarah Simmons)<\/p>\n
Dr. Heather Skanes opened Alabama\u2019s first freestanding birth center in 2022 in her hometown of Birmingham. Skanes, an OB-GYN, wanted to improve access to maternal health care in a state that\u2019s long had one of the nation\u2019s highest rates of maternal and infant mortality.<\/p>\n
Those rates are especially high among Black women and infants. Skanes\u2019 Oasis Family Birthing Center opened in a majority-Black neighborhood, offering midwifery services as well as medical care.<\/p>\n
But about six months after the center\u2019s first delivery \u2014 a girl who was Alabama\u2019s first baby born in a freestanding birth center \u2014 the state health department ordered Skanes to shut it down. A department representative informed her that by holding deliveries at the birth center, she was operating an \u201cunlicensed hospital,\u201d she said.<\/p>\n
Hospital labor and delivery units are shuttering across the nation \u2014 including more than two dozen<\/a> in 2025 alone. Freestanding birth centers like Skanes\u2019 could help fill the gaps, but they too are struggling to stay open.<\/p>\n They face some of the same financial pressures that bedevil hospitals\u2019 labor and delivery units, including payments from insurers that don\u2019t cover the full cost of providing maternity care.<\/p>\n Birth center owners also must contend with arcane state rules and antipathy from politically powerful hospitals that view them as competition, especially in rural areas with few births.<\/p>\n Nationwide, the number of freestanding birth centers doubled between 2012 and 2022, but more recently the pressures have taken a toll: About two dozen centers have closed since 2023, bringing the total number down to about 395, according to the most recent data from the American Association of Birth Centers.<\/p>\n In November, Pennsylvania Lifecycle Wellness and Birth Center announced<\/a> it would shut down birth center services, citing pressure from regulatory challenges and sharp surges in malpractice premiums. It had served Philadelphia for 47 years. And New Mexico\u2019s longest-operating<\/a> freestanding birth center stopped delivering babies<\/a> in December.<\/p>\n \u201cWhen a new business opens, within the first three to five years you expect a certain number will close,\u201d said Kate Bauer, executive director of the American Association of Birth Centers. \u201cBut we\u2019ve had several long-standing birth centers close [in 2025] and that hits particularly hard.\u201d<\/p>\n In California, which has some of the strictest birth center licensing rules in the country, concern over the closure of at least 19 birth centers<\/a> between 2020 and 2024 prompted the state legislature to pass a law in October to streamline birth center licensure.<\/p>\n Freestanding birth centers are not attached to hospitals and aim to provide a more homelike, less traditional medical setting. They employ midwives and focus on low-risk pregnancies and births. Some also have an OB-GYN or family medicine doctor on staff, and they often have partnerships with nearby hospitals and doctors if more specialized care is required.<\/p>\n Some Black and Indigenous midwives and doulas say birth centers can be helpful alternatives to their community members, many of whom have had experiences in more medicalized settings that left them feeling marginalized, dismissed or unsafe.<\/p>\n Midwife Jamarah Amani, executive director of Southern Birth Justice Network, runs a mobile midwifery clinic serving majority-Black and Latino neighborhoods in Miami-Dade County, Florida. The nonprofit, which aims to make midwife and doula care more accessible, recently bought a building for a freestanding birth center it aims to open in 2027.<\/p>\n \u201c[Midwifery] presents like a luxury concierge-type of service, and our goal is to really change that and to bring it back to the community in a very grassroots way,\u201d Amani said. She added that expanding access to prenatal care could help address inequities in maternal health, as maternal death rates among Black women are three times higher than those among white women.<\/p>\n Freestanding birth centers also can be a solution for communities without a hospital nearby.<\/p>\n The closest hospital to the Colville Indian Reservation, located in northern Washington state, is half an hour away, said Faith Zacherle-Tonasket, founder of the nonprofit xa?xa? Indigenous Birth Justice.<\/p>\n So far, the group has trained nearly a dozen tribal doulas and midwives to serve the area. In the next few years, it plans to open a freestanding birth center. Zacherle-Tonasket said Indigenous-run birth centers are crucial alternatives for tribal women, who also have some of the highest maternal mortality rates in the nation and often face prejudice in clinical settings.<\/p>\n \u201cThey don\u2019t feel safe. So a lot of them just don\u2019t get prenatal care,\u201d said Zacherle-Tonasket. \u201cBringing traditional midwives that are from our own communities, that were born and raised in our communities, that know the families \u2014 we know that those babies will be birthed with love.\u201d<\/p>\n When the Georgia legislature relaxed state health care regulations<\/a> in 2024, it felt like a long-awaited win for Katie Chubb. A registered nurse and mother of three who\u2019s worked in health and nonprofits, Chubb has spent years trying to open a birth center in Augusta.<\/p>\n The state denied her application<\/a> to open the center in 2021. Georgia, like many states, requires health care providers to get state approval, called a certificate of need, before they can build a new facility or expand services. Rival providers, like other hospitals, can challenge an application, effectively vetoing their local competition.<\/p>\n That happened in Chubb\u2019s case: Two local hospitals filed letters of opposition against her and refused to say they\u2019d accept emergency transfers from her birth center, another requirement for opening.<\/p>\n Georgia currently has three freestanding birth centers, a fraction of the more than two dozen<\/a> that operate in neighboring Florida.<\/p>\n \u201cWe\u2019re seeing women giving birth in hospital hallways or at home unassisted, because there\u2019s no in-between option like a birth center,\u201d Chubb said. In October, Georgia lost another labor and delivery unit<\/a> at a rural hospital two hours north of Augusta.<\/p>\n \u201cWomen are just left to figure things out.\u201d<\/p>\n We\u2019re seeing women giving birth in hospital hallways or at home unassisted, because there\u2019s no in-between option like a birth center.<\/p>\n<\/div>\n \u2013 Katie Chubb, a registered nurse who\u2019s trying to open a birth center in Georgia<\/b><\/p>\n<\/div>\n<\/div>\n In Kentucky, the Republican-controlled legislature passed a bill<\/a> in March that aimed to clear the way for freestanding birth centers by exempting them from the certificate of need process.<\/p>\n But Republican lawmakers attached a last-minute anti-abortion amendment to the bill, prompting Democratic Gov. Andy Beshear to veto it<\/a>. The legislature eventually overrode his veto. Midwifery advocates hope<\/a> the new law will help make it easier to open a birth center in the state.<\/p>\n Georgia legislators similarly revised<\/a> Georgia\u2019s certificate of need rules in 2024, exempting freestanding birth centers. Chubb, who championed the new law, hoped it would clear the path for herself and others.<\/p>\n But they hit another roadblock. The state still requires<\/a> birth centers to secure a written agreement with a local hospital to accept transfers of clients in emergencies. Chubb and at least one other prospective birth center owner have been unable to get their local hospitals to sign such transfer agreements.<\/p>\n \u201cWe\u2019re still fighting,\u201d Chubb said. \u201cBehind closed doors we\u2019re still working very hard on getting legislation and regulations changed to make opening birth centers more equitable.\u201d<\/p>\n Some hospitals view birth centers as a threat to the viability of their labor and delivery units, siphoning off patients and revenue from a service that\u2019s already unprofitable for most hospitals.<\/p>\n Daniel Grigg, CEO of Wallowa Memorial Hospital, a 25-bed critical access hospital in northeast Oregon, said there aren\u2019t enough births in the area for both hospitals and birth centers.<\/p>\n \u201cWhen you\u2019ve got a small-volume community like we have, every birth helps the providers keep their skills up and their competency,\u201d he said. \u201cWhen you\u2019ve got a midwife taking, say, 10 patients out of that pool,\u201d it can have an impact on physicians and hospitals.<\/p>\n After the Alabama Department of Public Health shut down Skanes\u2019 birth center in 2023, she joined with two other women who had also been attempting to open birth centers in Alabama: Dr. Yashica Robinson, an OB-GYN in North Alabama, and Stephanie Mitchell, a licensed midwife in Alabama\u2019s rural and economically disadvantaged Black Belt region. Together they sued the Alabama Department of Public Health<\/a> over what they called a de facto ban on birth centers.<\/p>\n The state insisted its tighter regulations would ensure that birth center facilities are safe. The birth center owners said the state\u2019s rules were overly burdensome and clinically unnecessary for the low-risk, nonsurgical births that are attended by midwives. And, they said, the rules prevented more families from accessing care where it\u2019s desperately needed. The state has lost at least three hospital labor and delivery units since 2020.<\/p>\n \u201cEntire swaths of the state are maternity care deserts without access to essential health care,\u201d said Whitney White, a staff attorney with the American Civil Liberties Union, which is representing the birth center owners and their co-plaintiff, the Alabama affiliate of the American College of Nurse-Midwives.<\/p>\n \u201cHospital labor and delivery units are closing, and pregnant folks are reporting they\u2019re really struggling to access the care they need, struggling to get appointments, struggling to find a provider,\u201d White said.<\/p>\n Last May, an Alabama trial court permanently blocked the state from regulating freestanding birth centers as hospitals. Birth center staff are still overseen by state boards of midwifery and nursing.<\/p>\n All three Alabama centers are now open. But their licensed midwives are delivering babies under a cloud of uncertainty about the future.<\/p>\n The state appealed the ruling in November. The case is ongoing.<\/p>\n Bauer, of the American Association of Birth Centers, said many centers face the same financial barriers. Uncomplicated births at freestanding birth centers cost less<\/a> than they do at hospitals, but research has shown that insurers, including Medicaid, reimburse centers at lower rates. Some state Medicaid programs don\u2019t cover some of the nonclinical services, such as lactation consultants and doulas, that birth centers may provide. And malpractice premiums are rising.<\/p>\n \u201cWe\u2019re volunteering our time, essentially, to keep the birth center open as a service to the community,\u201d said Sarah Simmons, co-owner of Maple Street Birth Center in rural Okanogan County, Washington. The center can\u2019t afford to hire a front-desk staffer or another midwife, Simmons said. She added that on average, the center makes less than a third of what the local hospital makes for providing the same obstetric service.<\/p>\n But there may be solutions to some of these financial problems. For example, the Center for Healthcare Quality and Payment Reform, a national health care policy center, has recommended<\/a> that health insurance plans, both Medicaid and commercial, pay hospitals and birth centers monthly or quarterly \u201cstandby capacity payments\u201d per woman of childbearing age covered by that health plan in the facility\u2019s service area. It also recommends that plans pay a separate delivery fee for each birth.<\/p>\n In 2024, Democratic U.S. senators proposed<\/a> a bill to allow for a similar payment model.<\/p>\n Standby payments could help freestanding birth centers, especially those that fill gaps in maternity care deserts \u2014 but not unless centers receive payments that are comparable to those that hospitals get, said Simmons, whose center serves four sparsely populated counties along with the Colville tribal communities.<\/p>\n \u201cThis would be most beneficial to freestanding birth centers if pay parity laws were enforced, so rural freestanding birth centers were paid the same rates for the same services as rural hospitals, \u201d she said.<\/p>\n State grants also can help, but birth centers say a one-time infusion won\u2019t be enough. In 2024, Washington opened grant applications<\/a> for distressed hospital labor and delivery units and freestanding birth centers.<\/p>\n Ashley Jones, of True North Birth Center and president of the Washington chapter of the American Association of Birth Centers, said the grant has helped keep their doors open.<\/p>\n Meanwhile, Chubb, the Georgia nurse, recently had to take another job to support her family while her birth center remains in legal limbo.<\/p>\n \u201cI\u2019m just waiting until the government figures out what they\u2019re doing.\u201d<\/p>\n Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org<\/a>. Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org<\/a>.<\/em><\/p>\nAn appealing alternative<\/h4>\n
Regulatory hurdles<\/h4>\n
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Struggles and solutions<\/h4>\n