KATHERINE RUSHFIRTH, who lives in Lynn, had her first child three years ago with care from the North Shore Birth Center in Beverly, cared for by the same midwives who provided her pregnancy care. During her second pregnancy, the birth center announced plans to close, and Rushfirth, who is herself a nurse midwife, found nowhere on the North Shore where she could be guaranteed that a midwife rather than a doctor would attend her birth.
Rushfirth delivered her baby in November with midwives at Massachusetts General Hospital in Boston, a top hospital, but one that lacks a tub for water births, which she was interested in, and is a setting that carries a higher risk of medical intervention. “I’m being funneled into a much more expensive place, a place I know is more interventive. That’s not what I would have chosen myself,” Rushfirth said.
Massachusetts is a mecca for medical care, home to world-renowned hospitals offering the most advanced treatment in medicine. But people like Rushfirth face an astonishing lack of options in how they want to deliver their baby, with those who want a more natural setting with less medical intervention often left with nowhere to turn.
With the scheduled closure of North Shore Birth Center on December 1, Massachusetts will have only one operating birth center, Seven Sisters Midwifery & Community Birth Center in Northampton. That will put Massachusetts behind 32 other states that have two or more birth centers, according to the American Association of Birth Centers, which counts around 400 birth centers nationwide.
The North Shore Birth Center is only the latest in a spate of closures of birth centers, midwifery practices, and maternity wards in the state. The reasons for the closures do not appear to be a lack of demand for such services or a lack of positive health outcomes. The Massachusetts Health Policy Commission has found that midwifery care in the state is correlated with fewer deaths of mothers and infants, fewer complications, fewer medical interventions, shorter hospital stays, and lower costs than births attended by a physician. National studies have reported similar findings.
The closures are the result of a combination of forces, both financial and policy-related, as low reimbursement rates for midwives and burdensome regulations make the birth center model increasingly difficult to sustain. Those factors seem driven by a health care culture that gravitates toward high-cost, high-tech medicine.
The result: While Massachusetts residents facing serious illness have access to some of the best hospitals in the world, the state’s high-cost health care system seems to be squeezing out alternatives like birth centers, which can often provide care equal to or better than that available at more expensive hospitals.
Eugene Declercq, a professor at Boston University’s School of Public Health who studies childbirth and maternal health, said philosophically, birth centers can be an “embarrassment” to hospitals since they demonstrate that for low-risk women there is a more efficient, lower cost way to provide obstetric care. Hospitals may argue that the advanced equipment and training their staff can provide is necessary, but Declercq said it is mostly important in a small number of high-risk, complicated cases. “Some of this is financial and competitive,” he said. “Some of it is just the belief system that they have.”
TRACKING CONTRACTIONS
Birth centers, which began to become popular in the US in the 1970s, can offer a middle ground between home births, which carry more risk and are costly to patients because they are usually not covered by insurance, and hospital births. Birth centers provide a more homey setting than a hospital, and are staffed by licensed midwives – registered nurses with additional training in child birth – and covered by insurance. The centers offer personalized care and natural birth options, though no medication for pain control, with the ability to quickly transfer to a hospital if necessary.
Despite growth in US birth centers – the number has more than doubled in the last decade, according to the American Association of Birth Centers — the US has, by far, the smallest share of births with midwives as primary care providers of any high-income country. Just 10 percent of US births are handled by midwives, compared with 50 to 75 percent in other high-resource countries. In Massachusetts, the figure is well above the national average, at 17 percent, but that overwhelmingly reflects births handled by midwives in hospital settings.
Beverly Hospital, which operates the free-standing North Shore Birth Center on its hospital campus, announced plans to close the center in May, sparking community protests. The center stopped accepting new patients this summer and will close December 1.
“When they announced the birth center was closing, I, along with hundreds, maybe thousands, of people who have experienced this care, was dumbfounded, because it seemed to be the gold standard for maternal health care,” said Emilee Regan, a public relations strategist who got care from the North Shore Birth Center for two of her three pregnancies and is leading an effort to try to stop the closure. “It just felt like another elimination of reproductive choice coming at a time when we’re seeing those choices taken away at the national level.”
Beverly Hospital president Tom Sands said the problem was staffing. He said it takes two supervisors and the equivalent of 8.4 full-time midwife positions to offer 24/7 access to care. The birth center was down to two full-time midwives, and two who were undergoing their one-and-a-half-year training to become credentialed. The hospital has been unable to find traveling midwives to fill the staffing gaps, and since January, all birth center patients have had to deliver in Beverly Hospital because there were not enough midwives available.
“We simply, due to workforce reasons, weren’t able to maintain a complement of midwives,” Sands said. He said some midwives left to find jobs with a better work-life balance and less on-call time – like work in a hospital, where the care team also includes a doctor and nurses.
In fiscal 2017, the North Shore Birth Center delivered 87 babies, and by 2019, the number had dropped to 51. The birth center cared for around 200 patients a year, but most delivered at the hospital for medical or staffing reasons.
The hospital now plans to expand midwifery care and natural birth options within Beverly Hospital, expand midwifery care at local physicians’ practices, and give $1.5 million in grant funding to support the “creation, expansion, or reopening” of a community-based birth center.
The closure of the Beverly center is only the latest chapter in the ongoing demise of birth centers and maternity services across the state. The Cambridge Birth Center, run by Cambridge Health Alliance, stopped doing deliveries in March 2020. It continued offering outpatient midwifery services, but babies were delivered at Cambridge Hospital.
David Cecere, a spokesperson for Cambridge Health Alliance, said the move was made “in response to changes in health care brought on by the COVID-19 pandemic, including staffing shortages and rising costs.” Cambridge Health Alliance has hired an independent consultant to assess whether to reopen the birth center for deliveries, with results expected in early 2023. “This review will examine the program’s sustainability and potential growth around deliveries,” Cecere said.
Holyoke Medical Center closed its entire maternity ward and an affiliated midwifery practice in the fall of 2020. Officials told MassLive that the hospital had fewer than 400 births a year and was losing $3 million to $4 million annually. Tobey Hospital in Wareham closed its maternity ward in 2019 and Cape Cod Hospital closed its Falmouth maternity ward in 2020, citing declines in births. Both locations had affiliated midwives.
The Department of Public Health says it has no legal authority to prevent a hospital from closing particular services. The department does set out a process for closures where DPH reviews the hospital’s plans and holds a public hearing, and requires the hospital to take steps to minimize the impact of the closure on patients by ensuring they continue to have access to those services elsewhere.
Patricia Noga, vice president of clinical affairs for the Massachusetts Health and Hospital Association, a trade association that represents hospitals, declined to comment on individual closures. “Thoughtful consideration and planning — including feedback from patients, families, staff and community members — goes into every decision made by hospitals and health systems, including around the shifting of maternity services and facilities,” she said.
Massachusetts Medical Society president Ted Calianos said in a statement that the organization, which represents physicians, supports more options for women when it comes to childbirth. “The Medical Society is concerned over the closure of birthing centers, including those that served to meet the cultural needs of those from underserved populations,” Calianos said. “A reduction in safe places to give birth further taxes other segments of our health care system and raises a public health risk.”
REGULATORY AND INSURANCE HURDLES
One bright spot amid the dwindling delivery choices in Massachusetts is an effort to open a new birthing center in Roxbury. Neighborhood Birth Center aims to revitalize community-based midwifery while improving birth outcomes in the region.
The center’s founder, Nashira Baril, said the concept of having a birth center in the heart of Black Boston was decades in the making. Midwives began talking about it in the 1970s as a response to a state report detailing racial inequities in maternal health outcomes. Baril, who has a degree in public health from Boston University, revived the idea in 2015.
Baril, who is Black, makes a strong case for the need for a Black-run birth center. In addition to continuing maternal health inequities, she said out of 400 birth centers in the United States, just 13 are owned or led by people of color. That she attributed that to history – the movement of childbirth away from Black midwives into hospital settings in the early 1900s – and finances, with Black midwives generally having less personal savings to invest in a new business.
The planning process for Neighborhood Birth Center, which has taken eight years so far, and the experience of Seven Sisters, the Northampton center, which opened in 2020 and will soon be the state’s only birth center, highlight the reasons why it is so hard to operate such facilities. Both Baril and Seven Sisters co-owner Kirsten Kowalski-Lane said navigating unreasonable state regulations has stymied their progress.
Kowalski-Lane said it took her five years to open the Northampton birth center, which has a capacity of 15 or 16 births a month and is booked solid. A big reason, she said, is state regulations for birth centers that are not part of a hospital were written in 1985 and are embedded in a Department of Public Health regulation governing freestanding surgical centers – even though birth center clinicians do not perform surgery.
As a result, birth centers are required to have the same expensive lighting as operating rooms, which Kowalski-Lane said she turns on only for cleaning. The Northampton center also had to spend more than $4,000 on a neonatal warming device that sits unused, because a baby needing medical help will be transferred to a hospital within minutes. Rules about exam room sizes are intended for surgical operations, not labor.
The centers got waivers from some rules but had to comply with others. “The regulations have never caught up to being able to say we can’t treat a birth center like a surgical center,” Kowalski-Lane said.
Baril added that Massachusetts regulations are out of sync with national guidelines from the trade association that represents birth centers and do not represent best practices. One rule she pointed to as particularly burdensome is a requirement that centers have a medical director who is an obstetrician – even though a 2012 state law gave nurse midwives the ability to practice independently without a doctor’s supervision.
“Frankly, I think they continue to advantage obstetrics, and the result is we have one birth center in the state,” Baril said.
Once a center is open, insurance coverage can be another challenge. Kowalski-Lane said because her birth center is not attached to a hospital, it had to negotiate every single insurance contract. Its final contract, with Aetna, was just agreed to after two-and-a-half years. Until recently, birthing there was out-of-network for a patient with Aetna insurance.
Insurance contracts for birth centers are also less lucrative than for hospitals. Commercial insurance companies reimburse midwives practicing independently at 85 percent of what they pay a physician. (MassHealth provides equal reimbursement, but its rates tend to be low to start with.)
“I do the same things a physician does but am reimbursed at 85 percent,” Kowalski-Lane said, calling the practice “completely ridiculous.”
Rushfirth, the Lynn nurse midwife who delivered her first baby at North Shore Birth Center, does advocacy work for the American College of Nurse Midwives and is the policy director at Neighborhood Birth Center. She said Massachusetts is among a minority of states, and the only one in the Northeast, that does not mandate equal reimbursement for midwives.
“Massachusetts, for all its progressivism and health care leadership, does very poorly when it comes to integrating midwives,” Rushfirth said.
Birth centers are also at a financial disadvantage compared to hospitals because they do not bill for all the additional services a hospital provides during and after birth – such as an anesthesiologist, medication, and an inpatient hospital stay.
But midwife care also provides value. The Health Policy Commission looked at birth-related costs based on what percentage of a hospital’s births were attended to by midwives. It found that in hospitals where more than 40 percent of births were attended by midwives, the average cost per birth was just under $21,000. For hospitals where fewer than 20 percent of births were midwife-attended, the average cost was nearly $28,000 per birth.
One national study, The Strong Start for Mothers and Newborns Initiative, found that delivery at a birth center typically costs around $1,700 less than a hospital birth – approximately $6,500 compared to $8,200.
As she prepares to open, likely in 2024, Baril has made spreadsheet after spreadsheet trying to find a financial model that fits her moral values. She wants half the center’s births to be low-income patients on MassHealth, the state Medicaid program, and she wants her midwives to be able to work 40-hour workweeks and get paid comparably to hospital midwives. But, she said, there is no way to make that work financially. She tried adjusting her spreadsheet to have midwives working more hours with lower pay or accepting fewer Medicaid patients, but it felt wrong. “It felt like, wait a minute, the big problem is midwifery is undervalued in our healthcare industrial complex, and where we’re going to look to correct for that is to put the midwives’ hours up, to pay them less, and have fewer Medicaid patients? It just didn’t jive with our values,” Baril said.
Baril’s new plan is to turn to philanthropy to break even – something that could make it hard to launch and sustain the birthing center.
LEGISLATION STALLED
Advocates for midwifery care and birth centers have tried unsuccessfully to get legislative help. A bill introduced this session would have required that midwives be paid equally to physicians for the same work. But lawmakers did not advance it.
The Massachusetts Association of Health Plans, which represents insurers, opposed the bill, writing in testimony that one benefit to midwife births is the lower cost, and raising reimbursement rates would increase costs. The group suggested that doctors should be paid more because of their advanced training. “The rate of reimbursement established during contract negotiations between health plans and providers reflects the technical skill, educational background, and clinical experience of health care professionals,” the insurance association wrote. “Therefore, any increases in reimbursement and compensation rates should remain linked to both services provided and performance. Mandating higher reimbursement for certified nurse midwife services could undermine health plans’ efforts to keep costs down.”
Midwives say staffing issues are also worsened by credentialing policies. Massachusetts licenses nurse midwives, who complete nursing school. But it does not license certified professional midwives, who are accredited by a national organization based on an apprenticeship or training program. Thirty-seven states recognize certified professional midwives. Massachusetts lawmakers have not acted on a bill that would create state licensing of certified professional midwives.
Certified professional midwives are generally those who perform home births, and a major reason the bill has not passed is opposition from the medical field, including the Massachusetts Medical Society, to expanding home birth access.
“MMS respects a woman’s right to choose between a diversity of health care professionals and settings, but also recognizes the safest location for birth is a hospital or birthing center due to the unforeseen and life-threatening crises that could cause serious injury and harm to a woman and her newborn, such as severe maternal bleeding and fetal delivery problems,” the society wrote in legislative testimony.
But the lack of licensing has had the additional consequence of limiting the staffing pool available to birth centers. Birth centers cannot hire certified professional midwives, since they cannot claim insurance reimbursement.
For women seeking care outside a hospital, the birth center closures, combined with a lack of policy support, feel like an attack on their reproductive choices. Emily Anesta of the Bay State Birth Coalition, a consumer advocacy group that supports midwifery care, said midwifery care “is an ancient tradition” and reflects how humans have traditionally given birth. “What we see is that people who have access to this option, they are able to have more agency and autonomy in their care rather than being swept into medical interventions that they don’t necessarily need or want,” Anesta said. For example, she said, a woman might want to eat or walk during labor, which she cannot do with an epidural, or have more visitors present than a hospital allows.
Anesta added that statistics show the US has worse maternal and infant outcomes than other wealthy nations – while countries that rely more on midwife care have better outcomes. “What we see from a public health perspective when we look at maternal health outcomes is the increasing medicalization of childbirth in the United States has not led to better outcomes,” Anesta said.
Regan, the public relations strategist fighting the planned closure of North Shore Birth Center, first got care at the center when she was 32 weeks pregnant with her second child, after her obstetrician in another practice started talking about inducing labor early because of concerns about the baby’s growth – an intervention Regan believed was not evidence-based or necessary. “The type of care I received was night and day,” Regan said. “Because I’m a younger, healthier person, I’ve never had a lot of interaction with the health care system, and it felt to me like this is the way it’s supposed to be. This is how health care should be. This is the type of attention and personalization that people should receive.”
Regan worries the next woman won’t have that opportunity.