Scaling the Strong Start Birth Centers: Promoting Equitable Maternity Outcomes

Implementing birth centers can transform the failing maternity care system in the United States. The Centers for Medicare and Medicaid Innovation concluded that birth centers in their Strong Start for Mothers and Newborns initiative reduced preterm births and babies born at low birth weight (LBW) for Medicaid beneficiaries.^1,2 Birth centers are uncommon in the United States and deviate from the highly interventive care provided in hospitals. The midwifery model of care, which is characterized by individualized education and time-intensive, holistic care focused on promoting physiologic childbearing, is provided in birth centers. Increasing access to birth centers could improve pregnancy outcomes and decrease cost.^3–5

PREMATURE BIRTHS AND LOW-BIRTH-WEIGHT NEWBORNS

Prematurity and infants born at LBW are intractable problems for the US health care system, which spends more money than any other country on maternity care yet has the worst outcomes of all high-income countires.⁶ Infants born prematurely have a higher incidence of death and disabilities than infants born at term.⁷ The prematurity rate for Blacks in 2019 was 14.39%, compared with 9.26% for Whites.⁸

Burris et al. posit that Blacks consistently have disparate pregnancy outcomes because of long-standing inequities.⁹ A retrospective study found a 25% increase in preterm births for Blacks living in the most segregated and deprived locales compared with Blacks living in the most integrated and privileged areas.¹⁰ Blacks living with institutional, interpersonal, and internalized racism experience chronic stress described as “weathering” by Geronimus.¹¹ A systematic review of 28 studies found that experiencing racism predicted higher allostatic load and poorer pregnancy outcomes.¹² Chambers et al. conducted focus groups to understand the lived experience of racism.¹³ Participants related experiencing discrimination and inadequate medical care and expressed a desire for providers who looked like them.

TRANSFORMING MATERNITY CARE

It is time to replace care that focuses on pathology with the midwifery model of care, which focuses on promoting normal physiologic birth and is consistently practiced in birth centers.⁵ Evidence of quality outcomes at birth centers has been consistent from the evaluation of the first birth center demonstration project in 1978¹⁴ to the study of the Strong Start Initiative for Mothers and Newborns.^3–5,15,16 Safety of birth centers relies on collaborative practice, as defined by the Standards for Birth Centers, which ensures appropriate levels of care for all birthing situations.⁵ An integrative literature review appraised 23 studies using 14 data sets and nine qualitative studies of perinatal outcomes for 84 000 births in international birth centers from 1980 to 2011 and found birth center care was safe and resulted in fewer inductions of labor, cesarean deliveries, and operative deliveries.¹⁷

Dubay et al. highlighted the impact of the five-year initiative by the Centers for Medicare and Medicaid Innovation comparing three alternatives to traditional maternity care: the birth center model of care, group prenatal care, and maternity care homes.³ Outcomes for 52% of Strong Start participants in the three enhanced models of care were compared with a matched group of Medicaid clients within the same counties who received traditional care. Strong Start birth centers reported prematurity rates 2.2 percentage points lower than the comparison group (6.3% vs 8.5%; P < .001), LBW rates 1.5 percentage points lower than comparison group (5.9% vs 7.4%; P < .05), 11.5 percentage points fewer cesarean deliveries (17.5% vs 29.0%; P < .001), and 11.7 percentage points more vaginal births following cesarean deliveries (24.2% vs 12.5%; P < .01) while the other two models of care had outcomes similar to traditional care except group prenatal care showed a slight cost saving. Birth centers also saved $2010 per birth.

A study compared the birth outcomes of 6424 Medicaid beneficiaries from 45 Strong Start birth centers with outcomes for 3 945 875 births reported on national birth certificates.¹⁸ The sociodemographic characteristics of birth center participants mirrored national data except birth center clients were more likely to be adolescents, unmarried, and White. Birth center clients had histories with more preterm births, smoking, domestic violence, and drug usage. Midwives provided most of the care in birth centers with transfers to hospitals and collaborating physicians when necessary. Physicians attended 89.7% of births in the national group and midwives attended 8.5%. More birth center clients gave birth at home or in the birth center (65.4%) in contrast to the 98.5% of national births occurring in hospitals. In Strong Start birth centers, the LBW rate was 3.7% compared with 8.2% nationally, and the prematurity rate was 4.4%, half the national rate of 9.9%. Black babies in the Strong Start group had a prematurity rate of 5.1% compared with the national rate of 13.8%. Birth center clients had fewer labor inductions and cesarean deliveries.

To determine what women receiving enhanced prenatal care in the three Strong Start models thought about these enhancements, 133 focus groups including 951 women were held.¹⁹ Participants appreciated the additional time spent in prenatal visits, supportive relationships they developed with the providers, intensive education concerning breastfeeding and family planning, engagement of family members in the childbearing process, and referrals to meet financial and social needs.

BIRTH CENTERS AND MIDWIVES

There have been many calls for reforming the maternity care system in the United States because of high cost and poor outcomes, especially persistent racial disparities.^20–22 The success of Strong Start birth centers in reducing prematurity and LBW rates for Medicaid recipients rekindles this effort.^4,5,23 Researchers evaluating the Strong Start birth centers believe scaling them up would provide the right care for low-risk pregnancies and improve outcomes.²³ They recommend expansion of state laws to facilitate opening and operating birth centers and utilizing the rigorous accreditation program of the Commission for the Accreditation of Birth Centers for licensure. They also call for funding to expand birth centers by replacing the poorest performing Strong Start maternity care homes sites with birth centers.

Alliman and Bauer advocate grassroots efforts to influence policy to fund demonstration projects opening more birth centers in rural and underserved areas as proposed by the Birth Access Benefiting Improved Essentials Facility Services Act (HR 3337).⁴ They also urge insurance companies to include birth centers and midwives as distinct options in provider directories. Funding for additional research about developing birth centers in perinatal shortage areas by incorporating birth centers into rural access hospitals and federally qualified health centers was posited. A major change necessary to increase birth center availability for Medicaid beneficiaries is establishing sustainable reimbursement rates.⁵

Courtot et al. examined how Strong Start birth centers experienced Medicaid reimbursement and found crucial barriers including low reimbursement rates and midwives receiving less reimbursement than physicians resulting in birth centers capping Medicaid beneficiaries.⁵ Medicaid beneficiaries comprise only 24% of birth center clients. Birth centers were unable to contract with managed care organizations, which execute most state Medicaid programs.

Recommendations by researchers involved in the Strong Start initiative are echoed by the Aspen Health Strategy Group in their report highlighting the failure of the traditional highly interventive model for childbirth and supporting a holistic approach by having states adopt a suite of policies related to licensure for providers and reimbursement mechanisms that support proven approaches to reducing poor maternal and newborn outcomes.²¹ Integrating birth centers is also recommended in the consensus report “Birth Setting in America: Outcomes, Quality, Access, and Choice.”²²

To increase access to birth centers, more midwives are needed because the majority of birth center care is delivered by midwives. Midwives are essential to improving pregnancy outcomes according to a study published in The Lancet.²⁴ The authors concluded,

These findings support a system-level shift from fragmented maternal and newborn care focused on identification and treatment of pathology for the minority, to skilled care for all. Midwifery is pivotal to this approach.^24(p1129)

Educating more midwives requires federal funding for midwifery education modeled after medical education. The number and capacity of midwifery education programs needs to increase. There are currently no midwifery education programs in historically Black colleges and universities; developing them should be a priority.

The Black Maternal Health Momnibus Act of 2021, introduced in the US Congress, proposed investments in programs that improve the social determinants of health. Funding for community-based initiatives that improve perinatal outcomes and mitigate inequities is a key component of the bill and could fund birth center development. The bill advocates diversifying the maternity workforce to foster culturally congruent care and could fund midwifery students of color and initiate midwifery education programs in historically Black colleges and universities. Passing this landmark legislation could profoundly affect perinatal outcomes.

CONCLUSIONS

The maternity care system in the United States is broken. Reliance on technology and overtreating low-risk pregnancies results in extreme costs both in dollars and lives. The evaluation of the Strong Start birth centers demonstrates improved outcomes and reduced costs. It is time to ensure access to birth centers, especially for Medicaid beneficiaries. To scale the birth centers, consumers, health care providers, community organizations, reproductive justice advocates, and state and local governments must align to make critical systems changes as depicted in Box 1. These changes will repair the broken inequitable maternity care system, saving lives.

Box 1—

System Changes to Scale the Strong Start Birth Center Model of Care

Scaling birth centers to meet the needs of mothers and babies in the United States will require the following changes: •Increase Medicaid reimbursement for birth centers and midwives. •Require managed care organizations to contract with birth centers and midwives.     oInclude and highlight birth centers and midwives as categories in provider directories. •Optimize state birth center regulations recognizing Commission for the Accreditation of Birth Centers accreditation for licensure.     oRemove certificate of need requirements.     oRemove requirements for medical directors.     oRemove signed transfer agreements with hospitals. •Pilot birth centers in the poorest performing Strong Start maternity care homes sites. •Incorporate birth centers into federally qualified health centers, rural health clinics, and critical access hospitals. •Fund midwifery education in a manner similar to medical education. •Remove restrictive state licensure of midwives so they can practice to full potential. •Increase the number and capacity of midwifery education programs.     oEstablish a midwifery education program within consortium of historically Black colleges and universities. •Pass Black Maternal Health Momnibus Act of 2021 (HR 959 and S 346), which has provisions for many of the above recommendations. •Pass the reintroduced Birth Access Benefiting Improved Essentials Facility Services Act (HR 3337 and S 1716) to require the Secretary of Health and Human Services to establish a Medicaid demonstration program to develop and advance innovative payment models for freestanding birth center services for women with low-risk pregnancies and for other purposes.