Abstract
This contribution reprints the Executive Summary from a technical report issued by the National Partnership for Women & Families within its larger Improving Our Maternity Care Now project. This project identifies the priority of continuing the long, challenging work of maternity care system transformation, while also increasing access to high-performing care models that can help meet current urgent, dire needs for equitable high-quality care now. The Community Birth Settings report (encompassing birth center and planned home birth care) is the second in a series of four reports on these care models, which share distinctive features. They reliably provide highly appropriate services that minimize both underuse of beneficial practices and overuse of unneeded, often harmful practices. They prioritize relationship-based, whole person care that builds trust, confidence and resilience and helps meet the varied needs of birthing families. They incorporate skills and knowledge to support the innate physiologic processes of birthing people and their fetuses/newborns. They achieve remarkable results for consequential outcomes relative to standard maternity care. And childbearing people greatly desire access to these forms of care relative to current access and use. Community-based versions offering trustworthy, respectful, culturally-congruent care are especially powerful. The community birth settings report includes recommendations for federal policymakers, state policymakers, and private sector decision makers to increase access to these settings. It was carried out in partnership with the American Association of Birth Centers, American College of Nurse-Midwives, Birth Center Equity, National Association of Certified Professional Midwives, and National Black Midwives Alliance. Access the full project through https://www.nationalpartnership.org/improvingmaternitycare/. The project is supported by the Yellow Chair Foundation. Reproduced with permission of the National Partnership for Women & Families.
Keywords: midwifery, birth justice, maternal health, maternal health policy
EXECUTIVE SUMMARY
Our nation’s maternity care system fails to provide many childbearing people1 and newborns with equitable, accessible, respectful, safe, effective, and affordable care. More people die per capita from pregnancy and childbirth in the United States than in any other high-income country in the world. Our maternity care system spectacularly fails communities struggling with the burden of structural inequities due to racism and other forms of disadvantage, including Black, Indigenous, People of Color; rural communities; and people with low incomes.
Both the maternal mortality rate and the much higher severe maternal morbidity rate (often reflecting a “near miss” of dying) have been increasing. Both reveal inequities by race and ethnicity. Relative to White, non-Hispanic women, Black women are more than three times as likely—and Indigenous women are more than twice as likely—to experience pregnancy-related deaths.
Moreover, Black, Indigenous, Hispanic, and Asian and Pacific Islander women disproportionately experience births with severe maternal morbidity relative to White, non-Hispanic women.
This dire maternal health crisis, which has been compounded by the COVID-19 pandemic, demands that we mitigate needless harm now.
Fortunately, research shows that there are specific care models that can make a concrete difference in improving maternity care quality and producing better outcomes, including for birthing People of Color. One of these is the care provided in community birth settings, an increasingly used term for both birth centers and home birth care. Almost exclusively, such care is led by midwives. This report outlines the evidence that supports the unique value of community birth settings across different communities, the safety and effectiveness of care in these settings in improving maternal and infant outcomes, the interest of birthing people in use of birth centers and home birth care, and the current availability of, and access to, birth centers and home birth care in the United States. We also provide recommendations for key decisionmakers in public and private sectors to help support and increase access to care in community birth settings.
Research shows that community birth settings provide many benefits for birthing people and newborns relative to experiences of similar people in hospital settings. These include lower rates of many interventions; more favorable assessments of experiences; better outcomes for such crucial indicators as rates of preterm birth, cesarean birth, and breastfeeding; and lower overall costs. Birth centers and home births are safe options for essentially healthy birthing families in the context of policies and practices that integrate community birth providers into the maternity care system. Care in these settings that is led by Black, Indigenous, People of Color is a crucial approach for meeting the needs of communities affected by structural racism and other forms of discrimination. While use of these settings has been steadily growing, and interest far exceeds access, just a fraction of births that might occur in these settings take place there at present. Access to, and use of, these beneficial settings by People of Color, who might disproportionately benefit from this attentive, individualized, relationship-based, and often culturally congruent model of care, is disproportionately lower than that of White people.
Expanding access to care in community birth settings is a cost-effective solution to providing higher quality care and better birth outcomes, and—with intentional focus—to advancing birth equity. Barriers to this care must be eliminated. These include: barriers to the growth of the midwifery workforce, which is most likely to practice in these settings; capital costs needed to establish and operate birth centers; inconsistent reimbursement or unsustainable levels of Medicaid and other reimbursement of midwifery and birth center services; needlessly restrictive birth center licensure; and failure to license and regulate birth centers in all states.
Enabling more birthing people to receive care in community birth settings and increasing access to community birth care provided by and for People of Color should be a top priority for decisionmakers at the local, state, and federal levels. To achieve this, we recommend the following:2
FEDERAL POLICYMAKERS SHOULD:
Ensure coverage of birth center services and of midwives practicing in birth centers by all federal providers and payers of maternity services.
Ensure coverage of midwifery-led home birth services by all federal providers and payers of maternity services, with the exception of Bureau of Prisons and Department of Homeland Security detention centers.
All midwives holding the three nationally recognized midwifery credentials should be eligible providers under federal health programs and should receive payments at parity with physician-provided maternal-newborn health services.
Enact the Midwives for Maximizing Optimal Maternity Services (Midwives for MOMS) Act (H.R. 3352 and S. 1697 in the 117th Congress) to increase access to midwives.
Include in appropriations bills monies to increase the supply of midwives holding the three nationally recognized credentials by supporting programs or schools, preceptors, and students who will diversify the midwifery workforce and build capacity in underserved areas.
The Department of Health and Human Services (HHS) should include Certified Midwives and Certified Professional Midwives as health professionals eligible for loan forgiveness under the National Health Service Corps program.
HHS should issue updated guidance clarifying the ACA Section 2301 requirement of Medicaid coverage of birth center services to expand coverage and access for Medicaid enrollees.
Enact the Birth Access Benefitting Improved Essential Facility Services (BABIES) Act (H.R. 3337 and S. 1716 in the 117th Congress) to increase access to birth centers.
Include in appropriations bills monies to support community-led solutions to maternal health inequities by supporting the capital needs of developing birth centers led by and serving birthing families in most adversely affected communities.
Ensure sustainable payment of birth center services, of midwives practicing in birth centers, and of midwives providing home birth services by Medicaid, Medicaid managed care organizations, Child Health Insurance Programs (CHIP), and other federally supported programs.
The Office of the National Coordinator should include birth centers as primary birth facilities when formulating the national strategy relating to electronic health information.
The Veterans Affairs Community Care Network, TRICARE, and Military Treatment Facilities should include in-network birth centers and collaborating physician practices in any demonstrations of purchased care electronic health information interoperability.
The Office of Personnel Management should encourage plans participating in the Federal Employee Health Benefits Program to increase the percentage of midwives, birth centers, and other maternity services purchased through value-based contracting.
Reallocate available Coronavirus Aid, Relief, and Economic Security (CARES) Act provider relief fund monies to prepay electronic health records and Health Information Exchange expenses for qualified birth centers and their collaborators.
Enact all provisions of the Black Maternal Health Momnibus Act of 2021 (H.R. 959 and S. 346 in the 117th Congress) to advance birth equity through a broad range of strategies.
Congress should ensure that all Medicaid enrollees have coverage for one year postpartum by passing a permanent universal extension of the American Rescue Plan’s state option to expand postpartum Medicaid coverage.
Identify, track, and address health inequities, require collection and public reporting of key maternal-infant health indicators disaggregated by race and ethnicity and other dimensions across federal programs.
Whenever feasible, include community birth settings, providers, and service users in data collection and reporting, performance measurement, payment reform, and quality improvement initiatives across federal programs.
STATE AND TERRITORIAL POLICYMAKERS SHOULD:
Enact birth center licensure without unnecessary legal restrictions limiting access in the nine states that do not currently regulate birth centers and amend current state statutes to remove widespread and unnecessary restrictions.
Enact certified midwife and certified professional midwife licensure in states and territories that currently fail to recognize holders of these credentials.
Require Medicaid managed care organizations to contract with state-regulated birth centers and with midwives who practice in birth centers and provide home birth services.
Whenever feasible, include community birth settings, providers, and service users in data collection and reporting, performance measurement, payment reform, and quality improvement initiatives.
Develop and enact state “Momnibus” legislation modeled on legislation recently enacted in California and Colorado to advance birth equity.
In consultation with relevant people from the most affected communities, create processes for equitable development investments that support community birth centers, modeled on similar work in Seattle.
PRIVATE SECTOR DECISIONMAKERS, INCLUDING PURCHASERS AND HEALTH PLANS, SHOULD:
Incorporate clear expectations into purchaser-payer contracts about access to, and sustainable payment for, care in birth centers and home birth settings and for services of midwives with nationally recognized credentials.
Educate employees and beneficiaries about the benefits of midwifery-led care in community birth settings.
Ensure that plan directories maintain up-to-date listings that identify all available birth centers and midwives.
Educate maternity care providers and hospitals about the safety of maternity care that is integrated across providers and settings, with seamless consultation, shared care, transfer, and transport from community birth settings as needed.
Whenever feasible, include community birth settings, providers, and service users in data collection and reporting, performance measurement, payment reform, and quality improvement initiatives.
ACKNOWLEDGMENTS
We are grateful to the Yellow Chair Foundation for its generous support of this work. Contributions of the following partners strengthened this report in a myriad of ways: Jill Alliman and Kate Bauer of American Association of Birth Centers; Karen Jefferson and Amy Kohl of the American College of Nurse-Midwives; Nashira Baril, Julie Quiroz, and Leseliey Welch of Birth Center Equity; Mary Lawlor of the National Association of Certified Professional Midwives; and Jamarah Amani and Kim Banton of National Black Midwives Alliance.
Biographies
CAROL SAKALA is the Senior Director for Maternal Health, National Partnership for Women & Families.
SINSI HERNÁNDEZ-CANCIO is the Vice President for Health Justice, National Partnership for Women & Families.
RACHEL WEI is an OB Practice Consultant, Anthem, Inc.
NOTES
We recognize and respect that pregnant, birthing, postpartum, and parenting people have a range of gender identities, and do not always identify as “women” or “mothers.” In recognition of the diversity of identities, this report gives preference to gender-neutral terms such as “people,” “pregnant people,” and “birthing persons.” In references to studies, we use the typically gendered language of the authors.
The main body of this report provides fuller, more detailed versions of these recommendations.
DISCLOSURE
The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.
FUNDING
The Yellow Chair Foundation supported this work.