Boston Globe Editorial | License midwives to help struggling birth centers

By the Boston Globe Editorial Board
Story Originally Appeared in the Boston Globe

Massachusetts politicians like to hold the Bay State up as a mecca of reproductive rights. Yet while pregnant people can choose whether to carry a baby to term, they have less choice in where to deliver that baby.

While Massachusetts has world-class hospitals — and 99 percent of births occur in a hospital — there is only one birth center, Seven Sisters in Northampton. The North Shore Birth Center, run by Beverly Hospital, closed in December, while the Cambridge Health Alliance-affiliated Cambridge Birth Center closed when COVID-19 hit and never reopened.

With nearly 400 birth centers nationally, Massachusetts’ single birth center makes the state an outlier. It is a problem for a state that prides itself on high-quality care but struggles with high health care costs.

A birth center gives women with low-risk pregnancies a more homey setting than a hospital, with personalized prenatal care provided by nurse midwives, more natural birth options, and fewer medical interventions. For example, a birth center may offer a tub for a water birth or allow multiple family members to be present, but a center cannot offer medication for pain relief or perform a cesarean section. A 2018 report by the Centers for Medicare and Medicaid Services looked at groups of Medicaid patients and found that birth center births were tied to better health outcomes for the mother and infant at an average cost of $2,000 less than traditional settings. The Massachusetts Health Policy Commission found similarly that midwifery care — offered at a hospital or birth center — is associated with better outcomes and lower costs.

There are steps Massachusetts policy makers should take to make birth centers more financially viable. The Department of Public Health should rewrite its regulations to better suit the care modern birth centers provide. The Legislature should allow the licensing of certified professional midwives, a class of childbirth professionals who could expand the workforce.

Current state regulations license birth centers under guidelines for hospitals or health clinics, with some birth center-specific rules. But practitioners say it makes no sense for birth centers to have to conform to some of the same rules as surgery clinics.

Kirsten Kowalski-Lane, a midwife and cofounder of Seven Sisters, said in other states clinics are set up in rehabilitated houses — a feat that would be virtually impossible with Massachusetts’ regulations about space, lighting, and ventilation. Kowalski-Lane initially sought to rehabilitate a former pediatrician’s office but the HVAC system and exam room sizes did not adhere to birth center regulations. Seven Sisters had to install expensive lighting that Kowalski-Lane said is unnecessary.

Nashira Baril, who is in the process of opening a birth center in Roxbury, said she is frustrated that although state law allows nurse midwives to practice independently without physician oversight, regulations require birth centers to employ an obstetrician or gynecologist as medical director — raising costs and threatening birth center operations should that person leave their job.

The state’s Special Commission on Racial Inequities in Maternal Health issued a report last year urging the Department of Public Health to modernize its regulations. Currently, Black women have higher rates of death and complications from pregnancy and childbirth, and research has shown that having access to culturally competent birth centers can improve patient health outcomes. There are examples of best practices in birth center regulations in other states and the American Association of Birth Centers offers best practices. The Department of Public Health should convene medical experts and launch a regulatory review process to craft modern rules that ensure patient safety and relate to how birth centers actually operate.

Another problem is staffing. When Beverly Hospital closed the North Shore Birth Center, officials said they could not find enough midwives. There is a nursing shortage in Massachusetts, and birth centers have particular trouble hiring because they tend to pay less than hospitals due to lower insurance reimbursements.

A bill pending before the Legislature to license certified professional midwives could help the workforce challenge by credentialing a new pool of potential staff who are trained in out-of-hospital births and have lower salary expectations than nurse midwives.

As opposed to nurse midwives, who graduated nursing school, certified professional midwives hold a credential from a national organization, based on a midwifery-focused education and apprenticeship. They can only attend non-hospital births. Thirty seven states license certified professional midwives. Because Massachusetts does not, they cannot be reimbursed by insurance, are not overseen by a state licensing board, and cannot work in birth centers.

“There’s a huge pool of midwives they’re not able to recruit from,” said Rebecca Herman, a board member of the Massachusetts chapter of the National Association of Certified Professional Midwives.

The main opposition comes from the Massachusetts Medical Society, which has argued that having a physician-led care team is the best way to provide high-quality care and ensure patient safety. The society has raised concerns about how the bill addresses issues including who would oversee midwives, what data midwives must report to public health authorities, and their scope of practice. Those implementation issues need to be worked out before a bill passes. But if safety is the concern, it makes more sense to license certified professional midwives and impose standards for insurance, training, and scope of practice than to continue the status quo where midwives attend home births with no state oversight.

Advocates for birth centers also support a bill to increase insurance reimbursement rates so nurse midwives are paid the same as physicians. But this issue is far more complicated than paying the same rate for the same service. Insurance companies typically pay more to providers with higher levels of skill and education. Adjusting insurance rates raises myriad issues surrounding market negotiating power, billing practices, and who should control rates. These issues could be considered as lawmakers delve into broader issues surrounding health care provider price variation, but if past is precedent, lawmakers will struggle to reach agreement.

Meanwhile, Baril is in her eighth year of trying to open a Black-owned birth center in Boston. Prompt action on regulations and licensing could help her birth center and others open and stay open to provide choices to pregnant women.