The bombshell announcement came without warning at a staff meeting last September. In the Denver suburb of Thornton, Colo., midwives, birth assistants and other staffers gathered in the conference room at Seasons Community Birth Center for their monthly all-hands meeting.

Two representatives of Elevate Women’s Health were there, too. Elevate is a healthcare group that owned Seasons, and had recently been purchased by a private equity firm.

The Elevate representatives told the assembled staff that the owners were shutting down the birth center in 30 days’ time.

“We were shocked,” said Aubre Tompkins, the center’s longtime clinical director and a certified nurse-midwife. “There were a lot of tears, anger, confusion. I can’t really put into words how I felt in that meeting. It was rough.”

Nobody expected closure; the birth center’s client base had been growing steadily. “My staff’s first reaction was, ‘What about our families who are due?’” said Tompkins. “We had 62 people who were going to have babies with us and were in their third trimester.”

Birth centers – and the midwifery model of care typically practiced in them – are more popular than ever. While births in birth centers only account for about 0.6% of all U.S. births, their number has doubled since 2010, even as the overall number of U.S. births decreased. Seasons had been open for just three years and had delivered nearly 700 babies. Birth centers themselves have seen a particular explosion of growth over the past 15 years, and now number about 400 nationwide.

As the U.S. grapples with a high maternal mortality rate and severe racial and economic health inequities, more families are looking for alternatives to the physician- and hospital-based birth that has dominated the U.S. healthcare landscape for a century.

And yet despite their popularity, many birth centers face uncertain futures, even in states with robust community support (think Massachusetts, Colorado). Birth centers in cities like Boston, Asheville and Portland have closed in recent years, their owners citing financial barriers to keeping them open.

Advocates say systemic issues like low insurance reimbursement rates, restrictive state policies on midwifery and a profit-driven healthcare system threaten the expansion of midwife and birth center care. Closures have become cautionary tales for those hoping to open birth centers in other states.

“Birth centers can be sustainable,” said Tompkins, who also serves as the president of the American Association of Birth Centers. “They can pay their bills, pay their employees and make a profit. But they’re never going to make the type of profit a private equity group wants, because in our current system, women’s health is not reimbursed well.”

Despite economic hurdles, for some midwives like Tompkins and the staff at Seasons, a forced closure represents an opportunity to try a new approach.

“Our healthcare system doesn’t value the health of the childbearing people,” said Tompkins. “So we have to change the system.”

Profits and relationships

As word spread about the closure of Seasons last fall, its supporters mobilized. Seasons was popular in the community, a center that actively welcomed pregnant people from marginalized groups, including LGBTQ+ families and families of color. As Tompkins and the other midwives searched for ways to keep their doors open, community supporters signed petitions and organized fundraisers.

Midwifery care is a labor-intensive model, no pun intended. Midwives care for clients with normal, low-risk pregnancies. They may spend more time with clients during prenatal visits than physicians are able to spend, and remain with their clients during labor. Birth centers like Seasons typically have home-like birthing rooms, offer options like water birth, and may have fewer restrictions than hospitals on things like laboring positions or how many visitors can be in the birthing room.

A growing body of research has shown that birth centers can provide high quality care, high patient satisfaction and lower costs for low-risk pregnancies. Multiple studies have found planned birth center births are associated with lower rates of cesarean births and fewer birth interventions. A review of birth center studies that included more than 84,000 women over 30+ years found few severe outcomes and no reported maternal deaths.

Shore Capital Partners, the private equity firm that owned Seasons, said the reason they closed the birth center was that it wasn’t profitable enough, said Tompkins.

“Our current healthcare system is based on fee-for-service, meaning in order to get paid, you have to do something to somebody. There has to be a procedure involved,” said Tompkins. “That’s not how midwifery works. It’s about time and relationships. That’s why in the current system, midwifery will always be struggling.”

Similar closures have played out in birth centers and midwifery practices across the country. Last year, the Beth Israel Lahey hospital system closed a birth center in Boston that had been operating for 42 years, citing staffing shortages. Supporters argued the hospital was prioritizing profits over patients. The for-profit Hospital Corporation of America shut down its two Denver-area midwifery practices in 2018 that mainly served families with low incomes and refugee families.

For midwives and advocates like Tompkins, birth center closures are visible reminders of how little the U.S. healthcare system values reproductive care that happens outside of a hospital. Insurance companies and government-funded public insurance plans like Medicaid pay well for surgeries and specialist care, but not for preventative care.

“People say our healthcare system is broken,” Tompkins said. “I would say our healthcare system is working exactly as it’s designed to work: To serve capitalist, for-profit healthcare companies. What we need to do is tear it down and start over.”

Pivoting to nonprofit

Elephant Circle, a Colorado-based reproductive justice organization that works with groups across the country, reached out to Seasons leadership and offered to help.

“It felt like they were really just hitting their stride (at Seasons), especially in terms of how many people they were serving,” said Indra Lusero, director at Elephant Circle and a birth justice attorney. “To me, it seemed like a dumb time to close because they were doing so well.”

Elephant Circle offered to be the birth center’s fiscal sponsor, providing financial oversight and other administrative services. This allowed Seasons to transition into a fully nonprofit organization and accept donations from angel investors and other fundraising efforts.

Tompkins, Lusero, other midwives and activists from Elephant Circle’s partner organizations created a task force to, as Lusero put it, “build the plane while flying it.”

They purchased the birth center’s equipment and building furnishings from the private equity firm and took over the lease of their building. The state let them keep their current birth center license. Members of the task force worked on a new set of values for the birth center, with racial justice and health equity at its heart.

“Because we were preexisting and we had the space and the immediate fiscal sponsorship of Elephant Circle and the support of the community, it all came together with a lot of hard work,” said Tompkins.

“But our example is like a unicorn. Not everybody has what we have.”

Community rallies

In 2019, a large not-for-profit hospital system in Oregon named PeaceHealth announced it was closing its Eugene-area birth center, one that had served the region for more than 40 years.

The community outcry was intense. Supporters organized marches outside the hospital, contacted local media, met with PeaceHealth administrators, signed petitions and arranged fundraisers.

But the hospital system refused to budge, citing a decline in revenue. The birth center shut its doors. It would take two years and a massive community effort to open them again.

AlexAnn Westlake, a certified nurse-midwife who’d worked at the birth center, joined with other supporters to form a nonprofit shortly after the birth center shuttered. Over the next two years, they raised more than $300,000 in donations, found a new facility, remodeled it, purchased equipment and got the appropriate licensing, all in the middle of the COVID pandemic.

They reopened as the Our Community Birth Center in the fall of 2021.

“I think going nonprofit was the exact right way to open a birth center,” said Westlake, “because it’s made the community so involved, made this a team effort and has contributed to it being sustainable.”

She works to keep costs low by maintaining a small center with a small team. The center accepts clients with private insurance, Medicaid (public insurance for low-income individuals), and has a sliding-scale fee for self-pay clients.

“We are busy and full, which has made it challenging sometimes to serve everyone who deserves to be served,” she said. “But we’re committed to not turning anyone away for financial or insurance reasons.”

For midwives, reimbursement from Medicaid and some private insurance for the services they provide typically doesn’t pay all of the bills.

But Medicaid reimburses midwives less than it costs to provide prenatal, birth and postpartum care, said Tompkins. And facility fees that birth centers receive are often less than the fees hospitals get, even for the same kinds of low-risk, vaginal births.

Essentially, most birth centers lose money when they take on Medicaid clients. But not taking Medicaid – which covers nearly half of U.S. births – wasn’t an option that the staff at Seasons or Our Community wanted to consider.

For community-focused birth centers, an integral part of their mission and values lies in caring for pregnant people who are economically disadvantaged.

That’s one way that nonprofit status can help small community birth centers: It allows them to rely on multiple sources of funding, including donations and grants, to offset costs that aren’t covered by Medicaid reimbursement.

Westlake recently secured grants to be able to offer a competitive salary to hire a second nurse-midwife, who is expected to begin working this spring.

But the nonprofit model isn’t a slam dunk for everyone. Westlake believes it’s a model that works best in places where birth centers already enjoy strong community support from families, business owners and healthcare providers.

“I think it would be hard to start a nonprofit birth center in a community that wasn’t familiar with what a birth center is and the benefits it provides,” she said, “because it would be hard to get community donations and support.”

In Asheville, N.C. a popular nonprofit freestanding birth center shut its doors in 2021. At the time of its closure, the center’s executive director, Nancy Koerber, told the Asheville Citizen-Times that the center’s leadership had become “overwhelmed” by the numerous barriers to operating, including financial issues and “antiquated” state regulations that require nurse-midwives to work under a physician’s supervision and prohibit professional midwives from practicing at all. It was the fifth birth center to close in North Carolina in three years.

The collaborative model

When a freestanding birth center in Nashville, Tenn. faced closure by its troubled parent company, the Vanderbilt Health System acquired the center. Now called Vanderbilt Birth Center, it’s staffed with more than a dozen nurse-midwives and serves as a training site for Vanderbilt University’s nurse-midwifery students. It’s also used to educate Vanderbilt medical students about working with midwives.

Having the support of a large healthcare system can work for some birth centers, said Dr. Richard Thigpen, an OBGYN and director of the Vanderbilt Birth Center.

“One of the most important things we have at Vanderbilt is our collaborative care model,” he said. Integrating a birth center and its midwives into a health system is better and safer for patients, he said, rather than keeping midwives and their clients separate from the medical community and subsequently treated with suspicion by area hospitals or physicians.

One risk to a hospital-run birth center is the potential to dilute the midwifery standards of care. Some hospital systems, for example, offer birth centers that are inside the hospital and may function more like a wing of the obstetrical unit. Thigpen said he once worked in one of these centers, but found his patients had higher rates of birth interventions like epidurals. While some patients may like that hybrid model, he has preferred Vanderbilt’s freestanding model.

“I would encourage larger health systems to consider birth centers,” he said, “as an opportunity to serve those low-risk, healthy patients who don’t necessarily need all the services of a hospital.”

Training the next generation

Seasons reopened in January as a nonprofit with a renewed focus on reproductive equity and racial justice. Its new mission includes providing gender-affirming care within an anti-racist framework.

“I think the midwifery model does a lot, but it’s possible to have a birth center based in the midwifery model that doesn’t serve communities of color well,” said Lusero. Most of the U.S.’s 400 birth centers are for-profit organizations run by white midwives, according to the AABC.

“This birth center was, for us, not just about being a birth center but about helping to redress some of the inequities in perinatal care that acutely impact communities of color,” said Lusero.

And in that vein, Lusero sees an opportunity to help midwives who want to start birth centers in historically marginalized communities avoid the financial pitfalls that have closed other centers.

“One of the things we’ve learned is how much infrastructure is needed to make a birth center sustainable,” Lusero said. Within the next couple of years, they hope that Elephant Circle, in partnership with Birth Center Equity, an organization created to support and invest in BIPOC-run birth centers, can offer trainings at Seasons that will focus on teaching midwives how to handle the business side of running a birth center – from negotiating with insurance companies to handling billing and human resources issues.

“The experience and expertise in the community made (the reopening of Seasons) possible,” said Lusero. “That is what we hope will give a new birth center a fighting chance.”

This story was published with support from The Solutions Journalism Network through its Health Equity Initiative.