A Community-Led Approach to Transforming Maternity Care

As evidence of maternal health disparities continue to mount, showing consistently higher rates of death and pregnancy complications for Black and Indigenous populations, women in the communities most affected are rallying together to build safer systems of care. By increasing access to comprehensive, individualized care in low-income communities, they aim to prove that disparities are a function of delivery system design, not demographics. It’s a distinctly collectivist approach that is uniting providers, public health experts, and community residents around a common goal: helping families thrive.

The first Black-led birth center in Michigan, Birth Detroit, is slated to open this fall. It’s a dream a decade in the making for its founders, who are intent on preventing deaths in a city where Black women are four times more likely to die of pregnancy-related causes than the state’s white residents.

Birth Detroit is one of 40 similar efforts across the U.S. to establish or sustain freestanding birth centers in low-income communities where health disparities abound. Many aim to become an engine for economic empowerment and an anchor in the community where Black, Indigenous, and other people of color can access midwifery care. The relationship-centric model emphasizes informed decision-making, cultivated through longer visits that surface broader medical and social issues that have a direct bearing on birth outcomes. The midwifery model has been shown to reduce preterm births, the numbers of low-birthweight babies, cesarean sections, and neonatal intensive care unit admissions.

Many of the developers are building on the work of Jennie Joseph, LM, CPM, a British-trained midwife who set out two decades ago to establish a more humane system of care for people who struggled to find providers willing to accept Medicaid or treat the uninsured. Her Commonsense Childbirth Easy Access Clinic, in Winter Garden, Fla., is designed to make midwifery-led prenatal and postpartum care accessible to everyone.

In her high-touch practice, patients meet separately with midwives, nurse practitioners, doulas, and lactation educators who inquire about different facets of their health. Each conversation is an opportunity to forge a deeper relationship and cultivate a sense of safety. Through these exchanges, staff can identify problems that may be overlooked or dismissed during rushed medical visits — such as the subtle signs of a blood clot — that left untreated can quickly become life-threatening.

“We’re showing people it’s possible to be treated right, to engage in shared decision-making, and have your dignity maintained,” Joseph says. “The model generates a sense of power and agency that moves with you through the system as a protective bubble.” Even when Easy Access Clinic patients opt to give birth in local hospitals under the care of unaffiliated providers, they end up having fewer preterm births, cesarean sections, and postpartum complications.

The midwives influenced by Joseph’s model are hoping to replicate its core features: unimpeded access to providers who look like the patients they serve, and education that empowers people to demand better care. They also want to overcome the “impossible math” of sustaining a birth center while serving high numbers of Medicaid beneficiaries. Medicaid, which covers a majority of Black and Hispanic births, pays a small fraction of what commercial insurers do. Joseph, for example, makes only $40 to $50 per appointment, not enough to cover the cost of her staff.

This issue of Transforming Care describes how these socially minded entrepreneurs are bringing their expertise in business, public health, and medicine to bear on the problem. We show how they are negotiating their way into insurance networks, partnering with hospitals that may see them as competitors, and deconstructing the notion that a highly medicalized hospital birth is superior to the safety and effectiveness of midwifery-centered care.

A Person-Centered Model of Care

When Rebecca Polston, CPM, looked at Camden, a low-income, majority-Black neighborhood in North Minneapolis, the community-organizer-turned-midwife saw only potential. “I didn’t see violence. I saw families and kids and elders and people walking their dogs. I thought this is where we live. Why shouldn’t we be born here?”

The neighborhood had one of the highest infant mortality rates in the city, and she reasoned it wouldn’t be fixed by sending people to doctors and hospitals that had a track record of disappointing them. She launched Roots Community Birth Center in 2015 using $300,000 she amassed from loans and personal savings. It’s located in a duplex she and her husband purchased and renovated themselves, creating a homelike environment with two birthing suites on the second floor.

Placing it in Camden enabled her to leverage a Minnesota statute that requires insurers to contract with any providers working in underserved areas. Blue Cross and Blue Shield of Minnesota was an early and supportive partner, but other health plans didn’t always comply with the statute; some argued a hospital sufficed as a birth center. “There were many times I had to print out the law or call the state and complain,” she says.

Now nearly a decade in, she and three other midwives serve 200 patients a year. Most — 80 percent — are Black or Indigenous; 60 percent are covered by Medicaid. Their care model resembles Joseph’s in many ways. They cultivate relationships through long medical visits, none shorter than 30 minutes. With as many as 22 appointments before and after birth, staff can attend to mental health issues, chronic conditions, and downstream cardiovascular risks. (The American College of Obstetricians and Gynecologists recommends that patients with medical conditions or pregnancy complications have at least 13 prenatal and postpartum visits.)

Polston often reminds patients that she’s simply a steward who is leveraging people’s innate ability to care for themselves. “It’s believing that the birthing person is the smartest person in the room and that they love their baby more than anyone else. They want a healthy pregnancy more than anyone else on the whole planet,” she says.

Families decide on the number of people who will be present and have the option to decline services that might be forced on them in a hospital setting, such as frequent cervical checks or intravenous fluids. With two staff at every birth — a midwife and a birth assistant — most patients return home four to six hours after giving birth. The midwives make home visits three times that first week, after which patients come for at least three office visits over several weeks, allowing the team to detect postpartum complications, including depression.

Ten percent of patients are transferred to a hospital during birth, primarily for pain management. Only 5 percent of those undergo cesarean sections, compared to the state average of 30 percent. And 99 percent of the birth center’s patients are still breastfeeding at six months, compared to 25 percent nationally.

Polston and staff are mindful that many hazards of pregnancy manifest in the weeks and months after giving birth. “A lot of the morbidity of pregnancy is played out after the fact. That’s the benchmark we use. Did we help someone take control of their family history of diabetes? Did we make sure someone with preeclampsia is seeing a cardiologist afterwards?” she says.

Developing Partnerships with Health Systems to Promote Safety

Polston spent four years establishing strong ties with two local hospitals to ensure seamless transfers of patients requiring more intensive medical or surgical intervention. Such transfers are inevitable for birth centers, but they can become problematic if a hospital refuses one, forcing a patient to enter through the emergency department.

She or another staffer accompanied every patient who needed a transfer, bringing along medical records and demonstrating a willingness to support hospital staff, including debriefing after challenging cases.

Now she has the medical directors’ phone numbers on speed dial. “If we say we need an operating room, they believe us. And everyone’s there in gloves, ready for us. It’s fabulous,” she says. The transfer protocol Polston codeveloped with one hospital has been used by hospitals across the city. Staff from the partner hospital have joined Polston in presenting what they see as best practices at meetings of the American College of Obstetricians and Gynecologists.

Financial Sustainability Remains a Challenge

Despite these successes, reimbursement remains a challenge. For Medicaid-covered births, Polston only receives $1,386 to cover all prenatal and postpartum care, a rate Medicaid hasn’t increased since 2011. Equally problematic, if a patient transfers to the hospital out of necessity, Polston receives only $400, or 20 percent of the facility fee. The birth center’s facility fee is already substantially lower than that of hospitals for Medicaid-covered births and commercial ones, requiring her to make up 25 percent of her budget with philanthropy.

Designing for Sustainability

Birth Detroit will open with more cash reserves than Roots Community Birth Center. Of the $4 million its founders raised from foundations, donations, and t-shirt sales, they set aside $2.5 million for operations. They also frontloaded the cost of management expertise that most small midwifery practices can’t afford. Their team includes people with years of experience in business, public health, health policy, and midwifery care, including Leseliey Welch, MBA, MPH, former deputy director of Detroit’s public health department.

The team leveraged their knowledge of city government to buy land from Detroit’s landbank for less than $20,000 and then purchased an adjoining parcel for $100,000, giving them nearly three acres on Detroit’s west side on which to develop a hub for community health. The first phase — the 3,570-square-foot birth center — is under construction. With a sleek modern design, it will have two exam rooms, two birth suites, a community room, a kitchen, and office space.

Their longer-term goal is to add space for aligned providers — primary care physicians, pediatricians, and therapists, among others — to practice. Other enterprises are also envisioned, including a midwifery training center and revenue-generating businesses to sustain their operation. “We want to provide an oasis of care and of love to our community and demonstrate how birth centers can support neighborhood development, health systems, and our economy,” Welch says.

The campus has been designed with community input, including a 2018–2019 survey that revealed 98 percent of 400 respondents wanted the type of care they proposed, and wanted it yesterday. In response, Birth Detroit opened a grant-supported clinic in 2020 in collaboration with Brilliant Detroit, a child development center. The clinic offers prenatal and postpartum care two days a week. Welch says families travel up to two hours to see Black midwives at Birth Detroit’s Easy Access Clinic. Additionally, the midwives visit families in their homes within 48 hours of birth — a key part of the model.

Overcoming Red Tape

In Boston, the high price of real estate and construction led the founders of Neighborhood Birth Center to seek community organizations as partners to share in the expense of building a $12.5 million hub for community health and empowerment. Their partners include Resist, Movement Sustainability Commons, the Center for Economic Democracy, Sisters Unchained, and Matahari Women Workers’ Center. Together, they are planning to build on four parcels of land in the Roxbury neighborhood, with the goal of opening in late 2025. The birth center will have four birth suites, a living room, kitchen, and a sanctuary for meditation and grief support. The architectural plans also include space for an atrium and gardens.

“We bought residential property because we wanted the birth center to feel like it was in a neighborhood, and not in a commercial district,” says Nashira Baril, MPH, the executive director, who is also the daughter and great-granddaughter of midwives. This involves going through a rezoning process and addressing neighbors’ concerns about ambulance noise. “It’s been a journey of community education and organizing to get through the process,” Baril says. And it’s not over — as they seek city approval, they are going to be in line behind many other residential and commercial development projects, which could impact their timeline for opening.

Like Birth Detroit, Neighborhood Birth Center has senior leaders with backgrounds in midwifery, public health, and policy who are poring over budgets in hopes of developing a self-sustaining model, one that’s less reliant on philanthropy or the sacrifices of midwives to succeed. Their projected annual operating budget is $2.6 million; nearly half comes from philanthropy. They want to lower that share to 10 percent by pushing for higher reimbursement based on achieving superior outcomes. “Our argument is this money is in the system and should be used to support places that offer better outcomes and better patient experience,” says policy director Katherine Rushfirth, CNM.

Baril and Rushfirth have asked MassHealth, the state’s Medicaid agency, to pay midwives on par with physicians, as half of states have done, and plan to ask the agency to equalize payments between birth centers and hospitals that are providing the same level of care. Currently, midwives are reimbursed 85 percent of what physicians are for a low-risk birth, Rushfirth says, and birth centers receive one-third to one-half of what a hospital is paid for an uncomplicated delivery. Without adjustment, birth centers are vulnerable to closure, she says. “I think it’s just challenging for the state to hear how much more the reimbursements need to go up,” she says.

They are also advocating for the elimination of onerous regulations that add to the expense of operating a birth center without necessarily improving safety. These include the state requirement that birth centers operate with physician oversight and include certain design features, such as floor lighting, that are only relevant to hospitals. “The good news is the governor at the end of last year passed down to the Department of Public Health a mandate to review those regulations,” Rushfirth says.

Building Birth Centers in Less Populated Areas

It can be even more challenging to build birth centers in areas where the population is more dispersed. In New Mexico, where three-quarters of all births are covered by Medicaid and nearly one in five people lives in poverty, finding a location near pregnant people, midwives, and the hospitals needed to handle transfers is particularly tough, especially when the people you want to serve live in remote areas, including Indian reservations.

Nicolle L. Arthun, MSN, CNM, a Dine’ midwife from the Navajo Nation, founded the Changing Woman Initiative eight years ago in Albuquerque, N.M., with the goal of creating a center that embraced the unique birthing traditions of Indigenous people. “There’s a whole fabric of stories and language and songs and protocols that we should be following,” she says. The ceremonial pieces of Indigenous birth and prenatal care don’t easily align with rigid appointment slots generally used by health care systems.

Arthun also found other Indigenous traditions are not easy to accommodate in hospitals, such as burning cedar or sage and having multiple family and community members, including a medicine man, present at the birth. “It didn’t make sense to try to merge traditional wisdom knowledge practices into a system that was not prepared to adopt them or to make space for them,” Arthun says.

Finding a site to build upon was equally challenging. She was hoping to find land that could accommodate a hogan, an octagonal structure with a fireplace in the center and dirt floors, and also have room for a garden to grow medicinal herbs and food for large families that gather for the birth. She and her partners — three other midwifes — spent years on plans to build a facility on tribal land but had to scrap the idea because they couldn’t afford the monthly rent for the proposed four-acre site.

They then considered building in Santa Fe, but that proved too expensive and too far for staff and patients to travel. A final study determined it would cost roughly $2.5 million to build a center closer to Albuquerque, a goal they never reached owing to the difficulty of fundraising. Arthun says she would write as many as 10 grant proposals a month but never raised more than $100,000 a year, because there’s little funding for maternal health and even less for projects geared to Indigenous populations. “We need a larger investment to be sustainable and also to expand the work.”

Arthun has stepped back from the organization to help birth centers in cities where market conditions are more favorable. Her colleagues continue to provide care via home births.

Next Steps

Ensuring birth centers can thrive in all markets will require more collaboration between the public and private sectors to address funding impediments. Here are some of the ways policymakers, philanthropists, and investors could come together to tackle five of the biggest challenges.

Strengthening the Midwifery Workforce

In 2021, fewer than 1 percent of births occurred in birth centers. As more people elect to use to freestanding birth centers or have home births led by midwives, the U.S. will need a comprehensive strategy to ensure it has the workforce to meet growing demand.

Expanding the workforce requires coordinated investments in education programs and adjustments to loan repayment programs to encourage midwives to work in underserved areas. Arthun says her midwives couldn’t qualify for loan repayment because the program would require them to locate their offices in a remote area that had an insufficient number of patients to sustain a practice.

Funding education programs directly sidesteps this challenge. The Health Resources and Services Administration recently awarded the University of Michigan a $4 million grant that enables the school to offer full scholarships to midwifery students living or working in underserved areas. The Michigan Maternity Care Traineeship Program’s first cohort of 13 students begins this fall and will rotate through Birth Detroit.

Hospitals also may need to be incentivized to hire midwives, including those in training. Mimi Niles, PhD, MPH, CNM, an assistant professor at New York University’s Rory Meyers College of Nursing who studies the midwifery workforce, says hospitals have little incentive to do so now because they will be reimbursed more for physicians who are providing the same level of care.

Increasing Access to Capital

The birth centers that have made the most progress have benefited from lower land costs, cooperative hospital or real estate partners, and supportive payment policies. Still, they rely heavily on grassroots fundraising. To support innovators who need capital and technical assistance, Baril and Welch launched Birth Center Equity (BCE) in 2020. Now led by Welch, the organization has distributed $2.2 million in grants, loans, and other investments in birth centers. BCE is currently raising money for a “business studio” that will bring experienced entrepreneurs, subject-matter experts, and investors together to design and launch solutions for birth centers’ real estate, marketing, and other business needs.

BCE is also partnering with Orchid Capital Collective, a nonprofit based in Oakland, Calif., that aims to provide community-based organizations, including birth centers, with access to financial supports, including recoverable grants, below-market loans, and loan guarantees. Orchid Capital launched a $1 million pilot fund last year, with plans to make as many as seven investments this year, ranging from $50,000 to $250,000. The organization also provides capacity-building grants and technical assistance.

To date, Orchid Capital’s funding has come from private foundations. Far more is needed, both from investors and philanthropists who recognize the importance of making simultaneous investments in care models that prioritize healing and wellness, social supports, and advocacy and policy reform, says Tenesha Duncan, MBA, Orchid Capital’s founder and CEO. “In the next decade, I want to see at least $1 billion committed to BIPOC-led organizations. And to be clear, to hyper-local organizations and statewide and regional coalitions that are collaborating to grow a deeply connected national ecosystem,” she says.

Role of Policymaking

Overhauling payment to support proven birthing models is also key. The new Transforming Maternal Health Model, announced by the Centers for Medicare and Medicaid Services (CMS) in December, will provide participating state Medicaid agencies $1.7 million per year over a decade to test innovative models of care that improve maternal health outcomes. “By demonstrating the value of these models, the pilots have the potential to reshape payment and care,” says Jennifer E. Moore, PhD, RN, executive director of the Institute for Medicaid Innovation, a nonprofit that runs a Commonwealth Fund–supported collaborative to bring together providers, payers, policymakers, and philanthropists interested in improving maternal health.

While these short-term investments help, they don’t address a fundamental challenge that birth centers have: their size. With a low volume of patients, they have had little leverage with managed care plans, especially ones reluctant to design new contracts for facilities serving a small number of patients. They also don’t receive disproportionate share payments some safety-net providers receive to offset low Medicaid reimbursements. New Medicaid managed care regulations that set new access standards and allow for increased payment rates for primary care, obstetric services, and mental health services might help birth centers as they negotiate inclusion in managed care networks at fairer rates.

Some states are trying to address the payment issue. In September, Oregon’s Medicaid agency sought permission from CMS to raise the facility fee for freestanding birth centers threefold, from $1,200 to $3,700. And in January, Washington State increased the facility fee for birth centers to $2,500 for fee-for-service Medicaid births, more than double the amount in 2016. The Medicaid agency also pays midwives and physicians the same professional fee, regardless of birth setting, for the same level of care.

Birth centers in other states may need local allies or changes in state policy to compel payers to treat birth centers and their staff equitably. “We have to stop having bake sales to sustain birth centers,” Moore says.

Building Public Interest and Trust in Birth Centers

Moore believes the biggest driver of change will be consumer demand, but that may require an awareness campaign aimed at educating the public about the value of midwifery and birth center care and overcoming distrust. “Without structural analysis, the headlines surrounding Black maternal deaths frighten people,” Baril says. ”They tell us, ‘I’ve heard Black women are more likely to die in childbirth — why do you want to take us out of the hospital?’”

Such public awareness campaigns, when coupled with positive testimonials from people who’ve experienced the midwifery care model, may build momentum. But awareness campaigns must be paired with structural changes to take hold, Niles says. “If you don’t start upstream and start going systematically through those policies and payment mechanisms that restrict access to midwifery care, nothing is going to change,” she says.

Promoting Supportive Partnerships and Accountability to Promote Safety

As birth centers become a more established part of the health care delivery system, the U.S. will also need more formal ways of monitoring the degree of collaboration between birth centers, area physicians, and hospitals. Patient safety depends on strong communication between all parties, and policies that promote collaboration and center community leadership are critical for success.

Integrating birth centers more fully into the continuum of care is likely to yield benefits for birth centers, hospitals, and the public alike, as Jennie Joseph’s model demonstrates. Patients who opt to receive prenatal and postpartum care from birth centers, but give birth in hospitals, will be better prepared to advocate for themselves during childbirth. Hospital staff may also be reassured that patients who experience complications have access to postpartum care that knits together medical, behavioral health, and social supports. If this results in dramatically improved outcomes, hospitals may be willing to adopt a more holistic approach themselves. At the very least, having staff who are aware of what happens to patients as they transit between settings may make it easier to identify problems with the quality of care in one setting or both.

Leseliey Welch has been heartened to see how local primary care clinicians, hospital executives, and maternal health specialists have stepped up to support Birth Detroit, including lobbying for a recently introduced birth center licensing bill that will enable the birth center to obtain Medicaid payment. “If you asked me five years ago whether we’d have this level of support, I couldn’t have imagined it,” she says.