Birth Centers Remain Out of Reach in 10 States

Birth center care is unavailable in 10 US states, and payers don't cover nearly 4 in 10 birth center deliveries, according to a recent Commonwealth Fund analysis of the CDC's WONDER birth files and state-level birth center data.¹

These maternity health care facilities are uniquely positioned to help women with low-risk pregnancies throughout their pregnancy, birth, and postpartum period, thus broadening maternal health care access for underserved populations. Yet women still face access and insurance barriers when seeking care at these centers, including state regulatory requirements, provider shortages, and insufficient Medicaid and private insurance reimbursement.¹ The share of US births occurring at birth centers has grown substantially over the past 2 decades, from 0.23% in 2004 to 0.62% in 2024, although they still account for less than 1% of all births.¹ And prior research from other countries showed that when birth centers are properly integrated into a maternal health system, they can lower health care costs while maintaining positive maternal and newborn outcomes.¹

"As an OB-GYN, I know that the care a mother needs begins well before birth and continues long after. Birth centers offer the kind of continuous, midwife-led care, shaped around each family's needs, that can be part of the response to our maternal health crisis," Laurie Zephyrin, MD, Commonwealth Fund Senior Vice President, Achieving Equitable Outcomes, and report coauthor, wrote in a statement to The American Journal of Managed Care^® (AJMC^®). "But birth center care is out of reach for many who could benefit most."

Black and Hispanic Mothers Increasingly Turn to Birth Centers

Non-Hispanic White women remain the most concentrated demographic, accounting for more than 3 in 4 birth center births in 2024. However, Hispanic and non-Hispanic Black mothers are increasingly opting for birth centers, rising from 8.6% in 2012 to 12.2% in 2024 and from 3.9% in 2012 to 6.6% in 2024, respectively.¹

The maternal mortality rate among Black women is 3 times that of White women and still significantly higher when compared with that of Hispanic and Asian women.² Yet, despite policies such as the extension of Medicaid postpartum coverage, these disparities persist.²

But birth centers could help improve maternal outcomes for Black women and Medicaid beneficiaries. Community of Hope Family Health and Birth Center in Washington, DC, highlighted in the Commonwealth Fund's report, expanded access for Black families and Medicaid beneficiaries by combining a birth center with a federally qualified health center.¹

From January 2023 to June 2024, the center served more than 700 perinatal patients, 87% of whom were Black and 71% of whom were insured by Medicaid. In 2023, its patients with Medicaid had a lower proportion of low-birth-weight babies (10%) than Medicaid beneficiaries in DC overall (15%).¹

Licensing Rules, Low Medicaid Pay Strain Birth Center Finances

However, this model is unique, as state policies regulating licensure vary. Approximately 80% of states formally recognize birth centers and have specific regulations under which they can legally open and operate.¹

A handful of states oversee birth centers under a separate regulatory authority that relies on general standards, such as those for ambulatory surgery centers, while 4 states have no form of licensure. Several states require certificates of need for centers to open, which can give health systems an opportunity to block new centers.¹ State Medicaid programs can also determine the level of facility fees a center can receive for each birth. But Medicaid and private insurer reimbursement has been shown to be insufficient, despite being imperative for these centers' survival.¹

"Birth centers are being asked to operate under policies that can undermine their financial survival," Eugene Declercq, lead report author and professor of community health sciences at Boston University School of Public Health, wrote in a statement to AJMC. "Onerous licensing requirements can impose substantial costs before a center opens, while Medicaid payments often fail to cover the cost of providing care once it does. We cannot expect this model to grow if centers struggle to sustain even their current services."

Research also shows that this model could reduce the likelihood of cesarean deliveries (C-sections).¹ The US C-section rate was 32.3% in 2023, and C-sections are associated with a higher risk of complications.^1,3 Among employer plan enrollees, the mean total health care spending across pregnancy, delivery, and postpartum care is $28,998 for a C-section, whereas the mean for a vaginal delivery is $15,712.³ Of that, $3,071 is paid out-of-pocket for C-section deliveries compared with $2,563 for vaginal deliveries.³

But approximately 18% of birth center births are funded by Medicaid compared with 41% of hospital births, whereas 39% of birth center births are self-pay compared with 3% of hospital births.¹

"Policymakers, insurers, and health system leaders can change that by reimbursing birth centers adequately, modernizing state rules, and integrating them into the broader maternal health care system," Zephyrin wrote.

References

1. Declercq E, Amodio N, Maksut J, Zephyrin LC. The current state of freestanding birth centers in the United States. Commonwealth Fund. October 20, 2026. Accessed October 20, 2026. https://www.commonwealthfund.org/publications/issue-briefs/2026/oct/current-state-freestanding-birth-centers-united-states

2. McCrear S. Black maternal health week highlights persistent disparities and policy action. AJMC. April 21, 2026. Accessed October 20, 2026. https://www.ajmc.com/view/black-maternal-health-week-highlights-persistent-disparities-and-policy-action

3. Winger A, Rae M, Cox C. Health costs associated with pregnancy, childbirth, and infant care. Peterson-KFF Health System Tracker. September 9, 2025. Accessed October 20, 2026. https://www.healthsystemtracker.org/brief/health-costs-associated-with-pregnancy-childbirth-and-postpartum-care