Help us remove barriers to Birth Centers in New York
Why are birth centers an important?
Birth Centers are imperative to improving maternal care outcomes as they have lower preterm birth, and cesarean section rates. Birth Centers also have significantly lower rates of medical intervention and anesthesia, thus reducing overall costs for families and insurance companies. Finally, birth centers provide holistic, personalized, respectful care for the whole family increasing patient satisfaction.
Why are there no midwifery birth centers in New York?
Despite having the 4th largest population in the U.S.A., New York State has just three licensed birth centers, and none are owned by midwives. For comparison, Florida, which is the state closest in population size has 32 birth centers.
New York has so few birth centers because the regulations for licensure with the Department of Health were not adequately adapted for birth centers and instead rely on the same processes created for and used by hospitals. The process of obtaining licensure is obtuse, onerous, and cost prohibitive for new birth centers. It was just within the last few years that efforts to allow midwives to open birth centers, as opposed to physician led birth centers, were initiated. Prior to this, midwives could not own and operate a birth center, even though they represent the majority of care providers within these facilities.
Midwife-led birth centers were legalized in 2016 and regulations for them were passed in 2019. However, it wasn’t until grassroots efforts and the COVID-19 Maternity Taskforce's intervention after the peak of the pandemic that the Department of Health released guidelines on the application process.
In April 2020, the Taskforce called for diversifying birthing site options to support patient choice, stating “to increase access to midwifery services, the Task Force recommends DOH move to expedite, within the next 45 days, the finalization of the licensure process for the establishment of midwifery led birthing centers in New York State to ensure there are sufficient birthing facilities available to meet community need during emergency situations.” Read the full report here.
Yet, only one midwife-led birth center has been able to apply for licensure and been unduly delayed by several years and rejected.
What is a Certificate of Need?
The main issue preventing licensure of midwife-led birth centers in New York State is the Certificate of Need (CON) requirement.
CON laws were developed in the 1970s to regulate the establishment and expansion of healthcare facilities in a particular community. At the time, the goal was to keep healthcare costs affordable by preventing an oversupply of hospital beds and capital equipment that have high fixed costs. CON laws now focus on outpatient facilities in direct competition with hospitals. They require that these facilities seek approval from regulators and comply with specific facility requirements. However, evidence has demonstrated that CON requirements may actually increase healthcare costs our communities and can negatively impact access. In fact, in the 12 states that have CON requirements for birth centers, 75% have 0 to 1 birth center.
What are the problems with the Certificate of Need (CoN)?
The reduced supply of birth centers caused by the CON requirement means that there is insufficient access to a model of care that improves outcomes, narrows racial disparities, enhances patient satisfaction, and reduces healthcare costs. There is no evidence that CON laws enhance safety or improve the quality of birth center care. These laws were created for facilities that operate very differently than birth centers, which typically have less than five beds and are only used for low-risk maternity care.
Birth centers do not provide surgical birth, or regional or general anesthesia. Rather, they provide services that are not offered by hospitals, such as midwifery model care and non-pharmacological pain management. Because midwifery birth centers do not provide the same services as a hospital, the beds within these facilities are not equivalent to hospital beds and should not be subject to the same regulatory process.
The CON application is long and costly, with estimates ranging up to $75,000. Associated fees include secure architectural drawings, legal information, and a designated consultant to navigate the complicated process before an approval for construction is even issued. Midwifery birth centers are independent small businesses that are often unable to afford this significant upfront investment.
In short, the CON requirement for midwifery birth centers is burdensome and unnecessary.
What are the problems with CoN facility requirements for licensure?
The CON application for licensure of midwifery birth centers includes costly and unnecessary facility requirements that are incongruent with the reality of birth center care.
These regulations enforce the same architectural standards of Article 28 facilities (i.e. hospitals, nursing homes, and surgical centers) for midwifery birth centers. These regulations do not increase safety, but do significantly increase start up costs which prevents access to this option.
Midwifery birth centers limit the population they serve to people who are ambulatory and well, and they care for people during a normal human event. Unlike other Article 28 facilities, they do not care for people who are sick or at a higher risk for complications, manage infectious conditions, or perform any high risk procedures. The safety of birth centers has been proven, and no birth room size or configuration has been shown to be safer than another. Birth center settings are more of a ‘“maximized home” than a “mini hospital”, but New York’s architectural requirements do not reflect this distinction.
The American Association of Birth Centers (AABC) National Standards and the Commission for Birth Center Accreditation (CABC) Indicators ensure that birth center facilities meet all construction, fire, safety, and health codes.
How do other states license birth centers?
Increasingly, states are granting "deemed status" to CABC-accredited birth centers. “Deemed status” means that the rigorous CABC accreditation process is the only requirement for state licensure of birth centers.
This saves states the cost of inspecting birth center facilities themselves while ensuring that birth centers evolve with new evidence and industry best practices. Many states have successfully shown that when birth centers achieve and maintain licensure through CABC accreditation, they are providing safe, high quality care and real access to this option for low risk birthing families.
What does accreditation mean?
As the basis for accreditation, the CABC uses the AABC’s Standards for Birth Centers to create definite indicators of excellence and accountability. These national standards address philosophy and scope of service; planning, governance, and administration; human resources; facility, equipment, and supplies; the health record; research; and quality evaluation and improvement. The AABC Standards are periodically reviewed to ensure they remain consistent with advancements in evidence-based maternity care. In multiple studies, these standards have proven to promote safety as well as the numerous positive outcomes that freestanding birth centers are known to achieve for birthing people.
The CABC Indicators of Compliance are used to complete a robust and exhaustive evaluation spanning several months. During the CABC accreditation process, specialists conduct multi-day site visits and review policies, procedures, personnel files, practice statistics, and patient records to ensure a birth center is in compliance with AABC Standards. The Indicators span the breadth and depth of facility services, including patient evaluation for risk factors, readiness for maternal and newborn emergencies, and the collection and review of outcome statistics. After a birth center achieves its initial accreditation, this process must be completed every 3 years to maintain CABC accreditation.
CABC accreditation guarantees that national standards and best practices for birth centers are uniformly applied, eliminating state and local inconsistency. Achieving and maintaining accreditation means that a birth center has met a high standard of evidence-based and widely recognized benchmarks for maternal and neonatal care, business operations, and safety
What can we do to make midwifery birth centers a reality in New York State?
We need to advocate for a licensure process that allows the proven model of midwifery birth centers to thrive. The current application and regulation processes are depriving our communities of access to this important option. Midwifery birth centers should not be subject to the same CON process and architectural regulations as other Article 28 facilities. We need a licensure process that is specific to the safe, low risk care provided by midwifery birth centers. Adopting deemed status for CABC-accredited facilities is critical to making midwifery birth centers a reality in New York State.