The state’s only freestanding birth center for low-risk deliveries is in danger of shuttering, a Northampton senator recently alerted the state’s top public health official.
At a budget hearing, Sen. Jo Comerford reminded Public Health Commissioner Dr. Robbie Goldstein that he’s visited Seven Sisters Midwifery & Community Birth Center in Florence.
“What do you think, Dr. Goldstein, we should do in the commonwealth so that this birth center doesn’t close?” Comerford had asked. “I just am here to say it’s at risk of closure, even though again, we are doing what we can and you are doing a lot. And others can flourish.”
The 2024 maternal health law removed regulatory barriers to opening freestanding birth centers and created a pathway for certified professional midwives to become licensed. But low reimbursement rates for care offered in birth centers are threatening the profitability of the facility model, said Ginny Miller, owner and clinical director at Seven Sisters. The dynamic is unfolding even as the state looks to boost access to alternative care options and alleviate poor maternal health outcomes for people of color.
Cleared legislation could deliver relief
The Special Commission on Racial Inequities in Maternal Health in 2022 highlighted the importance of birth centers in curbing disparities, building relationships between providers and patients, improving outcomes with lower rates of C-sections, and moving away from expensive and “intervention-heavy” hospital-based births. The centers on average also save more than $1,000 per birth.
The report noted Massachusetts has “fallen behind” in the availability of birth centers compared to other states. The North Shore Birth Center at Beverly Hospital closed in December 2022, and a birth center at Holyoke Medical Center shut down in 2020.
The Cambridge Health Alliance Birth Center closed in 2020 but plans to reopen for deliveries in July, according to its website. The renovated facility features a “home-like, calm environment” and a “spa-like atmosphere” with birthing tubs, the website says.
Seven Sisters doesn’t do any advertising, but it has a monthly waitlist, Miller said. The center counts about 120 births every year, with about half of patients on MassHealth coverage. Only about 6% of patients undergo C-sections, and Seven Sisters doesn’t provide anesthesia.
Miller said the “major problem” for Seven Sisters comes down to reimbursement. Commercial insurers pay birth centers significantly less than hospitals for delivery and related care, which can reflect the differences across equipment, facility infrastructure and staffing.
Miller estimates that Seven Sisters needs to secure an additional several thousand dollars from insurers per birth “to keep us solvent.”
“We have to negotiate every single insurance company separately, and then all the ACOs and MCOs, which are the MassHealth products,” Miller said. “They kind of don’t think they need to pay more than the MassHealth rate, or we’re not even getting close to the MassHealth rate. … Even if they paid what we need to just break even, then that’s less than what they’re paying for somebody to go to the hospital.”
Questions of reimbursement
For Bay Staters on public insurance, the Executive Office of Health and Human Services has set a birth center rate of $4,560 for routine obstetric care that includes prenatal care, vaginal delivery and postpartum care.
Sen. Cindy Friedman, co-chair of the Health Care Financing Committee, said lawmakers are “very much looking” into parity issues.
“My feeling is that in a birth center, that any regular birth — non-emergency birth or non-critical — should be paid at the same level as the hospital,” Friedman told the News Service Tuesday.
Birth center providers also deserve to be paid at the same level as doctors in hospital settings, Friedman argued.
“Why should one person be paid less than another to deliver?” she said. “And also, we want people in birthing centers — we want people out of hospitals. If we don’t validate that through how we pay, it’s not going to happen.”
Senators on the committee last week advanced legislation (S784) ensuring that certified nurse midwives, certified professional midwives and licensed freestanding birth centers are not paid less than physicians and hospitals delivering the same services.
Lora Pellegrini, CEO of the Massachusetts Association of Health Plans, said insurers recognize “the value” that birth centers can offer when asked to explain the existing reimbursement dynamic.
“At the same time, it is important to be clear about how these services fit within the broader health care system,” Pellegrini said in a statement. “Birth centers are not hospitals; they operate under a different clinical model, serve a narrower patient population, and have different capabilities and cost structures. As a result, reimbursement is not, and should not be, treated the same as hospital-based care.”
A spokesperson for MAHP said the trade group did not have average reimbursement rates for births at hospitals and birth centers, and directed the News Service to Blue Cross Blue Shield of Massachusetts. A Blue Cross spokesperson said the insurer doesn’t share fee schedules publicly.
A 2022 report from the Health Policy Commission said out-of-pocket spending for “birthing episodes” is growing more quickly than the cost of care, creating a greater burden on patients. The trend is partly driven by high deductible insurance plans.
The Maternal Health Access and Birthing Patient Safety Task Force, created under the 2024 law, also wants to see a shift in insurance practices. Draft recommendations say the commonwealth “should further investigate opportunities” to tackle birth center reimbursement.
Task force member Leigh Simons, vice president of policy and regulatory affairs at the Massachusetts Health and Hospital Association, said maternal health and “birthing patient care must be sustainable in Massachusetts across all settings – including in both hospitals and birth centers.”
“Currently, maternal health services are ‘loss leaders,’ with high fixed costs and a lack of adequate reimbursement to maintain a sufficient workforce at all hours, even when there is low volume,” Simons said.
Awareness as a partial solution
At the March 27 budget hearing in Clinton, Goldstein said the updated birth center regulations will eventually cut operating costs, as he pointed to reduced equipment costs and new staffing requirements that are meant to promote the midwifery workforce. But to make birth centers sustainable, Goldstein said Bay Staters need to learn that the facilities even exist as a possible care alternative.
“We need to educate people across the state, so that as birth centers open, as they get this investment to get their doors open, they can sustain themselves with enough volume as folks continue to come through,” Goldstein said. “What I worry about oftentimes with Seven Sisters is that the volume is so low, but yet their overhead costs remain fixed. And if we can get them some additional deliveries, some additional folks coming through their doors, they will move toward more sustainability.”
As a midwife at the now-closed birth center in Holyoke, Miller saw 22 patients daily. Now at Seven Sisters, she sees eight patients.
“It’s better for the provider and their satisfaction, and it’s better for the families,” Miller said. “But if you’re crunching numbers, it’s not very productive in terms of how much money you’re bringing in.”
Construction is expected to start on the Neighborhood Birth Center in Roxbury this summer, with the facility opening in 2027. Worcester Community Midwifery is working on purchasing property for a birth center, which Executive Director Rachel Blessington said remains several years away from opening.
For now, Blessington runs a small community practice in Worcester that includes office visits and home births, with the aim of closing health care access gaps in the area. Blessington said more patients are traveling to Worcester for care after Harrington Hospital closed its birth center in 2017 and a maternity ward at UMass Memorial HealthAlliance-Clinton Hospital in Leominster closed in 2023.
A more personal experience
Patients are drawn to midwifery care as they seek personalized services and more autonomy, Blessington said.
“People seek care because they want to be seen as individuals and not enter a large system that’s overtaxed, trying to take care of too many patients with too little resources,” Blessington said. “Many people who seek us are actually other health care providers, and they know what it’s like in the hospital system.”
Blessington envisions her future center as a training resource for midwives. Massachusetts currently doesn’t have enough midwives to keep up with demand, she said.
“When we can open birth centers and have a higher volume of midwife-attended births, then we can create more midwives in those places,” Blessington said. “That’s a really important goal for us in Worcester.”