“Is your birth center open?” the worried voice said on the phone.
Since the start of the COVID-19 pandemic, we have received a growing number of calls like this. These callers, often people far along in their pregnancy, want a safe place to give birth, somewhere that is not a hospital overwhelmed with COVID-19. What they seek is the safety of a freestanding birth center, a homelike facility where prenatal, labor, birth, and postpartum care is provided in the midwifery and wellness model. But right now, our heartbreaking answer to each caller in Detroit and Boston, where we are raising funds to open birth centers, is “No, not yet.”
In the coming six weeks, roughly 400,000 babies are expected to be born in the United States, based on 2018 numbers. But in communities across the country, people—especially Black, Indigenous, and people of color (BIPOC)—have little to no access to birth center care. As a result, they are being subjected to a health-care environment that pits their human right to birth in a trauma-free setting against a flailing system’s response to a global crisis. We, the leaders of Neighborhood Birth Center (Boston) and Birth Detroit, have been working to ensure that birth centers are a real option for pregnant people in our communities, and to develop a birthing infrastructure that transforms the culture of birth for generations to come.
This urgency and opportunity led us to create the Birth Center Equity Fund as a channel for donations to people of color-led efforts that would increase access to birth center care during COVID-19 and beyond. We are proud to launch the fund during Black Maternal Health Week, April 11-17.
Research suggests the majority of people who birth in hospitals are considered low risk and could birth safely with midwives in a community setting (e.g., in birth centers or at home). A recent report on birth settings in the United States identified birth centers as an integral part of an effective health system, and a study published in 2018 found that rates of preterm birth, low birth weight, and cesarean section were lower among birth center patients. Birth centers are essential for families and health systems in the best of times. COVID-19 has made it clear that in the worst of times, birth centers are even more essential.
At this moment, birth centers are stepping up to make a difference during the COVID-19 pandemic. Birth centers, typically small organizations with few staff, are adapting to meet their community’s needs. In Arcadia, California, and Southfield, Michigan, birth centers have set up drive-thru prenatal care to meet increasing need and reduce families’ exposure to COVID-19. In Colorado, birth centers are working to develop a coordinated approach to care for the growing number of birthing people seeking birth center care. In some cities, birth centers are asking donors to fund additional birth spaces to meet the increasing demand. Others are turning hotel suites into birth suites to reduce strain on local hospitals.
National organizations like the Foundation for the Advancement of Midwifery are sounding the alarm, stating that we “must act quickly to involve out-of-hospital midwives in pandemic planning and response” as COVID-19 places increasing strain on hospitals. The American Association of Birth Centers and the Commission for the Accreditation of Birth Centers have issued guidelines for the implementation of “auxiliary maternity units” to address hospital surge capacity and improve safety for pregnant people, and some well-resourced birth centers are working on answering this call.
Innovation is critical. Yet now and on the other side of this crisis, we must be careful that well-intentioned interventions do not create or exacerbate inequity. In the past decade, the number of birth centers in the country has grown. Between 2010 and 2017, the number of birth centers rose by 76 percent to more than 345 located in 37 states and Washington, D.C. Yet, many communities of color remain woefully behind the rest of the nation in access to birth centers.
We must expand access to birth centers and do so in ways that create sustainable organizations that don’t replicate unhealthy organizational practices. To ensure that birth centers can respond effectively to the COVID-19 moment and beyond, we as a nation have to generate new and long-term investments in birth centers and midwifery to avoid incessant fundraising. This includes policy changes to ensure public and private insurance reimbursement, and equitable opportunities for startup funding. We must invest in initiatives led by Black, Indigenous, and people of color who are deeply connected to what our communities need. When we design birth centers that center the needs of people of color, they work better for everyone.
Right now, more than 80 percent of birth centers are for-profit entities that were seeded by personal savings, loans, or family gifts. Our country’s history of unfair wealth distribution means inequitable access to the capital needed to start birth centers. Gathering data through our existing networks, we identified about a dozen birth centers owned or led by people of color, about 3 percent of all U.S. birth centers. We also count only seven birth center startups led by people of color. While these numbers are estimates, they make clear that the need for birth centers in communities of color far outstrips the availability.
The COVID-19 pandemic is a painful reminder that when one person is sick, no one is well. But our health-care system was not designed with equity at the center—in fact, it was originally designed to the full exclusion of Black, Indigenous, and people of color. By contrast, our birth centers are being designed to reflect the stories and dreams and heal the frustrations and traumas of people and families who are usually not centered in the design of health-care spaces.
Patient-centered care and shared decision-making are hallmarks of midwifery care. At the same time, as birth centers are implementing necessary COVID-19 screening and prevention protocols, they are maintaining key elements of midwifery practice that also have significant health benefits, like allowing support persons to be present at births and keeping newborns and birthing parents together to support breast and chestfeeding success. Moreover, community-based birth centers, especially those led by people of color, honor and respect cultural and spiritual traditions that are essential in times of crisis.
We are facing a worst-case scenario for birthing people in the United States: fear of hospital birth in a global pandemic and inequitable availability of safe out-of-hospital birth options. We must not wait for tragic after-action reviews of our COVID-19 response to point out what we always knew—we need more community birth centers. We must act quickly to fortify established birth centers and make birth centers a real option for all birthing people in every city. Using evidence-based models of care and trained professionals, we can reduce the risk of COVID-19 for birthing people today and increase safe birth options for our children and grandchildren. Today’s babies—and tomorrow’s generations—cannot wait.