As the COVID-19 pandemic began to spread in the United States, freestanding birthing centers became a popular alternative for pregnant people who wanted to avoid overcrowded hospitals and potential exposure to sick patients.

In Colorado this past June, as cases rose and area hospitals restricted the number of support people allowed during labor, Seasons Midwifery & Birth Center in Thornton, about ten miles north of Denver, saw a roughly 30 percent spike in enrollment, said Aubre Tompkins, the center’s director of midwifery. Overall demand has gone up about 15 to 20 percent during the pandemic. Now the facility is seeing another influx as hospitals reinstate restrictions in response to higher positive cases.

But Tompkins and other birth center administrators say they’ve sustained higher demand even as the number of COVID-19 cases have ebbed and flowed in their communities. They believe it’s a sign of a long-term paradigm shift in the way the United States approaches maternal care. More patients and families are weighing different options. Meanwhile, insurers, legislators and state regulators are looking at ways to have more low-risk births take place outside the hospital setting, said Amy Johnson-Grass, president of the American Association of Birth Centers and executive director of the Health Foundations Birth Center in St. Paul, Minnesota.

“There’s been a catalyst with COVID to look at freestanding birth centers in a different way,” Johnson-Grass said.

In May, Rewire News Group highlighted the opening of New York City’s Jazz Birth Center of Manhattan, which received a temporary license from New York state regulators in response to increased need during the pandemic.

The facility is Manhattan’s only freestanding birth center and is an offshoot of Brooklyn Birthing Center; the two are the only private, freestanding birth centers in New York City. Jazz Birth Center has gotten off to a strong start with about 10 to 15 due dates per month and several inquiries each day, Midwifery Director Jessica Henman said.

During the summer, the facility saw what Henman called “fear-based transfers,” or patients who were too scared to give birth in a hospital and decided to switch to the birth center. While that initial terror has waned, as have hospital restrictions, there’s been continued interest in the birth center, Henman said. Jazz Birth Center is now in the process of applying for a long-term license—and eyeing an expansion into the Bronx next.

“It was way overdue to have a birth center in Manhattan. Our dream would be to have a birth center in every borough,” Henman said.

Freestanding birth centers operate under the midwifery model of care and are separate from hospitals, though they have agreements with hospitals for transfers (Jazz Birth Center has one with Mount Sinai West). Birth centers typically allow more support people to be present during the birth, whereas hospitals in some hard-hit areas have been limiting patients to just one support person in the birthing room.

Jazz Birth Center’s patient population has been representative of Manhattan’s diversity, Henman said. One of the center’s top goals is to provide high-quality care to people who face race-based health disparities.

Racial health disparities are especially evident when it comes to pregnancy-related mortality. Black, American Indian, and Alaska Native people are two to three times more likely to die from pregnancy or its complications than white people, according to a 2019 report from the Centers for Disease Control and Prevention.

The pandemic has had a greater impact on certain racial and ethnic minorities, and that’s drawn attention to maternal health disparities and the need for birth centers in underserved areas, said Kate Bauer, executive director of the American Association of Birth Centers.

Advocates say these facilities are well-suited to address these issues due to their design. The smaller centers have lower overhead costs than complex hospital organizations, so it should be easier to open more locations closer to marginalized populations. In Detroit, the city’s first freestanding birth center is scheduled to open in 2021.

While hospitals tend to be more focused on efficiency and the needs of the facility, birth centers offer more community-focused care, Henman said. That could mean getting a care provider that looks like you or has a social background more similar to yours, she said.

Henman contributed to a report published in November that looked at how maternal health care can be improved in light of lessons learned from the pandemic. The report from Ariadne Labs and University of California, Davis discussed leveraging virtual access to care, using birth centers and other alternate care settings, customizing care planning, and coordinating multidisciplinary team care.

“Kind of a silver lining of a pandemic is that more people are being informed of this model of care, but I think also we need to be vigilant about addressing health disparities,” Bauer said.

The pandemic has led people to question whether hospital births for healthy, low-risk pregnant people are the best use of hospital staff, resources, and time.

“If there’s a positive thing about this pandemic, [it’s] that hopefully that realization—that you don’t need to go to the hospital when you’re not sick—that realization sticks around,” Tompkins said.