As some states grapple with high rates of maternal mortality, access to pregnancy and birth services have become a key topic for solutions amid closing hospital labor and delivery departments.

Birth centers, in particular, have been met with obstacles from hospitals and state departments in many states, though advocates say they could help reduce infant and maternal morality — especially in states where birth centers are limited and mortality rates are among the highest.

All of the top eight states with the highest maternal mortality rates are in the South, a region with the largest Black population, and a demographic with higher rates of maternal mortality based on 2021 data for Centers for Disease Control and Prevention and National Vital Statistics System.

Alabama currently has no freestanding birth centers that can perform births and is ranked fourth highest in the U.S. for maternal mortality rate. Georgia ranked seventh and only has three birth centers licensed to perform births.

Texas, California and Florida have the highest number of birth centers and ranked 17th, 37th and 16th respectively in maternal mortality rates.

Dr. Yashica Robinson, an Alabama OBGYN, is celebrating a recent victory as a court ruled for the Alabama Department of Public Health to create a licensing process for birth centers to be able to perform births.

In 2021, Robinson opened Alabama Birth Center in Huntsville where screenings and various classes — including breastfeeding, lactation support and childbirth education — are offered.

Robinson said birth centers can help lead to improved outcomes and provide an alternative to women for birth outside of hospitals or homes.

“When people are given options, that’s going to improve the quality of care in the community. When you have no options, historically, that drives down the quality of care,” she said. “If you’re a low-risk mom, it is an excellent option. In those places where you just don’t have a hospital available, it’s a lot easier to get a skilled midwife provider in those communities and to get a person on the ground so that they can serve that appropriate patient population.”

According to the American Association of Birth Centers, a birth center is a health care facility for childbirth where care is provided in the midwifery and wellness model. Midwives are trained health professionals (at different levels of education) who care for, support and advise women during pregnancy, labor and the postpartum period. They can also provide gynecologic care and work in and outside of hospital settings.

“Things like lower cesarean section rates, patients feeling more satisfied with the care that they have been provided. That one-on-one intimate care will decrease the chances of things being missed when you have someone that can spend more time with the client and addressing the client in a holistic way,” Robinson said. “We know that with midwifery care, and with clients having access to this one-on-one model of care, we’ll see increases in breastfeeding rates — which improves outcomes for babies.”

Access to equitable maternal care

In Alabama, 37.3% of counties are in maternity care deserts, or are a county without a hospital or birth center offering obstetric care and without any obstetric providers, according to a March of Dimes report from 2020. In Georgia, 35.2% of counties are considered maternity care deserts. Most of the maternity care deserts are in rural areas.

Research published in the National Library of Medicine in 2022 suggests that birth centers can lower the risk of low birth weight of the baby, lower the rate of pre-term births, increase the rate of prenatal education and lower infant mortality rates.

The March of Dimes 2022 maternal and infant health report card rated Georgia and Alabama an “F” based on pre-term birth rate and infant mortality rate.

A recent CDC report showed that the infant mortality rate for the United States in 2022 was 5.60 infant deaths per 1,000 live births, 3% higher than the rate in 2021.

The CDC report showed that Georgia was one of four states — including Iowa, Missouri and Texas — that saw an increased infant mortality rate from 2021 to 2022.

“In Georgia, just in general, Black babies are two times more likely to die before their first birthday as compared to white babies, and Black moms are almost three times more likely to die as compared to white women,” said Tamara Mason, a director of Maternal and Child Health Care Collective Impact for March of Dimes for the Atlanta Georgia market.

Maternal care deserts, could be a large factor in high maternal mortality, Mason said.

“If there’s no OBGYN, you may not have access to prenatal care and you have to drive at least a county over to get care,” she said. “Not everyone is able to do that, whether they don’t have reliable transportation, their work schedule, just whatever of many myriad of reasons.”

Structural and systematic racism is also large issue in the maternal care disparities, Mason added.

“We’ve heard Black women say that even if you have access to care it may not be respectful, dignified care and that Black women tend to not be listened to,” said Mason, who is also a labor doula at the Atlanta Birth Center. “So, even if you have access to the care, it may not be equality and they may not be addressing issues or listening to you. If there needs to be interventions, they may not be done in a timely manner because again, you’re not being listened to.”

Barriers to maternal care choices, birth centers

Birth centers require transfer agreements with a local hospital, which is often difficult to obtain.

Anna Adams of Georgia Hospital Association said the birth center’s safety risks and clinical measures are primarily assessed when a hospital weighs a transfer agreement.

“The reason that it’s important for that transfer agreement to be in place is because things do go wrong in delivery sometimes and when they do, you want to be able to get them to a location where they can handle that type of emergency,” she said.

Adams said transfer agreements are necessary with health care facilities, so that if a patient arrives at the hospital in an emergency, its staff will have information on health history to help reduce risks or mistakes and be able to respond more quickly. Location of a birth center near a hospital with labor and delivery and OBGYN services is critical deciding on agreements with birth centers, Adam said.

“I would have a concern that birthing centers in rural areas, depending on where they’re located, may give those community members a sense of security that maybe they shouldn’t,” she said. “(Hospitals) have different levels of care and different types of specialists and clinical staff. and so, when it comes to things as serious and as complicated at times, as giving birth, you want to make sure that you have that backup plan.”

Throughout the years, as several hospitals have shuttered labor and delivery departments, the push for birth centers have become more prevalent.

Most recently, Donalsonville Hospital in south Georgia closed its labor and delivery as of June 30. It subsequently collaborated with Bainbridge Memorial Hospital & Manor nearly 24 miles away.

In Alabama, labor and delivery departments in three Alabama hospitals closed in October: Shelby Baptist in Alabaster, Monroe County Hospital in Monroeville and Princeton Baptist in Birmingham.

While decisions to reduce or cut services are often related to finances, Adams said demand also is a critical factor.

“If you’ve got a hospital that is doing labor and delivery, and maybe they only do 150 births a year, you’re keeping it fully staffed to see three patients a week, maybe,” Adams said. “The cost to keep the labor and delivery unit open and fully staffed is going to outweigh the reimbursement that you’re getting for those patients that come in.”

While the labor and delivery aspect of birth centers brings pushback from many hospitals, GHA has recommended that Georgia lawmakers make adjustments to certificate of need laws to allow more access to prenatal services and postnatal services offered by most birth centers.

“I don’t know that the birthing center itself is what the need is, but those women do need access to prenatal care, and they don’t have it right now,” Adams said.