Association for Public Policy Analysis & Management

The Birth Center model of care offers comprehensive midwife-led maternity care provided in freestanding facilities. The Strong Start for Mothers and Newborns initiative aimed to improve birth outcomes and lower costs through three evidence-based enhanced prenatal care models, Maternity Care Homes, Group Prenatal Care, and Birth Centers. The Strong Start evaluation found that women obtaining maternity care in Birth Centers had superior outcomes compared to similar women receiving typical care or care in other Strong Start models. This study examines features unique to Birth Centers that may have contributed to positive outcomes for Strong Start mothers and newborns.

We analyzed qualitative data from 187 key informant interviews (n=248), 29 participant focus groups (n=215), and surveys of Medicaid officials participating Birth Centers to identify common aspects of Birth Center and midwifery care and explore participants’ experiences under the model.

Strong Start Birth Centers had common features unique to the model as compared to other forms of care in Strong Start or care available to Medicaid participants generally. Longer prenatal visits allowed midwives adequate time to build relationship with patients and identify and address medical, psychosocial, and educational needs. Women appreciated the individualized, collaborative approach to their care, and positive patient-provider relationships enhanced women’s willingness to attend appointments, adhere to recommended diet and lifestyle changes, and practice self-care.

Not only did Birth Centers practice a holistic model offering services not normally available in a typical clinical care, they also built referral systems to serve the influx of Medicaid participants who enrolled through Strong Start. Staff commonly made referrals for food assistance, behavioral health, dental care, housing or utility subsidies, and free baby supplies.

Most Strong Start Birth Centers offered patients a choice to birth at either the Birth Center or hospital, and a few offered home birth. Birth Centers also had more pain relief options for women (including both pharmacological and non-pharmacological methods) than hospitals did.

Birth Centers offer enhanced patient-centered options, continuity, and individualized care. According to most Strong Start participants, these features were not available in typical Medicaid prenatal care. Quantitative analysis of Strong Start found that Birth Center care was associated with better health outcomes and high satisfaction. Birth Center characteristics that may be key to those successes include time-intensive, relationship-based care; processes for assessing patient needs and linking them to services; and providing women with options for how and where they labor and give birth, all hallmarks of the midwifery model of care.

Most Medicaid beneficiaries do not have the same level of access to Birth Centers as privately-insured women. Policy changes at the state level could increase access, but current Birth Center capacity could not support a large increase in patient load. Lessons from Birth Centers, however, can be applied outside of a Birth Center setting to improve maternity care for all women.