Senate Health & Welfare hears testimony on S.18 to license freestanding birth centers

The Vermont Senate Health & Welfare Committee on Feb. 13 took testimony on S.18, a bill to establish licensing for freestanding birth centers, hearing from midwives, a consumer who gave birth in a birth center, medical society representatives, hospitals, and state officials.

The bill would create a licensure pathway for freestanding birth centers in Vermont. Supporters said those centers expand access to midwifery-led, lower-intervention care and can improve outcomes for lower-risk pregnancies; hospitals and payers raised questions about financial sustainability, the certificate-of-need (CON) process and Medicaid reimbursement.

Jill Aleman, a certified nurse-midwife who taught for Frontier Nursing University and worked on the federal Strong Start initiative, told the committee that freestanding birth centers are an evidence-based, midwifery-led model of care and emphasized national data showing improved outcomes. She said, “The midwifery led birth center model of maternity care has birth occurring in a freestanding health care facility that is not a hospital, but that is integrated into the health care system.” Aleman cited data used by the American Association of Birth Centers showing roughly 400 freestanding birth centers in the U.S., about 25,000 births annually (about 1 percent of U.S. births), and lower cesarean rates in birth-center populations.

Lindsey LaShawn, a certified nurse-midwife who said she wished to open a freestanding birth center in southern Vermont, argued S.18 would increase options without expanding services paid by insurers. “I believe Vermonters deserve choice in where they give birth and that birth centers are an evidence based, affordable, high quality option that is missing from the healthcare landscape,” LaShawn said, and she described personal and professional experience practicing in freestanding centers out of state.

Consumer Carolyn Barnwell described her own birth at a New Hampshire freestanding birth center and urged lawmakers to provide the same choice in Vermont. “It was one of the most empowered, beautiful experiences of my life,” Barnwell said of her birth-center delivery and the immediate postpartum support.

Dr. Lauren McAfee, speaking for the Vermont Medical Society and citing guidance from the American College of Obstetricians and Gynecologists (ACOG), said ACOG supports accredited birth centers as appropriate for low-risk births but stressed the need for a system that can manage unexpected complications and transfers. “ACOG believes that hospitals and accredited birth centers are the safest settings for birth,” McAfee said, and she voiced concern about workforce and the capacity needed for continuous obstetric coverage.

Alex McCracken, director of communications and legislative affairs for the Department of Vermont Health Access (DVHA/DIVA), told the committee that Medicaid already covers labor and delivery for home and hospital births and that creating birth centers would not increase the number of deliveries but could provide a lower-cost setting for some births. McCracken cautioned that Medicaid reimbursement for freestanding birth centers would require a federal state plan amendment and recommended involving the Department of Health in implementation planning.

Hospital representatives, including Devin Green of the Vermont Association of Hospitals and Health Systems, described Vermont’s maternity landscape as “fragile” because of low birth volume (about 5,000 births in 2022) and 24/7 staffing requirements. Green and others supported licensure but recommended careful review of the CON exemption language and concern that differential payer mix—if birth centers accept primarily commercially insured patients—could leave hospitals with a disproportionately higher share of complex, lower-reimbursed births.

Multiple midwives and birth-center advocates stressed equity and rural access. Erin Mandeville, a certified midwife with decades of experience in birth centers and international work, said birth centers can improve access for rural residents and new Americans and noted racial disparities in maternal mortality. Mandeville said birth centers are typically small operations (often a handful of births per month) and not major revenue drivers, and she urged attention to reimbursement structures that reflect the full scope of prenatal, labor and postpartum care.

Committee discussion identified several recurring policy questions for further work: (1) whether freestanding birth centers should be exempted from the state certificate-of-need process and how the bill’s current CON language would apply, (2) how Medicaid would reimburse birth-center services and whether a state plan amendment or waiver would be required, (3) the mechanics and expectations for formal transfer agreements with nearby hospitals, and (4) workforce and financing measures needed to ensure hospital labor-and-delivery units remain viable. The committee did not vote on S.18 during the Feb. 13 hearing and said it would seek additional information from the Vermont Department of Health and may request written testimony from several witnesses.

The hearing included multiple data points provided by witnesses: proponents cited U.S. birth-center data showing lower cesarean rates (about 6 percent among women admitted to birth centers in cited studies), transfer-in-labor rates around 15 percent with only about 2 percent emergency transfers, and findings from the CMS Strong Start project showing reduced preterm and low-birth-weight rates and an estimated cost savings of roughly $2,000 per mother–baby pair in the first year for Medicaid populations. Hospital witnesses noted Vermont’s roughly 5,000 births in 2022 and cautioned that small shifts in monthly birth volume—two births a month was cited as roughly 10 percent of some hospitals’ birth volume—could materially affect some facilities’ financial stability.

The committee announced plans to reconvene the bill’s discussion with Department of Health staff present and to obtain written testimony and additional detail on Medicaid reimbursement, CON impacts and transfer-agreement expectations before taking further legislative action.