Kansas and Missouri should prioritize mothers and children, not hospitals | Opinion
A business should not need permission from its largest competitor to open. Yet in some states, that is effectively what is required of birth centers before they can operate. Regulations requiring physician medical directors, hospital approval or hospital-affiliated signoff often turn hospitals into gatekeepers over lower-cost, higher quality maternity-care.
Care at freestanding birth centers is generally provided by certified nurse-midwives or CNMs, with lower overhead and fewer unnecessary interventions than hospital-based delivery, as well as higher rates of maternal satisfaction with the process. Birth centers are not hospitals. They are designed for screened, low-risk pregnancies and provide expecting parents with a lower-cost option. Hospitals remain essential for high-risk pregnancies and emergencies, but that does not mean every low-risk birth should be forced into an expensive and opaque hospital model, especially when birth centers can be just as safe as hospitals for low-risk births.
Instead of protecting expecting mothers and their children, many regulations protect incumbent hospitals and doctors from CNM-led competition. Hospital veto rules condition birth center entry, licensure, renewal or payment on cooperation from hospitals or hospital-affiliated physicians. This means that a licensed birth center in good standing still needs a signed transfer agreement with a hospital or physicians with admitting privileges. On top of that, birth centers must often hire or contract with a physician medical director, sometimes one with nearby hospital privileges.
Rules about control, not safety
These rules do not regulate safety. They give competitors control over CNMs and birth centers. CNM-led care at birthing centers has demonstrated better health outcomes for mothers and similar health outcomes for newborns compared to hospitals in low-risk cases. Regulations that block these providers limit access to one of the safest and most cost-effective maternity-care option.
Transfer planning is necessary, but mandatory transfer agreements are different because they give hospitals the power to block competition. Birth centers certainly must have a plan in place for when a routine birth becomes complicated. But if a birth center complies with state health and safety regulations, is licensed and is in good standing, a hospital should not be allowed to turn away a transferred expectant mother any more than it could turn away anyone else in need of emergency care, and they center should not need the hospital’s permission to operate.
Currently, in many states a birth center is required to have a signed private agreement with a hospital to operate. This gives hospitals leverage to refuse an agreement for business reasons rather than safety concerns. Birth centers should have transfer plans, emergency protocols, receiving hospital contacts, transport procedures and record-transfer systems. A transfer plan protects patients. A transfer-agreement mandate protects incumbents.
Kansas requires birth centers to have a transfer agreement with an obstetrician or medical facility, but it does not require a collaborative agreement. Yet nearly 6 in 10 Kansas counties have no hospital or birth center offering maternity care. Missouri is more restrictive, requiring birth centers to have both a collaborative agreement with a physician and a transfer agreement with a local hospital. The shortage is even worse there, with more than half of Missouri counties lacking maternity care facilities.
Another barrier birth centers face in many states is the physician medical-director requirement. Birth centers are generally designed around licensed midwives and low-risk care. Requiring a physician director raises costs without improving safety. This can be particularly problematic in rural areas where physicians are scarce and few may be available to serve in that role. If the physician must also hold hospital privileges, the rule links birth center licensure to hospital-controlled credentialing, just as transfer-agreement mandates do.
Higher satisfaction with midwife care
Some states offer a better model by allowing licensed midwives to direct low-risk birth centers without physician supervision, while having more limited requirements for consultation with physicians and transfer arrangements with hospitals for higher-risk situations. This allows lower cost care for expectant mothers while still retaining access to both physician and hospital resources when necessary. That approach is more consistent with evidence finding comparable adverse outcomes and higher maternal satisfaction with midwife led care.
Hospital veto and physician staffing rules reduce entry of new birth centers, preserve hospital dominance and suppress competition. Fewer alternatives for expecting mothers mean less pressure on hospitals to lower prices or improve the patient experience. When regulation blocks the lower-cost competitor, the market loses the price comparison before the patient ever has a chance to shop for the most affordable provider.
Safety does not require giving hospitals veto power. It requires clear risk screening, emergency readiness, transfer protocols and accountability. Birth centers do this by limiting their care to low-risk pregnancies and ensuring high-risk pregnancies are handled in a hospital setting where emergency services are immediately available. States should require emergency equipment, outcome reporting and transport procedures, and hospitals should receive transfers when needed, just as they would take other emergency patients. But routine, low-risk maternity care should not be conditioned on incumbent consent.
Birth centers are not cure-alls, but they are practical, lower-cost options that should not be strangled by rules that protect hospitals from competition. Hospitals will always be necessary for complicated pregnancies and emergencies. But that is no reason to force every low-risk birth into the hospital system or let hospitals decide whether lower-cost competitors may exist. States should replace hospital veto and physician staffing rules with objective safety standards. Expectant parents need safe and lower-cost choices.
Justin Leventhal is a senior policy analyst for the American Consumer Institute, a 501(c)(3) nonprofit education and research organization. For more information, visit TheAmericanConsumer.org