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What is a freestanding birth center?
When it comes to giving birth, you probably know that there are a couple ways to go about it: go to a hospital, or plan a home birth. But there’s another option that may be unfamiliar to many Vermonters: the freestanding birth center, which is pretty much the middle ground between a hospital and a home.
Here’s how Morgan Evarts, a doula we spoke with, describes them:
“When I picture birth centers, I picture the feeling and the vibe of home, the option to labor how you want, where you want, even using outside the facility — walking around, walking the stairs. You have your own private room, your own private bathroom. Most often there's a birthing tub in every room; in a hospital they also have your own private room and bathroom, but ... it's a regular size tub."
In other words, a freestanding birth center is not quite your home, and not quite a hospital. But it does have midwives, and is always in close proximity to a hospital in case specialized or urgent care is needed during labor. It's like your own private birthing sanctuary.
But here in Vermont, we don’t have any. In fact, we’re one of eight states in the country who don't have them, alongside Wyoming, Kentucky, Alabama, Mississippi, Arkansas, North Dakota and Hawaii. That’s according to the American Association of Birth Centers.Meet our question-asker
"I've actually had this question for a long time," says today’s winning question asker, Alison Fischman. She lives in Wolcott, in the Northeast Kingdom. Back in September, she wrote to Brave Little State to ask:
“Why doesn’t Vermont have freestanding birth centers?”
And full disclosure: Alison has a vested interest in this topic. She’s a certified professional midwife who runs a home-birth practice, and she wants to change the fact that Vermont doesn’t have any freestanding birth centers.
“I am working with a group, we're trying to get legislation passed. It's been a project that's been ongoing for, I think, over 20 years," says Alison. "And the main goal is really just to get this as an option, as a choice for Vermonters."
This group is called the Vermont Birth Center Coalition, and it’s working to expand access to out-of-hospital birth options for Vermonters. We didn't know Alison was associated with them when we put her question in a BLS voting round. But a winning question is a winning question. It's the people's choice!
Alison specifically wants to know about the history of this issue in Vermont. She asks, “Where did this start? When did it become an issue? Because I know people have worked to change it. And how has it sort of persisted over all of this time, while all the states around us and the rest of the country has sort of moved in a different direction?”
It turns out, this issue around birth centers — or lack thereof — is not a new one.
Mary Lawlor, a longtime certified professional midwife who is licensed to practice midwifery in both Vermont and New Hampshire, is no stranger to the red tape around this issue.
“I worked for 10 years to try to open up the opportunity to open birth centers in Vermont, and then went across the river and opened in New Hampshire,” she says.
In the late 1970s, Mary was part of a small group that tried to open a birth center in Bellows Falls. Mary says that to her knowledge, it was the first attempt to open a freestanding birth center in the state. But it wasn't successful.
Then, in the early 2000s, Mary worked hard to create a path for freestanding birth centers in Vermont.
At one point she connected with a lobbyist in Montpelier, who got her a meeting with the director of the Office of Aging and Disability Licensing and Protection, which regulated birth centers at that point. However, she didn’t make any headway.
When I asked her what’s changed regarding the regulation of freestanding birth centers since then, she replied, “Nothing. Absolutely nothing.”
After spending a decade advocating for freestanding birth centers in the state, Mary decided to go across the border and open up a birth center in Keene, New Hampshire.
“When I called New Hampshire and said I wanted to open a birth center in New Hampshire, they said, 'Great, well, let's find somebody to help you,’” said Mary.
I asked Mary what exactly people are fighting for with birth center legislation in Vermont right now.
“What they're trying to do in the legislation, specific to birth centers, is carve out an exception to the Certificate of Need law that would require birth centers to go through that,” she says.
This three-word roadblock – Certificate of Need – popped up in every interview I had in my search to answer this question.
A Certificate of Need is basically a lengthy legal document all new health care projects in Vermont have to get from the Green Mountain Care Board. That board regulates almost all aspects of health care in Vermont, and its website says its intent is to guide these new establishments in order to meet public need, keep costs in check and ensure equity in health care — but it’s a bit more complicated than that.
Regulation and legislation
“Certificate of needs laws were designed — it's a great example of something that was designed for good reason, but then quickly devolved to become very punitive and restrictive,” says Aubre Tompkins, the president of the American Association of Birth Centers, which is based in Pennsylvania.
Aubre says that in the early 20th century, there was an oversupply of unregulated hospitals popping up and offering services. So in 1963, New York was the first state to make a certificate of need law. Then in 1974, it was enacted federally as part of the National Health Planning and Resource Development Act.
“And again, the idea was understandable and was trying to do a good thing — in, you know, making sure we didn't have too many hospitals that didn't give good care,” Aubre added. “What it has devolved into, particularly when we're talking about birth centers, is a massive restriction of trade, in that states that have certificate of needs laws that specify birth centers, the birth center has to essentially ask hospital systems if they can exist.
“And of course, many hospital systems are going to say, ‘No, we don't need a birth center in our community. We have a big hospital, labor and delivery unit.’ So essentially, it makes birth centers almost impossible to open.”
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Aubre says that there are 15 states that have certificate of need requirements for birth centers, and in those states, there are significantly fewer birth centers, if any. But, Aubre says, there is no correlation between the quality of care and having a Certificate of Need, or CON.
“In states that have CON laws, unfortunately, the thing that has to happen is it has to work through the legislative process to either repeal the CON laws completely or to specifically remove birthing centers from the list of facilities that are overseen by the CON law, that,” she says.
So, that’s one reason why Vermont doesn’t have any free standing birth centers. It’s not illegal, it’s just a huge pain to get one open. But there’s another reason why pushing past some of these roadblocks might not be the biggest priority in Vermont: There just aren’t a lot of babies being born.
“Nationally, the birth rate has been falling across the country. So it's not unusual that Vermont's birth rate is falling,” Aubre says. “Hospital systems are businesses, and that is something that needs to be acknowledged in our current health care system that we have in this country. And when a big business sees their revenue source decreasing, they're going to get nervous. And they're going to, you know, kind of sink their feet in even more to really protect those certificate of need laws."
If you want to open a birth center in Vermont but don’t want to have to go through this giant process to get it done, you’ll have to swap that process for another process: the process of trying to become exempt from a Certificate of Need – and that decision is also in the hands of Green Mountain Care Board.
Representatives from the Green Mountain Care Board, an independent board separate from the Vermont Legislature, didn’t want to talk on tape for this episode. But they did share that they are neutral on the issue of whether or not birth centers should be exempt from certificate of need laws.
Laurie Foster, a retired midwife who was in practice for 40 years, said that lawmakers put the birth center conversation on the back burner because of some other more urgent health care stuff that’s been going on.
Laurie says that in 2021, the Vermont Birth Center Coalition got together, and proposed the bill H.121. However, the bill never went anywhere because lawmakers were overwhelmed with COVID issues at the time.
Laurie says that last session, they tried again.
The bill, S.204, was taken up by Vermont Senate. Laurie says there was a lot of discussion, two hearings, and then the bill died in the House this past April after being referred to to the House Committee on Health Care.
“And, you know, the legislators were supportive of the idea of birth centers. But there was a lot of input from the hospital about, sort of, concerns and fear that a birth center might impact a rural hospital maternity center in a negative way,” says Laurie.
Like this argument from Kat McGraw, a Chief Medical Officer at Brattleboro Memorial Hospital who testified in front of lawmakers: “That is in fact the whole purpose of a Certificate of Need. It is intended to ensure that there are no duplicative services, to provide some cost containment and provide equity of access."
“There's really no evidence for that that we know of," says Laurie Foster of the Vermont Birth Center Coalition. "We don't know of any hospital units closing down because birth centers were opened. I think that it just kind of has been blown out of proportion because there's always been this resistance in Vermont that's come from the hospital interests around birth centers,” she adds.
And Laurie says that’s too bad, because she thinks there are some great benefits to having birth centers in Vermont: “They often run support groups, you know, they can be a resource for people to get information or take classes. And for the hospital, they're going to bring in ultrasounds, lab work, referrals, transports — I mean, there's some ... rather lucrative aspects of maternity care that a birth center would bring to the closest hospital."
However, Laurie says that as long as freestanding birth centers are required to get a certificate of need, there won’t be any in Vermont.
Meanwhile, advocates are going to introduce another bill next legislative session to try to tackle this issue again.
“And it will specifically say that a CON should not be required," says Laurie. "And, you know, that will likely be the tripping point as we move through this again."
A birthing center in a hospital
We know there are no freestanding birth centers in Vermont – meaning birth centers that are their own entity outside of a hospital. But our state does have birth centers within hospitals. Like the birthing center in Gifford Medical Center in Randolph, which is smack in the middle of Vermont.
There are some major differences between a hospital birth center and a free standing one. A big one? It’s physically in a hospital. Another involves drugs: A hospital has anesthesia, while freestanding birth centers do not.
Gifford’s Birthing Center is well loved by many Vermonters. When we began assembling this story, lots of our listeners told us they had a positive experience there.
Hillary Sylvester is a midwife who has been working at Gifford since last April. She says if she could summarize what makes Gifford so popular, she said it comes down to shared decision making.
“We can hand you data and you get to pick," ” she says. "Even if it's stuff that is so serious, like a C-section, you still get to pick. It is your body."
In other words, Gifford emphasizes options — from the big choices to the small ones.
“Birthing in showers is something we do here, birthing in a tub is something we do here, birthing on the bed is something we do here, birthing on a chair is something that we do here," Hillary says. "If you can get in that position, and a baby can come out of your body, we can get in that position beneath you and support you with pillows and whatever else that are going to help us catch babies. We don't deliver babies, we catch them into this world, which I think is really darn cool.”
And Hillary wants more birth-givers to have these kinds of options.
“If we could have more birthplaces in the state of Vermont, it would be amazing. That'd be cool. That'd be beyond cool, because driving 45 minutes — if you have the money, if you have the time — it is too far to get good quality health care,” Hillary says. “And we have patients that are doing that right now. We have patients that are driving from the Milton area, the Essex area to get to Gifford because they like the idea of having shared decision making and low intervention birth, and options, and all those things that they should have in their community, too.”
I asked Hillary about the view that some of the pushback to freestanding birth centers is rooted in a fear that it will take patients away from hospitals.
“That is a normal fear, I hear where that fear is coming from,” she responded. “Because you can't have change without fear. But it's not a rational fear. And can I sit here and say that I have never had that fear? That's absolutely insane. [But] more options does not mean less for Gifford, it doesn't mean less for other hospitals. It just means that we are dividing resources.”Crossing the border for more options
And because freestanding birth centers are not yet an option here, some Vermonters are choosing to leave the state to give birth.
"I felt really healthy, really strong, and like I wanted to have an epic adventure," says Carolyn Barnwell, who moved to Woodstock from Washington, D.C., at the start of the pandemic. Carolyn knew she wanted to start her family in Vermont, but she chose to cross over the border to do it.
That wasn’t always the plan. Carolyn was originally planning on having a hospital birth at Dartmouth Health, in New Hampshire. But she didn't really want to.
“This is not some medical event. I'm not ill. I am healthy and strong, and I need to be able to really tap in and be present and harness my own, like, primal power," says Carolyn. "And I sure don't want to do that while I'm lying on my back and I don't have any agency over my body."
But Carolyn and her husband knew that they didn’t want to try a home birth because they didn’t feel comfortable with that option.
After researching online, Carolyn found out about the third option – the freestanding birth center:
"And I was like, wow, that seems like such a great happy medium in between, because I don't really want to have a home birth for my first child that is not going to make me feel safe. But I also don't want to be in a hospital, around all of these sick people, especially during a pandemic, when I'm trying to have a healthy pregnancy and a healthy birth."
A friend of Carolyn’s mentioned Gentle Landing – a freestanding birth center that was in process of opening in Hanover, N.H. Carolyn did not hesitate.
“I found the phone number, gave them a call and made an appointment. And I had such a good feeling about it. And so even though I was well into my pregnancy, I just switched care, switched providers and signed up to give birth at the birth center should I stay as a low risk birth,” she says.
A low risk pregnancy is essentially a pregnancy without complications, ranging from gestational diabetes, to an abnormal placement of the placenta, to the baby being positioned upside down.
And lucky for Carolyn, she fell into the category of low risk birth, which meant that she could have her baby at Gentle Landing.
Carolyn says that the space was beyond comfortable.
“Oh, my gosh, it was like a nice European hotel room,” she recalls. “Just beautiful, clean design, this really super comfortable king-sized bed, a walk in shower. The big birthing tub was in the room with a bed, [and] I was able to, you know, request low lighting, whatever music I wanted. I really was able to control the environment, which I thought was amazing.”
In April of 2021, Carolyn went into labor, and it wasn’t exactly the swiftest journey across the border.
“We have a 40-minute drive to the birth center, and I kid you not, I was trying not to push her out in the truck the entire time," she says with a laugh. "So, you know, gripping the handlebar, and we had the window open, and you could hear the spring peepers and it was all foggy. And my husband I don't think said a word the entire time. He was just staring at the road, trying to make sure he was driving as fast as possible, but safely, to get us there really quickly."
Carolyn was dilating on arrival – and the birth was practically quicker than the drive there. She chose to give birth in the tub, surrounded by her husband, doula, and what she describes as exceptional midwives that she had come to know in the months leading up to that day.
“It was the perfect dynamic. I'm so grateful for it, I just might start crying, really thinking about it,” Carolyn says. “It was the sort of thing where they knew me well enough, and they respected me and my process enough to intervene and get involved if I really needed help, and to just let me do my thing. And let me trust my own body, when that was what I needed in the moment.”
Among those supporting Carolyn through her birth were Gentle Landing’s two founding midwives, Meghan Sperry and Katherine Bramhall.
Meghan and Katherine are both Vermonters, and while they were hoping to open up a birth center in their home state, they decided to start looking for properties in New Hampshire instead of tackling Vermont’s legislation. But the location of their birth center is strategically placed close to the border.
“So [that] people from Vermont would have access to a free standing midwife-led birth center, because the state of Vermont didn't and still does not have legislation to support that kind of choice in birth,” Katherine says. “And so we feel passionately that women have a right to that. So we kept it really close to both Vermont and Dartmouth.”
(That’s Dartmouth Health, the nearby hospital.) While there is no Certificate of Need Law in New Hampshire, it is still a challenging and thorough process to open up a birth center. When Katherine and Meghan were in the process of opening, they had to co-write a 750-page document to ensure the safety of their center.
“The state gives us a full outline of requirements in order to be licensed to run as a freestanding birth center ... There are standards that need to be met as far as making sure we're not practicing out of scope, or are giving medications that aren't allowed within our center and how we document all of those things. So all of that had to be developed as well,” says Meghan.
Katherine describes the process as “amazing,” and says it “was like co-writing a Ph.D.”
Money money money
When it comes to the cost of these options, there are a lot of different factors – from where you give birth, to what kind of insurance you have, to if you deliver vaginally or have a C-section.
The bottom line is no matter where you choose, giving birth is not cheap.
Katherine Bramhall, who co-founded Gentle Landing, was unable to put an exact price on the cost of birth at their facility, as every birthing person's needs are different. She did say that with insurance, the cost of a Gentle Landing birth is comparable to a birth in a small hospital in Vermont. This does not include Gentle Landing’s facility fee, which is $3,500.
And inevitably, the decisions most of us make around birth are are motivated, at least in part, by financial considerations. And also, sometimes, fear — like, fear of the unknown.
"What's such a shame with our culture is how hidden birth is from us," says doula Morgan Evarts. "Oftentimes, the first birth that we're seeing is our own, which is such a disservice. I think it makes a lot of us afraid of birth. Or, the only birth that we're seeing is very dramatically depicted on a Grey's Anatomy episode, you know, it's a hospital birth, there's an emergency, it's happening really fast, there's a lot of screaming."
But for all this discussion about hospitals versus home births versus birthing centers, it’s important to remember that there are people who can help you have a positive experience no matter where you are: doulas.
Fun fact: The word doula comes from the Greek word doulē, which translates to "female helper, or maidservant." Of course, the doula you hire is not a servant, and may not be female. But they are there to support you through birth.
“By having a doula, you're never left alone. Doulas know birth, they trust birth, they're not afraid of birth,” says Morgan. “And so they're able to remind you and your partner of the strength and the power that you have."
As a private doula, Morgan does charge for her services – but she’s also a volunteer doula at UVM Medical Center.
“If someone cannot afford a doula, they have access to this volunteer program,” Morgan explains. “Or if someone could afford a doula, but did not think they needed one, and all of a sudden, they're in the middle of their labor, and they're realizing how often you're left alone..."
As a mother of two, Morgan has given birth both at a hospital, and at home — and she says if she has another baby, she’d be open to birthing at a freestanding birth center.
That is, if Vermont had one.
“I would love there to be a third choice, I would love there to be freestanding birth centers mainly just to give birthing families choice,” says Morgan. “I think the fact that you have that choice, and you are able to make that choice, you are saying, ‘I trust my body, I trust this process.’ And I think that Vermont — you know, allowing freestanding birth centers would be Vermont saying, 'We trust you, we trust birth.’”
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Credits
Thanks to Alison Fischman for the great question.
This episode was reported by Joia Putnoi, with mix and sound design by Myra Flynn. Additional editing from Lynne McCrea and the Brave Little State team: Angela Evancie, Josh Crane and Mae Nagusky. Ty Gibbons composed our theme music; other music by Blue Dot Sessions.
Special thanks to Scott Fleishman, Gail Zatz, Peter Hirschfeld and all the midwives and birthing peoples who trusted us with their stories.
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