This story was originally produced by The Keene Sentinel. NHPR is republishing it in partnership with the Granite State News Collaborative. For more reporting on maternal health in New Hampshire, check out NHPR's coverage here.
Alysha Bradley found out at her 36-week prenatal appointment last November that she couldn’t give birth at the Monadnock Birth Center as planned.
The Swanzey center, which had been a staple in the Monadnock Region since it opened in 2008, closed permanently on Dec. 27, 2024.
“It was pretty shocking,” said Bradley, who had to quickly adjust and opted for a home birth. “I didn’t really see it coming.”
Although Bradley, who lives outside Royalston, Mass., could have given birth in a hospital, the Monadnock Birth Center gave her the option of becoming a mother in a non-medical setting. The center was also 15 minutes from Cheshire Medical Center, where Bradley receives primary care.
“My husband and I absolutely did not want a hospital birth,” Bradley said. “I already don’t like hospitals, so I knew I wasn’t going to be comfortable in a hospital setting during one of the biggest events of my life.”
The center, the only freestanding clinic of its kind in the region, closed its doors because of financial difficulties. Its founder, Mary Lawlor, said low birth volumes, insufficient Medicaid reimbursement rates, and workforce challenges made it hard to stay in business.
These issues are mirrored in other birth centers across the state. Financial troubles caused the Concord Birth Center to close in 2023. Another center, Gentle Landing Birth Center in Hanover, is open, but contending with similar challenges.
Despite these challenges, freestanding birth centers are often cheaper for insurers and patients, compared with hospital births. A 2021 study in the International Journal of Environmental Research and Public Health found that on average a vaginal birth at a hospital costs upwards of $14,000 on average, compared with a national average of roughly $8,000 in freestanding birth centers.
“We basically save a boatload of money for Medicaid and yet, our reimbursement rates are in the toilet,” said Katherine Bramhall, director of Gentle Landing Birth Center. “It is frustrating beyond belief.”
Related coverage from the Keene Sentinel: A mother's perspective
The bottom line
Like any other business, birth centers have overhead costs for facilities, equipment and personnel. Industry standards say birth centers need an average of 115 births a year to break even and 500 births to make a profit, according to a report by the consulting firm Guidehouse.
Throughout its tenure, the Monadnock Birth Center performed approximately 40-50 births per year, according to Lawlor.
In that environment, making sure reimbursements keep pace with costs becomes even more important, according to Dr. Stephanie Radke, a professor of obstetrics and gynecology at the University of Iowa.
“Unfortunately, in many states, the Medicaid reimbursement isn’t high enough to offset that until you get to a high enough volume [of births] or essentially you get to a volume where you pretty much always have patients there,” Radke said. “If they have an average payer mix, the average hospital probably needs to deliver at least 200 babies a year for their unit to be financially viable.”
In the years leading up to its closure, the Monadnock Birth Center was losing money on most of its births, according to Lawlor. That’s because nearly all forms of insurance were reimbursing at a rate that wasn’t enough to cover the $3,600 expenses per birth the center incurred, Lawlor said.
Of the forms of insurance that the center accepted, Medicaid reimbursements lost the most money, according to Lawlor. While Medicaid funds roughly 21 percent of births in New Hampshire, Lawlor estimated that about 30 percent of the center’s deliveries were funded by Medicaid.
Between the birth center’s opening in 2008 and 2023, N.H. Medicaid paid the facility $620 per birth, excluding fees for individual providers.
Lawlor, who also works in maternal policy advocacy, pushed the state to raise the reimbursement rate. In July 2023, rates for freestanding birth centers went up to about $950, a figure that rose again three months later to just shy of $2,145. This was “still too low, but it certainly was better than it was,” Lawlor said.
“You can’t pay 2023 bills with 2015 income,” she said.
To make up for the deficit, Lawlor said the center had to borrow money.
“I ended up saying that we actually had to pay to do Medicaid births,” said Lawlor, who did not turn down patients on Medicaid plans.
“I couldn’t stand it anymore,” she said. “It was just too much. It was terrible.”
The $620 per birth reimbursement from Medicaid was also a source of struggle for the Concord Birth Center, which closed permanently in July 2023. Kate Hartwell, a certified midwife who operated that facility, said between 40 and 60 percent of the center’s 100-120 births a year were paid for by N.H. Medicaid.
“If I did the [Medicaid] birth myself, I would lose about $400 total [and] if I had to pay my midwives to do it, I would lose around $1,000 per Medicaid birth,” Hartwell said.
By the time Medicaid reimbursement rates increased to $950 per birth in July 2023, it was “too little too late,” Hartwell said.
Although the majority of Medicaid funding comes from the federal government, state governments manage and distribute Medicaid funding and set reimbursement rates. In New Hampshire, Medicaid reimbursement rates are among the lowest in the nation, according to Kaiser Family Foundation.
For smaller operations like Gentle Landing Birth Center in Hanover, the Medicaid reimbursement rates are a significant source of financial stress.
“We struggle all the time and there are times where I don’t get paid as the owner in order to stay open,” Bramhall said.
Radke said the low reimbursements are an ongoing national issue. By the time state Medicaid programs increase their reimbursement rates, most birth centers are already struggling financially and may be on the brink of closing.
Higher, private insurer reimbursements also have not kept pace with costs, according to Lawlor. Private insurers reimbursed $1,800-$2,000 per birth, still far short of the $3,600 each delivery cost at the center, Lawlor said.
At the same time Lawlor was fighting with inadequate reimbursement rates, the birth center was struggling with building a workforce large enough to increase its birth volumes, and, by extension, its revenue.
Sacred Transitions in Bellows Falls, which offers home deliveries, contended with similar issues when one of its three providers left in 2020. With fewer providers, the center can accommodate six home deliveries a month.
With fewer freestanding birth centers, it is harder for midwives-in-training to find a place to help them learn the ropes, Sacred Transitions’ Director Rebecca Price-Wood said.
“What ends up happening is there gets to be this squeeze,” Price-Wood said. “If there’s fewer midwives, there’s fewer clinical sites for more midwives to train.”
A changing perspective
For Abigail Herrington, a local mother who gave birth to her second child at the Monadnock Birth Center, working with midwives helped make her second birth joyful. Her first birth, which took place in a hospital room that she described as “cold and sterile,” was a 35-hour labor that resulted in a caesarean section.
Before the Swanzey facility closed, the Chester, Vt., resident was planning to deliver more children at the center.
“I was really sad,” she said. “Especially for my future children, I want that same experience.”
Midwives and maternity care experts like Lawlor believe the lack of systemic support for non-medical birth settings reflects a broader misunderstanding within the maternity care system. Hospitals are necessary for high risk pregnancies, Lawlor said, but in low-risk births, “they think of it like preventing a heart attack when that’s not what [birth] is. It’s a healthy life function. It’s not an illness or a disruptive health situation.”
The type of birthing care that sees labor as positive experience, as opposed to a health risk, was what Lawlor sought to provide at the Monadnock Birth Center.
But keeping the center going eventually became exhausting for Lawlor. “I was fine by the time it was done, and I was ready when it was closing up,” Lawlor said. “Now, I’m so relieved to be done.”
Now, Lawlor advocates for strengthening maternity care policy, and is currently trying to increase federal funding for midwifery education. She fears that expected cuts to Medicaid in Washington and Concord could make a bad situation even worse.
“The whole system just takes you out of yourself,” Lawlor said. “There’s no sense of agency anymore for people giving birth, and birth is a pivotal life process.”
These articles are being shared by partners in the Granite State News Collaborative. For more information, visit collaborativenh.org.
