Sarah Simmons, a midwife and co-owner of Maple Street Birth Center in rural Okanogan County, Wash., holds a newborn. Freestanding birth centers can address maternal health inequities, but many are facing mounting financial and regulatory pressures. (Photo courtesy of Sarah Simmons)

Dr. Heather Skanes opened Alabama’s first freestanding birth center in 2022 in her hometown of Birmingham. Skanes, an OB-GYN, wanted to improve access to maternal health care in a state that’s long had one of the nation’s highest rates of maternal and infant mortality.

Those rates are especially high among Black women and infants. Skanes’ Oasis Family Birthing Center opened in a majority-Black neighborhood, offering midwifery services as well as medical care.

But about six months after the center’s first delivery — a girl who was Alabama’s first baby born in a freestanding birth center — the state health department ordered Skanes to shut it down. A department representative informed her that by holding deliveries at the birth center, she was operating an “unlicensed hospital,” she said.

Hospital labor and delivery units are shuttering across the nation — including more than two dozen in 2025 alone. Freestanding birth centers like Skanes’ could help fill the gaps, but they too are struggling to stay open.

They face some of the same financial pressures that bedevil hospitals’ labor and delivery units, including payments from insurers that don’t cover the full cost of providing maternity care.

Birth center owners also must contend with arcane state rules and antipathy from politically powerful hospitals that view them as competition, especially in rural areas with few births.

Nationwide, the number of freestanding birth centers doubled between 2012 and 2022, but more recently the pressures have taken a toll: About two dozen centers have closed since 2023, bringing the total number down to about 395, according to the most recent data from the American Association of Birth Centers.

In November, Pennsylvania Lifecycle Wellness and Birth Center announced it would shut down birth center services, citing pressure from regulatory challenges and sharp surges in malpractice premiums. It had served Philadelphia for 47 years. And New Mexico’s longest-operating freestanding birth center stopped delivering babies in December.

“When a new business opens, within the first three to five years you expect a certain number will close,” said Kate Bauer, executive director of the American Association of Birth Centers. “But we’ve had several long-standing birth centers close [in 2025] and that hits particularly hard.”

In California, which has some of the strictest birth center licensing rules in the country, concern over the closure of at least 19 birth centers between 2020 and 2024 prompted the state legislature to pass a law in October to streamline birth center licensure.

An appealing alternative

Freestanding birth centers are not attached to hospitals and aim to provide a more homelike, less traditional medical setting. They employ midwives and focus on low-risk pregnancies and births. Some also have an OB-GYN or family medicine doctor on staff, and they often have partnerships with nearby hospitals and doctors if more specialized care is required.

Some Black and Indigenous midwives and doulas say birth centers can be helpful alternatives to their community members, many of whom have had experiences in more medicalized settings that left them feeling marginalized, dismissed or unsafe.

Midwife Jamarah Amani, executive director of Southern Birth Justice Network, runs a mobile midwifery clinic serving majority-Black and Latino neighborhoods in Miami-Dade County, Florida. The nonprofit, which aims to make midwife and doula care more accessible, recently bought a building for a freestanding birth center it aims to open in 2027.

“[Midwifery] presents like a luxury concierge-type of service, and our goal is to really change that and to bring it back to the community in a very grassroots way,” Amani said. She added that expanding access to prenatal care could help address inequities in maternal health, as maternal death rates among Black women are three times higher than those among white women.

Freestanding birth centers also can be a solution for communities without a hospital nearby.

The closest hospital to the Colville Indian Reservation, located in northern Washington state, is half an hour away, said Faith Zacherle-Tonasket, founder of the nonprofit xa?xa? Indigenous Birth Justice.

So far, the group has trained nearly a dozen tribal doulas and midwives to serve the area. In the next few years, it plans to open a freestanding birth center. Zacherle-Tonasket said Indigenous-run birth centers are crucial alternatives for tribal women, who also have some of the highest maternal mortality rates in the nation and often face prejudice in clinical settings.

“They don’t feel safe. So a lot of them just don’t get prenatal care,” said Zacherle-Tonasket. “Bringing traditional midwives that are from our own communities, that were born and raised in our communities, that know the families — we know that those babies will be birthed with love.”

Regulatory hurdles

When the Georgia legislature relaxed state health care regulations in 2024, it felt like a long-awaited win for Katie Chubb. A registered nurse and mother of three who’s worked in health and nonprofits, Chubb has spent years trying to open a birth center in Augusta.

The state denied her application to open the center in 2021. Georgia, like many states, requires health care providers to get state approval, called a certificate of need, before they can build a new facility or expand services. Rival providers, like other hospitals, can challenge an application, effectively vetoing their local competition.

That happened in Chubb’s case: Two local hospitals filed letters of opposition against her and refused to say they’d accept emergency transfers from her birth center, another requirement for opening.

Georgia currently has three freestanding birth centers, a fraction of the more than two dozen that operate in neighboring Florida.

“We’re seeing women giving birth in hospital hallways or at home unassisted, because there’s no in-between option like a birth center,” Chubb said. In October, Georgia lost another labor and delivery unit at a rural hospital two hours north of Augusta.

“Women are just left to figure things out.”

In Kentucky, the Republican-controlled legislature passed a bill in March that aimed to clear the way for freestanding birth centers by exempting them from the certificate of need process.

But Republican lawmakers attached a last-minute anti-abortion amendment to the bill, prompting Democratic Gov. Andy Beshear to veto it. The legislature eventually overrode his veto. Midwifery advocates hope the new law will help make it easier to open a birth center in the state.

Georgia legislators similarly revised Georgia’s certificate of need rules in 2024, exempting freestanding birth centers. Chubb, who championed the new law, hoped it would clear the path for herself and others.

But they hit another roadblock. The state still requires birth centers to secure a written agreement with a local hospital to accept transfers of clients in emergencies. Chubb and at least one other prospective birth center owner have been unable to get their local hospitals to sign such transfer agreements.

“We’re still fighting,” Chubb said. “Behind closed doors we’re still working very hard on getting legislation and regulations changed to make opening birth centers more equitable.”

Some hospitals view birth centers as a threat to the viability of their labor and delivery units, siphoning off patients and revenue from a service that’s already unprofitable for most hospitals.

Daniel Grigg, CEO of Wallowa Memorial Hospital, a 25-bed critical access hospital in northeast Oregon, said there aren’t enough births in the area for both hospitals and birth centers.

“When you’ve got a small-volume community like we have, every birth helps the providers keep their skills up and their competency,” he said. “When you’ve got a midwife taking, say, 10 patients out of that pool,” it can have an impact on physicians and hospitals.

Alabama lawsuit

After the Alabama Department of Public Health shut down Skanes’ birth center in 2023, she joined with two other women who had also been attempting to open birth centers in Alabama: Dr. Yashica Robinson, an OB-GYN in North Alabama, and Stephanie Mitchell, a licensed midwife in Alabama’s rural and economically disadvantaged Black Belt region. Together they sued the Alabama Department of Public Health over what they called a de facto ban on birth centers.

The state insisted its tighter regulations would ensure that birth center facilities are safe. The birth center owners said the state’s rules were overly burdensome and clinically unnecessary for the low-risk, nonsurgical births that are attended by midwives. And, they said, the rules prevented more families from accessing care where it’s desperately needed. The state has lost at least three hospital labor and delivery units since 2020.

“Entire swaths of the state are maternity care deserts without access to essential health care,” said Whitney White, a staff attorney with the American Civil Liberties Union, which is representing the birth center owners and their co-plaintiff, the Alabama affiliate of the American College of Nurse-Midwives.

“Hospital labor and delivery units are closing, and pregnant folks are reporting they’re really struggling to access the care they need, struggling to get appointments, struggling to find a provider,” White said.

Last May, an Alabama trial court permanently blocked the state from regulating freestanding birth centers as hospitals. Birth center staff are still overseen by state boards of midwifery and nursing.

All three Alabama centers are now open. But their licensed midwives are delivering babies under a cloud of uncertainty about the future.

The state appealed the ruling in November. The case is ongoing.

Struggles and solutions

Bauer, of the American Association of Birth Centers, said many centers face the same financial barriers. Uncomplicated births at freestanding birth centers cost less than they do at hospitals, but research has shown that insurers, including Medicaid, reimburse centers at lower rates. Some state Medicaid programs don’t cover some of the nonclinical services, such as lactation consultants and doulas, that birth centers may provide. And malpractice premiums are rising.

“We’re volunteering our time, essentially, to keep the birth center open as a service to the community,” said Sarah Simmons, co-owner of Maple Street Birth Center in rural Okanogan County, Washington. The center can’t afford to hire a front-desk staffer or another midwife, Simmons said. She added that on average, the center makes less than a third of what the local hospital makes for providing the same obstetric service.

But there may be solutions to some of these financial problems. For example, the Center for Healthcare Quality and Payment Reform, a national health care policy center, has recommended that health insurance plans, both Medicaid and commercial, pay hospitals and birth centers monthly or quarterly “standby capacity payments” per woman of childbearing age covered by that health plan in the facility’s service area. It also recommends that plans pay a separate delivery fee for each birth.

In 2024, Democratic U.S. senators proposed a bill to allow for a similar payment model.

Standby payments could help freestanding birth centers, especially those that fill gaps in maternity care deserts — but not unless centers receive payments that are comparable to those that hospitals get, said Simmons, whose center serves four sparsely populated counties along with the Colville tribal communities.

“This would be most beneficial to freestanding birth centers if pay parity laws were enforced, so rural freestanding birth centers were paid the same rates for the same services as rural hospitals, ” she said.

State grants also can help, but birth centers say a one-time infusion won’t be enough. In 2024, Washington opened grant applications for distressed hospital labor and delivery units and freestanding birth centers.

Ashley Jones, of True North Birth Center and president of the Washington chapter of the American Association of Birth Centers, said the grant has helped keep their doors open.

Meanwhile, Chubb, the Georgia nurse, recently had to take another job to support her family while her birth center remains in legal limbo.

“I’m just waiting until the government figures out what they’re doing.”

Stateline reporter Anna Claire Vollers can be reached at avollers@stateline.org. Stateline reporter Nada Hassanein can be reached at nhassanein@stateline.org.

Reading Time: 7 minutes

This story was originally published by ProPublica.

The most powerful Republican in Wisconsin stepped up to a lectern that was affixed with a sign reading, “Pro-Women Pro-Babies Pro-Life Rally.”

“One of the reasons that I ran for office was to protect the lives of unborn children,” Assembly Speaker Robin Vos told the cheering crowd gathered in the ornate rotunda of the state Capitol. They were there on a June day in 2019 to watch him sign four anti-abortion bills and to demand that the state’s Democratic governor sign them. (The governor did not.)

“Legislative Republicans are committed to protecting the preborn because we know life is the most basic human right,” Vos promised. “We will continue to do everything we can to protect the unborn, to protect innocent lives.”

Now, however, Vos has parted with some in the national anti-abortion movement in its push for a particular measure to protect life: the life of new mothers.

Many anti-abortion Republicans have supported new state laws and policies to extend Medicaid coverage to women for a year after giving birth, up from 60 days. The promise of free health care for a longer span can help convince women in financial crises to proceed with their pregnancies, rather than choose abortion, proponents say. And many health experts have identified the year after childbirth as a precarious time for mothers who can suffer from a host of complications, both physical and mental.

Legislation to extend government-provided health care coverage for up to one year for low-income new moms has been passed in 48 other states — red, blue and purple. Not in Arkansas, where enough officials have balked. And not in Wisconsin, where the limit remains two months. And that’s only because of Vos.

The Wisconsin Senate passed legislation earlier this year that would increase Medicaid postpartum coverage to 12 months. In the state Assembly, 30 Republicans have co-sponsored the legislation, and there is more than enough bipartisan support to pass the bill in that chamber.

But Vos, who has been speaker for nearly 13 years and whose campaign funding decisions are considered key to victory in elections, controls the Assembly. And, according to insiders at the state Capitol, he hasn’t allowed a vote on the Senate bill or the Assembly version, burying it deep in a committee that barely meets: Regulatory Licensing Reform.

Vos’ resistance has put him and some of his anti-abortion colleagues in the odd position of having to reconcile their support for growing families with the failure of the Assembly to pass a bill aimed at helping new moms stay healthy.

“If we can’t get something like this done, then I don’t know what I’m doing in the Legislature,” Republican Rep. Patrick Snyder, the bill’s author and an ardent abortion foe, said in February in a Senate hearing.

Reached by phone, Vos declined to discuss the issue with ProPublica and referred questions to his spokesperson, who then did not respond to calls or emails. Explaining his opposition, Vos once said, “We already have enough welfare in Wisconsin.” And in vowing to never expand Medicaid, he has said the state should reserve the program only for “those who truly need it.”

His stance on extending benefits for new mothers has troubled health care professionals, social workers and some of his constituents. They have argued and pleaded with him and, in some cases, cast doubt on his principles. ProPublica requested public comments to his office from January 2024 to June 2025 and found that the overwhelming majority of the roughly 200 messages objected to his stance.

“I know this is supported by many of your Republican colleagues. As the ‘party of the family’ your opposition is abhorrent. Get with it,” one Wisconsin resident told the speaker via a contact form on Vos’ website.

Another person who reached out to Vos chastised him for providing “lame excuses,” writing: “The women of Wisconsin deserve better from a party that CLAIMS to be ‘pro-life’ but in practice, could care less about women and children. We deserve better than you.”

 ‘A commonsense bill’

Donna Rozar is among the Wisconsin Republicans who staunchly oppose abortion but also support Medicaid for new mothers.

While serving as a state representative in 2023, she sponsored legislation to extend the coverage up to one year. Her effort mirrored what was happening in other states following the end of Roe v. Wade and the constitutional right to an abortion. Activists on both sides of the abortion issue recognized that there could be a rise in high-risk births and sought to protect mothers.

“I saw this as a pro-life bill to help mothers have coverage for up to a year, in order to let them know that they would have the help they needed if there were any postpartum complications with their pregnancy,” said Rozar, a retired registered nurse. “I thought it was a commonsense bill.”

Vos, she said, would not allow the bill to proceed to a vote even though it had 66 co-sponsors in the 99-person chamber. “The speaker of the state Assembly in Wisconsin is a very powerful individual and sets the agenda,” she said.

Rozar recalled having numerous “frustrating” conversations with Vos as she tried to persuade him to advance the legislation. “He was just so opposed to entitlement programs and any additional expenditures of Medicaid dollars that he just stuck to that principle. Vehemently.”

Vos has argued as well that through other options, including the Affordable Care Act, Wisconsinites have been able to find coverage. While some new mothers qualify for no-cost premiums under certain ACA plans, not all do. Even with no-cost premiums, ACA plans typically require a deductible or co-payments. And next year, when enhanced premium tax credits are due to expire, few people will be eligible for $0 net premiums unless Congress acts to change that.

Rozar lost her race for reelection in August 2024 after redistricting but returned to the state Capitol in February for a Senate hearing to continue advocating for the extension. She was joined by a variety of medical experts who explained the extreme and life-threatening risks women can face in the first year after giving birth.

They warned that without extended Medicaid coverage, women who need treatment and medication for postpartum depression, drug addiction, hypertension, diabetes, blood clots, heart conditions or other ailments may be unable to get them.

One legislative analysis found that on average each month, 700 women fell off the Medicaid rolls in Wisconsin two months after giving birth or experiencing a miscarriage because they no longer met the income eligibility rules.

Justine Brown-Schabel, a community health worker in Dane County, told senators of a new mother diagnosed with gestational diabetes who lost Medicaid coverage.

“She was no longer able to afford her diabetes medication,’’ Brown-Schabel said. “Not only did this affect her health but the health of her infant, as she was unable to properly feed her child due to a diminishing milk supply.”

She described another new mother, one who had severe postpartum depression, poor appetite, significant weight loss, insomnia and mental exhaustion. Sixty days of Medicaid coverage, Brown-Schabel said, “are simply not enough” in a situation like that.

Currently, new moms with household incomes up to 306% of the poverty line (or $64,719 a year for a single mom and baby) can stay on Medicaid for 60 days after birth. But the mother must be below the poverty line ($21,150 for that mom and baby) to continue with coverage beyond that. The new legislation would extend the current protections to a year.

Bipartisan unity on the legislation is so great that Pro-Life Wisconsin and the lobbying arm of the abortion provider Planned Parenthood, which offers some postpartum services, both registered in support of it before the Senate.

“It’s something that we can do and something that’s achievable given the bipartisan support for it,” Matt Sande, a lobbyist for Pro-Life Wisconsin, said in an interview. “It’s not going to break the bank.”

Once fully implemented, the extended coverage would cost the state $9.4 million a year, according to the state Legislative Fiscal Bureau. The state ended fiscal year 2025 with a budget surplus of $4.6 billion.

With the Assembly bill buried by Vos, Democratic Rep. Robyn Vining tried in July to force the issue with a bit of a legislative end run. She rose during floor debate on the state budget and proposed adding the Medicaid extension to the mammoth spending bill.

All of the Republicans who had signed on to the Medicaid bill, except one absent member, voted to table the proposal, sinking the amendment. They included Snyder, the bill’s sponsor, who in an email to ProPublica labeled the Democrats’ move to raise the issue during floor debate “a stunt.”

“Democrats were simply more concerned with playing political games to garner talking points of who voted against what, than they were in supporting the budget negotiated by their Governor,” he said.

Said Vining of the Republicans who tabled the amendment: “They’re taking marching orders from the speaker instead of representing their constituents.”

Well-funded opposition

Vos’ opposition echoes that of influential conservative groups, including the Foundation for Government Accountability, a Florida think tank that promotes “work over welfare.” Its affiliated lobbying arm openly opposed the Medicaid extension for new moms when it first surfaced in Wisconsin in 2021, though it has not registered opposition since then. Reached recently, a spokesperson for the foundation declined to comment.

Over the past decade, the foundation has received more than $11 million from a charitable fund run by billionaire Richard Uihlein, founder of the Wisconsin-based shipping supplies company Uline. In recent years, Uihlein and his wife, Liz, also have been prolific political donors nationally and in the Midwest, with Vos among the beneficiaries.

Since 2020, Liz Uihlein has given over $6 million to Wisconsin’s Republican Assembly Campaign Committee, which is considered a key instrument of Vos’ power. And in February 2024, she donated $500,000 to Vos’ personal political campaign at a time when he was immersed in a tough intraparty skirmish.

One concern cited by extension opponents such as the Foundation for Government Accountability is that Medicaid coverage for new moms could be used for health issues not directly related to giving birth. Questions over how expansive the coverage would be spilled into debate in Arkansas in a Senate committee in April of this year.

“Can you explain what that coverage is? Is it just like full Medicaid for any problem that they have, or is it somehow specific to the pregnancy and complications?” asked GOP Sen. John Payton.

A state health official told him new mothers could receive a full range of benefits.

“Like, if they needed a knee replacement, I mean, it’d cover it?” Payton said.

“Yes,” came the reply.

The bill failed in a voice vote.

In Wisconsin, no lawmaker voiced any such concern during the February Senate hearing, which was marked by only positive feedback. In fact, one lawmaker and some medical experts in attendance openly snickered at the thought that Arkansas — a state that ranks low in public health measurements — might pass legislation before Wisconsin, leaving it the lone holdout.

Ultimately, the Wisconsin Senate approved the legislation 32-1 in April, sending it along to the Assembly to languish and leaving Wisconsin still in the company of Arkansas on the issue.

Despite the setbacks and Vos’ firm opposition, Sande of Pro-Life Wisconsin and other anti-abortion activists are not giving up. He thinks Vos can be persuaded and the bill could move out of its purgatory this winter.

“I’m telling you that we’re hopeful,” Sande said.

Rozar is, too, even though she is well aware of Vos’ unwavering stance. “He might have egg on his face if he let it go,” she said.

ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.

He vowed to ‘protect the unborn.’ Now he’s blocking a bill to expand Medicaid for Wisconsin’s new moms. is a post from Wisconsin Watch, a non-profit investigative news site covering Wisconsin since 2009. Please consider making a contribution to support our journalism.