Equitable access to maternity care practices that promote high-value family-centered intrapartum care
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BACKGROUND: Despite large investments in maternity care services, perinatal health outcomes in the U.S. are among the worst compared to other industrialized countries, with documented perinatal health disparities disproportionately impacting racial and ethnic minorities. Midwifery-led freestanding birth centers (FSBC) have emerged as an underutilized model for the safe and cost-effective care of women with low-risk pregnancies. Despite approximately 85% of all US pregnancies being considered low-risk, only 0.5% of all US births occurred in a FSBC in 2016. The goal of the study is to elucidate strategies used to develop and sustain freestanding birth centers (FSBCs) that are seeking to serve high proportions of publicly-insured women and women of color. METHODS: I conducted an embedded unit case study, including semi-structured in-depth interviews and focus groups with 49 stakeholders from three exemplary FSBCs. Supplemental interviews were led with five key informants from three additional FSBCs and a relevant national membership organization. Additional data sources used to complete this case study include, where relevant and permitted, observations of maternity care settings, patient-provider encounters, management meetings, community events, and review of pertinent documents. Qualitative analysis methods were used to identify common themes and variations. FINDINGS: Midwifery-led birth center care can improve the experience and outcomes of maternity care among publicly insured women of color. The study revealed persistent multi-level challenges, as well as the use of common approaches to overcome these organizational, financial, and cultural barriers, resulting in greater, yet still fragile, access to family-centered intrapartum care within the communities in which these FSBCs operate. CONCLUSIONS: The careful integration of FSBCs into health systems such as a Federally Qualified Health Center (FQHC) may contribute to the broad scale-up of this underutilized model of care. While integrating FSBCs into FQHCs may be helpful in expanding equitable access to birth center care, it is not necessary, and also not sufficient. Expansion efforts should include additional deliberate processes and strategies to ensure equitable uptake and sustainability of birth center care.