When Evie Reese and her husband were deciding where to give birth to their third child, they considered giving birth at home. However, paying out of pocket wasn’t an option for them.

“We chose the birth center because we had insurance with Kaiser and didn’t want to have a hospital birth,” said Reese. “We applied for Medi-Cal just for my pregnancy and that would cover a birth center.”

Fortunately for the Reese family, a freestanding birth center located just minutes from a large hospital in town provided them with the option to give birth with midwives in a family-centered, low-intervention setting.

“My mom was able to be there to watch my other two children so they could come in right after the baby was born,” said Reese.

The family loaded up all three kids, including their hours-old, nine-and-a-half pound addition, and headed back to their home for bedtime.

According to Jennifer Stevens, co-chairperson of the marketing committee of the American Association of Birth Centers, birth center births comprise the smallest fraction of the out-of-hospital births in the U.S., but represent something more significant.

“Birth centers are a permanent commitment to women’s choice,” said Stevens. “They are a brick and mortar presence in a community that says birth is normal.”

At a typical freestanding birth center, women receive prenatal care from midwives that includes screening for complications. Birth center eligibility is determined by meeting the center’s guidelines for a low-risk pregnancy. Continuous labor support and intermittent fetal monitoring is provided by midwives in a home-like setting, and women are free to eat, drink and move around as they wish. Life-saving equipment and drugs are immediately available but typically kept hidden from view.

The American College of Obstetricians and Gynecologists, while opposed to home birth, ranks birth in a freestanding birth center as equally safe to birth in a hospital or hospital birth center, provided the freestanding birth center “meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers,” according to the organization’s 2008 statement on home births.

Even with ACOG’s strong endorsement on paper, freestanding birth centers have long struggled to attain equitable reimbursement. Birth centers are very cost effective, yet many insurers and some states have traditionally refused to pay the facility fee portion of the bill. 

The American Association of Birth Centers has spent the last six months celebrating the inclusion of freestanding birth centers as approved facilities for Medicaid reimbursement in the health care reform bill. According to the AABC web site, the guarantee of facility fee payments to birth centers all over the U.S. will have “far reaching benefits to sustainability of birth centers, and the development of new birth centers in under-served communities.”

Insurers look to government programs like Medicaid to set precedence for payment, and Medicaid payment for birth center services supports the growth of birth centers. This year, the AABC has seen a 20 percent increase in membership and its Developing Birth Center membership has grown 59 percent.

For birth center administrators attempting to navigate what one speaker at the AABC Conference in September 2010 called “the reimbursement minefield,” billing Medicaid can be more difficult than it initially seems.

Sarah Davis, co-owner of Birth Roots Birth Center in Chula Vista, California, feels that reimbursement can be a challenge.

“We don’t accept HMO or any government insurance,” said Davis. Davis and co-owner, Darynée Blount, offer clients prepayment discounts and the option to pay by credit card. Maintaining access to the birth center for families with low incomes and resources remains a priority for Birth Roots Birth Center.

“We won’t turn anyone away for lack of funds,” said Davis.                  

Julia Hall, who opened the Babymoon Inn on July 22, 2010 in Phoenix, Arizona, estimates that about 50 percent of her efforts in starting the birth center were invested in tackling issues of billing and reimbursement. She and her husband Steven, a Certified Public Accountant, ultimately decided to outsource their billing process.

“Initially we intended on doing the billing ourselves,” said Hall, “but quickly learned that at least for now, we are much better off using a biller who knows the rules of the game.”

Relying on a professional to handle insurance billing frees Hall to work on community outreach with the goal of making midwifery care available to families who cannot or prefer not to use a private home for their birth, yet do not want to give birth in a hospital.

The modern birth center walks the line between home birth and hospital birth, and for the Reese family, it was a perfect compromise.