Quality Care in Midwifery‐Led Birth Centers: Assessing the Disconnect Between Reimbursement and Perinatal Outcomes

BACKGROUND: Health care financing is thought to be a driver of health care quality. The purpose of this research was to analyze reimbursement for midwifery-led US birth centers and to evaluate the association between reimbursement ratios and clinical outcomes. METHODS: Secondary analysis of the American Association of Birth Centers Site Survey and the American Association of Birth Centers Perinatal Data Registry was completed. Descriptive statistics and logistic regression were used to analyze reimbursement ratios and their relationship to clinical outcomes. RESULTS: Between 2012 and 2020, 107 participating birth centers cared for 78,773 enroled pregnant people. Public payors (Medicaid, Tricare, CHIP) were reported to pay less than a third of all charges. Comparing private payors to public payors, lower reimbursement ratios were demonstrated for professional services (77% vs. 43%), facility fees (89% vs. 45%), and newborn care (66% vs. 40%). Core clinical outcomes demonstrated high quality without significant variation between public and private payor groups: cesarean birth (10.2 vs. 9.2%), NICU admissions (0.9% vs. 1.1%). The median reimbursement ratio for public payors was 0.379. For every 1000 dollars increase in reimbursement, the odds of cesarean birth increased by a factor of 1.39 for nulliparous women (aOR 1.39; 95% CI, 1.10-1.75) and 2.15 for multiparous women (aOR 2.15; 95% CI 1.54-3.01). DISCUSSION: Despite poor reimbursement ratios, birth centers consistently exceeded national quality benchmarks in perinatal outcomes. Low reimbursement ratios for time-intensive, midwifery-led care without consideration of quality outcomes limit the potential for sustainability and spread of the birth center model of care.