The share of U.S. births taking place in freestanding birth centers has nearly tripled over the last 20 years, but access varies widely from state to state, and 10 states have none, according to an Oct. 20 Commonwealth Fund report.
Birth centers are community-based facilities that operate separately from hospitals. They are led by midwives and care for people with low-risk pregnancies before, during and after birth, according to the Commonwealth Fund. The report’s authors analyzed CDC birth data, reviewed state-level birth center availability and regulation, and interviewed leaders of three birth centers.
Here are six things to know:
1. The share of U.S. births in birth centers rose 170% from 2004 to 2024, from 0.23% to 0.62%, with demand surging during the COVID-19 pandemic. Births at birth centers have dipped slightly since 2022, possibly due to some centers closing. Western and Southern states accounted for more than 80% of that decline.
2. Access depends heavily on state policy. Texas has 90 birth centers, while 10 states have none and eight states have one each. About 80% of states formally recognize birth centers and have regulations specific to their operation, though Maine, Wisconsin, Alabama and Oklahoma have no licensure for birth centers at all. Several states require a certificate of need before a birth center can open, which the report said health systems can use to prevent new centers from opening.
3. In 2023 and 2024 combined, 5.18% of births to Alaska residents took place in birth centers. In states with no birth centers, such as Mississippi and Arkansas, the rate was 0.02%, with some women traveling out of state to give birth at one. Washington, Idaho, Delaware, Montana and Oregon each saw at least 1.5% of births in birth centers.
4. Paying for care is a major barrier. Thirty-nine percent of families who gave birth at a birth center paid out of pocket, compared with 3% of families who gave birth in hospitals. Medicaid covered 18% of birth center births and 41% of hospital births. A July 2025 study of nine states found Medicaid reimbursement for birth centers ranged from $1,300 in New Jersey to $6,012 in Massachusetts. A 2017 study cited in the report found about 1 in 8 planned birth center births required a hospital transfer during labor, and when that happens the center may receive reduced payment or none at all.
5. Midwives deliver nearly all birth center care. In 2024, certified nurse-midwives and certified midwives attended 49.5% of birth center births, while certified professional midwives attended 42.7%. Physicians attended 1.4%. The midwifery workforce is unevenly spread: Vermont has more than 230 midwives per 10,000 births, while Mississippi, Alabama and Louisiana each have fewer than 20.
6. The report’s authors called on hospitals to work with birth centers on protocols for transferring patients smoothly. They also called for state rules written specifically for birth centers rather than borrowed from those governing surgical centers, and for Medicaid and private insurer payments that reflect birth center staffing and operating costs. They pointed to partnerships with federally qualified health centers as one of the most promising ways to grow access. The report highlighted Community of Hope in Washington, D.C., which pairs a birth center with a federally qualified health center. In 2023, its Medicaid patients had a lower rate of low birthweight babies (10%) than Medicaid beneficiaries across the district (15%).
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