When Katie Chubb announced in 2021 she was planning to open a freestanding birth center in Augusta, Georgia, it seemed like everybody in town was excited about it.
She met with local physicians and nurses who said they would welcome her Augusta Birth Center as a provider of midwifery services for low-risk pregnancies. Hundreds of people signed the interest form on her website. She had a positive meeting with the head of obstetrics at University Hospital (now Piedmont Augusta), located less than a mile from the proposed birth center location, she said.
But when Chubb submitted her 800-page application to the state health department for a so-called certificate of need -- a requirement to open a licensed birth center in Georgia -- she discovered that not everybody in town was enthusiastic about the Augusta Birth Center.
Two local hospitals, including the one she'd met with, filed letters of opposition with the state. They cited several concerns, including a belief that the center hadn't demonstrated its services were needed in the community. Those hospitals, plus a third in the area, refused to sign a written agreement with Chubb saying they would accept emergency transfers from the birth center. As a result, the state denied Chubb's application.
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The property in downtown Augusta that she'd planned to purchase for the birth center remains vacant and filled with weeds, since the sale was contingent upon her receiving state permission to open. With the future of the business uncertain, her main funder backed away.
The South has long had poorer birth outcomes than the rest of the nation. Most of the highest maternal and infant mortality rates are in Southern states, which tend to have higher rates of poverty and the types of health conditions -- such as high blood pressure -- that make pregnancy more dangerous. Access to care is thinning out: More than half of rural hospital closures over the past two decades have been in Southern states.
12% of births
Supporters say birth centers can help improve that record. Nationwide, birth alternatives such as freestanding centers and midwifery care have surged in popularity, particularly since the COVID-19 pandemic prompted increased interest in out-of-hospital birth options. The number of birth centers nationwide has doubled over the past decade, while midwife-attended births now account for about 12% of all births.
But the South lags the rest of the nation in offering birth alternatives, in part because of regulatory roadblocks, such as the transfer agreements with area hospitals that thwarted Chubb.
Hospital and physicians' groups in the South say such rules are necessary to protect the health and safety of women and babies. Critics counter that doctors and hospitals are more interested in preserving their monopoly on maternal care.
In Chubb's case, the state regulatory board denied her application despite concluding that there was a need for her birth center's services and that the center would offer "a low cost, high quality alternative" for maternal health in the area.
"A week before the deadline, (the hospitals) went quiet," said Chubb, who works as a personal trainer focused on prenatal and postnatal exercise and who is currently a nursing student. "We've tried to contact the hospitals multiple times, even since they switched management. And yet we still can't open because the hospitals want to block us."
Piedmont Augusta did not answer requests for comment. Augusta University Health did not respond in time for publication.
Chubb has sued the state, challenging the constitutionality of the state's certificate of need law. The case is ongoing.
"If we're not going to do it, nobody's going to do it," she said. "You've got to have someone who's tenacious and has the resources to go after this."
Lower cost
At least 34 states operate certificate of need programs, which vary by state but are designed to control the number of health care resources in an area by requiring a hospital or health system to prove the community needs a certain service before the provider builds or expands it.
In their letters of opposition to Chubb's Augusta Birth Center, two Augusta-area hospitals cited several reasons, including the center's lack of written transfer agreements, which the hospitals declined to sign.
The Augusta University Medical Center, in its opposition letter, noted the birth center "has garnered opposition from two of the hospitals precisely because it will not function well as part of the established system of perinatal care" and recommended the birth center "work much more closely with the local hospitals and physicians."
"Instead," the letter said, "it is proposing a project that will only take from the existing hospitals."
Chubb proposed charging about $5,000 for an uncomplicated birth, far below the $15,000 at Augusta University Medical Center or the $7,300 at University Hospital, according to the health department's decision letter. Both hospitals questioned the financial feasibility of the birth center's proposed charges in their letters of opposition.
Absolute veto
Chubb, in her lawsuit against the Georgia Department of Community Health, is being represented by the Pacific Legal Foundation, a national public interest law firm that often champions conservative or libertarian causes.
"We're opposed to certificate of need laws of any variety, but we believe the ones in Georgia for birth centers are worse because they give an absolute veto to competitors who simply don't want the competition," said Joshua Polk, an attorney at Pacific Legal who is working on Chubb's case.
Kentucky's certificate of need law is the primary reason that state has no freestanding birth centers, said state Sen. Shelley Funke Frommeyer, a Republican who filed one of the bills during Kentucky's 2023 legislative session that would have exempted freestanding birth centers from certificate requirements.
"We want to promote and inspire people to take responsibility for their health, but the hospitals aren't giving us the freedom to do that," said Funke Frommeyer. "The hospital association and our hospitals are battling to restrict this offering."
Hospital officials from around Kentucky testified against removing the certificate of need requirement for birth centers, and the Kentucky bills ultimately failed.
Jim Musser, senior vice president for policy and government relations at the Kentucky Hospital Association, pointed out that three certificates of need have been granted for freestanding birth centers over the past 20 years, though those centers were ultimately never built.
The hospital association's position is that freestanding birth centers should be overseen by obstetricians, staffed by certified nurse-midwives and "closely aligned with a hospital" via a written transportation agreement or being operated by the hospital, he said.
"Kentucky has some of the worst infant and maternal mortality rates in the country, and we want to make sure we're doing things to improve that and not jeopardize the lives of mothers and children," Musser said.
Earlier this year, South Carolina passed a law that eliminated its certificate of need requirements for nearly all health care facilities, including birth centers. And West Virginia amended its law to exempt hospitals and birth centers.
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