Eight years after New York passed a law allowing midwives to open childbirth facilities, the Bronx, the borough with the city’s worst maternal mortality and morbidity rates, lacks any birth center at all.
“Birthing centers exist in other parts of the city. And guess what? They work,” Bronx Borough President Vanessa Gibson said in her 2023 State of the Borough address, vowing that “we will create a Bronx birthing center to achieve the health equity and the justice that we know that our women deserve.”
At these freestanding facilities, people with low-risk pregnancies can have babies and receive holistic pre- and post-natal care in an alternative to a hospital ward.
The need for more maternal care options looms large in The Bronx, where the childbirth deaths of Amber Rose Isaac and Elaina Boone in borough hospitals brought widespread attention.
But more than a year after Gibson’s announcement, there’s still no birthing center in the borough and advocates say there isn’t much progress toward opening one.
“The only options that we have in The Bronx are all very similar. They have similarly poor outcomes,” Bronx doula Nicole Jeanbaptiste told THE CITY. “And the reason why we need a Birth Center in the Bronx is because we need to diversify people’s options.”
Birth centers emphasize natural deliveries without medication and holistic support from doulas, midwives and other birth workers for people with low-risk pregnancies as a safer and less stressful alternative to hospitals where medical interventions from labor-inducing narcotics to c-sections are common.
But despite a 2016 state law passed over the objections of the American Congress of Obstetricians and Gynecologists, only two centers operate in the city, both in Brooklyn, and none in The Bronx.
In 2020, the most recent year for which city health department data is available, The Bronx had 25 deaths tied to pregnancies — more than any other borough.
“Our office remains committed to working with our healthcare professionals and birth advocates to support bringing a birthing center to the Bronx and support policy that would improve health outcomes for Bronx mothers and birthing people,” Gibson told THE CITY in a written statement.
Gibson added that the office is having “conversations with our city and state partners and birthing advocates” about feasible locations for a potential birthing center.
After Boone’s death last September, Gibson promised to issue a report recommending steps to combat maternal mortality. She now says it will debut at her State of the Borough address on April 18, following Black Maternal Health Week, “as a way to bring attention to how the Black maternal health crisis disproportionately affects Black mothers and birthing people in The Bronx.”
Slow Motion
Some Bronx residents decide to give birth in suburban Westchester County in hopes they’ll have a better experience.
Angelica Easton, 37, had her first of three births in 2016 at Lawrence Hospital, now New York-Presbyterian Westchester, in Bronxville. When her labor began, she hadn’t dilated much so she visited her gynecologist, who recommended a process that clears the membrane in the sac that contains the fetus to help speed up labor.
“It definitely made contractions more intense,” Bronx resident Easton said, adding that she felt speeding up a delivery is unfairly pushed onto people giving birth. “It’s called labor for a reason.”
Easton went to the hospital when her contractions became “more manageable,” and her water broke there shortly after arrival.
At the hospital, during the delivery process, doctors gave her an episiotomy, a procedure that cuts part of the skin to clear a larger path for the baby.
“‘I’m going to give you a little cut to help the baby’s head come out,’” Easton, a Black woman who lives in Laconia, recalls her doctor saying. She was in a daze after requesting an epidural because of the pain, which doctors then followed by administering pitocin.
During the summer of 2020, Easton was set to try a home birth, influenced not only by the pandemic but also by her birthing experience at a hospital, maternal health inequities for Black women and her own research on unnecessary interventions.
“After having a home birth and learning more about the birthing process and what is medically necessary, I realized much more things happened to me that didn’t have to happen,” said Easton. “I got much more attentive care at home than I did at the hospital. It felt more routine as opposed to genuinely checking on me.”
Her third child was also delivered via home birth, assisted by a midwife.
Many births in the borough happen at Montefiore’s two hospitals offering obstetric care in Wakefield and Morris Park, accounting for 43% of all births in The Bronx in 2020. Bronxcare Hospital in Mount Eden, Lincoln Medical Center and Jacobi Medical Center also have busy maternity wards.
Bronxcare and Jacobi have cesarean section rates well above the national average of 33%, at 39% and 38%, while Montefiore Wakefield was the only hospital with a rate lower than than 32% — there, just 24% of births occur via c-section.
Myla Flores, a doula who co-founded The Birthing Place, a collective of birth workers and advocates pushing for a birth center in The Bronx, said that the state Department of Health dragged its feet implementing the 2016 law.
It required the state to create regulations “in consultation with representatives of midwives, midwifery birth centers, and general hospitals providing obstetric services.” But the state Department of Health didn’t release the regulations until late 2019, just before the pandemic.
“DOH let that sit for years,” said Flores.
Those regulations keep midwives on the margins. They mandate that the medical director for a birth center must be a physician. They also require centers to obtain a state licensure, even if they already have accreditation at the national level, and applicants must provide a certificate of need that proves the birth center doesn’t offer services that compete with a local hospital.
According to the American Association of Birth Centers, New York State is one of just 13 states requiring a certificate of need and has seven birth centers, far below the 92 in Texas, 48 in California, 34 in Washington State and 33 in Florida, none of which requires a certificate of need.
“Once you get a national accreditation, you should have licensure here in New York State,” said Flores, noting that the state focused on regulations like ceiling heights, elevator sizes and hallway widths and is “just trying to fit a square peg in a round hole” with “rigorous regulations that aren’t even about safety.”
“We’re not dealing with people in wheelchairs and stretchers. We’re dealing with low-risk birthing people,” she said.
Flores has joined forces with Amber Isaac’s partner, Bruce McIntyre, and ob/gyn and doula Carla Williams to launch the Womb Bus, a mobile wellness center they use to offer education and “essential resources.” And late last month, they opened a maternal health clinic in Norwood called Maryam, what they see as a major stepping stone to a larger birth center.
“Midwives — who are the experts in low risk populations and normal labor and delivery processes — should be involved in the care of the majority of birthing people in the United States,” Williams told THE CITY. “Obstetricians are capable of doing so. But there should be that collaboration where obstetricians step in when it’s necessary, when interventions are deemed necessary. That’s our area of expertise.”
The Business of Birth
The state Department of Health has only received four applications for midwife-led birth centers since the 2016 law permitting them. High insurance rates also stifle birth centers, leading to many closures of independent facilities that were unattached to hospitals.
No one understands how long and arduous the process to license a birth center better than Maura Winkler, a midwife who runs The Coit House, an unlicensed birth center based in Buffalo. She submitted her application for licensure to the state health department in August 2020. The Commission for the Accreditation of Birth Centers, a national organization, granted Winkler accreditation the following year.
But the New York state Department of Health turned her down for a license in early 2023, citing an open investigation regarding two infant deaths at The Coit House. Winkler did not attend either birth and is appealing the state’s decision.
“The process has probably cost about $200,000 in legal and consulting fees,” Winkler said.
A major reason Winkler and other midwives want state licensing is because it would entitle them to facility fees charged for services.
“Thirty to 50% of your income could potentially be from a facility fee,” added Winkler, estimating that without a license, a midwife running a birth center is losing between $3,000 to $10,000 per birth. She has attended close to 700 births since opening in 2019.
Insurance coverage can also affect patients. Easton said that while her health plan covered all of her $20,000 hospital birth, it only covered $4,000 of her home birth, which that cost $11,000.
Midwives hoping to open birthing centers staked high hopes on a bill the state legislature passed in 2021 that would have allowed midwives to obtain a state license to run a birth center based on their national accreditation. Then Gov. Kathy Hochul forced a last-minute change to let the state health department retain its licensing power, New York Focus and City and State reported.
The state reforms got “gutted from what it was truly supposed to be and what it was truly supposed to serve,” said McIntyre. “We knew that we had a lot of stipulations in our way to obtaining the type of birthing center that we want.”
Meanwhile, the state Department of Health is currently revising proposed streamlined licensing rules after getting public input, according to agency spokesperson Danielle DeSouza.
Midwives and doulas say the high rate of cesarean sections and other procedures in hospitals are a sign more birthing centers are needed.
C-sections can be medically necessary in high-risk situations. But they are also performed far more frequently now than in the past. In 1970, c-sections were performed on 5.5% of births. Today, the surgical procedure is used for one-third of all births nationally, and can cost as much as $60,000. Maternal mortality and morbidity rates for c-section births are nearly five times higher than those for vaginal births.
Flores describes powerful financial incentives nudging doctors to use medical interventions, even when such procedures are not necessary. Doctors frequently administer an epidural, a powerful drug that is a cross between a painkiller and an anesthetic, a pitocin, a synthetic form of oxycontin used to induce labor.
“So if you charge for the epidural, you charge for the c-section you charge for this and that, why would you be wanting to do a service where you’re basically not doing anything and you’re trusting the body to do the wonderful physiological thing it does called birth?” said Flores. “You’re not going to get paid.”
These methods are encouraged to speed up the birthing process so that doctors can get to the next person in labor, but one intervention often leads to another, said Jeanbaptiste.
“We call it the cascade of intervention,” said Jeanbaptiste. “The speed with which providers expect the doula, the birthing person, the entire birthing team to move when it’s not up to us. And that is the essence of birthing that is lost in hospital spaces in particular.”