When a private equity firm closed Seasons Midwifery and Birth Center in Thornton, Colorado, in October, the state lost one of its few non-hospital birthing centers and 53 families with pregnancy due dates in November and December were left scrambling to find providers.

But then staffers and community advocacy groups stepped in to fill the void for the suburban Denver community and its patients, many of whom rely on Medicaid, the federal-state insurance program for people with low incomes. They reorganized Seasons as a nonprofit organization and struck a note of triumph and defiance in announcing its reopening in January as the free-standing Seasons Community Birth Center. Seasons has five deliveries scheduled in February and 30 in March.

Over the past two decades, the number of at-home and birth center deliveries nationwide was on the rise — until the covid-19 pandemic hit. The number of out-of-hospital births increased 22% from 2019 to 2020 and an additional 12% from 2020 to 2021, according to a Centers for Disease Control and Prevention report.

Nationally, birth centers — medical facilities for labor and childbirth that rely on midwives to help with healthy, low-risk pregnancies — have lower rates of preterm births, low birth weights, and women transferred to hospitals for cesarean sections.

While C-sections can be lifesaving, they are major surgeries that come with significant risk and cost. A 2013 study of about 22,400 women who planned to give birth at a birth center found that 6% of those who entered labor at such a facility were sent to a hospital for a C-section. By contrast, about 26% of healthy, low-risk pregnancies in hospitals end in C-sections.

Before Seasons closed, staffers transferred about 8% of patients to a hospital for a C-section.

The funding model for birthing centers is complicated: In Colorado they are regulated and licensed by the state health department, yet because they’re not hospitals, they can’t bill insurance in the same way as a hospital. So Seasons, for example, receives about $4,000 per birth from private insurance, said Heather Prestridge, the clinic’s administrative director, while a hospital birth costs on average $19,000 and is reimbursed by insurance for about $16,000.

The only option for patients who don’t have private insurance and cannot pay out-of-pocket is to deliver in a hospital. Most birth centers don’t accept Medicaid, but Seasons is different. Before its closure, about 40% of its clients were on Medicaid, which reimburses less than other insurance providers, Prestridge said.

“Every time we take a Medicaid client on, we lose money,” Prestridge said. “It’s so important for everyone to have access to this kind of care, so we continue to do it anyway.”

Medicaid’s restrictions and low reimbursement rates have led to financial problems for birth centers, including Seasons, despite their being inundated with patients. In Colorado, 19% of the population and 36% of births were covered by Medicaid in 2022.

As a nonprofit, Seasons will need to lean on fundraising to fill the gaps, Prestridge said.

Colorado has seven birth centers, including Seasons, which often have rooms that look more like bedrooms than hospital rooms, and bathtubs as an option for delivery.

In 2018, two other Colorado birth centers — associated with hospital groups but owned by a for-profit parent company — closed. The two Denver-area practices primarily served patients who had low incomes or were refugees, according to The Colorado Sun.

“It came as a shock to us, but unfortunately it has become our reality,” Miki Tynan, co-founder and managing director of Colorado Birth and Wellness said of the birth center closures.

When Seasons closed Oct. 4, Colorado Birth and Wellness, a collaboration between two birth centers in the Denver area, took on more than 60 of its clients.

The physicians group that started Seasons in 2019, called Women’s Health Group, partnered with a private equity group, Shore Capital Partners, in late 2020 and became Elevate Women’s Health. Executives there determined that Seasons was unprofitable and closed it, said Aubre Tompkins, clinical director at Seasons Community Birth Center, and others who worked for Seasons at the time.

“It was pretty devastating,” Tompkins said. “There were a lot of tears, there was a lot of anger, there was a lot of confusion.”

After the closure was announced, Elephant Circle, a reproductive justice organization, reached out to Tompkins with a plan to raise money for Seasons to reopen as a nonprofit. The organization’s founder, Indra Lusero, said members wanted to save Seasons but also wanted to invest in making the nonprofit model work more broadly.

“There’s been some investment, there’s been federal studies, there’s great data — all the things saying, ‘Hey, I think this model looks like it could work. We should invest in this model,’” Lusero said.

As a nonprofit, Seasons plans to expand its services to include gender-affirming care and train more people as midwives and doulas to increase diversity in the field. Seasons offers annual gynecological exams, contraceptives, lactation services, and newborn care through the first two weeks of life.

Tompkins is a member of what she described as an emergency and temporary task force that reopened the facility with a reproductive justice mission. Nazario will also sit on the board, along with representatives from the Colorado Organization for Latina Opportunity and Reproductive Rights, or COLOR; Elephant Circle; and Soul 2 Soul Sisters, a racial justice organization.

Nazario, who describes herself as Afro-Latina, has experienced firsthand how essential her identity and experiences are to her work in birthing. Potential clients often reach out to her saying they had been looking for someone like her, someone like them.

Katherine Riley, who gave birth to her daughter at Seasons last year, is policy director at COLOR and a member of the Seasons Community Birth Center board. She said she’s excited to advance Seasons’ mission and expand teaching opportunities for future midwives.

“The practice of midwifery, I think, in itself is an act of resistance,” Riley said. “There’s a long history of racism and patriarchy in ousting midwives, and so I think returning as a community to that is so important.”

By Claire Cleveland
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.