Shannon Long, a certified midwife with a doctorate in nursing, has thought about opening her own freestanding birth center for years. After working in hospitals for more than two decades, Long said she wanted to get away from policy-driven care.
“There's a population of people out there that don't feel comfortable delivering at home, and they really don't want to deliver in a hospital, so the birth center is a good fix for those people,” Long said.
Long, who lives in Danville, imagines a house with a living room and kitchen, where each patient has their own bedroom. She said she would want her birth center to have its own backyard and have an open feeling, even if it's close to the city.
“Just kind of make it look like home,” Long said.
Kentucky doesn’t have any birth centers that aren’t attached to hospitals, at least not yet.
Though birth centers are legal in the state, midwives and providers have struggled to open them because of certificate of need laws that require new facilities to prove there’s a need for that service in the area. The laws have made it difficult to open birth centers within reach of hospitals.
Now, thanks to a Kentucky law passed this year and set to go into effect later this month, birth centers with for beds or less in Kentucky will be exempt from the certificate of need process. While it likely won't be some time until any centers can open as the state creates regulations, it’s something midwives like Long have been fighting for for years.
Mary Kathryn DeLodder, who volunteers with the Kentucky Birth Coalition, said she’s been working on a legislative fix to the birth center dilemma since 2020, when Middletown GOP Rep. Jason Nemes first proposed exempting the centers from the arduous certificate of need process. DeLodder says it was a natural progression for the group, which previously saw success pushing for a certified professional midwife designation.
“It's just kind of a natural progression that we took on as the next step to continue to expand birth options,” DeLodder said. “To have another place where midwives can practice in an out-of-hospital setting in Kentucky, because not everybody wants a home birth, not everybody wants a hospital birth, and there's nearly no middle ground.”
Crossing State Lines
DeLodder said it took a long time to compromise enough with rural hospitals concerned about their solvency and obstetricians worried about patient safety. But DeLodder said patients are already leaving the state to access the care that they want. In Louisville, some families opt to head for the Tree of Life Family Birth Center in Jeffersonville, Indiana, instead of delivering in Kentucky. Meanwhile Kentuckians living near the Tennessee border sometimes choose to cross rather than give birth in the state, DeLodder said.
“It's not fun to travel in a car when you're in labor, for anybody who's ever done that, trying to get to the hospital,” DeLodder said. “We want those families to not have to go that far to be able to stay in Kentucky, be close to home, not have to then travel two hours back home, if that's the case, once they've got a newborn with them.”
Not only has the prohibition meant patients crossing state lines, but providers too. Jenny Fardink, and her business partner Christy Peterson are licensed midwives in both Tennessee and Kentucky. They own Clarksville Midwifery and are hoping to open their own birth center just over the Tennessee border in fall this year. Fardink said she just had to pull the trigger and begin finalizing her own birth center plans after waiting years for Kentucky laws to change.
“We were hoping the last two years that it was going to pass in Kentucky, and then we would have opened in Kentucky,” Fardink said.
She said many of her clients are based in Kentucky and she otherwise appreciates the laws surrounding midwifery in Kentucky, but right before the state legislature moved to change the certificate of need laws to exempt birth centers, Fardink and Peterson got approval from Tennessee to open their own clinic.
“We thought it was going to pass last year, and we've been planning birth centers for so long that it's kind of like you have a plan in place, you know what you need to do, and you just start moving,” Fardink said.
Fardink said she knows hospitals were concerned that birth centers would take away their clientele, but she said many of her patients would have gone to great lengths to receive midwifery care or might opt for a home birth instead. She’s had patients calling from well outside her one hour radius, seeking a non-hospital option.
“We try really hard to accommodate people and come up with creative ways for people to be a little bit closer, so that we all feel safe,” Fardink said. “Sometimes people will deliver at a friend's house or relatives house, if they can.”
Ensuring safety
When bills to make birth centers easier to open first began appearing in the legislature years ago, some medical providers in the state were concerned about how it would affect patient care and their own revenues. Cory Meadows, the deputy executive vice president of the Kentucky Medical Association, said they are now “neutral” on the birth center portion of the bill, and believe that the ultimate version has enough safeguards to ensure patient health.
The birth center provisions were part of a larger bill that drew great scrutiny from medical providers by the end of the session. Toward the end of the session, legislators slotted in provisions to update the state’s abortion ban. That new piece of the bill got a lot of attention, but the original provisions on birth centers survived.
House Bill 90 in its final form requires centers to get accreditation from the Commission for the Accreditation of Birth Centers and medical malpractice insurance. It also requires centers to be within 30 miles of a hospital and have a transfer agreement in place with one of the nearby hospitals. The center also needs to have a licensed doctor on staff as a medical director, largely in an advisory role.
“The bill lays out a number of requirements for birthing centers. Now, the devil is always in the details,” Meadows said. “We do remain interested and will remain engaged in monitoring whatever regulations are released, and if necessary, will comment.”
While HB 90 laid out several rules and safety precautions, it also left a lot up to the state to create more regulations, giving the Cabinet for Health and Family Services until December 1 to update its rules. Meadows said he is particularly watching regulations around a potential loophole in the bill that allows centers to avoid a transfer agreement if they can submit “evidence of a failure by a hospital” to enter a patient transfer agreement.
DeLodder with the Kentucky Birth Coalition said regulations on things like insurance and facility requirements could make or break the viability of centers in the state.
“We haven't had any birth centers open in Kentucky since the mid 1980s so the regulations that exist around birth centers haven't been really substantially updated since that time,” DeLodder said. “So for somebody who really wants to open a birth center, they need to know what all the rules are going to be before they start to pursue that, so they can make sure that they have everything in place.”
Long, who worked as an obstetric nurse for 22 years before turning to midwifery, said she knows what the standard of care is in hospitals. She said that hospital policies don’t work for all women — rules requiring women remain lying down for labor or must be hooked up to monitoring machines and have an IV placed.
“There's people that's going to deliver in the hospital period because they want an epidural and you have all the access to emergency C-sections,” Long said. “But there's still such a need for people who don't want the hospital setting, that would desire a more natural setting, more peaceful, not so rushed.”
Long, who is currently working toward certification as a nurse midwife, said the new certification would allow her to deliver in a hospital. She knows how to screen for complications that could mean a more dangerous delivery.
She encourages her clients to go through standard testing, but tries not to be “pushy.” Long hopes being more understanding and taking the time to explain the evidence and research behind different procedures will help improve outcomes among communities that typically forgo testing or are distrustful of the medical establishment.
“I think that's why most people deliver in the home setting, because they don't want the pressure of what is required at the hospital,” Long said.
Long said she also hopes any facility she opens will be able to address maternal care deserts in the state – especially in her region in central Kentucky. While Casey and Russell counties to the south both have a hospital, neither of those hospitals have dedicated maternity units.
“That's the most important thing about the birthing center is it will provide another avenue of safety to improve our outcomes,” Long said. “A lot of people who live in rural areas, they acknowledge that if they deliver at home, it'll be a good hour … before they could get to a hospital. So the birthing center mitigates that for them.”
State government and politics reporting is supported in part by the Corporation for Public Broadcasting.
This story was produced by the Appalachia + Mid-South Newsroom, a collaboration between West Virginia Public Broadcasting, WPLN and WUOT in Tennessee, LPM, WEKU, WKMS and WKU in Kentucky and NPR.
