Shortly after Emily Goodwin relocated her family across the country, they got some big news.
“We found out we were pregnant less than a month after we moved here and that was a huge surprise,” says Goodwin, who has a homestead in Melba, Idaho.
Goodwin had already given birth to three boys, and she had a different birth experience each time. But her best experience was in a birthing tub.
“I really prefer to give birth in the water. That wasn’t an option for me to do at any of the hospitals in town."
But a water birth was an option at a birth center in Boise.
When Goodwin looked into her insurance coverage though, there was a surprise. Her health plan would pay for her to have a midwife, but wouldn’t cover the roughly $1,500 facility fee at a birth center.
Hospitals and birth centers charge facility fees to cover costs like medical equipment, lights, laundry — everything that goes into keeping a medical facility running. In most Mountain West states, that fee is paid by insurance.
But here’s the hitch in Idaho: It’s one of a handful of states that don’t regulate birth centers. And that means Medicaid and many insurance companies won’t cover their facility fee.
“Especially for women on Medicaid, that creates a huge barrier,” says Kate Bauer, executive director of the American Association of Birth Centers. “They don’t have that extra income to pay additional health care costs and may end up having to choose a hospital birth, when what they really wanted a birth center birth.”
Nationwide, fewer than 1 percent of births take place at a birth center rather than a hospital. But that number is inching up.
“[Birth centers] are a nice middle ground for families who are not quite ready to have a home birth but really don’t want to enter the more medicalized care of a hospital,” says Paula Wiens, a certified nurse midwife and owner of the Boise birth center Treasure Valley Midwives.
The American College of Obstetricians and Gynecologists does recognize accredited birth centers as an option for low risk pregnancies.
"I think for a woman who is healthy, delivering in a birth center that has the ability to elevate care to a higher risk facility if needed, then an out-of-hospital birth can be very safe," says Dr. Kate Menard, a maternal fetal medicine specialist at the University of North Carolina School of Medicine-Chapel Hill.
At least one large study has shown that out-of-hospital births are associated with fewer medical interventions, like cesarean sections or induced labor. However, it also showed a very small but increased risk of neonatal death. Menard says parents need to make an informed choice.
"Data does demonstrate that it might be riskier for the baby," says Menard. "And it’s a risk that they would have to accept."
In states that do regulate, birth centers have to meet standards. For example, that birthing tub that Emily Goodwin wanted has to be washed and disinfected. Medical equipment has to be sterilized and there must be procedures in place for dealing with medical emergencies.
So why doesn’t Idaho and other states license these facilities?
“Idaho in general is not a state that is pro-regulation,” says midwife Paula Wiens. She says just getting midwives licensed in Idaho was a big challenge about a decade ago.
“Even among the midwifery community, there were varied opinions about whether licensing was a positive step,” says Wiens. “In the end, a licensing bill was passed. It took many years and a lot of work.”
There is another option to state regulation: Birth centers can choose to be accredited nationally, by the Commission for the Accreditation of Birth Centers. That accreditation is sort of like the gold standard for birth centers. Still, Wiens' center is the only one of about 10 centers in Idaho that’s done that. For some birth centers, accreditation is too expensive, and it's not clear whether patients care about the rigor that accompanies the accreditation.
In Idaho, a birth center can be anything: a historic house, a trailer or a bonafide medical facility.
"None of them are accredited or licensed as a facility in Idaho, which means that they all practice very differently," says Wiens. "There’s not a standard of care that they provide that is consistent."
Some of the resistance to licensing and regulations comes from midwives who don’t want the state creating mandates for their work. In Washington State, for example, birth centers are regulated, and must meet a number of criteria to receive state license.
Inga Arts runs a birth center called Dayspring Midwifery in Hayden, Idaho. It’s a 1905 farmhouse that she says she wants to feel kind of like a bed and breakfast.
“Birth and breakfast, instead of a bed and breakfast,” Arts jokes. “That’s the only difference is you go home with a baby.”
Arts is wary that state regulation could infringe on some of her signature services. For example, she lets families stay as long as they need to after giving birth, and she likes to cook them a big meal.
“You have the whole medical side, and I like that, but also hospitality is just a gifting of mine,” says Arts. “[Birthing moms] don’t feel like a number. We definitely give their undivided attention to them.”
For Emily Goodwin, the extra $1,500 facility fee she had to pay out of pocket felt worth it. Her fourth son, Canon, is now a bubbly, joyful three-year-old.
“I absolutely did have the birth that I wanted. It was in the water. It was everything that I wanted. You just can’t put a price on a positive birth experience.”
But Goodwin notes that she and her husband are lucky — they could afford the fee without too much sacrifice. For other moms in Idaho, especially pregnant women on Medicaid, that might not be the case.
Paula Wiens would welcome state licensing as a way to be able to offer the birth center experience to more parents.
“I think that regulating birth centers and having insurance companies cover facility fees would make out-of-hospital birth more financially viable,” says Wiens. “I think it would be good for families to have that choice."
Find reporter Amanda Peacher on Twitter @amandapeacher.
Copyright 2019 Boise State Public Radio
This story was produced by the Mountain West News Bureau, a collaboration between Wyoming Public Media, Boise State Public Radio in Idaho, KUER in Salt Lake City and KRCC and KUNC in Colorado.