State Regulation of Birth Centers: A 50-State Survey of Women’s Birth Freedom
The United States spends more than any other country on maternity care—more than $111 billion annually. Despite those efforts, the nation ranks 60th globally in preventing maternal mortality. High costs and poor health outcomes can be attributed, in part, to the landscape of onerous state regulations that limit women’s access to nonhospital birth settings, such as freestanding birth centers. These facilities are led by midwives and have been shown to lower costs and improve health outcomes for low-risk pregnancies. Though the majority of women continue to choose hospital births over nonhospital settings, many would choose nonhospital births if they were free to do so.
The experience of Pacific Legal Foundation client Katie Chubb illustrates these regulatory hurdles. In 2022, Chubb tried to open a birth center in Augusta, Georgia, but was denied a certificate of need (CON), a government-mandated permission slip that healthcare providers must obtain before opening or expanding facilities. Georgia CON laws require birth centers to enter into a transfer agreement with a local hospital, despite the rarity of emergency transfers. All three Augusta hospitals refused to enter into transfer agreements with Chubb—predictably, given that Chubb was a prospective competitor—so Chubb challenged in court the ability of incumbent hospitals to effectively veto CON applications for birth centers.
Although Governor Brian Kemp signed a law repealing CON requirements for birth centers in April 2024, obviating a key part of Chubbs legal complaint, Georgia law still requires birth centers to secure hospital transfer agreements. As a result, Chubb’s birth center remains unopened.
Chubb’s experience is not unique. In most states, birth center entrepreneurs face regulations, such as licensing requirements, CON laws, and staffing directives, that slow or stop their enterprise. Amid this regulatory landscape, 17 states had no birth centers as of 2025, according to the American Association of Birth Centers (AABC). Despite the dearth of birth options in these states, numerous studies support the safety and cost savings of birth centers.
This research in brief surveys regulations in the 50 states that govern birth centers. Such a survey enables further study of the relationship between state regulation and competition, entrepreneurship, the number of women’s healthcare providers, and the extent of birth freedom.