What is birth freedom?
One of the most personal healthcare decisions a woman can make is how she brings her babies into the world. Whether she chooses to deliver in a hospital with a doctor, or with a midwife in a birth center or at home, a mother has the fundamental right to make that choice for herself. And yet, in many states, governments routinely interfere in this decision-making process.
Across the country, burdensome regulations prevent qualified healthcare professionals from providing safe and affordable birth options. In states like Ohio, and Georgia, for example, certificate of need (CON) laws give hospitals the authority to veto new competitors from entering the birth market. In other states, like Nebraska, scope of practice restrictions prohibit advanced practice healthcare providers from freely practicing to the full extent of their education and training.
Under this arbitrary regulatory framework, qualified birthing professionals are denied their right to earn a living, and expectant mothers are paying the tragic price.
Unmet needs
The United States is one of the most industrialized nations in the world, and yet, we are severely lacking when it comes to birth safety. According to data from The Commonwealth Fund, in 2024, the U.S. had the highest maternal mortality rates of any high-income, industrialized country. The neonatal mortality rates for babies are equally abysmal. According to 2023 data collected by The Organisation for Economic Co-operation and Development (OECD) the “U.S. ranked No. 33 of the 38 OECD countries.”
In some areas of the country, like Augusta, Georgia, the situation has been even worse, with maternal mortality rates ranking higher in some years than in Cuba or Syria. State-wide, a report from WalletHub lists Georgia as the fifth-worst state in which to have a baby. Pacific Legal Foundation client Katie Chubb and her husband Nick wanted to help mitigate the problem by opening the Augusta Birth Center, staffed with certified midwives to give women more safe options.
The options available to women in the Augusta area were not meeting the needs of the community, and the nearest birth center was three hours away—a distance Katie knew all too well because she had made that trek to the Atlanta Birth Center while she was in labor with her own child. But due to Georgia’s CON laws, the Chubbs were not allowed to open their birth center, even though the data clearly showed that the area was in dire need of more birthing options.
In April 2024, after over a year of PLF litigating on behalf of Katie, Georgia Governor Brian Kemp signed a bill overhauling the state’s CON law to exempt some services and reduce review periods. This was great news for Katie, who is now working to open the birth center under the improved law.
Expanding birth centers isn’t just about creating physical alternatives to hospitals. It’s also about making the costs more affordable for mothers of all backgrounds.
Unaffordable care, unnecessary interventions
Women from all socio-economic backgrounds have babies, and every single one of them should have safe options that they can afford. The United States has some of the most expensive childbirth costs in the world. For the insured, standard costs for uncomplicated pregnancies (which include doctor visits during pregnancy, labor, and post-partum care) are about $19,000, with mothers and fathers paying around $3,000 out of pocket.
For the uninsured, when doctor visits, ultrasounds, delivery, and post-partum care are considered, families can pay anywhere from $15,500 to well over 20k. Using a certified nurse midwife (CNM), on the other hand, costs an average of $4,650, according to 2021 data.
Pacific Legal Foundation client and certified midwife Caitlin Hainley and her husband were struggling financially during her pregnancies and knew all too well how crushing childbirth costs can be. That’s part of the reason she was inspired to become a midwife—she wanted to give women in the Des Moines area more affordable options for care.
Caitlin teamed up with fellow certified nurse midwife Emily Zambrano-Andrews to start the Des Moines Midwife Collective, a homebirth practice that serves woman of all economic backgrounds. While midwives are far less expensive than hospital births, many midwives and birth centers do not take insurance. But the Des Moines Collective is insured and accepts insurance, including Medicaid, which has allowed them to keep out-of-pocket costs as low as $1,500 in some cases.
Affordability wasn’t the only motivator for Caitlin and Emily. Caitlin’s first delivery had resulted in an emergency C-section. When she got pregnant again, she wanted the option of having a vaginal birth, which many doctors will not allow if a mother has previously had a C-section. In the hospital setting, Caitlin felt disempowered to direct the circumstances of her own birth without doctors intervening to make those decisions for her—a common problem, unfortunately. All too often, these interventions are unnecessary and complicate otherwise-uncomplicated births.
Lauren Hall, in The Medicalization of Birth and Death, writes:
Almost 40 percent of those women will be induced, over one-third will have a cesarean section, and many more will have forceps deliveries, episiotomies, labor augmentation, or other interventions. These intervention rates are much higher than those in comparable developed countries. Despite the high rates of interventions, and in part because of them, maternal mortality has actually risen in the past decade[.]
Caitlin opted to use a midwife and was relieved by the midwives’ faith in her ability to deliver without needing major surgery. They made her feel supported, an experience both she and Emily wanted to give other mothers. But like Georgia, Iowa CON laws make it near-impossible to open birth centers. Caitlin and Emily’s birth center was denied. The midwives could still legally use their clients’ own homes or other locations pre-arranged by clients, including hotel rooms, short-term rentals, or friends’ houses—but not a birth center.
But in April, things started looking up for Caitlin and Emily. Iowa passed a law that removed birthing centers from CON law requirements. This mooted their case and delivered a victory not just for the midwives, but for expectant mothers across the state.
Scope of practice limitations
In states like Nebraska, arbitrary scope of practice laws limit and block qualified professionals from being able to serve expectant mothers altogether.
Heather Swanson, another PLF client, has spent over two decades practicing as a certified nurse midwife (CNM) and a nurse practitioner, and she served as the Nebraska affiliate president for the American College of Nurse-Midwives. Even though homebirth is legal in all 50 states, Nebraska laws ban CNMs from assisting in home deliveries. Meanwhile, lay midwives and unlicensed doulas are wholly unregulated by the state and face no such restrictions. Nebraska’s illogical law goes even further as it is among three states that mandate CNMs practice only under a physician’s direct supervision and only in hospitals, public health agencies, or physician-approved settings. Home births are explicitly off-limits even with a doctor present. Failure to comply with these laws can result in felony charges.
The law has nothing to do with the health and safety of mothers and children; its only purpose is to protect physicians’ economic interests by limiting their competition. Heather and other CNMs should be allowed to use the full scope of their medical training. And women who chose to have homebirths should have the right to use qualified CNMs during their deliveries.
Protecting birth freedom
It goes without saying that hospitals are an invaluable childbirth option that the majority of women would continue to choose, no matter how many other options were available. (Over 98% of American women currently give birth in hospitals.) But what works for the majority doesn’t work for everyone. Some women argue hospitals have a one-size-fits-all model—operating almost like a childbirth factory—that de-values the agency of mothers while leading to skyrocketing costs. Protecting birth freedom means empowering women to choose the manner and circumstances of their delivery, including choosing where to give birth and with whom present. Securing this right is not possible without also securing the right of certified midwives to earn a living by providing the full extent of the services they are trained to offer.
Pacific Legal Foundation is helping Katie, Nick, Caitlin, Emily, and Heather stand up for birth freedom. PLF has also launched a new initiative dedicated to securing full practice authority for advanced practice healthcare providers—a critical step in expanding access to safe, affordable, high-quality care for millions of Americans, along with abolishing unnecessary certificate of need laws.
“Arbitrary regulatory barriers that limit where and how healthcare professionals can practice do more than burden providers: They restrict access to care, especially in underserved and rural communities,” said PLF attorney Donna Matias. “It’s time to challenge outdated laws that prioritize turf wars over patient well-being.”
