Restricting proven models of care is indefensible.
I n 2022, Katie Chubb tried to open a birth center in Augusta, Ga., that would offer women the choice of midwifery-led maternity care outside of a hospital setting. She followed the rules, built a business plan, found investors, and sought to meet a growing need for safe maternity care in her community, where the rate of pregnancy-related deaths ranks higher than in some third world countries. But before she could open her doors, she ran into Georgia’s certificate of need (CON) laws, which require government permission before a health care provider can open or expand a facility.
One requirement of Georgia’s CON laws is a hospital transfer agreement. However, such emergency transfers are rare, and federal law requires hospitals with emergency departments to accept any patient who seeks care. All three Augusta hospitals refused to enter into an agreement with Chubb, who, after all, would be their direct competition. With the help of the Pacific Legal Foundation, Chubb sued, challenging a warped system that allows entrenched hospitals to veto new providers and limit patient access to health care services.
In 2024, Governor Brian Kemp signed a law repealing the certificate of need requirement for birth centers, and the parties to the case filed a joint motion to dismiss. Yet, the law did not address the hospital transfer agreement requirement, and Chubb is still unable to open her birth center. She receives weekly calls from families asking when the birth center will open, and she has no estimate to give them.
Freestanding birth centers provide prenatal, intrapartum, and postpartum care in a home-like setting. They are a proven alternative to hospital-based childbirth for women with low-risk pregnancies.
Numerous studies confirm the safety of midwife-led care at birth centers. Nurse-midwives competently manage low-risk pregnancies while avoiding unnecessary interventions. Outcomes for babies are comparable to those of hospitals, and patient satisfaction is often higher. In short, birth centers improve health outcomes, lower costs, and expand access.
But state policy barriers limit the growth of the birth center model, thus restricting women’s freedom to choose how to give birth. Although there are more than 400 birth centers across 40 states, nearly 70 percent are concentrated in just 10 states. Birth centers are especially valuable for the 28 million women of reproductive age who live in rural America, where access to maternity care is even more limited. Over one-third of U.S. counties are now considered maternity deserts with no obstetric facilities or clinicians at all. Birth centers can help fill these gaps.
Increasing the number birth centers means more than just choices for individual women. They create an environment of health care abundance where families aren’t stuck competing for limited services, communities have multiple safe options, and providers can innovate to meet local needs. In a health-care system often defined by scarcity, birth centers can expand capacity where it is needed most.
Chubb’s story is not unusual. Across the country, women and providers who want to open birth centers encounter similar regulatory barriers. According to the American Association of Birth Centers, as of 2025, 17 states had no birth centers at all. That scarcity is not because women don’t want birth centers, but because regulations make them almost impossible to open.
New research catalogs the regulations that prevent birth centers from opening. Ten states and the District of Columbia require a CON to open a birth center. Some states have physician supervision requirements, forcing birth centers to enter into supervisory or collaborative agreements with physicians, even when certified nurse-midwives may be free to practice independently. Other states, including Georgia, require hospital transfer agreements or limit the distance from a hospital where a birth center can be located. Many states employ a mix of these regulations that, rather than promoting safety, create burdensome hurdles that stifle the growth of birth centers, especially in rural areas.
Every regulatory roadblock translates into fewer choices and less health care abundance. Despite overwhelming evidence of safety, quality, and cost savings, policymakers keep birth centers tied up in red tape. As a result, women in rural or underserved communities have fewer options, higher costs, and worse access.
Policymakers should take a hard look at the outdated rules that keep birth centers from growing. An ideal law would enshrine a mother’s right to choose where to give birth and who is present. Mothers should be free to decline unnecessary services during labor and delivery, and providers should respect a mother’s birth plan.
But the right to make these decisions isn’t worth much if the law keeps birth centers or other modalities of care from opening. Any model policy, such as the Pacific Legal Foundation’s “Birth Freedom Act,” should eliminate barriers that keep birth centers from flourishing, including certificate of need laws, transfer agreement requirements, and geographic proximity requirements. Such reform would shift the status quo from health care scarcity toward health care abundance, where women in every community could find safe maternity care options close to home.
Repealing CON laws was a good first step in Georgia, but reform cannot stop there. At a time when parts of our nation face rising maternal mortality rates and widening maternity deserts, restricting proven models of care is indefensible. Women and families deserve freedom, dignity, and an abundance of birth options.
Jaimie Cavanaugh is the state policy counsel at Pacific Legal Foundation, where she works with legislators around the country to end burdensome laws and create opportunities for individuals to thrive. Caitlin Styrsky is a strategic research manager at PLF, where her research supports litigation and policy efforts to secure equal freedom for all.