“I’m sorry. If you were looking for a solutions story, I cannot give you one.”
Nancy Myrick opened our call with an apology. She has been attending births since 1993 — first as a doula, then as a certified nurse-midwife with a busy home birth practice. In 2016, with fellow midwives Sara Van Acker and Julie Birdsong, she opened the San Francisco Birth Center on Sutter Street – the city’s first freestanding birth center in years. It has been serving families ever since. What she could not tell me is how much longer it can keep doing so.
Ten years and hundreds of babies later, the center being open should be an unremarkable fact. Nancy is precise about why it isn’t – and about the difference between surviving and a solution.
“Midwifery school,” she told me, “does not teach you to run a business.” They were starting from scratch, with no existing center in the city to take over, so three midwives raised money from friends and family and built the infrastructure themselves. Providing a full course of care from pregnancy through postpartum costs more than most families ever see itemized; the facility’s share alone runs about $7,000 per birth. A nine-member board, seven of whom gave birth at the center, fundraises constantly to bring what families pay down to roughly $4,000, and to zero for those most in need. These costs are almost entirely out of pocket; insurance covers little to none of it.
And it works! But the fact that it works is exactly why there is no solutions story here: the fix is nine driven and passionate people, not a policy that holds.
Through all of it, the babies keep coming. The first time we scheduled a visit to the center, Nancy had to cancel the morning of, as she had been up all night at a birth. The natural rhythm of this field – a baby had arrived, and everything else waited.
Everything else, mostly, is insurers. The center’s Medi-Cal contract is, in Nancy’s description, a daily negotiation. When the midwives email payers with several questions, an answer to one of them arrives weeks later; when they call, they hear their contact has left. When I asked whether anything they know about care ever flows back into what insurers pay for, the answer was a flat no. And this, Nancy was careful to say, is not a San Francisco story – in the national birth center owners’ groups she belongs to, it is everyone’s story.
Nancy’s decade tracks California’s retreat from birth. Since 2020, the state has lost 80% of its licensed birth centers – from more than twenty down to four – under a licensing regime that can take years to navigate. In the same stretch, about one in six California hospitals closed their maternity wards, carving maternity care deserts across the rural parts of the state. Even the state’s first licensed and accredited birth center – Best Start in San Diego, open since 1989, more than 5,600 babies – closed its doors in 2024.
All of this sits inside the worst maternal health record in the wealthy world. In 2024, 649 women in the United States died of maternal causes; for Black women, the mortality rate was more than three times that of white women. The CDC’s own review committees find that roughly four in five of these deaths are preventable. In the most recent comparison of high-income countries, the US came last; Norway recorded zero maternal deaths.
Here is what makes the closures so hard to explain: on the evidence, midwifery-led care is about as close to a silver bullet as maternal health has.
The Cochrane review of midwife continuity of care – seventeen randomized trials, more than 18,500 women – found that people cared for by a known midwife or midwifery team had more spontaneous vaginal births, fewer caesareans and instrumental births, better experiences of pregnancy and postpartum, at lower cost. Globally, a modelling study in The Lancet Global Health estimated that universal midwife-delivered care in the countries carrying most of the world’s burden would avert two-thirds of maternal deaths – 4.3 million lives a year by 2035. And when the US federal government tested the model on its own terms, enrolling Medicaid families in birth center care through the Strong Start initiative, participants had markedly fewer preterm births than matched counterparts, at lower cost – and racial disparities in outcomes narrowed.
That last finding matters, because who this care reaches is not incidental. Medi-Cal pays for more than half of California’s births, and the vast majority of those babies are babies of colour — the same communities who, in statewide surveys, say they want midwifery and doula care most and can least access it. The people closing that gap are, overwhelmingly, birthworkers from the communities being failed: in San Francisco, SisterWeb‘s network of community doulas for Black families; in Watsonville, nurse-midwife María Ramos Bracamontes’s Campesina Womb Justice, which is training Mixteco-speaking farmworkers as doulas so that women labouring far from home can be accompanied in their own language.
And the midwives I have spoken to, both here and across the world, consistently describe their scope as wider than birth itself. In the liminal space women’s health occupies in medicine, the midwife is often a woman’s trusted medical touchpoint, full stop. The words that most often floated around the midwifery model of care were: integrated, holistic, whole-person. At Moonstone Midwives in Humboldt County, prenatal appointments run an hour, against a standard visit of fifteen to twenty minutes. “When midwives design care, you see whole-person care – robust counselling, health education, support for personalised decision-making,” Liz Donnelly told me. “That care can’t be provided in a fifteen-minute visit with a provider who is seeing twenty-four or more people in an eight-hour day.”
Monica Levine felt it from the other side. She gave birth at the San Francisco Birth Center; today she is vice president of its foundation board, and doggedly fights for adequate reimbursement for the care they provide there. What she remembers most is the group prenatal circle the center built around her cohort – a handful of people who understood exactly what she was living through from pregnancy well into her child’s early years, gathered into one WhatsApp thread. In birthing at the center, she noted the privilege she felt around her birth in comparison to peers who had delivered in a hospital – she never felt like she had to push back against the system, she told me, because the system had been built for her birth. Monica’s arc – cared for, then governing, then fundraising — is the center’s survival mechanism in miniature. Seven of nine board members are its alumni.
So if the evidence is this unambiguous, why does the model keep losing ground?
Ask the co-founders of Midwifery Access California (MACa), a coalition of roughly a hundred midwives and allies doing the legislative and regulatory work on community birth access – and the answer comes back consistent: because most people, including many of the people who run and pay for healthcare, do not actually know what midwifery is.
Holly Smith spent seventeen years as a practicing midwife before moving fully into systems work, taking the fight for maternal healthcare access to the policy world. Liz Donnelly has spent the better part of a decade in policy and advocacy work to integrate midwives into the healthcare system. Their shared diagnosis is that the fundamental fight is not clinical but epistemic: getting midwives recognized as the competent, extensively trained health professionals they are, against decades of inherited misinformation.
That misinformation was not an accident. In 1900, midwives attended about half of all American births. By 1930 it was roughly 15%; by 1980, 1.1%. The collapse was engineered – a white coat-oriented medical establishment, backed by the 1910 Flexner Report’s recommendation to abolish midwifery, ran deliberate campaigns painting midwives as unscientific and unsafe. Those campaigns fell hardest on the Black “grand” midwives who attended up to three-quarters of births in the American South into the 1940s, and who were dismantled through licensing laws, educational exclusion, and public vilification – even as studies of the era showed midwife-attended births were safer than those attended by the doctors replacing them. Barbara Ehrenreich and Deirdre English traced this history half a century ago in Witches, Midwives, and Nurses: the devaluation of midwifery was never a verdict on the care, but rather, a verdict on who was giving it.
What survived instead is a system whose incentives run against the model. Midwifery is relational, integrated care – long visits, continuity, nutrition and psychosocial assessment, health education, counselling and referrals — deliberation that has to be funded as care. And it sits fundamentally at odds with the paternalistic, capitalistic logic that organizes American healthcare more starkly than any system in the world. Nancy sees the mismatch on every remittance: hospital birth revenue is built on what insurers reimburse, the IVs and non-stress tests dispensed freely, while the things a birth center actually does (long clinic visits, extensive postpartum care) go largely unpaid.
Follow the money and you arrive at what my conversation with Holly kept circling: precarity, at every single step of the service-provision process, for people who are trained, certified health professionals. Midwives are left to fend for themselves against payers, regulators, vendors, and databases never designed with them in mind – a hundred points of systemic friction. And none of it is catching babies.
One number carries the argument. Sacramento midwife Madeleine Wisner, who served mostly Medi-Cal families, told CalMatters that insurance reimbursed on average 17% of her costs — roughly $1,451 of an $8,500 full course of prenatal, birth, and postpartum care – denied most of her claims, and took months to pay. After 451 births, she closed her center and moved to New Zealand.
Those who stay are expected to roll over or negotiate alone. In Humboldt County, Laura Doyle of Moonstone Midwives spent a year of meetings with her regional Medi-Cal plan to reach a workable rate – precisely why Moonstone is now one of very few birth centers in the state where most clients can be low-income families.
A year of meetings, per midwife, per payer, is not a system. This is precisely what MACa exists to end. Much of the coalition’s work is unglamorous by design: convening midwives so that the hard-won knowledge from every one-off negotiation – who to call, what finally worked, which door opened – is captured and made transferable, instead of evaporating with each exhausted practice. They’ve brought the state’s health agencies and payer groups to the table too. “The work is very slow, slower than the reproductive health crisis demands,” Liz says, “but it is translating into tangible change.” In response to the group’s advocacy, Medi-Cal significantly expanding the codes a community-based midwife can bill for. Partnership Health Plan, itself a MACa member, is working with midwives across its twenty-four Northern California counties toward reimbursement rates that sustain and support them.
And yet, in spite of the crushing weight of all of this, the two people tending most doggedly to the gaping leaks in this system were the most optimistic people I spoke to. Their optimism is not naive – if the root problem is misinformation, the antidote is information delivered consistently, to the people with the power to act on it. “I’ve seen people change their minds in real time, after hearing that their assumptions were wrong,” Liz grinned, “so I know that it works.”
The state is beginning to move. Last October, Governor Newsom signed AB 55, which took effect this January: it modernizes birth center licensing – removing unnecessary hospital-proximity requirements – and enables more birth centers to access Medi-Cal reimbursement for facility fees. The fix is seven months old; whether it translates into centers that stay open is a question MACa is positioned to help answer from the inside – both the agency that runs Medi-Cal and the one that licenses birth centers are now coalition members. The workforce pipeline is being rebuilt too, after years without one, California again has in-state training for certified professional midwives, including a new school focused on Black maternal care opening this fall.
MACa is hesistant to claim triumph just yet, opting instead for direction. “I don’t feel like there’s a closed door there,” Liz told me of the payers and agencies she has spent years convening. “I just feel like it hasn’t been knocked on consistently enough.” Holly goes further: she believes California is building something replicable – that if the midwifery model can be integrated here, in a system this large and this ossified, the blueprint travels. “It is really hard,” Liz says, “and it is getting better.”
At the end of our conversation, I told Nancy what I had heard in her self-professed non-solution: that every day for the last ten years, she has solved enormous problems for the families who came through her doors. She had kept her promise – this is a no solutions story – and she had been telling me one anyway, just not the kind that ends.
It is a fight in progress, being slowly and deliberately turned into a system, by professionals who keep catching babies while working as advocates, policy wonks, business people, coalition builders, accountants – to name a few. Over the coming weeks, I’ll be publishing portraits of these midwives of all trades, exploring how they define their work, what it costs them, and what it makes possible for the families they serve.
References
Books: Barbara Ehrenreich & Deirdre English, Witches, Midwives, and Nurses: A History of Women Healers (Feminist Press, 1973; 2nd ed. 2010); see also their For Her Own Good: Two Centuries of the Experts’ Advice to Women (1978).
Data and reporting: California Health Care Foundation, “What Is a Birth Center?” (2026) — https://www.chcf.org/resource/what-is-a-birth-center/ KFF Health News, “Midwives Blame California Rules for Hampering Birth Centers Amid Maternity Care Crisis” (Apr 2026) — https://kffhealthnews.org/rural-health/midwives-birth-centers-maternity-care-crisis-california/ CalMatters, “They delivered 5,600 babies…” (Aug 2024) — https://calmatters.org/health/2024/08/birth-center-closures/ CDC/NCHS, Health E-Stat 113, “Maternal Mortality Rates in the United States, 2024” (Mar 2026) — https://www.cdc.gov/nchs/data/hestat113.pdf Commonwealth Fund, “Insights into the U.S. Maternal Mortality Crisis” (Jun 2024) — https://www.commonwealthfund.org/publications/issue-briefs/2024/jun/insights-us-maternal-mortality-crisis-international-comparison Sandall et al., Cochrane Database of Systematic Reviews (2024) — https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004667.pub6/full Nove et al., The Lancet Global Health (2021) — https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30397-1/fulltext American Association of Birth Centers, “Strong Start National Report” — https://www.birthcenters.org/news/strong-start-national-report Jolles et al., Journal of Midwifery & Women’s Health (2023) — https://pmc.ncbi.nlm.nih.gov/articles/PMC10107204/ CalMatters, “California birth centers are shutting down…” (Dec 2024) — https://calmatters.org/health/2024/12/birth-center-licensing-bill/ CHCF, “The Untapped Power of Midwives in California’s Maternity Care Ecosystem” (May 2026) — https://www.chcf.org/resource/untapped-power-midwives-californias-maternity-care-ecosystem/ SisterWeb — https://www.sisterweb.org/our-story Santa Cruz Local (Sep 2025) & KAZU (Nov 2025) on Campesina Womb Justice — https://santacruzlocal.org/2025/09/19/watsonville-hospital-seeks-to-add-mixtec-doulas-but-challenges-remain/ ; https://www.kazu.org/kazu-news/2025-11-07/watsonville-farmworkers-train-as-doulas-to-help-other-indigenous-women OHSU, “A Brief History of Midwifery in America” — https://www.ohsu.edu/womens-health/brief-history-midwifery-america Black Midwifery Collective, “History of Midwifery” — https://blackmidwiferycollective.org/advocacy-birth-justice/history-of-midwifery/ CalMatters, “She opened a business to deliver babies…” (Feb 2024) — https://calmatters.org/health/2024/02/midwife-medi-cal/ KQED, “In Northern California’s Maternity Desert…” (May 2026) — https://www.kqed.org/news/12082596/in-northern-californias-maternity-desert-a-humboldt-midwife-offers-intimate-births CalMatters, “Newsom signs legislation expanding support for California birth centers” (Oct 2025) — https://calmatters.org/health/2025/10/birth-centers-law-impact/ Health Net provider bulletin on AB 55 (Dec 2025) — https://providerlibrary.healthnetcalifornia.com/news/25-1364m-assembly-bill-55-expands-access-to-birth-centers-and-mo.html Mission Local, “Mission Resident Helps Found ‘Birth Center’…” (Jul 2016) — https://missionlocal.org/2016/07/mission-resident-helps-found-citys-first-birth-center/ San Francisco Birth Center, team page — https://sfbirthcenter.com/team-2/