When Gov. Maura Healey signed a maternal health omnibus bill in August 2024, health professionals celebrated it as a major step forward toward improving care and decreasing disparities in care for mothers and infants across Massachusetts.
That law included provisions around access to midwives and doulas, improved maternal mental health support and revamping how the state approaches birth centers.
Now, a little over a year later, advocates are watching as the rubber meets the road and the many pieces of law are put into practice. Legislators, advocates and health care workers say this part of the process is as important as getting the law passed in the first place.
“We all know that you can pass a bill, but if it’s not implemented correctly, or with the right people or with accountability, it just sits on paper; it’s a wishful thinking list,” said Sen. Liz Miranda at an Oct. 7 panel on maternal health disparities and care. “Good policy without enforcement doesn’t really change the outcomes.”
While the law had a wide range of provisions — including the creation of a maternal mental health fund that received $220,000 in the most recent state budget and steps regarding transparency around maternal health data — central to much of the legislation was the focus on midwives and birth centers.
Those birth options, which provide out-of-hospital choices for giving birth, have been hailed by the state’s Special Commission on Racial Inequities in Maternal Health as a way to improve maternal health delivery.
Maternal mortality and morbidity have been a worsening problem in the state, especially for women of color. A 2023 report from the Massachusetts Department of Public Health found that severe complications during labor and delivery nearly doubled over the previous decade.
Black women were at the highest risk, according to that report.
In Boston, Black infants were twice as likely to be born with a low birth rate compared to their white counterparts and nearly twice as likely to be born preterm, according to a 2023 report from the Boston Public Health Commission. That report found the rate of death among Black infants to be over three times that of white infants.
“We need to change the way we provide health care,” said Michael Curry, CEO of the Massachusetts League of Community Health Centers at the maternal health forum, which was held at NeighborHealth’s South End community health center.
Advocates said last year’s legislation, as it is rolled out in practice, offers a path to make those changes. One major step in that legislation was the creation of new birth center regulations. The state promulgated those regulations in February.
That implementation could mean improvement in maternal health outcomes as well as spending on health care in the state.
“It’s really a win-win, but we do need to make sure that we can see that payoff happen, both in terms of the outcomes and our health as well as the cost savings that will come,” said Emily Anesta, president of the Bay State Birth Coalition.
A 2022 report from the state’s Health Policy Commission found that maternity care was the top category of hospital admissions statewide for residents under 65, though there was wide variation in spending and quality.
That report identified expansion of the state’s birth centers and midwife workforce as a way to improve maternal care and lower spending.
Katherine Rushfirth, policy director at the Boston-based Neighborhood Birth Center, said she believes the new regulations mean Massachusetts has “some of the best birth center regulations in the nation.”
At the recent annual meeting of the American College of Nurse Midwives, Rushfirth said that midwives from across the country were heralding the changes under the Massachusetts legislation.
Those improvements, she said, largely come from bringing the state’s regulations in line with recommendations from the national standards from the American Association of Birth Centers.
Prominently, Rushfirth said, those new regulations recognize midwives as independent practitioners. Previously, birth centers needed an obstetrician to serve as a medical director and a specific signed transfer agreement with a local hospital.
“What they’re saying now is, ‘Let’s have the experts in community birth run these centers,’” Rushfirth said.
They also shift how birth centers are recognized as a facility.
Previously, they were grouped with outpatient surgical units, which included a set of complex requirements that Rushfirth said tend not to be needed for the low-risk births that birth centers are intended to handle.
That change makes it easier to build or open new birth centers. For Neighborhood Birth Center, the only reasonable way to try to get the center open was to build from scratch — an ongoing process that was delayed after community opposition to the proposed location near Nubian Square led the Zoning Board of Appeal to dismiss the proposal without prejudice at a hearing in February.
Instead, the new rules from the state mean that prospective birth center operators could, instead, more easily renovate an existing facility or even a house into a birth center.
“I think it just really helps the sense that you could expand this model of care,” Rushfirth said.
Those changes may have helped spur some other prospective centers into gear. Rushfirth said she’s heard talk about opening birth centers in Springfield and Leominster, as well as a potential move to reopen a birth center in Cambridge, near Harvard Square, operated by the Cambridge Health Alliance.
As the numbers grow, Rushfirth said Neighborhood Birth Center and others plan to create a Massachusetts chapter of the American Association of Birth Centers to bring more structure to their advocacy.
For Rushfirth, the long-term goal is even greater access — she said her vision includes birth centers in every gateway city across Massachusetts to increase health equity.
“Starting with communities that don’t always have access to community birth, that are not always well served in the systems we have right now — communities of color, immigrant communities, low-income communities — I think it gives a roadmap of … really great places where you could have a lot of investment, and it would benefit the state overall,” Rushfirth said.
Other parts of the legislation have been slower to roll out, tangled up in governmental bureaucracy. The 2024 legislation included language setting up the licensure for certified professional midwives — maternal health professionals without a nursing degree — a process that has been slower to come to bear.
“There’s a challenge of the urgency with which we know we need a midwifery workforce, and the urgency of addressing the maternal health crisis, and then just some pretty slow bureaucratic processes,” Rushfirth said.
Under the legislation, the state convened a Board of Registration in Midwifery in February; that body has since been working to put together regulations around licensure of certified professional midwives.
For facilities like Neighborhood Birth Center, until that licensure process pans out, it also means potential limits on who they’re able to hire once they open.
“It opens up a whole new workforce that’s specifically trained in that model of care,” Anesta said. “As that workforce comes online and once that licensure gets implemented — which we hope will happen soon — they are then a key workforce for birth centers as well as home births and even potentially other sites like community health centers.”
Now, the same advocates who pushed for and celebrated the passage of last year’s maternal health omnibus legislation have turned their attention to a new bill.
If passed, the new bill would close some gaps left in the first law’s work around establishing parity for midwives under MassHealth — the 2024 legislation established a requirement that certified nurse midwives be reimbursed at the same fee as physicians for the same services, but the way it was written didn’t extend that requirement to managed care organizations under MassHealth.
It would also create requirements for parity under private insurance and require parity for certified professional midwives.
The proposed legislation would also take steps to establish a workforce development fund for future licensed certified professional midwives and implement student loan forgiveness opportunities for all categories of licensed midwives.
Advocates said the new bill is an opportunity to build on last year’s legislation.
“If you think of last year’s maternal health omnibus as the thing that opened the door, this is the vehicle that gets us over the finish line in the way that birth centers and midwifery are accessible and sustainable,” Rushfirth said.
In the meantime, as the state continues to implement the 2024 legislation, supporters said the potential results it might bring aren’t theoretical.
At the NeighborHealth panel, many panelists highlighted the poor maternal health outcomes they or their family members had faced.
“This work is really personal for a lot of us,” Curry said. “Mothers are dying and babies are dying and there’s an opportunity for us to do something different, to embrace technology, to change the way we provide care and to address those most impacted by these inequities.”