DESCRIPTION OF TOPIC:
Background: Health care financing is thought to be a driver of health care quality. The purpose of this research was to analyze reimbursement for midwifery-led US birth centers and to evaluate the association between reimbursement rates and clinical outcomes. Methods: Secondary analysis of the American Association of Birth Centers Site Survey and the American Association of Birth Centers Perinatal Data Registry was completed, and descriptive statistics and logistic regression were used to explore reimbursement rates and their relationship to clinical outcomes. Results: Midwifery-led birth center charges and reimbursement ratios were both lower than nationally reported comparisons, with public insurance reimbursement rates less than half of charges. Despite lower reimbursement and variations in socioeconomic characteristics, clinical outcomes such as cesarean birth remained consistent between payor types. However, medically low-risk people with public insurance receiving midwifery-led care within sites characterized by higher reimbursement rates had higher cesarean birth rates (10.4% vs. 8.4%). Discussion: The health care financing system should serve as a lever for perinatal quality. Despite poor reimbursement ratios, birth centers consistently exceeded national quality benchmarks in perinatal outcomes; however, improved reimbursement rates did not positively impact these outcomes. Low reimbursement rates for time-intensive, midwifery-led care without consideration of quality outcomes limit the potential for sustainability and spread of the birth center model of care.

RELEVANCE TO MIDWIFERY:
Freestanding birth centers achieve high-quality perinatal outcomes that meet or exceed national quality benchmarks for consumers despite low reimbursement. Public insurance reimbursement had an inverse relationship to clinical quality, which indicates that current payment systems are not driving quality outcomes in birth centers. Low reimbursement rates limit the sustainability and spread of birth centers. Breastfeeding - support (including three-minute presentation competition)