Birth Center Operations: The 5 Ps for Sustainable Growth

Birth center operations are about more than serving more clients. A sustainable center needs a clear purpose, equity-centered decision-making, strong systems, an engaged workforce, appropriate contracts and a location that supports the community it is designed to serve.

When leaders feel stuck, whether the concern is limited financial runway, difficulty recruiting staff, inconsistent workflows, unhelpful payer contracts, facility constraints or growth, start with purpose, apply an equity lens and assess the five Ps: People, Profit, Place, Processes and Planet.

Start With Purpose

Before diagnosing any operational problem, clarify your purpose.

What need does your birth center exist to meet? Who is it intended to serve? What care model, community relationship and financial future are you working to build?

Purpose helps leaders avoid reactive decisions. For example, accepting every insurance contract may sound like the only way to increase access, but a contract with an inadequate fee schedule can create a financial burden that threatens the center’s ability to remain open. Sustainable reimbursement is central to a viable birth center model, not separate from the mission. Birth center organizations and advocates have specifically worked to advance reimbursement structures that recognize the value of both professional and facility services.

Ask:

• Who are we here to serve?

• What does accessible, high-quality, relationship-centered care mean in our community?

• What does financial sustainability need to look like for our center?

• What growth is aligned with our mission, capacity and care model?

• What are we willing (and not willing) to compromise to achieve that growth?

  
  

Apply an Equity Lens

Equity is not a sixth P and should not sit in a separate category. It is the lens through which each of the five Ps is evaluated.

An equity lens asks: Who benefits, who faces barriers, who bears the burden and whose voice is missing?

Use that lens when reviewing:

• People: Who is hired, retained, represented, listened to, referred and supported?

• Profit: Can families access care regardless of payer type or ability to pay? Do payment policies and contract decisions expand or restrict access?

• Place: Can the people your center intends to serve realistically reach, navigate and feel safe in the facility?

• Processes: Do communication, intake, scheduling, eligibility, billing, referral and grievance workflows work fairly for people with different languages, disabilities, work schedules and support needs?

• Planet: Do supply, transportation and facility decisions shift unnecessary cost or burden onto clients, staff or surrounding communities?

  
  

The Five Ps of Birth Center Operations

People: Clients, Staff and Relationships

People includes clients, staff, leaders, referral partners, consultants and the communities connected to the center.

Workforce challenges should not be treated as a simple hiring problem. A center may struggle to find staff because roles are unclear, on-call expectations are unsustainable, compensation is not competitive, onboarding is inconsistent or the team culture does not support retention. A sustainable workforce requires staffing models that align coverage with client needs while protecting quality and well-being.

For example, a center may believe it has a recruitment problem because it cannot keep enough birth assistants on the schedule. But if the role requires unpredictable overnight call, offers inconsistent compensation and provides little structured onboarding, adding more job postings may not solve the problem. The more useful question may be: What about this role makes it difficult for people to stay?

Consider:

• Staff recruitment, retention, compensation and workload

• On-call structure, coverage, burnout and cross-training

• Clear roles, leadership and accountability

• Client communication, trust, satisfaction and continuity

• Referral relationships and community partnerships

• Feedback systems that lead to meaningful change

  
  

Profit: Financial Control and Sustainability

Profit means having enough financial strength to pay people fairly, maintain quality care, invest in the facility and systems and remain open for the long term.

Birth centers may not control every reimbursement policy, but they do have choices. They can understand their cost to provide care, model the impact of each payer contract, negotiate when possible, choose not to accept contracts that create unsustainable losses, improve coding and claims follow-up, manage expenses, diversify revenue and build financial reserves.

Low reimbursement, startup costs, ongoing operating expenses and payer policies are documented financial barriers to birth-center sustainability. Recent research also demonstrates substantial variation in Medicaid birth-center facility reimbursement across states, reinforcing the importance of analyzing the local payer environment rather than assuming all contracts support the model.

For example, knowing that a payer reimburses $X for a birth is not enough. If the center's average cost to provide that episode of care is $Y, the contract may generate volume without generating enough contribution margin to support the organization. Looking at reimbursement alongside actual costs can turn a vague concern about "low rates" into a specific financial decision.

Consider:

• Pricing, cost-per-client and service-line profitability

• Payer contracting, fee schedules, credentialing and negotiation strategy

• Reimbursement, denials, claims follow-up and collections

• Payroll, vendor, facility, supply and other operating expenses

• Cash flow, reserves, debt and financial runway

• Revenue diversification and appropriate space utilization

  
  

Place: Location, Facility and Market Fit

Place is not simply the building address. It includes the center’s service area, physical accessibility, visibility, transportation options, community trust, payer environment, local demand, referral ecosystem and facility costs.

A center may have a strong clinical model and committed staff but still face operational pressure if the location does not align with its intended community, is difficult to access, costs too much or limits the number and types of services the center can provide.

For example, a facility may have attractive rent and enough space for today's census, but require clients to travel long distances, have limited public transportation access or sit outside the referral patterns that generate new clients. A lower lease payment does not necessarily make a location more sustainable if it also creates barriers to access and demand.

Consider:

• Service-area demand and fit with the center’s intended population

• Client transportation, parking, transit, safety and disability accessibility

• Facility layout, capacity, maintenance and regulatory requirements

• Lease, occupancy, utility and renovation costs

• Visibility, community presence and neighborhood trust

• Proximity to referral partners, hospitals and transport pathways

• Local competition, payer mix and market conditions

  
  

Processes: Repeatable Workflows That Create Reliability

Processes are the documented, repeatable workflows that allow a center to provide consistent care, protect staff time and operate predictably.

When an important task depends on one person’s memory, availability or goodwill, it is not yet a reliable process. Strong birth center operations make key work visible, trainable, measurable and resilient.

For example, if only one person knows how to verify Medicaid eligibility, submit a particular claim or prepare a required report, the center has a person-dependent system rather than a reliable process. Documenting the workflow, identifying who owns each step and creating a way for another trained person to complete it makes the organization more resilient.

Consider:

• Inquiry response, consultation, enrollment and onboarding

• Scheduling, care coordination and follow-up

• Benefits verification, financial counseling, billing and collections

• Clinical documentation, chart review, quality improvement and incident follow-up

• Staff onboarding, training, competency validation and policy implementation

• Credentialing, compliance tracking and readiness for surveys or accreditation

  
  

Planet: Community and Environmental Sustainability

Planet reflects the long-term health of the environment and community surrounding the center.

For a birth center, this may include responsible supply purchasing, waste reduction, laundry and energy practices, transportation burden and use of local resources. The goal is not performative sustainability or expensive upgrades. It is to make choices that are clinically safe, financially sound and supportive of the communities the center serves.

For example, inventory management can be both a financial and environmental decision. Overstocking supplies that expire creates unnecessary waste and ties up cash. On the other hand, reducing inventory without understanding clinical needs can create shortages and disrupt care. Sustainable operations look for the point where responsible resource use and reliable patient care meet.

Consider:

• Supply purchasing, waste reduction and inventory management

• Laundry, energy use and facility operations

• Environmental impact of clinical and office practices

• Transportation needs for clients and staff

• Community partnerships and local economic impact

  
  

Focus on What You Can Control

Birth center leaders cannot control every market condition, staffing shortage, payer policy or regulatory requirement. But they can identify what they can control, influence, measure, negotiate, redesign or decide not to accept.

For example:

• You may not control a payer’s initial fee schedule, but you can calculate whether it covers your costs, build a negotiation case, request a review or decide whether the contract supports the center’s long-term sustainability.

• You may not control the workforce pipeline, but you can redesign roles, strengthen onboarding, improve compensation and scheduling, develop internal talent and create a workplace where staff want to stay.

• You may not control where a building is located, but you can evaluate whether its cost, access and market fit are helping or limiting your purpose.

• You may not control every financial disruption, but you can monitor cash flow, establish reserves, reduce avoidable revenue leakage and plan for risk.

The goal is not to pretend that every problem has an easy solution. It is to distinguish between the constraints you cannot change and the decisions you still have available.

Get a Birth Center Systems Partnership

If your leadership team is uncertain where to begin, a Birth Center Systems Partnership can identify the operational factors that are helping or holding back, your center.

A systems partnership looks across your birth center to identify:

• Financial risks, revenue opportunities and runway needs

• Staffing, workload, retention and capacity challenges

• Workflow bottlenecks and undocumented processes

• Compliance, quality and operational risks

• Facility, location and service-area opportunities

• Clear, prioritized actions that align with the center’s purpose

A Birth Center Systems Partnership does not begin with a preselected answer. It helps you see the whole system, find the true constraint and make the next decision with confidence.

Ready to understand what is holding your birth center back? A Birth Center Systems Partnership can help you evaluate your operations through an equity lens, prioritize what matters most and build a more sustainable path forward.

References

1. Ofrane, R. H., Kantor, L., Blumenfeld, J., & Rokicki, S. (2025). Comparison of Medicaid financing for birth centers: A nine-state policy analysis. Frontiers in Health Services, 5. Read the full article

2. Ofrane, R. H. (2025). Financial barriers to expanded birth center access in New Jersey: A qualitative thematic analysis. Journal of Midwifery & Women's Health. Read the article abstract and publication information

3. American Association of Birth Centers. Birth Center Contracting. Resources from the AABC Industry Relations Committee addressing contracting, reimbursement, break-even analysis and payer negotiations. View AABC's birth center contracting resources

4. American Association of Birth Centers. Facility Billing for Birth Centers. Resources addressing facility billing, revenue codes, billing practices and contract renegotiation. View AABC's facility billing resources