DES MOINES, Iowa (AP) — As a certified nurse midwife, Cosette Boone has delivered hundreds of Iowa babies to mothers who wanted an alternative to giving birth at a hospital.

For seven years Boone’s Healing Passages Birth and Wellness Center has operated in Des Moines, the only stand-alone, midwife-led birth center in Des Moines.

At least, it was. The center is shutting its doors, and Boone will deliver her last baby there this month.

It wasn’t for lack of patients. Instead, Boone and other midwives say Iowa and the health care industry have stacked the deck against them — despite the growing demand for non-hospital spaces to give birth in the metro.

So, even though Boone has a certificate of need from the state, she is leaving the practice after she couldn’t obtain insurance coverage for her facility.

“It feels right for me to step away from birth management and what seems like a constant fight to push for change and the right for the consumer to have this paradigm of care as an option,” she told the Des Moines Register. “There are newer, younger midwives now to carry that on.”

The birth center closure comes as other Des Moines-based certified nurse midwives also are saying state laws have stifled competition at the detriment of consumers. Two midwives with the Des Moines Midwife Collective are suing the state for requiring a certificate of need to operate a birth center, saying the process of obtaining one is hugely expensive and “designed to fail.”

The lawsuit against the Iowa Health Facilities Council, the board that issues certificates of need, asks the court to declare the law requiring the application process unconstitutional.

For clients like Christina Nelson-Johnson, an Ames resident who birthed her second child at Boone’s center, losing services like it means women will be denied the means to have a more comfortable experience for childbirth.

Arranging a hospital-free birth already was more difficult than it should be because insurers and medical providers view the practice with skepticism, she said.

“These spaces aren’t respected the way they should be,” Nelson-Johnson said. “The fact it’s hard to even put insurance through this and that everything has to be out-of-pocket is ridiculous. Because in my experience, it was a better experience.

“I’m glad I’m not having any more children, because I couldn’t imagine having another baby with someone else.”

Boone, who has worked as a certified nurse midwife in Des Moines since 2001, opened Healing Passages Birth and Wellness Center in 2016.

The facility was in a historic Sherman Hill building her husband, Chaden Halfhill, renovated to house it. The center also was just a few blocks away from local hospitals.

After more than a decade of assisting home births in the metro, Boone wanted to open a standalone birth center to earn accreditation and provide a more affordable option for women. Nationwide, Most insurance companies don’t cover home births.

“The whole plan was to build a center that Des Moines could be proud of, could be excited about,” Boone said.

She obtained a certificate of need in 2011. Iowa law requires the regulatory approval process for new health care facilities that allows competitors to weigh in.

If the state board deems a particular need is already being fulfilled, it will deny that government-issued certificate. But the state determined Boone’s facility did meet a need and granted the certificate, and Healing Passages Birth and Wellness Center also earned accreditation from the Commission for the Accreditation of Birth Centers.

In 2017, Boone applied to receive facility reimbursement as an in-network provider with Wellmark Blue Cross Blue Shield. She requested an additional reimbursement that hospital birth centers would receive for their facilities — separate from payments for care provided.

Her request was rejected. In a letter Boone received in 2018 and provided to the Des Moines Register, Wellmark said an internal committee determined the insurer would not expand the network to include birth centers as eligible providers.

“Wellmark is committed to protecting the health of parents and their children. That is why we cover access to state-licensed birthing centers staffed by medical professionals who provide safe care to mothers and babies, specific to their labor and delivery needs,” Cammy Jenkins, a registered nurse and vice president of health services at Wellmark said in a statement to the Register.

Boone said she believed her accreditation exceeds standards for state licensure. There’s also no licensure process for midwives in Iowa.

Wellmark officials said in the 2018 letter to Boone that the company does contract with certified nurse midwives who provide care in a birth center. However, Boone said, the reimbursement the insurer would have provided would not have been enough to cover the more than $6,000 she charges to provide care for her clients from prenatal to postpartum.

The revenue she generated from that service fee covered operation expenses, such as the salaries for five full-time staff at the center and contracts with independent nurses. Boone sought a facility reimbursement from Wellmark to cover overhead costs of the space.

Boone is disappointed that larger players in the health care industry did not embrace her freestanding birth center as a solution to the lack of maternal health care access in Iowa. The state has seen 41 labor and delivery units close since 2000, according to a recent study.

“It’s about options and choice in a paradigm of care. I don’t understand why it has to be such a fight,” Boone said.

Even before she was pregnant with her first child, Nelson-Johnson knew she wanted to give birth in a non-traditional setting.

However, her and her husband’s insurance fully covered a hospital birth and they couldn’t afford the cost to go elsewhere. So, when her labor started in June 2018 with her daughter, Riley, they drove to the nearest medical center.

The now 37-year-old said her experience birthing at a hospital was uncomfortable. The medical team provided a cascade of interventions, such as doses of Pitocin and pain medication, in an attempt to jump-start her inconsistent contractions, leaving her feeling pressured to manage childbirth on their timeline rather than hers.

“Birthing is the most vulnerable thing a person can do, I think, and having safety and feeling safe can make or break an experience,” she said.

By the time she was pregnant with her second child three years later, she knew she would not go back to a hospital to give birth. So she reached out to Boone.

The vast majority of births in the United States happen in hospitals, but Nelson-Johnson is among a growing number of women seeking out alternatives for their labor and delivery.

The U.S. Centers for Disease Control and Prevention found the national percentage of births taking place at home increased 22% during the early days of the pandemic, rising from 1.03% in 2019 to 1.26% in 2020.

When Nelson-Johnson gave birth to her son Quinn at Healing Passages Birth and Wellness Center in June 2021, she said Boone catered to her needs, giving her the space and the power she needed to make her own choices in her birthing experience.

“It will always be a really beautiful moment in my life, and to have shared that with her is incredibly meaningful,” Nelson-Johnson said.

With the center’s closure, Boone also is stepping away from offering home birth services and plans to instead transition to consultations and programming for women preparing for childbirth. Her new business is called The Willow’s Song.

Boone said the care provided by independent midwives is different from services offered at a hospital, and treating these services the same will only be a detriment to patients.

“We will never be competition to the health care system,” she said. “It’s like comparing McDonald’s to the organic store across the street. These are not women who are interested in a hospital birth. If you block a women and she can’t have (a) birth center, she’ll go find a home birth midwife.”