When 25-year-old Kayla Jones first realized she was pregnant, the only facility in Buffalo, New York, where she could give birth was the local women and children’s hospital. So for the first five months of her pregnancy, Jones sought services there. However, she says, its practices and policies often confused her.

“I always felt awkward at the hospital,” Jones explained to Rewire. “I saw a different nurse practitioner each time I went in and I never knew if I could bring my boyfriend into the exam room with me, or if he should stay in the waiting area. I also never knew in advance what was going to be done at an appointment or even why I was there on a particular day.”

But in the spring of 2014, Buffalo Womenservices, a 31-year-old reproductive health facility in the heart of the city, opened the nation’s first birth center to be located inside an abortion clinic. As a longtime Buffalo resident, Jones was familiar with Womenservices’ treatment; it also helped that the facility accepted her Medicaid insurance plan.

She quickly transferred into the center, eventually becoming the first woman to deliver in the now seven-month-old facility.

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“At the birth center, there was only one doctor, so I saw the same physician at every visit. She met my mother and my boyfriend, and after several months, she felt like a member of my family,” Jones said. “She knew everyone’s name and told me what she was doing at every step.”

Jones was heartened, she says, by her ability to control her delivery experience.

“The center has a birthing pool and I labored in the water for a while but found I could not push in there, so I birthed on the bed. When I was done, I got to go home,” she explained.

“The next day, a lactation consultant came to my house. She showed me how to use a pump and watched to see that my daughter was latching on correctly. I’d worried that she was not getting enough milk, so this was really helpful. I went back to the center for my follow-up eight weeks later, got an IUD, and [my doctor] made sure that everything was OK,” she continued.

There is only one doctor at the birth center, as Jones pointed out: Katharine Morrison, who has owned Buffalo Womenservices since 2005. So although the hospital would have likely offered similar services, Jones says the fact that she knew the people she was seeing was a comfort.

In the three months since Jones’ delivery, the birth center has attended 35 women, 20 of whom have had their babies in-house. Several of the others opted for home births, while a small number have delivered in the hospital because of complications that needed additional medical attention.

On any given day, Morrison bounces back and forth between the birth center and the rest of the practice, performing first- and second-trimester abortions, testing for and treating sexually transmitted diseases, providing contraception and Pap tests, and meeting the gynecological requirements of several thousand patients a year.

“One of our goals is to transform how abortion care in the United States is provided,” said Sally Heron, the center’s service coordinator. “We want to put it back into the sphere of general medicine.”

Despite raising eyebrows among some members of the Buffalo community who have bristled at putting birth and abortion care in one facility, the model has provoked interest elsewhere, too. Already, clinics in Kansas, Ohio, and Tennessee are exploring the feasibility of adding a birth center to their repertoire of services.

Many incoming patients are surprised by the array of available procedures, not expecting the provision of abortions alongside prenatal and obstetrical care. “I tell every woman coming into the birth center that this is also an abortion facility,” Morrison said. “I ask them to have compassion for all of the women who are here.”

Still, Heron maintains that the breadth has been a non-issue for patients. When a birth is in progress, those in the waiting area can often hear what’s going on; staff typically use the event to educate patients about that facet of their services.

“We go into the waiting area and explain what’s happening,” Heron reported. “People always have questions: ‘What’s a birth center?’ ‘Why do the women go home two to four hours after delivering?’ We also talk about having a vaginal birth after a past cesarean section, and about breastfeeding. They’re great conversations.”

The information provided in these question-and-answer sessions, Morrison adds, is especially important given that approximately 60 percent of the clinic’s abortion patients are already mothers and more than 80 percent will eventually go on to have a family.

“I want everyone to understand that they can demand better care for themselves when they have their babies. I see this as an opportunity to radicalize the women who come to Womenservices, whether [it’s] to give birth, have an abortion, or for some other reason,” she said.

That said, Morrison admits that back in 2007, when community members first floated the idea of opening a birth center, she was unsure of the benefits such an endeavor could provide. One advocate, a certified nurse midwife named Eileen Stewart, had previously asked Morrison to be on call to provide OB-GYN backup, should problems arise during a home birth. In spite of her skepticism, Morrison found herself wondering why some people felt strongly about avoiding hospitals and asked Stewart if she could accompany her as she attended patients.

“For a while I drove around with [Stewart] for prenatal appointments,” she recalled. “Finally, in July 2007, I saw my first home birth. Prior to this, I’d only seen in-hospital deliveries. I was transformed by the experience. I’d never seen anything so woman-centered. The mother-to-be was in a blow-up tub. There were rose petals sprinkled in the water and the baby emerged in the pool. When the labor was over the woman got out into the warm sun and nursed her child. It was unlike anything I’d ever seen in a hospital birth.”

Morrison says that she was attracted to the idea of letting women dictate the specific conditions of their labor if they wanted to do so. At the same time, she recognized that very few women—little more than 1 percent—choose to give birth at home, something Morrison attributed to the widespread belief that it is necessary to go somewhere “with machines and monitors” to have a baby.

Ultimately, she decided that a birth center was the ideal way for her to combine patient-directed care with modern medicine.

“We recognized that by opening a birth center we could do things that many women want,” Morrison said, “like giving them their placentas and allowing children into the birthing room.” While such practices are not universally forbidden in hospitals, many do enact restrictions surrounding the delivery process. Morrison continued, “We would also let mother and baby go home shortly after the birth, rather than making them wait 24 hours.”

But ideological principles aside, getting the state’s go-ahead to open a standalone birth center meant working with a nearly intractable government bureaucracy. According to Morrison and Heron, the entire process took five years, cost $300,000, and involved countless forms, face-to-face meetings with health department officials, and a raft of permits, licenses, and follow-up inspections. Because so few birth centers exist in the state, Morrison also notes that health department staff were often flummoxed, unsure of how best to proceed.

On top of this, added Heron, “The laws are very strict. First, you need a Certificate of Need (CoN). The fact that we already had a location where we performed abortions and provided gynecological care meant that we could expand our existing CoN.” Nonetheless, she called the process “grueling.”

“Some of the regulations seemed nonsensical,” she continued. “For example, we needed a portable ice maker. Of course, we went and bought one, which we have never used. Everything that we purchased or installed, including the birthing pool, had to meet specific measurements and had to be checked, inspected, and monitored.”

But the biggest hurdle—Heron called it a “challenge”—comes not from state oversight, but rather from insurance companies. So far, the Medicaid managed care provider Independence Health is the only health plan to cover deliveries at Womenservices, meaning that women without this coverage have to pay out-of-pocket if they wish to give birth there.

Both Heron and Morrison find this confounding. “At Womenservices, births cost less than hospital births, but for some reason, they are still opposed by insurance companies,” Morrison said. “A typical hospital birth costs nearly $10,000; at the Birth Center it’s $3,000.”

Even so, neither of them are discouraged. As Morrison said, “We’re working to give women the opportunity to have the birth they want or the abortion they need.”