BIRTH CENTERS: The Space Between Home Birth and Hospital

Elizabeth Smith, CNM, MSN

On the first of January, people celebrate the New Year with parties, champagne and “Auld Lang Syne.” For San Rafael couple David Chernus and Crystal Reed, Jan. 1, 2015, brought a far different beginning: the birth of their daughter, Franklynn Robin Chernus. Born at 1:10 a.m., the 7-pound, 19.5-inch infant was delivered at the Santa Rosa Birth Center and holds the honor of being Sonoma County’s first birth of the year.

Birth centers remain a source of confusion for much of the public, despite considerable evidence for their safety, cost effectiveness and patient satisfaction. The Bay Area is home to three birth centers and has two more in development. Santa Rosa Birth Center, the second-oldest birth center in the state, has served Sonoma County for more than 20 years. Berkeley’s Pacifica Family Maternity Center opened in 2012, and Santa Rosa’s Thrive Center for Family Wellness opened its doors last year. Marin City Health & Wellness Center, a federally qualified health center just outside Sausalito, plans to expand its services and open a birth center in late 2015. And the San Francisco Birth Center also targets this fall for its debut. Even with the increased presence of birth centers in the area, many people wonder what a birth center is, and what it seeks to do.

What is a birth center?
The American Association of Birth Centers (AABC) defines a birth center as a “homelike facility existing within a health care system with a program of care designed in the wellness model of pregnancy and birth.” Birth centers operate in the space between home birth and hospital, combining the low-intervention, natural approach of home birth with access to a hospital if needed. Birth centers care for medically low-risk women before, during and after normal pregnancy and delivery and utilize an evidence-based risk assessment tool to identify when mothers become too high-risk for birth center care. Most birth centers also provide comprehensive women’s health care that extends beyond maternity care and includes well-woman screenings, family planning and gynecological needs.

The goal of birth centers is to provide high-quality maternity care with a holistic, individualized approach. Practically speaking, birth center practices are small and offer a more intimate experience than a hospital. They focus on making the birth experience special, facilitating family involvement, limiting unnecessary interventions, and providing as much control and individualization as medically possible.

What are midwives?
Birth center care represents a collaborative model of health care delivery. Midwives, the primary providers, work with physicians and hospitals to provide comprehensive services. Midwives are medical professionals who have received extensive training in the care of healthy pregnancy and birth. They view childbearing as a normal physiologic process and focus their attention on maintaining normalcy within the context of evidence-based care.

While there are different types of midwives, the AABC states that most midwives practicing in California birth centers are certified nurse midwives (CNM). CNMs are registered nurses with graduate-level education in midwifery; they have passed a national board certification exam and provide general women’s health care throughout a woman’s lifespan. California CNMs have full prescriptive authority, enter into insurance contracts, maintain malpractice coverage and can hold hospital privileges. Many birth center CNMs hold concurrent credentials at their local hospital so they can care for patients who prove too high-risk for the birth center facility. The AABC Birth Center Standards require accredited birth centers to disclose the type and qualifications of the providers rendering care at the birth center.

All CNMs employed at the Santa Rosa Birth Center also attend births at Sutter Santa Rosa Regional Hospital. Likewise, certified nurse midwives own and will staff the future San Francisco Birth Center. Midwives at Santa Rosa’s Thrive Center for Family Wellness and Berkeley’s Pacifica Family Maternity Center are licensed midwives (LMs) and certified professional midwives (CPMs). They have a slightly more limited scope of practice and attend births both at the birth center and at home. Marin City Health & Wellness Center promotes a unique, open-model birth center. Staffed primarily by licensed midwives, its birth center will credential community physicians and midwives, allowing outside providers to attend birth center patients.  

All midwives rely on their physician colleagues to collaborate, co-manage or accept care of women who require treatment beyond the well-defined scope of midwifery practice. Indeed, the Standards of Birth Centers published by the AABC requires that a physician-midwife relationship exist in order to provide safe and effective care. Santa Rosa Birth Center has a formal relationship with the physician members of the Santa Rosa Community Health Centers obstetrics team that allows for consultation and/or transfer of care if needed. Pacifica’s medical director is a Board Certified OB-GYN who provides collaboration and co-management for its clients. The Marin City Health Center physicians and nurse practitioners will provide collaborative services for their pregnant patients. In addition to these formal relationships, midwives also maintain informal collaborative relationships with community obstetricians, pediatricians and neonatologists.

In addition to medical providers, the birth center model includes an interdisciplinary team to provide direct and ancillary support services. These roles can include educators for classes on childbirth and parenting; trained therapists to address family needs as they arise; and lactation support specialists for postpartum breastfeeding support. Birth centers also offer services like yoga classes, birth plan assistance and informal support groups. The focus is client-driven care across a full spectrum of interests.

Are birth centers safe?
“But what if something happens during labor?” As with hospitals and outpatient surgery centers, regulations and published standards of care dictate the specific training, supplies and medications that birth centers are required to have for each delivery. Careful, ongoing monitoring of mom and baby, as well as emergency medications, IV fluids, resuscitation equipment, and established physician and hospital backup provide the necessary backdrop to all care. In an emergency situation, providers and staff are trained and experienced in the provision of emergency care and stabilization while awaiting EMS transport. This includes the administration of emergency medications and full neonatal resuscitation according to American Academy of Pediatrics guidelines.

Several well-designed studies have established the safety of birth center care. The recent National Birth Center Study II,¹ a prospective study of over 15,000 women in 79 midwife-led birth centers across the country, found a 16.8% maternal transfer rate, 6% cesarean section rate, and intrapartum fetal and neonatal mortality rates of 0.47% and 0.04% respectively. It is important to note that the National Birth Center Study II did not include a hospital cohort for comparison. However, these findings are consistent with other studies comparing location of birth, midwife-led care and obstetric care, all of which corroborate that midwife-led birth center care is a safe option for medically low-risk women.^2–8

Birth centers use a model of care that supports wellness and physiologic birth and a diligent practice of risk assessment. This combination works to keep women healthy and low-risk while allowing early detection and treatment of potential complications. Identifying those women for whom a birth center birth is not appropriate lies at the base of this approach. The collaborative model of care allows co-management of these higher-risk pregnancies in the hospital by a CNM and a physician. Other times, risk guidelines necessitate the complete transfer of care to the physician collaborators.

A case study: Safety at the Santa Rosa Birth Center
In the Santa Rosa Birth Center’s 21-year history, CNMs have overseen 3,422 births. In 2014, they managed 138 births. Of 101 laboring women admitted to the Birth Center, 84 births occurred within the facility. Fifty-four Birth Center clients delivered in hospital. Of these births, six were managed by Birth Center CNMs and the remaining 48 were managed by the collaborating MD/CNM hospital practice. Thirty-seven were planned hospital births and 17 (16% transfer rate) were transferred in labor or postpartum after admission to the Birth Center. Of the 17 transfers, two were transferred because of failure to progress and one for postpartum bleeding. There were no maternal or fetal/infant deaths, and the cesarean section rate for all Birth Center patients was 6%.

These outcome data are comparable to those for all the births at the Birth Center since its inception in 1993. Furthermore, the 2014 statistics compare favorably with national data published by the CDC, as well as data from the National Birth Center Study II.¹

There are other benefits of birth centers beyond positive medical outcomes. One of the most striking is the breastfeeding rate. Ninety-nine percent of Santa Rosa Birth Center clients are breastfeeding at six weeks postpartum; 97% are exclusively breastfeeding. At one year postpartum, 55% continue to breastfeed.

How are birth centers regulated?
A common misconception is that birth centers have no external regulation or governmental oversight. This simply is not true. In addition to being subject to local, state and national laws concerning the practice of medicine and midwifery, the AABC publishes the Standards for Birth Centers, which forms the foundation for the safe functioning of birth center facilities. An independent authority, the Commission for the Accreditation of Birth Centers, uses these standards to evaluate birth center care and to accredit individual birth centers. While some states, including California, permit birth centers to operate without accreditation, most birth centers are accredited through the CABC. The Santa Rosa Birth Center has been accredited since 1997. Pacifica earned accreditation in 2013, and accreditation for Thrive Birth Center is in process.

In addition to national accreditation, California licenses alternative birth centers through the Department of Public Health, but does not require this licensure for business. California-licensed birth centers are required to comply with the state’s Health and Safety Code, which mandates that birth centers, among other things, adhere to the AABC Standards of Care and undertake the voluntary process of accreditation. The Santa Rosa Birth Center is the only licensed alternative birthing center in the Bay Area.

How much do birth centers cost?
Because of the nature of birth center care—its “low tech” approach, smaller physical facility and lower overhead—the cost of a birth center birth is significantly lower than that of a hospital birth. Most birth centers work with insurance plans to maximize coverage for services rendered. In California, Medi-Cal reimburses birth center facility fees, as well as maternity services provided by CNMs. Insurers—such as Anthem Blue Cross, Blue Shield, Cigna, Aetna and United—also cover care rendered by midwives in birth centers as well as the birth center facility fees.

On a larger scale, the cost savings of birth center care is a primary reason advocates for health care reform embrace the birth center model. The National Birth Center Study II estimates that the cost savings from reduced cesarean section and lower intervention rates among the 15,000 study participants came to nearly $30 million.¹

Who seeks birth center care?
“We wanted as natural and noninvasive a birth as possible,” says Crystal Reed when describing her family’s reasons for choosing a birth center. This desire for a natural birth is frequently expressed by birth center clients. Although some people choose birth centers to reduce costs, most choose this type of care because they want a natural, physiologic birth. Parents who choose a birth center prefer to avoid the perceived inconveniences of the hospital: unknown staff; unfamiliar routine and invasive procedures; lack of flexibility to respond to family desires; routine separation of mom and baby; and requirements for a prolonged post-partum stay.

During a pregnancy, the nature of birth center care allows families to develop a relationship with their midwives that fosters trust and a sense of safety. The birth center facility is important as well. It is a homelike environment. Mothers can labor in an atmosphere that is familiar rather than clinical. They can return to their own home within six to eight hours of birth if baby and mom are doing well. They know that going home is safe because they can call the midwife at any time and will receive a home visit within the first 24 hours and regularly throughout the first week.

There is no one-size-fits-all when it comes to birth. The decision of where to give birth and how is an intensely personal decision that should be based on the desires of the pregnant mother in collaboration with her family and health care provider. In most instances, an otherwise healthy woman with a low-risk pregnancy is a candidate for a birth center birth. But pregnancy and birth is a dynamic experience influenced by a woman’s medical condition, emotional needs and fiscal reality. Birth centers exist as part of the health care system, not outside of it. When licensed and accredited, they are a safe and cost-effective alternative to hospital or home birth, and represent one option on the continuum of birth choices.

---

Ms. Smith, a certified nurse midwife, is the director and owner of the Santa Rosa Birth Center.

Email: esmith@santarosabirthcenter.com

References
1. Stapelton S, et al, “Outcomes of care in birth centers,” J Nurse Midwifery, 58:3-14 (2013).
2. Hatem M, et al, “Midwife-led versus other models of care for childbearing women,” Cochrane Database Syst Rev (2008).
3. Hodnett ED, “Alternative versus conventional institutional settings for birth,” Cochrane Database Syst Rev (2012).
4. Stewart M, et al, “Review of evidence about clinical, psychosocial and economic outcomes for women with straightforward pregnancies who plan to give birth in a midwife-led birth centre,” UK National Perinatal Epidemiology Unit (2005).
5. Hollowell J, et al, “Birthplace national prospective cohort study: perinatal and maternal outcomes by planned place of birth,” UK National Perinatal Epidemiology Unit (2011).
6. Greulich B, et al, “Twelve years and more than 30,000 nurse-midwife-attended births,” J Nurse Midwifery, 39:185-196 (1994).
7. Blanchette H, “Comparison of obstetric outcome of a primary care access clinic staffed by certified nurse-midwives and a private practice group of obstetricians in the same community,” Am J Obstet Gynecol, 172:1864-70 (1995).
8. MacDorman MF, Singh GK. “Midwifery care, social and medical risk factors and birth outcomes in the USA,” J Epidemiol Community Health, 52:310-317 (1998).