FRESNO — Even as licensed midwife Detrah Hele explained why she recently opened a birth center in Fresno, she was in her car heading to a client’s home in Visalia.
Her client was a labor and delivery nurse who had already had two home births and was about to have a third one under Hele’s supervision. In fact, Hele has caught hundreds of babies since she got her license 10 years ago. She said it had been a dream of hers to establish a place where pregnant women could give birth outside a hospital setting.
After months of searching, she found the right property in downtown Fresno, a home on the historic register that was most recently the office of the Fresno Women’s Medical Group. She dealt with all the necessary city codes and opened The Birth Place in October 2014. It is the only birth center in the San Joaquin Valley. Another licensed midwife, Alex DePastene, works with her.
How Care Differs at Birth Centers, Hospitals
Birth centers in the U.S. operate according to standards defined by the American Association of Birth Centers. These include working only with low-risk pregnancies. Pain medications and epidurals aren’t used, while pain management techniques such as walking or sitting in a tub of water are encouraged. To facilitate more comfortable labor, women at birth centers are not connected to electronic fetal monitors, which can prevent movement.
The model of care offered at a birth center is different from a labor and delivery unit in a hospital, said Kate Bauer, director of the American Association of Birth Centers. “The philosophy is different,” she said. At birth centers, “pregnancy is not seen as an illness that needs to be cured. It’s a wellness event for a woman and her family.” Under birth centers’ wellness model, interventions are only used when medically necessary.
Hospitals, said Bauer, are more intervention-oriented. That’s useful when there are complications, but many healthy, low-risk pregnant women receive unnecessary interventions in hospitals, Bauer said. According to a report in the Journal of Perinatal Education, 47% of women have their labor artificially accelerated with medications, and 43% of women giving birth for the first time have labor artificially induced.
Study Highlights Birth Center Benefits
Multiple studies show that birth centers offer quality and cost-effective care, Bauer said. The most recent report, “The National Birth Center Study II,” published in the Journal of Midwifery and Women’s Health, found that birth centers not only provide safe outcomes for babies, but also have a much lower rate of cesarean sections. The c-section rate for low-risk women giving birth in birth centers was 6% percent, compared with a rate of 24% percent for low-risk women in hospitals.
There are 34 birth centers in California, many clustered around Southern California and the Bay Area. There are 295 nationwide, an increase of 20% since 2013, Bauer said. The country’s first recognized birth center opened in New York City in 1975.
Birth centers “have had to overcome some challenges in the reimbursement and liability insurance landscape,” Bauer said. The recent increase in centers may be related, in part, to the Affordable Care Act. The ACA mandates Medicaid reimbursement for birth center facility services and providers. Prior to the law, reimbursements were open to interpretation and varied from state to state. However, the mandate has only been implemented correctly in about half the states, Bauer said.
Few Women Opt for Birth Centers
Very few women use birth centers nationwide. According to the most recent data from CDC, only 1.4% of births took place out of a hospital in 2013. Of the more than 56,000 out-of-hospital births, about two-thirds took place at home and 30.2% in a freestanding birth center.
The Birth Place in Fresno can accommodate up to three laboring women at one time but Hele said most of her clients still opt for a home birth. Out of seven clients due in February, two of them want to give birth at the center. “Home births and the birth center are essentially the same,” she said. “The only difference is at the birth center, you’re eventually going to have to go home. At your house, you stay in bed and we go home.” She does concede that some clients are more comfortable at the birth center because it’s directly across from a local hospital.
The American College of Obstetrics and Gynecology recommends hospitals and birthing centers as the safest place for labor and delivery. According to an ACOG spokesperson, the organization just released a new Obstetric Care Consensus recommending the creation of a new system of classification of care levels, including birthing centers.
Classifications are important because birthing centers offer different levels of capability, according to ACOG officials. Although obstetrical complications are rare, they can progress rapidly and can be life-threatening for the woman and infant, so it is important that birthing centers have the ability to provide care in an emergency, the spokesperson said.
Emergency Transfers to Hospitals Are Rare
According to the “National Birth Center Study II,” most transfers to hospitals from birth centers were not emergencies. The most common reason was prolonged labor. The most common reason for an emergency transfer during labor was concern about fetal heart rate patterns; fewer than 1% of the study’s participants were transferred during labor for emergency reasons.
Hele said she always has two skilled attendants at a birth, also recommended by ACOG. “We’re always watching,” Hele said. “We know normal so when something’s not normal anymore, we’re going to notice it.”
California midwives are licensed and regulated by the Medical Board of California. Licensed midwives are different from Certified Nurse Midwives, who typically practice under doctors and deliver infants in hospitals. In January 2014, a state law was passed giving licensed midwives the right to practice without doctor supervision. Before that, licensed midwives were expected to work with doctors but found they had little support, according to Hele. “For 20 years, midwives operated out of the letter of the law and the state knew that,” Hele said.
Hele said she typically charges $4,000 for a home birth and about $500 more at The Birth Place. She said insurance policies vary widely when it comes to births at home or in a center.
A study published last year by UC-San Francisco found that costs for an uncomplicated vaginal delivery in California hospitals ranged from $3,296 to $37,227. Women who underwent c-sections were charged between $8,312 and $71,000.
“The birth center is not for everyone, but for many women it is a choice that can provide a really wonderful birth experience,” said Bauer. “It’s the appropriate level of care at the appropriate time and it starts with prenatal care.”