206207Birth Center Regulation in the United States

JILL ALLIMAN

LEARNING OBJECTIVES

Upon completion of this chapter, the reader will be able to:

1.  Describe the history of birth center regulation in the United States

2.  List components of state birth center regulation that impede access to birth center care

3.  Describe reimbursement challenges with Medicaid and TRICARE

4.  Describe the federally funded Strong Start project and its influence on access to birth center care

Freestanding birth centers have a history of more than 40 years in the United States, and progress toward becoming part of the mainstream maternity care system can be seen in regulations and policy changes over the years. Early leaders in the birth center movement went to great efforts to ensure the model would have standards for operation; high-quality, evidence-based care; and be integrated into the health care system for optimum safety and collaboration. Regulations and licensure were part of that effort early in the development of birth centers.

AMERICAN PUBLIC HEALTH ASSOCIATION DEFINITION AND MODEL REGULATIONS

The American Public Health Association (APHA) developed model birth center regulations in 1982 (APHA, 1982). The APHA defined the birth 208center as “any health facility, place, or institution which is not a hospital or in a hospital and where births are planned to occur away from the mother’s usual residence following normal, uncomplicated pregnancy” (1982). This definition continues be a useful description of the modern birth center facility that meets American Association of Birth Centers (AABC) standards (AABC, 2014).

STATES ADOPT REGULATIONS

As birth centers developed in various states, licensure statutes and regulations were written and approved. Some birth center laws and regulations have not been modified since they were originally written in the 1980s. At that time, states modeled regulations after ambulatory surgery centers or other medical facilities with stringent requirements for construction, hallway width, and size of a birth room being the same as an operating room. As licensed health care facilities, birth centers in all states must comply with all environmental, health, safety, laboratory, sanitation, and professional licensure standards as required by authorities at the federal, state, and local levels.

DEFINITION IN FEDERAL LAW IN 2010

Birth centers have experienced inconsistent payment from state Medicaid agencies. In some states, the midwife provider was paid for professional services, but the facility was not recognized as a state health care facility, and therefore not reimbursed. In an effort to improve access for Medicaid beneficiaries, a bill to mandate facility fee coverage of freestanding birth centers by Medicaid was introduced in 2009 and included in the Affordable Care Act (ACA) when it was passed in 2010 (Patient Protection and Affordable Care Act [PPACA], 2010). The definition of freestanding birth center in this federal statute is “a health facility that is not a hospital or physician’s office, where childbirth is planned to occur away from the pregnant woman’s residence that is licensed or otherwise approved by the state to provide prenatal labor and delivery or postpartum care and other ambulatory services that are included in the plan” (Patient Protection and Affordable Care Act, 2010). This definition uses the APHA definition as its basis (APHA, 1982).

Additional language in the Medicaid law identifies birth centers as a mandated covered service, with separate payment for the professional 209services of any licensed birth-attendant and facility services as a part of the statute (Patient Protection and Affordable Care Act, 2010). Language mandating payment by Medicaid of any licensed birth attendant providing services was the first recognition by Medicaid of direct-entry midwives or midwives other than certified nurse-midwives (CNMs) in federal statute.

This federal birth center definition provides an additional level of credibility for birth centers when working with federal and state agencies to improve payment and to reduce other barriers to access for women and families. The definition can also be used for standardization when including birth centers in other proposed legislation or regulation.

UNDERSTANDING STATE REGULATION

Current Licensure and Regulation Status

Forty-one of the 50 states and the District of Columbia license or otherwise recognize birth centers under other regulation or statute. Two states, North Carolina and Louisiana, operate under Medicaid regulations that deem birth centers eligible for Medicaid reimbursement. Birth center licensure or recognition by the states is necessary for eligibility for Medicaid reimbursement. Since almost half of U.S. births are paid for by Medicaid, it is beneficial to be eligible for Medicaid payment. In a few states, Medicaid reimbursement is too low to cover birth center costs, so birth centers in those states are not able to accept clients covered by Medicaid or must limit their numbers.

Licensure on a State-by-State Basis

States with the largest numbers of birth centers have fewer restrictive regulations in place. Conversely, in states where regulations or licensure requirements are difficult to achieve, there are fewer birth centers (Figure 9.1). This is similar to regulations for advanced practice registered nurses (APRNs) and midwives (Yang, Attanasio, & Kozhimannil, 2016) where restrictive regulations decrease access. In 2014, AABC filed comments with the Federal Trade Commission (FTC) to draw attention to ways in which restrictive birth center regulations limit access to birth center care (AABC, 2014).

210

FIGURE 9.1 Numbers of birth centers and associated regulations

Source: AABC (2016a).

Best Model Regulation Components

Birth center regulations function best and support development of birth centers when certain components are present and others are not required (Table 9.1). AABC issued a Position Statement in 2016 outlining components of regulation that promote the effective regulation of birth centers and those that are restrictive (AABC, 2016b).

The Position Statement suggests that regulations are most effective when they are based on current evidence, such as the AABC standards and those that support accreditation by the Commission for the Accreditation of Birth Centers (CABC). Regulations should be limited to requirements for the birth center facility itself and not the providers who practice there. Regulations for providers should be separate from those for facilities. It is helpful if regulations require that guidelines be put in place with plans for transfers to hospitals with both maternal and newborn care capabilities when needed. Collaborative planning best occurs between birth centers and the hospitals in their communities so when transfers are necessary, 211they can be safe and seamless for the women and/or their infants. Physical layout requirements for the birth center should be based on business occupancy codes, and requirements should not be added that increase cost without improving the safety of women and newborns utilizing the facility.

Those components of state regulations that impede the safe and effective operation of birth centers put restrictions in place without improving safety. Restrictive elements include requirements for written agreements with hospitals or physicians, Certificate of Need (CON), or requiring a physician be hired as medical director of the birth center. These components put control of the birth center in the hands of groups that can be seen as competitors and threaten the existence of birth centers and access to birth center care for women and families. Hospitals and birth centers should be required to participate in joint planning for transfers from birth centers, in the same way policies and procedures are put in place for transfers between hospitals when women or newborns require more complex levels of care than the facility where they are admitted offer (American College of Obstetricians and Gynecologists [ACOG], 2015).

Written Agreement With Hospital

212All birth center staff desire good relationships with collaborating hospitals so when transfers are needed, they can be accomplished in a seamless manner that prioritizes the safety of the mother and infant. However, when a written agreement is a regulatory requirement and some hospitals refuse to enter into such agreements, the requirement becomes a barrier for access to birth center care. For example, 15 states have requirements for written transfer agreements with a local hospital; however, only 37 of the total 319 birth centers and 15% of birth center births occur in those states. More than 88% of all birth centers are located in the states that do not require a formal written transfer agreement with the receiving hospital. Similar findings exist for other restrictive regulations, such as CON and requiring a physician medical director for birth centers.

Certificate of Need

Sixteen states and the District of Columbia require that a CON be approved before a birth center can be opened in that state. CON laws were designed to contain costs of health care facilities by requiring coordinated planning of new services and construction, and avoiding duplication of services. In 1974, the federal Health Planning Resources Development Act was passed, leading many states to enact CON laws (National Conference of State Legislatures [NCSL], 2016). The federal law was repealed in 1987, followed by 14 states discontinuing their CON laws (NCSL, 2016). However, 36 states maintain some form of CON law. Current CON laws tend to focus on outpatient facilities that are in direct competition with hospital facilities (NCSL, 2016). According to AABC, 15 states and the District of Columbia have CON laws that impact the development of new birth centers (AABC, 2016e).

Access to freestanding birth center care can be improved by reducing barriers for women seeking maternity care services in freestanding birth centers. State regulations requiring CON can be a barrier to freestanding birth center care when other providers in direct competition with freestanding birth centers oppose CON applications. Freestanding birth centers have only two or three beds, which differ from hospital beds in that care is limited to low-risk childbirth and does not include surgery or regional or general anesthesia. AABC believes that due to their small size and services that are not comparable to hospital services, freestanding birth centers should be exempt from the CON process. Removal of the CON process for freestanding birth centers is one way to improve access 213to this high-quality care option. Access to freestanding birth center care increases when states do not require a CON.

Medical Director or Written Agreement With Physician

Birth centers in states requiring a physician as medical director are not associated with better outcomes (AABC, 2016b). The CABC recommends that birth centers have a clinical director, who can be a midwife or physician. All birth centers desire relationships with physicians and other service providers for consultation or referral when needed. However, requiring that birth centers hire a medical director adds a cost that cannot be recouped through billing, which threatens sustainability of the birth center.

An additional vulnerability to birth center sustainability is the difficulty in finding and keeping a medical director on staff in states with this requirement. If the medical director has to leave abruptly due to illness, moving, or other outside causes, the birth center is subject to immediate cessation of operations. In those situations, birth centers cannot continue to operate legally and must therefore send patients to the hospital for care. In rural communities or areas with limited medical support of the birth center, loss of a medical director can force closure.

Risk Criteria or Required Distance From Hospital

Some states may add specific risk criteria to their definitions within birth center regulations that identify women as being too high risk to be eligible for birth center care. Examples of risk criteria contained in state regulations include diabetes or heart disease. History of conditions such as postpartum hemorrhage requiring a transfusion, or low transverse cesarean incision, may require a consultation with a physician or prohibit birth center care. It is important to maintain broad categories of risk to avoid language that may unnecessarily restrict patient enrollment. Several states specify the distance a birth center is allowed to be located from the hospital, usually expressed in minutes of travel time (AABC, 2016c). Requiring minimum distance from hospitals can limit access in rural communities with no local hospital for maternity care.

Regulations That Include CABC Accreditation

Several states refer to CABC accreditation in licensing statute or regulation. The state of Minnesota passed birth center licensure later than most 214other states, and ruled that birth centers that are accredited by the CABC are deemed licensed by the state (Minnesota, n.d.). This decision was popular among lawmakers who understood that no significant cost would be incurred by the state in establishing licensure in this way. Accreditation is required for licensure in Minnesota and Illinois. Montana, California, and Florida regulations include a provision that if a birth center is CABC accredited, CABC site visits can take the place of state inspections, at least during the years that accreditation site visits occur. Two other states, North Carolina and Louisiana, deem birth centers eligible for Medicaid reimbursement if they are accredited by the CABC (AABC, 2016c). A few states require accreditation but do not specify the accrediting body.

UNDERSTANDING REIMBURSEMENT

Medicaid funding comes from federal and state dollars, is administered by each state, and pays for 44% of all births in the United States (Kaiser Family Foundation, 2010). The freestanding birth center is a licensed and often accredited health care facility. As such, birth centers are eligible for both Medicaid reimbursement for professional service fees and facility service fees (PPACA, 2010). Professional reimbursement pays for all care provided by the licensed health professional in the birth center including pregnancy, labor and birth, newborn care, or postpartum care. Depending on the scope of practice, gynecological and primary care services may also be covered. The health care professional is usually a midwife but sometimes a physician practicing in the midwifery model of care. According to the federal Medicaid statute, any midwife licensed within that state is eligible for professional reimbursement by Medicaid, inclusive of CNMs, certified midwives (CMs), certified professional midwives (CPMs), licensed midwives (LMs), or direct-entry midwives.

Federal statute also requires that separate payments be made to birth centers for professional and facility services (PPACA, 2010). Facility reimbursement covers the cost of the licensed health care facility and is similar to the costs incurred by a hospital. Facility costs may include rent, furnishings, medical equipment, utilities, nursing or birth assistant staff, insurance, administrative staff, maintenance, and all other costs of sustainability of the facility that are not part of the professional reimbursement coverage. Facility reimbursement is available in most states for labor, birth, and recovery time until discharge, and for at least partial reimbursement if the baby is not born in the birth center due to the need for a transfer during labor.

215Several states currently reimburse a newborn facility fee as well as a payment for the mother’s care, and others are seeking to add a newborn payment. Equipment and trained staff that are required to be available to provide neonatal resuscitation at birth if needed and normal newborn care during the birth center stay provide the justification. In a birth center, mother and baby are cared for together in the same birth room until discharge. The midwife and birth assistant or nurse must be dually trained to handle normal birth and postpartum care, as well as maternal or newborn emergencies should they arise.

State Medicaid and Medicaid Managed Care Organizations

Since passage of birth center Medicaid payment, implementation of mandated Medicaid payment of birth centers has been slow and inconsistent in some states. A review of State Plan Amendments (SPAs) filed with Centers for Medicare and Medicaid Services (CMS) finds that five states that recognize or license birth centers have no SPA on file (AABC, 2016d). Nine states have SPAs on file that are not in compliance with the mandate to pay licensed birth centers with separate payments to the licensed birth attendant and facility (AABC, 2016d).

Medicaid managed care organizations (MMCOs) administer all or part of Medicaid plans in 39 states (CMS, n.d.; Kaiser Family Foundation, 2013). MMCOs in some states have refused to contract with freestanding birth centers (AABC, 2015). In California, State Medi-Cal officials issued an “All Plan Letter” instructing the MMCOs to include birth centers in their plans (California Department of Health Care Services [DHCS], 2015). The letter states that all Medicaid health plans must provide access to birth centers in the state to be in compliance with federal law. Furthermore, health plans are encouraged to contract directly with birth centers, or at least to pay for their services as out-of-network providers (DHCS, 2015). According to communications with California birth centers, Medicaid health plans have not changed contracting or payment patterns in response to the letter (AABC, 2016d).

TRICARE Payment

Birth centers have been recognized and reimbursed by CHAMPUS/TRICARE since 1988 (TRICARE, 2008). To be an authorized TRICARE birth center, the center must be accredited by CABC, Accreditation Association for Ambulatory Health Care, or The Joint Commission (TJC), and care must be provided by CNMs at this time (TRICARE, 2008). Current 216challenges with TRICARE are that plans are now administered by private contractors who are affiliated with private health plans. These plans may refuse to contract with birth centers that have met requirements, stating that they have adequate networks of obstetric providers within hospitals. AABC is working with TRICARE administrators to encourage them to include birth centers in all their networks (AABC, 2016d).

CURRENT POLICY AND BIRTH CENTERS

ACA and Birth Centers

Other components of the ACA have the potential to affect access to birth center and midwifery care (PPACA, 2010). The Harkin Amendment to the ACA, Section 2706(a) of the Public Health Service Act, is codified in the U.S. Code as 42 U.S.C. §300gg-5 (Patient Protection and Affordable Care Act, 2010). The Harkin Amendment requires that group health insurers and individual health plans may not exclude a health provider from participation in a health plan if that individual is acting within the scope of his or her license or certification. The provision was put in place to prevent health plans from discriminating against nonphysician providers. The amendment also states that although health plans are not required to contract with or include in network all willing providers, they may not exclude an entire class or type of provider. The Harkin Amendment does not apply to Medicaid, but to commercial health plans that qualify under the ACA, and to Employee Retirement Income Security Act (ERISA) plans, also known as self-insured plans. Thus far, birth center efforts to point to the Harkin Amendment when negotiating with commercial health plans have not been helpful because no mechanism for enforcement is included in the measure (AABC, 2015).

CMS Issues New Guidance

In 2016, the CMS issued new guidance to all states in a state official letter (CMS, 2016). The guidance addresses problems with payment to Federally Qualified Health Centers (FQHCs) and Rural Health Centers (RHCs). The guidance also addresses MMCO network insufficiency with FQHCs, RHCs, and freestanding birth centers, which CMS abbreviates as FBCs. It reiterates that coverage of all these facility types is mandated in federal law. The guidance further requires that as of July 2017, every MMCO must contract with at least one birth center to be considered as having an 217adequate network of providers. In addition, the letter states that birth center services must be provided in birth centers, so MMCOs can no longer claim that those services are being provided by physician providers in a hospital (CMS, 2016). The impact of this guidance on access to birth center care for Medicaid beneficiaries remains to be seen and must be evaluated periodically.

FEDERAL RESEARCH AND INITIATIVES

Strong Start for Mothers and Newborns

In 2012, the Center for Medicare and Medicaid Innovation (CMMI, 2016) initiated the Strong Start for Mothers and Newborns Initiative with an announcement by Secretary Kathleen Sebelius at the DC Developing Families Center and Birth Center. Strong Start I was an initiative to work nationally via public and private partnerships to reduce elective induction of labor before 39 completed weeks (CMMI, 2017). Strong Start II is a project to study enhanced models of prenatal care to determine their effectiveness in reducing preterm birth and other complications of pregnancy that are associated with significant racial disparities in the United States.

AABC was awarded a grant to convene a group of 45 birth centers in 20 states to provide enhanced prenatal care and collect data on outcomes over the course of a 3-year period. Currently, AABC is in Year 3 of enrollment and data collection using the AABC Perinatal Data Registry (PDR). As of fall 2016, 8,300 women have been enrolled and more than 4,900 babies have been born to AABC Strong Start mothers (AABC, n.d.). Birth center prenatal care topics related to cost, quality, and satisfaction have been discussed in many other chapters in this book, including Chapter 10. The enhanced model of prenatal care is essentially midwifery-led care of low-risk women that is time intensive and relationship based. Prenatal visits are longer than in standard prenatal care, with time spent getting to know women and their individual needs and providing education and supportive care that is individualized for their unique situations.

The AABC sample of 8,376 participants enrolled in AABC Strong Start is much more diverse than the populations in previous large cohort studies of birth center care (AABC, n.d.; Rooks et al., 1989; Stapleton, Osborne, & Illuzzi, 2013). According to preliminary data, participants include 12.9% Black women and 22.8% Hispanic women in the study group (AABC, n.d.; Cross-Barnet & Clark, 2016). All participants must be Medicaid or 218Children’s Health Insurance Program (CHIP) beneficiaries. Demographic and risk characteristics of the AABC sample are comparable to the U.S. childbearing population overall (Jolles, Stapleton, & Langford, 2016).

Preliminary data for AABC Strong Start show an overall 8.77% primary cesarean rate, a preterm birth rate of 4.87%, and low birth weight rate of 3.1%, compared with national rates of 21.5% cesareans for low-risk women, a preterm birth rate of 9.6%, and low birth weight rate of 8% (AABC, n.d.; Leapfrog Group, 2016; Martin, Hamilton, Osterman, Curtin, & Mathews, 2015; Osterman & Martin, 2014). Breastfeeding rates are significantly higher for AABC participants than the other models being tested. Participants also express a higher rate of satisfaction with their care (AABC, n.d.).

Quality Indicators for Maternal and Infant Health

Quality outcome measures comparing data from Medicaid beneficiaries in birth center care with national baseline levels and benchmark levels demonstrate that birth center outcomes are significantly better (AABC, 2016, n.d.; Osterman & Martin, 2014). Quality indicators such as elective inductions prior to 39 weeks and low-risk cesarean rates are used to monitor how providers and facilities compare with national benchmarks set by groups, such as Leapfrog Initiative and the National Quality Forum (Leapfrog Group, 2016; National Quality Forum, 2012; see Figure 9.2).

FIGURE 9.2 Birth center outcomes exceed quality benchmarks.

NTSVC, nulliparous, term, singleton, vertex
Sources: AABC (n.d.); Leapfrog Group (2016); Osterman & Martin (2014); and Stapleton et. al (2013).

CURRENT POLICY DEVELOPMENTS

American College of Obstetricians and Gynecologists Consensus Statement Levels of Maternal Care

219In 2015, the Consensus Statement 2 was published by the American of College Obstetricians and Gynecologists (2015). It states that freestanding birth centers are a recognized level of maternity care within the U.S. health care system. The purpose of the document is to describe each level of maternal care, document types of providers required to provide care, and identify levels of risk appropriate to each level of care. Levels of care were first recognized in the 1970s with the development of regionalization of maternity care (American College of Obstetricians and Gynecologists, 2015).

The Levels of Maternal Care document states that for birth center care, every birth should be attended by at least two professionals. Primary maternal care providers shall include CNMs, CMs, CPMs, and LMs who are legally recognized to practice within the jurisdiction of the birth center; family physicians; and OB/GYNs. An appropriate number of qualified professionals with competence in Level 1 care criteria and ability to stabilize and transfer high-risk women and newborns should also be available (American College of Obstetricians and Gynecologists, 2015). Levels of risk appropriate to the birth center are described as singleton, vertex, and term pregnancies and women who are expected to experience low-risk labor and birth without complications (American College of Obstetricians and Gynecologists, 2015). Capabilities of a birth center under the Levels of Care document include having equipment to provide low-risk maternal care and a readiness at all times to initiate emergency procedures to meet unexpected needs of the woman and newborn within the center, and to facilitate transport to an acute care setting when necessary. In addition, the document recommends that birth centers have an established agreement with a transfer hospital and procedures in place that will facilitate timely transport, quality improvement programs, and data collection capabilities (American College of Obstetricians and Gynecologists, 2015).

Finally, the American College of Obstetricians and Gynecologists document recommends that medical consultation be available at all times. As birth centers have repeatedly indicated, the availability of medical consultation is required for the safe practice of primary maternity care (AABC comments to FTC; AABC, 2014). Relationships for consultation 220should be mutually respectful with open and trusting communication, which will contribute to the safety of the mother and newborn and provision of seamless transfers of care when needed.

Alternative Payment Models

Alternative payment models (APMs) are new ways to reimburse health care providers and facilities for health care services provided. The prevalent payment model currently used is fee for service (FFS), in which payment is made based on the number of medical procedures and tests that are done and leads to higher overall costs for health care without an improvement in quality of care (CMMI, 2016). In alternative models, payments to providers are based on quality measures and clinical outcomes, sometimes called pay for performance (CMMI, 2016). To change the usual payment model to be more in alignment with efforts to transform health care, the U.S. Department of Health and Human Services (USDHHS) began work to emphasize value over volume (CMMI, 2016). USDHHS set the goal of tying 30% of Medicare fee-for-service provider reimbursements to quality or value by 2016 and 50% of all reimbursements by 2018 (CMMI, 2016). CMS met the goal of 30% of Medicare payments being tied to value in early 2016 (Baird, 2016).

To support this work, USDHHS launched the Health Care Payment Learning and Action Network (HCP-LAN) as a centralized work group to advance the adoption of value-based payments and APMs. This network is made up of USDHHS staff, private health plans, not-for-profit groups, and individual stakeholders working toward reforming the payment system (CMMI, 2016).

Maternity care is one focus of APM work by the HCP-LAN with specific goals of increasing the percentage of full-term births and the percentage of vaginal births in the United States (HCP-LAN, 2016). A white paper demonstrating examples of this work was released in August 2016. The white paper proposed combining innovative models of care such as birth centers with APMs (HCP-LAN, 2016). Examples included a payment bundling model where birth centers would be one of a network of options low-risk women can choose for their maternity care setting. A set rate would be paid for each woman who completes full maternity care with birth at the birth center. One example offered by AABC would make incentive payments to birth centers for providing enhanced prenatal care. Providing care in the birth center is time intensive, which limits the number of prenatal appointments a midwife can complete in 1 day. However, this model of education- and relationship-based care is worthwhile to 221women and payers due to cost savings over the whole maternity episode of care. Enhanced care in the birth center leads to improved outcomes of fewer cesareans, fewer elective inductions of labor, and fewer unnecessary medical interventions, providing higher value for lower cost (HCP-LAN, 2016).

CONCLUSION

As the benefits of birth center care are more widely recognized, additional effort will be needed to reduce barriers to birth center care. Activity will be needed at the federal legislative and agency level, and in individual states. Many of the current barriers to birth centers include outdated regulations requiring CON, written agreements with physicians, or limiting the scope of practice of the midwives practicing in birth centers to less than what they are educated and trained to provide.

All midwives working in birth centers desire positive collaborative relationships with physicians and local hospitals. Birth centers should be able to establish transfer policies and procedures with receiving hospitals. To decrease risk to mothers and infants that may occur during a transfer, policies should emphasize clear communication, respect, and support of the mother and family, as well as seamless handoffs of care. There should be no associated increase in risk to physicians or hospitals for consulting with birth centers (Booth, 2007). Birth centers are recognized as a part of the levels of maternal care; therefore, organized planning for safe and seamless transfers should be part of staff preparation and training (American Congress of Obstetricians and Gynecologists, 2015). Policies and procedures for nonemergent and emergent transfer should be in place in both the birth center and receiving hospital, and communication should be professional and focused on mother and newborn safety. Hospitals and birth centers must partner together to improve the safety of transfers between levels of maternity care.

All states need regulation allowing birth centers to operate within a positive business and health care climate. Of the eight states that do not yet recognize or license birth centers, three are in the process of adding licensure or Medicaid recognition in regulation. At least four states are currently working on revising regulations to improve access to birth center care.

Advocates for access to birth center care will continue efforts to educate Medicaid payers at the state level and TRICARE administrators about the value of birth center care and steps needed to reduce barriers to 222that care. Data from large cohort studies and AABC Strong Start will be used to demonstrate the value of birth center care. In addition, birth center advocates will encourage payers to include birth centers in their networks to help improve maternal and infant health indicators, such as cesarean rates, episiotomy, elective induction of labor, and breastfeeding rates for their entire networks.

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