Care Providers in Freestanding Birth Centers

168169Care Providers in Freestanding Birth Centers




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

1.  Describe the providers who most commonly work in freestanding birth centers

2.  Describe the typical scope of practice and skills unique to birth center providers

3.  Review national trends currently shaping provider practice in the birth center setting


The foremothers of today’s birth center providers were caring for childbearing women in community settings long before the Maternity Center Association (MCA) opened the first modern birth center in New York City in 1975. Although many of these early midwives’ stories are lost to history, we can surmise that they served their communities as helpers, companions, and experts. Native American midwives gave advice on healthy eating, herbal medicine, positioning, and ritual to guide women through pregnancy and labor. Midwives in the American colonies not only attended women in labor but also nursed their sick neighbors throughout the life span. Some had training in nursing and British herbal medicine. The capture and forced relocation of West African women to the colonies brought community midwives versed in traditional healing practices and herbalism 170who primarily attended women enslaved on southern plantations. All of these early community midwives had some important qualities in common. Although they occasionally traveled short distances to attend those in need, they rose from and lived as members of the communities they served. Some had formal training in an apprenticeship model, but most relied on experience, intuition, and their deep knowledge of the values, challenges, and hopes of women in their home communities to guide their practice (Borst, 1995; Maxwell, 2009; Rooks, 1997; Ulrich, 1990).

During the next 100 years, the role of community midwife evolved from women with homegrown expertise and apprentice training to midwives formally educated in professional nursing and/or midwifery programs. The goals of community midwifery care also shifted, from the necessary attendance of family, friends, and neighbors to public health efforts to improve outcomes for mothers and babies. The 1900s brought an influx of immigrants with training from rigorous programs in Italy and France, and apprentice-trained midwives from other parts of Europe (Rooks, 1997). In New York City, public health nurses were sent out into communities and pregnant and postpartum women’s homes to teach nutrition, self-care, and hygiene. The Boston Female Medical College created the first formal midwifery program in the United States, graduating a class of 12 women in 1850 (Boston University School of Medicine [BUSM], 2014). The Frontier Nursing Service, founded by Mary Breckenridge in 1925 to reduce maternal and infant mortality in rural Kentucky, brought midwives trained in the British model of nurses dually educated in midwifery to Appalachia (Breckinridge, 1981). In the 1940s, apprentice-trained “granny” midwives attended two thirds of births in Mississippi, South Carolina, Arkansas, Georgia, Florida, Alabama, and Louisiana. They were joined by graduates of the Tuskegee School of Nurse-Midwifery, which opened in 1941 and graduated 31 Black nurse-midwives before its closure in 1946 (Dawley, 2003; Kenney, 1942).


The early professionalization of providers of childbirth care in the United States saw a dramatic shift in place of birth from homes to hospitals; however, community midwives were largely prevented from following their patients into this new setting (Smith, 2008). Early hospital birth brought access to advances such as antibiotic therapy and anesthesia but also focused on the use of sophisticated and sometimes proprietary technology, the enforcement of institution-defined processes and standards of care, and 171pregnancy itself, often viewed as a disease process. Expansion of midwifery practice into the hospital setting was hampered by restrictive licensing and supervision laws and physician’s concerns over shared and vicarious liability (Rooks et al., 1989). The closure of many early midwifery training programs and the inability of trainees to secure midwifery preceptorships in hospitals further limited practice. Health care consumers, meanwhile, became increasingly disillusioned with the loss of autonomy experienced during institutionalized birth; in an effort to maintain safety and satisfaction, some families sought to avoid hospital birth altogether (Turkel, 1995). Hospitals had become the physician’s place for birth. Midwives needed to create a new place for birth outside of the hospital system, in order to protect their professional autonomy and model of care (Rothman in Turkel, 1995).

In 1975, the MCA opened Manhattan’s Childbearing Center (CbC) as a demonstration project, developed in response to rising rates of home birth unattended by a skilled provider (Rooks, 1997). The MCA considered other strategies to meet the needs of childbearing couples, including efforts to humanize the hospital setting, a return to home birth, and opening an independent hospital, but settled on opening a freestanding birth center (Turkel, 1995). The founders of the MCA CbC recognized the need to test a model of care that provided midwives with autonomy in their practice and women the safety and expert guidance of trained caregivers whose practice was integrated with the larger health care system. MCA Director Ruth Watson Lubic, EdD, CNM, spent 2 years preparing to open the center, extensively reviewing data pertaining to the safety of out-of-hospital birth. The CbC participated in the wider health care system by creating protocols for consultation, transport, and follow-up care. Outcome data were examined by multiple agencies in 1978 and demonstrated that the CbC operated safely while providing care that was much less expensive than hospital birth (Canoodt, 1982). The MCA CbC demonstrated the importance of providing care based on evidence, full integration into the health care system, and quality improvement through the examination of outcome data.


The American Association of Birth Centers (AABC) recognizes several types of providers able to care for women delivering in birth centers. Most are midwives; in the United States, birth centers are owned or operated by certified professional midwives (CPMs) or certified nurse-midwives/certified midwives (CNMs/CMs), or both CNM/CMs and CPMs. The 172standards for birth centers specify that providers in birth centers must be licensed according to state guidelines; the Commission for the Accreditation of Birth Centers (CABC) indicators for compliance with the standards specify that professional staff be licensed to practice in accordance with state and local laws (AABC, 2016; CABC, 2015; see Chapters 8 and 9). Therefore, the types of providers practicing in birth centers vary from state to state. CNMs are licensed providers in all states, CPMs are licensed providers in 28 states, and CMs are licensed providers in five states with a sixth anticipated soon. Physicians, including obstetrician/gynecologists and family practice physicians, also attend a small percentage of birth center births. According to 2004 to 2014 birth certificate data from 47 states and Washington, DC, 53.6% of birth center births were attended by CNMs/CMs; 39.0% by “other” midwives including CPMs, licensed midwives (LMs), and direct-entry midwives; 3.1% by physicians; and 4.3% by “other” (MacDorman & Declercq, 2016).

Certified Professional Midwives: Definition, History, Education, and Practice Model

CPMs are a rapidly growing segment of the midwifery profession in the United States. The number of CPMs increased from 500 in early 2000 to more than 1,400 in 2008, and more than 2,000 as of July 2016 (Ida Darragh, personal communication, August 6, 2016). A new generation of direct-entry (non-nurse) midwives emerged in the 1970s to serve women who were rejecting the medical model of care, rediscovering physiologic birth, and choosing to give birth at home. The CPM credential includes multiple routes of entry to the profession including accredited direct-entry programs and an apprenticeship model, which is currently evolving to meet international standards for midwifery education (U.S. Midwifery Education, Regulation, & Association [USMERA], 2015; International Confederation of Midwives, 2013). All CPMs meet the standards for certification set by the North American Registry of Midwives (NARM, 2016). Today approximately half of new CPMs are graduates of programs of study accredited by the Midwifery Education Accreditation Council (MEAC, 2016; Ida Darragh, personal communication, August 2016), a national accrediting agency recognized by the U.S. Department of Education (2016). CPM training occurs exclusively in out-of-hospital community settings focusing on supporting physiologic birth. Most CPMs attend birth in homes; however, more are moving to birth center practice as opportunities for legal practice expand, and health care consumers increasingly recognize that birth center care is associated with lower rates of unnecessary intervention, lower risk of 173cesarean birth, and excellent outcomes for mothers and babies (Dekker, 2013).

Certified Nurse-Midwives/Certified Midwives: Definition, History, Education, and Practice Model

Nurse-midwives are primary health care providers for women and newborns, focusing on health promotion and disease prevention for women of all ages. Nurse-midwives are dually educated; as nurses, they gain a solid grounding in the provision of skilled care inclusive of patients’ physical, emotional, and spiritual wellness (American College of Nurse-Midwives [ACNM], 2012a). To become a CNM, candidates complete a graduate program accredited by the Accreditation Commission for Midwifery Education (ACME) and pass the American Midwifery Certification Board (AMCB) national certification exam (AMCB, 2013). The Core Competencies for Basic Midwifery practice (ACNM, 2012b; Walker, Lannen, & Rossie, 2014) include ongoing, comprehensive assessment and treatment, prescribing, oversight and interpretation of appropriate laboratory testing, and individualized counseling about wellness (Walker, Lannen, & Rossie, 2014). Nurse-midwifery originated in the 1920s through the efforts of public health nurses and other advocates who believed nurse-midwives could play an important role in meeting the needs of underserved populations. Nurse-midwifery grew gradually until the 1970s when national standards for education and certification were established by the American College of Nurse-Midwives (ACNM, 2011), and federal funding was provided for nurse-midwifery education. Approximately 95% of all births attended by CNMs occur in hospitals; however, more CNMs are entering birth center practice as the number of birth centers in the United States increases.

The CM credential was created in 1994 as a direct-entry equivalent to the CNM. CMs are not nurses, and may hold other health care-related degrees or certifications. Like CNMs, they pass the same AMCB certification exam following completion of a graduate program accredited by ACME. CMs are licensed in New Jersey, New York, and Rhode Island. They are authorized by permit to practice in Delaware, and authorized to practice in Missouri (AMCB, 2013). Maine recently passed legislation that will award licensure to CMs as of January 1, 2020 (Whittle, 2016).

Other Midwives

Midwifery is an ancient profession whose origin predates formal education and government-granted regulation and licensure. There remains 174in the United States a small number of midwives who do not hold certification or license, practicing in states where licensure and/or certification is not required. The education of these individuals varies and may include apprenticeship, international education, and both degree-granting and non–degree-granting formal education. In addition, some individuals from specific communities, religious groups, or indigenous cultures may refer to themselves as midwives. These midwives are unlikely to practice in accredited freestanding birth centers, as both the standards for accreditation and state-level statute regarding outpatient medical facilities require all employed care providers to be licensed in accordance with state and local laws.

Additional Providers of Birth Center Care

Midwife leaders of birth centers function locally as health care entrepreneurs and often design care models and service offerings around needs specific to their home communities. Family practice physicians; pediatricians; family practice, pediatric, and mental health nurse practitioners (NPs); and physician assistants may provide services at freestanding birth centers. National data on extended services is limited (see Chapter 10).

In addition to the providers attending births and supervising prenatal and other women’s and infant health care, birth centers employ a variety of ancillary health professionals to further help integrate care delivery into the pregnant patient’s home community. These clinicians and others include birth assistants, registered nurses, doulas, nurse or peer home visitors, childbirth and health educators, and community health workers. Birth doulas may be hired by birth centers or by birthing mothers and provide skilled labor support. Birth assistants are most often employed by the midwife or birth center, and assist with providing care and monitoring the mother and baby. Perinatal community health workers are trained to provide support and education to women during the perinatal period by focusing on comfort measures, relaxation techniques, nutrition for pregnancy and breastfeeding, basic lactation management, and assessment for perinatal mood disorders in ways that are culturally appropriate (Mamatoto Village, 2013). Providers of lactation support including certified lactation consultants may also work in birth centers.


175Although midwives and others who work in birth centers come from different educational, practice model, and cultural backgrounds, they share several qualities in common. First, they all develop expertise in promoting physiologic labor and birth. Care delivery in community settings requires providers to be flexible and adapt their practice to the patient’s needs and often, as with home visiting, his or her physical environment as well. Birth center providers must develop clear, respectful, professional communication skills to be used in consultation, collaboration, and transfer or transport. To support the goal of remaining eligible for birth center birth, prenatal care must focus on keeping women in excellent health and low risk by promoting good nutrition, physical activity, and thorough preparation for unmedicated labor. Birth center providers deliver immediate postpartum and newborn care as part of their practice. And finally, birth center providers and staff often participate in the management of the birth center, necessitating a working knowledge of billing and coding, the business plan of the birth center, the quality assurance and improvement program, and marketing and community outreach (see Chapter 13). Facility tasks such as cleaning, ordering and stocking supplies, and maintaining equipment are sometimes carried out by providers as well.


The number of pregnant women choosing to deliver in community settings is increasing. Birth rates in nonhospital settings have been rising since 1990; the Centers for Disease Control and Prevention (CDC) reported that 0.87% of births occurred outside the hospital setting in 2004 and has increased to 1.5% in 2014 (MacDorman & Declercq, 2016). In response to this increased demand, new systems are evolving to integrate community-based care with the larger health care system. For example, the Home Birth Summit meetings and resulting collaborative statements recognize women’s right to autonomous choice of birth setting, and Summit workgroups have developed guidelines for safe and respectful intrapartum transfer of care to hospitals from out-of-hospital settings (Home Birth Summit, 2016).

The American College of Obstetricians and Gynecologists and Society for Maternal-Fetal Medicine consensus statement “Levels of Maternal Care” (Menard et al., 2015) defined birth centers as providing care to low-risk women with uncomplicated singleton term pregnancies with vertex presentations who are expected to have uncomplicated births. This statement 176marked the first time these organizations included birth centers in the conceptual continuum of maternity care in the United States. Over the past several years, new, collaborative guidance on interprofessional communication and transport has been published by several organizations, including ACNM, American College of Obstetricians and Gynecologists (ACOG), and Society for Maternal-Fetal Medicine’s (SMFM) Trans forming Communication and Safety Culture in Intrapartum Care: A Multi-Organization Blueprint (Lyndon et al., 2015). Others include Washington State’s Smooth Transitions program (Washington State Perinatal Collaborative, 2015), the Maine CDC Transport Guidelines (Maine Center for Disease Control and Prevention, 2014), and the Northern New England Perinatal Quality Improvement Network’s (NNEPQIN) Out of Hospital to In Hospital Perinatal Transfer Form (NNEPQIN, 2011).


“The birth center is the place for the practice of midwifery,” stated Kitty Ernst, Mary Breckenridge Chair of Midwifery at Frontier Nursing University (Ernst, 2012). Birth centers today are the exemplar of midwifery-led care and a haven for undisturbed, physiologic birth. The model of care continues to evolve, and further information is needed about the providers in birth centers, the range of services they offer, and how best to prepare new midwives and providers to work in this unique setting. As the national health care system shifts toward value-based payment models, supporting population health, and delivering care designed around patients’ needs, midwifery practice is gaining notice as a powerful tool to improve outcomes and patient satisfaction. From the beginning, birth center practice was directly shaped by the needs of women: safety, autonomy, and access to care within their own communities. The forces that gave rise to the birth center’s unique practice environment produced a care delivery model well equipped to meet the Institute of Healthcare Improvement’s Triple Aim of improved patient experience, improved population health, and lower health care cost. Assuring a full complement of birth center providers and staff will be important as the model continues to grow.


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May 31, 2018 | Posted by in GYNECOLOGY | Comments Off on Care Providers in Freestanding Birth Centers

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