23Organizing for Change: History, Pioneers, and the Formation of a National Organization

KATHRYN M. SCHRAG AND KATE E. BAUER

LEARNING OBJECTIVES

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

1.  Describe the social and health care landscape in the United States that led to the development of the birth center concept

2.  Identify early pioneers of the birth center movement

3.  Describe the formation and development of the birth center trade association

4.  Discuss the opportunities and challenges for birth centers

OVERVIEW AND CONTEXT

The birth center idea is not new. We know about the earliest “freestanding birth centers” in our time established by nurse-midwives caring for the poor and underserved: La Casita in Santa Fe, New Mexico (1944) and Su Clinica Familiar in Raymondville, Texas (1970). We do not know how many physicians, nurses, or traditional midwives have, over the years, responded to the needs of women and families in their communities, providers such as the family physician who shared the following example with me in the late 1990s.

This chapter describes the development of the model of birth center services in the United States, and its adaptation on a global scale (see the Appendix). Before proceeding, the reader must understand some basic circumstances facing anyone who embarks on replication of the modern birth center. Evidence shows that it is a viable model for midwifery-led care offering a safe, cost-effective alternative to the singular medical model of service that has dominated our present system in the United States (Ernst, 1996). The challenges to innovation and replication of any model of care in the United States, however, are vastly different from those facing most other developed countries in terms of geography, size, population distribution, access to care, economies, the positioning of professions, the role of government in regulations, and our multiple insurance mechanisms of payment for services. Among the major challenges are the following:

This difference in education and socialization of providers and lack of cooperation between facilities is compounded by a lack of uniformity in regulations among 50 different states that presents formidable challenges to introducing or replicating innovations, such as the freestanding birth center, nationwide (Lubic, 1979). Furthermore, the importance of payment mechanisms cannot be minimized, for without insurance reimbursement, no model of care can be sustained or replicated. Payment is a primary driver of how and by whom all health care is delivered. For example:

Birth centers, which support the start of life, can be compared to hospice care, which supports the end of life. Hospice care at the end of life was an innovation that was introduced about the same time as the freestanding birth center (National Hospice and Palliative Care Organization, 2016). The basic tenet of hospice is that the end of life cannot be cured, which is what physicians do, but it can be eased with comfort measures, which is what nurses do. Hospice has greatly relieved the burden on families at the end of life. Hospice care is now available in almost all communities nationwide, while birth centers are still struggling with obtaining legislation, regulation, and reimbursement state by state. Why? First, hospice is the provision of good old fashioned nursing care, which has always been viewed as essential and complementary rather than competitive to physician care. Second, hospice is included in the federally administered Medicare program, which is the single payer for universal health care for senior citizens.

There is no universal, single payer program for women and families at the beginning of life. The Affordable Care Act (ACA) has included midwives and birth centers under the Medicaid payment program. Time will tell if the ACA survives and, if so, whether all states will implement the ACA birth center provisions and if Medicaid reimbursement will be sufficient to meet the basic operating costs of birth centers, thus allowing women increased access to birth centers.

—Kitty Ernst.

EARLY MIDWIFE-LED MATERNITY CENTERS

La Casita

7La Casita, the “little house” in Santa Fe, New Mexico, is often cited as the precursor to the modern midwife-led birth center movement (Figure 1.1). Students and midwives reflecting on their experiences at La Casita (Kroska, 2010) noted that the term maternity home was used then as there was no formally defined concept of a birth center. The center was initially indeed a small house, a two-room adobe structure that the midwives at Catholic Maternity Institute (CMI) opened in 1946 to complement their existing home birth practice.

Sister Theophane Shoemaker and Sister Helen Herb, both Medical Mission Sisters and nurse-midwives, came to Santa Fe in 1944 as recent graduates of the Maternity Center Association’s (MCA) Lobenstine School in New York City (NYC; Varney & Thompson, 2016). The Society of Catholic Medical Missionaries had historically worked internationally providing nursing and medical care to profoundly underserved women and children. The instabilities of World War II, coupled with the lack of health care providers to address the high maternal and infant mortality rates in northern New Mexico, resulted in the decision of the sisters to accept a call to Santa Fe (Cockerham & Keeling, 2010).

FIGURE 1.1 La Casita.

Courtesy of Elizabeth Bear.

8The midwifery practice they created, the CMI, served a primarily poor rural Spanish-American population in the Santa Fe region, which then had a county population of 30,826 (Rob Martinez, New Mexico Assistant State Historian, personal communication, June 16, 2016). The institute was originally planned as a home birth service, but responding to practical considerations, the sisters added a place where women could give birth, La Casita. Initial reasons for adding a maternity center location included proximity to a hospital for transfers and minimizing long travel times to patients’ homes (Cockerham & Keeling, 2010). Soon the midwives realized that many of the women preferred to give birth at La Casita. Irene Matousek (Kroska, 2010, p. 163) commented that “only rare homes contained a shower, and the women luxuriated in the warm water, frequently shampooed their hair, and felt the therapeutic benefit of nice warm water pulsing over their lower back. Sometimes these were long showers!” Additional factors influencing the popularity of the maternity home were other modern conveniences, such as telephone and electricity, the ability to stay for several days free from household responsibilities, and, according to the midwives, the prestige of delivering in a medical facility (Cockerham & Keeling, 2010).

Demand for the use of La Casita grew, and by 1951 it had increased to about 20% of the births attended by CMI midwives. A new, larger facility was built across from the CMI’s main building. Historians Cockerham and Keeling (2010) described CMI’s mounting financial struggles and the midwives’ philosophical conflict about attending a diminishing proportion of their births in the home setting. The midwives also recognized the personal advantages such as avoiding travel over poorly marked mountainous roads; the reassurance of a hospital, St Vincent, two blocks away; and the logistical simplicity for them and their midwifery students to move back and forth between the center and the clinic. By the mid-1960s, the majority of the births occurred at La Casita. The increasing expense of providing birth services at the La Casita facility, coupled with the inability of families to pay for their care, led to a growing financial strain on the organization, and in July 1969 CMI closed its doors (Cockerham & Keeling, 2010).

Su Clinica

Only a few years after La Casita closed, another Catholic Sister, a thousand miles away, created what historically is considered to be the second birth center in the United States: Su Clinica Familiar in Raymondville, Texas. In 1971, Su Clinica opened its doors in a rural county in the deep south of Texas. Led by Catholic Charities and the Migrant Health Division of the U.S. Department of Health, Education, and Welfare, their mission was to provide much-needed medical services to the migrant community. Sister Angela Murdaugh, a recent and enthusiastic graduate of Columbia University’s midwifery program, volunteered to develop the maternity program at the clinic.

Sister Angela (personal communication, February 11, 2016) reports that the small local hospital had recently closed, and women had to travel far to give birth in the nearest hospital. Many women were attended by the community parteras (lay midwives) who often had a room in or behind their own homes for women to give birth, so the concept of a home-like, midwife-attended birth in another facility was familiar to women. Sister Angela was well aware of the work at La Casita, and approached the clinic administration with what to her seemed like an obvious solution to the problem: create a place within their clinic for healthy women to give birth. The administration and physicians were supportive, although initially they asked that women and their babies stay for 24 hours following the birth.

Within 3 months, Sister Angela and her support team of a licensed practical nurse (LPN) and a volunteer were attending births in Su Clinica Familiar maternity division, an eight-room area of the clinic with two 11exam rooms, a small office, a two-room birth area, and a two-bed postpartum room. They welcomed their first baby in July of 1972. Five months later, a much-appreciated second midwife joined the team. The midwives consulted with three obstetricians who received their transfers at the nearest hospital 25 miles away. Although the term birth center was not yet in common use, the philosophy and care was consistent with what we call a freestanding birth center today. The practice quickly grew and the midwives soon attended a caseload of about 150 births annually (Sister Angela, personal communication, February 11, 2016). According to the 10th anniversary report of the health center (Ramirez, 1981), the Raymondville clinic midwives had delivered more than 1,200 babies, accounting for 75% of all recorded births in Willacy County during its first 6 years.

By 1977, Su Clinica opened a second birth center, but this one was located within the walls of their transfer hospital in Harlingen. The newly formed National Health Service Corps contributed to the success of the centers with recently graduated midwives working in health care shortage areas in exchange for scholarships. Yet another national issue, the malpractice insurance crisis of the mid-1980s, resulted in the closing of both of Su Clinica’s birth centers (Sister Angela, personal communication, February 11, 2016).

Sister Angela left Texas in 1981 to fulfill her responsibilities as the newly elected president of the American College of Nurse-Midwives (ACNM). While in Washington, DC, she also completed a legislative internship. Two years later, Sister Angela returned to the Rio Grande Valley. With the assistance of Catholic Charities for the first 5 years, she devoted her energy and talents toward opening a new independent birth center, Holy Family Services and Birth Center in Weslaco, Texas. Three decades later, Holy Family continues to serve women and their families (Sister Angela, personal communication, February 11, 2016).

DEMONSTRATION AND DEVELOPMENT OF THE BIRTH CENTER CONCEPT IN THE UNITED STATES

In the 20th century, there was a cultural shift in the care of childbearing women from the midwife to the physician attending women in childbirth and a change in the place of birth from the home to the acute care hospital for more than 99% of all childbearing women. Unlike in most other developed countries with formally educated midwives, midwifery almost ceased to exist in the United States. The shift benefited the minority of women who experienced complications needing medical or surgical intervention and maternal mortality dropped dramatically. Other major influences on developing the system of care in the second half of the century included the discovery of antibiotics, medical school funding, and education under the GI Bill. Additional influences on the physician–hospital model of care were the Hill-Burton Act to establish hospitals in all eligible communities, and the beginning of employer and medical assistance insurance coverage, including maternity care. The promise to childbearing women of pain relief and the ability to deal with complications, coupled with third-party insurance, drove the shift to nearly all of childbearing women receiving physician care in hospitals (Devitt, 1977).

The singular focus on developing the specialty of obstetrics for treatment of medical complications of pregnancy and birth and the elimination of midwifery led to all birth being controlled and delivered 13as a medical event—an illness or an emergency waiting to happen. Identification of “low risk” and “high risk” for complications was not considered, and nurses were not trained nor hospital routines revised to meet the needs of the healthy childbearing women. Many invasive medical procedures and policies were widely accepted and routinely implemented without adequate study (e.g., pelvic shave, enema, routine episiotomy, separation of newborn from mother; Albers & Savitz, 1991). Electronic fetal monitoring, intravenous fluids, confinement to bed, and restriction of nourishment are still routine in many places in spite of the evidence that these procedures are of little value to healthy childbearing women. Epidural anesthesia became the preferred procedure for pain relief. Perhaps most important has been the promulgation of fear that eroded women’s confidence in their ability to give birth.

Furthermore, the shift to hospital birth included the routine disruption of the birth experience of families without examination of the consequences: Newborns were separated from their oversedated mothers and placed in central nurseries, breastfeeding gave way to formula feeding newborns by the clock, and fathers and children were excluded and denied participation in what we are now just beginning to understand as one of the most profound teaching and “bonding” experiences of anyone’s life (Johnson, 2013).

Lastly, almost all research on birth has been conducted in the acute care hospital setting where imposed routines interfered with the little understood normal physiologic process of human labor and birth. The incidences of infant mortality and low birth weight babies gradually dropped, but our rates continue to be higher than those in other developed countries where most of the care of low-risk women is provided by midwives (MacDorman, Matthews, Mohangoo, & Zeitlin, 2014).

Maternity Center Association Childbearing Center

In the early 1970s, activist, educated, insured women turned to “do-it-yourself” home birth as the only option that would guarantee the control they desired for their birth experience. Some public health and policy makers viewed this as a pending public health problem. MCA viewed it as a system’s need for a safe alternative to hospital medical services that embodied the midwifery model of supportive care.

MCA was founded in 1918 with a mission to work to improve the quality of maternity care, and had been a pioneer in demonstrating solutions to pressing problems: the need for prenatal care in the 1920s, the need for nurse-midwifery education in the 1930s, and the need for formal 14childbirth education in the 1950s. Responding to the public demand for alternatives in care, they decided to build on the experience of the two birth centers previously described, La Casita and Su Clinica, and establish a demonstration model of a freestanding birth center in New York City. There was considerable opposition from the obstetrical community to the center being freestanding but more acceptance of the concept if located within the hospital. Based on MCA’s past experience with in-hospital demonstrations, MCA decided it would only be successful if it had the autonomy to demonstrate and evaluate sustainability as primary midwifery health care for low-risk women, and pursued a freestanding model within an organized system of medical specialist collaboration and cooperation for access to acute care hospital services when indicated.

To be part of the health care system, MCA entered the complex political arenas of obtaining a certificate of need (CON) for the temporary establishment of the service, and public hearings after 2 years of operation. This required meeting all the New York codes for licensure, becoming accredited for the quality of services provided, securing liability insurance coverage, and obtaining a commitment of reimbursement from health care insurers. The development was led by Ruth Watson Lubic, CNM, general director of MCA, and in 1975 the first licensed, accredited, freestanding childbearing center (CbC) in the United States opened. The years of oppositional and redressive actions by powerful members of the medical establishment are detailed in Lubic’s dissertation (Lubic, 1979).

With determination and strategic support, the center negotiated access to needed specialist and hospital services, and a contract for payment from New York’s largest health care insurer, Blue Cross Blue Shield (BCBS). The contract provided that BCBS would evaluate the services for safety, client satisfaction, and costs to insurers. The published evaluation of the CbC by BCBS reported that the demonstration birth center care was safe, satisfying, and offered significant savings to payers (Canoodt, 1982), and the relationship continued.

MCA’s mission was to provide services to any woman seeking a change from the conventional system, but found that the majority of families that came to the center were the upper-middle class women of Manhattan. This led to Dr. Lubic’s work of the following decade: opening a birth center in a low-income NYC neighborhood. In 1988, a second MCA center, the Childbearing Center of Morris Heights Health in the South Bronx, began providing services to low-income women and their families.

15EXEMPLAR
The Childbearing Center (CbC), New York, New York

20THE FORMATION OF A NATIONAL ORGANIZATION

By the late 1970s, nurse-midwives and activist women across the country were responding to women seeking an alternative to hospital confinement by establishing birth centers, often in hostile environments, but without national resources and expertise. In 1979, Kitty Ernst was invited to be the graduation speaker for the nurse-midwifery program at the University of California, San Francisco (UCSF). With support from MCA, she added a tour of 14 known birth centers across the United States to assess their needs. Her findings were that, although founders were passionate about replicating the birth center model, they were all struggling with the same issues of a lack of uniform guidelines and standards needed to gain licensure and reimbursement for services and a mechanism for multisite data collection. The interviews with these pioneers further disclosed that, as a group, the founders of these centers had a common background of either social activism or missionary service that drove their passion to respond to the childbearing women seeking an alternative to the hospital medical model of care. Most were doing it alone with their own resources and support by friends. None had the support of a national voluntary health agency, such as MCA (Kitty Ernst, personal communication, August 5, 2016).

MCA responded immediately to the report of these observations by funding travel for representatives of these centers to meet in New York to determine how best to proceed. With no funding for food or hotels, participants arrived armed with sleeping bags to be housed on the couches, benches, and floors of MCA’s historical, elegant townhouse on the upper east side of Manhattan in New York City (subsequently the home of Woody Allen). Cooked food for the weekend was brought in from Pennsylvania by Kitty Ernst and supplemented with fresh salad material provided by Jane Powel, an MCA board member, from her gardens on Long Island. At that meeting, the Cooperative Birth Center Network (CBCN) was formed to facilitate sharing information. The participants prioritized the need for uniform guidelines and standards necessary for gaining licensure and reimbursement for services, as well as a mechanism for multicenter data collection to evaluate the program of care they were providing.

Anita Barbey Bennetts, a nurse-midwife working on her doctorate in public health at the University of Texas School of Public Health, came prepared to gain the collaboration of the group for the first multisite study of birth centers. Jane Powel pledged $20,000 for travel to the birth centers to collect the data. The participating centers promised to open their files 21and provide board and room during the data collection (Kitty Ernst, personal communication, August 3, 2016). This retrospective multisite study of outcomes in 14 birth centers was published in the Lancet in 1982 (Bennetts & Lubic, 1982).

The NYC meeting of the midwives from the 14 birth centers represents a critical turning point for the replication of MCA’s demons tration CbC through the establishment of a national organization to provide ongoing guidance for the further development and evaluation of this potentially important innovation. Funding for the establishment of the membership organization was secured by MCA from the John A. Hartford Foundation. As the work of the organization grew to meet the challenges of a changing health care marketplace, the name has changed but the founding mission has remained constant. The CBCN became the National Association of Childbearing Centers (NACC) in 1983 and the American Association of Birth Centers (AABC) in 2005 (see Table 1.1).

Throughout the 1980s, AABC laid the foundation for the promulgation of the birth center concept by developing national standards to assure quality care, fostering regulation through state licensure, securing liability insurance, establishing a mechanism for accreditation, promoting reimbursement for services, and launching a prospective multisite research study on birth center outcomes. These initiatives and the role of the birth center within the U.S. health care system are explored further in detail in Chapters 3, 8, and 9.

What Is in a Name?

What to call, and how to define, a birth center has been an ongoing discussion for the decades since the concept was introduced as a part of our health care system. The first demonstration project, MCA, used the term childbearing center, and this term was incorporated into the name of the professional organization in 1983, the NACC. The change to the AABC in 2005 was approved by the members to better reflect the use of the name “birth center” in public and professional parlance. In 1995, the term freestanding was dropped from the name of the Birth Center Standards, and from the title of the CABC. Without trademark protection, the name spread quickly to the hospital arena. The adoption of the name “birth center” by some hospitals to describe their medical-model labor and delivery units led to ongoing confusion regarding the model.

AABC has historically described the birth center model of care with five Ps (Ernst & Bauer, 2016b).

•  PEOPLE: Healthy women anticipating a low-risk pregnancy and birth, attended by qualified staff with full comprehension of midwifery practice, and qualified physician consultants

•  PLACE: A maximized home rather than a minimized hospital room, which is autonomous in its management, and separate from acute obstetric/newborn care, and is equipped to provide routine care and initiate emergency procedures

23•  PROGRAM: Clinical services that include education, antepartum, intrapartum, postpartum, and newborn care, with informed consent and family involvement

•  PRACTICE OF MIDWIFERY: Primary care that emphasizes support for pregnancy and birth as a natural physiologic process with emphasis on promotion of health and shared decision making, and operating within a system of delivery of health care

•  PART OF THE SYSTEM: Arrangements for referral to collaborating physicians, complementary services, community agencies, and transfers to other levels of care including access to an acute care obstetrical/newborn unit

The Standards

The definition of a birth center included in the AABC Birth Center Standards, most recently updated and approved by the membership in August 2016, is:

Regulatory Definitions

In 1982, AABC published a legal description of a birth center within its Recommendations for the Regulation of Birth Centers, which the American Public Health Association (APHA) used for its Guidelines for Licensing and Regulating Birth Centers. Since that time, 39 states and Washington, DC, have adopted specific definitions of and regulations for birth centers, many based on the APHA Guidelines. The 2010 ACA 24added a statutory definition of a “freestanding birth center.” Definitions are also found in industry organizations, such as the National Fire Protection Association, Facility Guidelines Institute, North American Industry Classifications System, National Uniform Billing Committee, and Ambulatory Health Care Facilities (Kate E. Bauer, personal communication, August 1, 2016).

 

---

On Conducting the National Birth Center Study

Reflections of Founding Midwife Kitty Ernst

Conducting the first National Birth Center Study was fraught with challenges from the beginning, but I felt deep down that the birth center concept could not survive without significant and credible evidence to support it. The first national, retrospective study voluntarily conducted by Anita Barbey Bennetts was not enough. With the voluntary help of a premier nurse-midwife researcher and epidemiologist, Judith Rooks, a plan for a large, multicenter prospective study was developed and proposed to MCA’s Research Advisory Committee. Their response was “Your proposal is ambitious and laudable but, my dear, you have $20,000 to conduct a $1,000,000 study?” and “I could not get nurse-midwives to complete a one-page data form—they will never complete a twelve-page data collection form.” I was crushed but without thinking responded to their challenge with, “These are birth center midwives. They will complete the forms and the study will be published in the New England Journal of Medicine.”

With the support and connections of Ruth Watson Lubic, director of MCA, Judith Rooks and I approached the Penn Science Center to provide the computer services necessary to proceed. They recommended the latest technology of scanned computer forms and connected us with a printer 50 miles away in Lancaster, Pennsylvania, who, upon hearing our story, also consented to print the 20,000 booklets with perforated pages of forms at their cost, which was nearly our full $20,000 budget. I was convinced that if we could get the data into a computer, someone would pay to get it out, but the challenges were just beginning.

25When the 25 boxes of printed forms arrived, we found that only the first page was perforated instead of all pages as stated in the contract. I felt that even the smallest glitch in the process of data collection would be a deterrent to busy practitioners collecting data. They were returned and reprinted.

The mid-1980s was a turbulent time for nurse-midwives and birth centers. After cataloguing and shipping the forms to the centers, the major liability insurance carrier for both the nurse-midwives and the birth centers withdrew from the market. About 25% of centers returned the unopened boxes informing us that, without liability coverage, they were forced to close. The remaining centers stayed the course, determined to provide evidence that the birth center was a concept that could become part of the solution to the problems we faced in the delivery of care to childbearing families. The returned 2,000 forms were distributed to nurse-midwives practicing in hospitals and analyzed for practice and outcome comparisons. “When you get handed a lemon, make lemonade.”

The next major challenge came with the need to “clean the data” on-site at the science center. Susan Rutledge Stapleton spent months driving 65 miles from her birth center in Reading, Pennsylvania, to Philadelphia, Pennsylvania, for an untold number of nights to complete this extraordinary task for what amounted to travel reimbursement.

Now we were at the tipping point for finding and funding a credible research base for analysis and publication of the data. Dr. Alan Rosenfeld, dean of the Columbia University Mailman School of Public Health and member of MCA’s Medical Advisory Board, consented to participating in the project if the funding was secured. Ruth Watson Lubic, director of MCA, after a touch and go meeting with the Kellogg Foundation, secured their consent to fund the project. Judith Rooks signed on to the staff of the Columbia University Mailman School of Public Health to work with statistician Norman Weatherby to complete the project.

The article was submitted to the New England Journal of Medicine and, after a year of reviews, was scheduled to be published in the 26late December issue, 1989. Mission accomplished, right? Not by a long shot.

When the MCA board was informed of the success, one of the women on the board who worked for a large advertising firm exclaimed, “Wait a minute. The end of the year issue is a dead issue for any marketing of the study. If you want any coverage it will have to be prepared and disseminated immediately. I’ll talk to my firm.” The firm agreed to do the marketing for $16,000 and it was up to the birth centers to raise it. When informed, an urgent request went out to all centers that 32 birth centers each contribute $500, which secured the funding. Some even borrowed the money to do it. The payoff was that the nationwide coverage was extraordinary from newspapers, radio, and TV.

Only then was the mission accomplished, and it was worth every month and dollar spent to produce what came to be called “a landmark study.”

Reprinted with permission from Eunice (Kitty) Ernst.

Reflections of Founding Midwife Susan Rutledge Stapleton

Kitty called me and said, “I need some help on a little project—you’re not very busy, are you?” Well, no, except for running a birth center. The “little project” was the First National Birth Center Study, and it consumed a staggering amount of time for everyone involved for more than 3 years—the NACC/AABC staff, Judith Rooks (primary investigator), and, most of all, the birth center midwives and staff who spent untold hours marking little circles on thousands of scanable data forms. Kitty and I would work all day in our respective offices, and then would work on the study data into the wee hours of the morning. I spent weeks sitting on the floor in the data center in Philadelphia, surrounded by boxes of forms, cleaning data and entering corrections from the birth centers. It was a herculean effort, an unprecedented accomplishment, and remains a landmark study of birth center care.

Reprinted with permission from Susan Stapleton.

---

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

1. Cost Outcomes and Finances of Freestanding Birth Centers
2. Clinical Outcomes in Birth Centers
3. Preparing the Workforce
4. Birth Center Regulation in the United States

Stay updated, free articles. Join our Telegram channel

Join