8081The Contemporary Birth Center as Part of an Integrated Care Model LINDA J. COLE LEARNING OBJECTIVES Upon completion of this chapter, the reader will be able to: 1. Describe two models of categorizing perinatal care 2. Explain how the birth center model fits into an integrated care model 3. Discuss the ideal transfer of care from the birth center setting Freestanding birth centers began to open in the 1970s, largely in response to women’s desire for more control in their birth environment. Publications such as Our Bodies Ourselves (Boston Women’s Health Book Collective, 1976), Immaculate Deception (Arms, 1979), and Spiritual Midwifery (Gaskin, 1980) brought new inspiration and awareness to women who desired to play a larger role in their own health decisions. These decisions intersected with a wave of antiestablishment sentiment among youth who were actively rejecting war as well as the overarching political, educational, and medical systems. Emerging from the counterculture of this time period was a model of care for birth that sought to take birth out of the medical model in the hospital and embrace a social model for birth in a new kind of facility called the freestanding birth center. The increase in the number of birth centers in recent years has brought this model of care to the attention of more health care providers, legislators, policy makers, and consumers. In the decade between 2004 and 2014, the number of births occurring in freestanding birth centers doubled from 23% of all out-of-hospital births in 2004 to 46% in 2014 (MacDorman & Declercq, 822016). The expansion and success of this innovative model of care has led to health care systems and birth centers working together in ways that are mutually beneficial. More importantly, the integration of health systems and birth centers ultimately benefits families and communities by placing the woman at the center of care and providing the most appropriate level of care for each individual woman. In this chapter, two models for defining levels of care are introduced. The first model, risk-based care, has been the prevalent model for decades. A more recent model based on appropriate levels of care, including birth center care, is also explored. Coordination of services between levels of care, and integrating the birth center into a larger system of care delivery, is examined. Within this framework, it is possible to understand how creating and maintaining a cooperative environment and facilitating efficient and safe transfer of patients between levels and systems can be achieved. DEFINING THE FREESTANDING BIRTH CENTER The American Association of Birth Centers (AABC), the nation’s foremost authority on birth centers, defines the freestanding 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 are guided by principles of prevention, sensitivity, safety, appropriate medical intervention, and cost effectiveness. Birth centers provide family-centered care for healthy women before, during and after normal pregnancy, labor and birth” (AABC, n.d.). The U.S. federal government defines the freestanding birth center as “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). A freestanding birth center is a facility separate from acute obstetric/newborn care with autonomy in formulation of policy and management of operation (AABC, n.d.). A birth center may be located in a house, a medical office setting, or within a hospital, as long as it functions separate and apart from the acute care setting traditionally housed in the labor and delivery unit, with accoutrements such as labor inductions, epidurals, and surgical capability. Various providers deliver primary care within the birth center facility including licensed midwives (LMs), certified professional 83midwives (CPMs), certified nurse-midwives/certified midwives (CNMs/CMs), and physicians. More important than the physical setting, or who provides care in freestanding birth centers, are the elements of the model of care. A recent consensus document defines birth center care as “peripartum care of low-risk women with uncomplicated singleton term pregnancies with a vertex presentation who are expected to have an uncomplicated birth” (Menard et al., 2015, p. 261). Additionally, philosophical elements of the birth center model of care include care of the low-risk woman and infant, support for pregnancy and birth as a normal physiologic process supported within the midwifery model of care, and high value placed on family-centered care. Inclusion of the woman’s family and chosen support person(s) is an important element of birth center care. The birth center is a place where partners and children are welcomed regularly at prenatal visits, as well as during birth and the postpartum period. There are provisions made for the family’s comfort during labor and birth, including a family room or living room and a food preparation area or kitchen. Common hospital policies limiting nutritional intake and freedom of movement are starkly absent in the birth center setting. The woman does not lose her identity by trading in her clothing for a hospital gown, and is able to transform the environment of the birth room—through decorations, pictures, music, and aromas—into a space that brings her a sense of comfort and safety. In Chapter 11, the impacts of these elements of birth center care on physiologic birth are explored in more depth. MODELS OF CATEGORIZING CARE Two models that categorize the care of pregnant women in the United States are the risk model and the levels of maternal care model. The purpose of categorizing the levels of care of pregnant women is to make the best effort to deliver the most appropriate care for the individual patient based on health status, care provider, and facility capabilities. Treatment intensity can then be tailored to the clinical presentation of each patient. The focus of the risk model is toward the fetus and newborn, whereas the focus in the levels of care model is on the parturient, or woman receiving care, and the most appropriate facility for her perinatal care, given her unique set of medical and social circumstances. Risk Assessment 84Risk assessment, or the practice of assigning a level of risk to an individual patient, has become a routine practice in the care of pregnant women over the past century. This has led to a more medicalized model of childbirth for the majority of childbearing women in this country, regardless of actual health status (Jordan & Murphy, 2009). Although no uniformly applied assessment tool exists, this systematic practice helps providers in decision making regarding antepartum testing and fetal surveillance. Routine testing, such as screening for gestational diabetes, and obtaining the patient’s blood pressure and weight at every visit are ways in which providers identify risk in pregnancy. Certain disease states in pregnancy such as gestational diabetes or preeclampsia place women and their fetuses at risk for poorer outcomes than women identified to have an absence of disease, and risk assessment can help to identify the appropriate provider and place of birth. It is generally accepted that only women without significant risk factors should be under the care of midwives in birth centers, although in some birth centers there is a collaborative care model allowing for a portion of the pregnancy or birth experience to be under the care of a midwife with some level of physician collaboration (Stevens, Witmer, Grant, & Cammarano, 2012). This arrangement is most likely to occur where midwives have hospital privileges, in addition to their birth center practice, giving them the opportunity to remain integrally involved with patients’ care in cases where a higher level of care is warranted. The purpose of risk assessment is to predict which women and their fetuses or neonates are most likely to experience adverse events, to assign resources to those most in need, and to avoid unnecessary interventions (Institute of Medicine [IOM] and National Research Council [NRC], 2013). Maternity care providers and the women they serve can interpret risk very differently (Bryers & Van Teijlingen, 2010; Stahl & Hundley, 2003). Risk assessment and assignment can have the effect of fostering fear and uncertainty in women throughout their pregnancy and delivery. For this reason, birth center providers focus on the normalcy of pregnancy and birth and encourage healthy lifestyle choices to optimize the pregnancy outcome. It is suggested that one of the roles of the midwife in this climate of fear, risk, and intervention is to help women build confidence in their ability to have a healthy pregnancy and give birth normally (Neerland, 2013). The Guidelines for Licensing and Regulating Birth Centers (American Public Health Association [APHA], 1982) advocated for birth centers to set their own risk identification criteria to assist in identifying appropriate low-risk clients 85for birth center care. This assessment was meant to be applied throughout pregnancy and delivery and focused on reducing perinatal risk with attention toward the fetus and newborn. A simple definition of low-risk pregnancy is “singleton, term, vertex pregnancies and the absence of any other medical or surgical conditions” (IOM and NRC, 2013, p. 32). A cornerstone of the risk model is the avoidance of intervention in the low-risk pregnancy. Any intervention in the normal physiologic process must be shown to do more good than harm, as adverse events can occur when low-risk women are treated in high-intervention sites (Carter et al., 2010; IOM and NRC, 2013; Jordan & Murphy, 2009). Women identified as high-risk feel a loss of control and have lower expectations for their birth, causing them increased stress during the pregnancy (Jordan & Murphy, 2009). Clearly, a change in how pregnancy is viewed in our society is needed, since the vast majority of pregnancies are normal and uncomplicated. Levels of Maternal Care In 2015, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine created a consensus document delineating five levels of obstetric care including birth center care as a distinct level of care appropriate for the care of normal, singleton pregnancy of women with term, vertex presentation expected to have an uncomplicated labor and delivery (Menard et al., 2015). Complementary to but distinct from the neonatal focus of the widely known risk-based model, this document was based on current evidence and sought to standardize care definitions and begin to encourage the distribution of equitable services in a system with wide geographic variances. It was endorsed by AABC, the American College of Nurse-Midwives (ACNM), the Association of Women’s Health, Obstetric and Neonatal Nurses, and the Commission for the Accreditation of Birth Centers (CABC; Menard et al., 2015). The document represents the first time that freestanding birth centers have been recognized by the larger mainstream obstetrical organizations in the United States as an entity included in the framework of a larger system of integrated care. This document followed a publication from the United Kingdom’s National Institute for Health and Care Excellence (NICE), which concluded that healthy women with normal pregnancies are safer giving birth at home or in a midwife-led unit than under the supervision of an obstetrician in a hospital (National Institute for Health and Care Excellence [NICE], 2014). One of the stated objectives of the U.S. document was “to foster the development and equitable geographic distribution of full-service maternal care facilities and systems that promote proactive 86integration of risk-appropriate antepartum, intrapartum, and postpartum services” (Menard et al., 2015, p. 259). This consensus document recognized primary maternal care providers in birth centers including CNMs, CMs, CPMs, and LMs who are legally recognized to practice within the jurisdiction of the birth center, family physicians, and OB/GYNs. Such an inclusive recognition of providers of maternity care was unprecedented. In many geographic areas of the country, women lack access to perinatal care, and approximately half of U.S. counties lack an OB/GYN (Rayburn, Klagholz, Murray-Krezan, Dowell, & Strunk, 2012). Therefore, it makes perfect sense to continue to grow the birth center model so that every community has access to care at this basic level. Additionally, every region of the country should have an integrated system to provide appropriate care based on the acuity of the patient and transfer to a higher level of care when needed. Staff at every freestanding birth center must have a clear understanding of their capability to handle more complex maternal and newborn cases than originally planned for, and have a well-defined threshold for transferring patients to a higher level of care (Menard et al., 2015). INTEGRATED HEALTH SERVICES Integrated service delivery is “the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results, and provide value for money” (World Health Organization, 2008). Freestanding birth centers cannot exist in a vacuum, and depend on the larger health care system for referrals both into and out of the birth center practice. Physicians in support of this midwifery-led care model have proposed building freestanding birth centers on a large scale in association with hospitals, where women with uncomplicated pregnancy can give birth. Similar to the way outpatient surgical centers served the purpose of moving less complex surgeries out of the hospital, this scaling of the integrated birth center model could improve the experience, and safely decrease the cost of birth (Woo, Milstein, & Platchek, 2016). Not all women who access antepartum care at a birth center are eligible, or remain eligible, for birth center care throughout their pregnancy, delivery, or postpartum periods. In addition, there are instances where a newborn exhibits symptoms suggesting the need for transfer to a higher level of care. In these cases, a referral arrangement needs to be in place so that patients may quickly be transferred to a different level of care 87appropriate to their condition. Figure 3.1 illustrates how the birth center, as the point of primary care, fits into the larger integrated health care system. Birth center providers and consumers rely on ancillary services, such as laboratory, social services, and nutritional services, to provide the full complement of perinatal care. Additionally, the availability of specialists located under the umbrella of hospital or acute care is crucial to maintaining the safety of birth center practice through consultation, collaborative management, or referral, depending on the clinical situation. Ideally, there is fluid movement back and forth between the different levels of integrated care. For instance, a woman may be referred to a specialist by a birth center midwife for evaluation of a suspected deviation in fetal growth. Fetal surveillance may ensue for a period of time with normal findings, in which case the patient may return to birth center care, anticipating a normal birth center delivery. The common goal within an integrated health system should always be that a patient receives the right care from the right provider at the right time and the right place to do the most good and the least harm (Carter et al., 2010). An example illustrating how a patient can move in and out of birth center care in an integrated health care system is explored in Figure 3.1 and the following case study.
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