Gindi, who had recently moved to Washington, had had a Caesarean section with her first child in 2008 at a Baltimore hospital where she felt pressured to give up her effort to deliver naturally. She was determined to feel more in control for the second. She wanted a provider who supported her desire to try again for a vaginal birth, and the birth center fit the bill.
Because professional guidelines say that a vaginal birth after Caesarean, or VBAC, should be attempted only in places where surgical intervention is “immediately available,” Gindi could not have her baby at the birth center. It has no physicians and is staffed by certified nurse-midwives, a type of advanced-practice registered nurse with expertise in low-risk pregnancies. But its agreement with Washington Hospital Center meant that Gindi could still have the birth center experience by doing her pre- and postnatal care at the birth center and then delivering at the hospital under the management of birth center midwives. Doctors would be called in only if problems developed.
“Maybe they were going to have to recommend a C-section all over again, but I could tell this was the kind of place where . . . they were going to listen to me,” she said.
How did it work out? After 30 hours of contractions and labor at home, Gindi and her husband met birth center midwife Dorothy Lee at the hospital for delivery. And about five hours after that, with Lee’s guidance and with doctors largely out of sight, Gindi delivered a healthy baby girl vaginally in May.
“If there was ever any second-guessing of what the midwife was doing, it certainly didn’t happen in front of me,” Gindi recalls. “It was a pretty amazing experience. I feel really, really lucky.”
The relationship between the birth center and the hospital began in 2000, when Ruth Lubic, a midwife and MacArthur “genius grant” recipient, set up the center near Benning Road in a part of Northeast Washington where infant and maternal mortality were high. Birth center patients have better maternal and child health outcomes than the District and national averages, says general director Cynthia Flynn. In 2010, for example, the center’s preterm delivery rate was 2.2 percent and its low birth weight rate was 3.8 percent. These rates for Washington overall in 2009 exceeded 14 and 10 percent, respectively, according to preliminary data from the Centers for Disease Control and Prevention.
Accredited free-standing birth centers are safe for labor, delivery and the immediate postpartum period, according to the American Medical Association and the American College of Obstetricians and Gynecologists, or ACOG. But some women, such as Gindi, are not eligible to deliver at the birth center. A previous Caesarean, anemia, a multiple pregnancy and substance abuse are all factors that make a woman “risk out” of delivering there, says Judith Krones, a midwife at the center and co-chair of the Washington chapter of the American College of Nurse-Midwives.
Other women may choose a hospital delivery because they want the option of pain relief or access to longer post-birth care (Washington Hospital Center keeps new moms for at least 24 hours, while the birth center releases them after four to six), or because they feel more comfortable in a hospital setting.
Washington Hospital Center, like several other hospitals in the area, has midwives on staff, but their patients are seen in the hospital setting throughout pregnancy and birth.
A birth center delivery, on the other hand, offers a woman more freedom to eat and drink throughout labor, as well as the expectation of an unmedicated birth. A large majority of those who receive prenatal care at the birth center — or about two-thirds of the 300 or so annual deliveries — end up having their baby at the hospital.
But in all cases, these deliveries are overseen by birth center midwives. After fullfilling certain requirements (such as attending 75 births, including 50 at a hospital, and passing an extensive background check and getting licenses by the District’s nursing board), these practitioners can have full privileges at the hospital. They can admit and discharge their patients, triage as they see necessary, order medication and generally manage patients independently from doctors.
Nationally, it’s common to find midwives employed by physician practices, hospitals or medical centers, HMOs and community health centers where they conduct a range of women’s health-care services. But it is rare for midwives who offer out-of-hospital births, such as those who staff the birth center, to also have full privileges at a hospital.
“I think women deserve the opportunity to receive midwifery-oriented care,” says Menachem Miodovnik, the hospital center’s chair of obstetrics and gynecology. “I respect the way they take care of patients, I respect the way that they conduct labor, I like the way that they interact with the patient. They take more time, they look at things differently.”
Relationships like the one between the hospital and the birth center are unusual because, in addition to numerous legal and policy issues, stereotypes and tensions between obstetrician/gynecologists and midwives can be a barrier.
Richard Waldman, the immediate past president of ACOG, admits that “in the early part of my career, ‘midwifery’ was sort of a dirty word in obstetrical circles.”
While Waldman (whose wife is a midwife) believes “that’s old news,” others say the sentiment is still alive in some places. Midwives’ relationships with nurses and other hospital workers can also be strained; hospital staffers sometimes feel confused, overruled and even fearful when managed by midwives, who have different expectations of them than doctors do, says Krones. “I am not here just to write a note on the chart that you are going to pick up at some point. I’m all about communication and teamwork, so we can be in everybody’s face a lot more than the docs can be.”
Yet midwives and doctors have good reason to work together. A 2011 ACOG study predicts a 15 to 25 percent shortage of OB/GYNs over the next 20 years due to retirements, a persistent dearth of residents entering the field and an expected influx of newly insured women beginning in 2014. “Collaboration is one of the ways that we hope to look to in the future in order to provide care to the women in America,” says Waldman.
Certified nurse-midwives, whose services are covered by Medicaid and most private insurance companies, say they help lower health-care costs. According to a 2008 report, an uncomplicated vaginal birth in an out-of-hospital birth center costs about 75 percent less than it would in a hospital.
“We are pretty much open to midwives,” says Mark Mitchell, Washington Hospital Center’s director of labor and delivery. “Do we always agree? No. Do we think there are some times when we’d like to just jump in? Yes. But I think that what we do have is a working relationship such that if [the midwives] do need to consult us, they feel very comfortable in doing so.”
Mitchell also stresses the partnership’s ability to work as a team. Every three hours, the doctors, nurses, residents and staff midwives on the labor and delivery unit get together to review patients and share concerns, says Mitchell. When birth center midwives are attending a delivery, they too join the huddle. That way, he says, “we can know if there are any issues so that if there is any type of emergency, we won’t be blindsided.”
Krones agrees: “The relationship we have with the doctors at the hospital makes it very easy for us to get their services when we need them,” she says. “That’s what makes this out-of-hospital experience really positive and possible, and it’s what makes natural childbirth at the hospital possible. Because we can close the door . . . and those on the other side know that what we are doing is good and okay and not crazy and keeps with their standard of care. Because it’s our standard of care.”
Miller is women’s health columnist for Thedailymuse.com and writes for the publications of the George Washington University Medical Center.