By Katherine Shaver
Washington Post Staff Writer
Friday, May 18, 2007
The closings of a well-known Takoma Park midwifery practice and a Bethesda birth center have sparked an outcry from some Washington area women who say they're disturbed by the dwindling number of opportunities to give birth outside a hospital or with a midwife's help.
At least seven other birth centers and midwifery practices, many citing rising malpractice insurance premiums and lagging insurance company reimbursements, have folded in the Washington-Baltimore area over the past decade. Those included midwifery practices at Georgetown University Hospital and in Frederick County, and birth centers in Greenbelt and Baltimore, according to activists and local midwives. The Bethesda birth center's closing means Montgomery County will lose its only non-hospital delivery option beyond private homes.
"There are countless women scrambling to find out-of-hospital birth support," said Mary Beth Hastings, 39, a board member of the new Birth Options Alliance. The group, with about 300 members, will advocate "for a full range of birth options" in the Washington area, said Hastings, who had her 4-year-old daughter at the Bethesda birth center and her 2-month-old daughter via a midwife at her Takoma Park home.
For a relatively small but devoted group of women, the idea of giving birth in a hospital with a physician connotes unwelcome images of being tethered to machines, talked out of natural childbirth or talked into a non-emergency Cesarean section. A birth center, they say, provides a more relaxed, homelike environment without anesthesia or C-sections. Others say they want the option of an epidural for pain relief in a hospital but believe midwives will provide more personal support and be less likely than physicians to intervene with machines, surgery or medication.
But finding a midwife delivery in the Washington area, either in a birth center or hospital, is increasingly difficult. In addition to the higher malpractice premiums, birth centers have found themselves competing with hospitals offering delivery rooms designed to give mothers a more homelike experience.
Last month, the Takoma Women's Health Center shut down when its physicians group owner folded the midwifery practice. At the end of this month, The Maternity Center will deliver the last baby at its Bethesda facility, though its midwives will continue doing hospital deliveries. Both practices, in business for more than 20 years, cited financial strains.
For Rachel Scherr, the closings raised a particularly pressing problem. She had planned to deliver at the Maternity Center, but it will close two weeks before her due date in mid-June.
With a healthy pregnancy and determined to avoid another hospital stay, Scherr said she considered birth centers in Alexandria, Annapolis and the District. But all seemed too far to drive from her Takoma Park home. After two weeks of research and dozens of phone calls to investigate her options, Scherr, 36, decided she will have her second baby at home with a midwife.
In a hospital, "everyone around you is looking out for something bad to happen," said Scherr, a University of Maryland researcher. "It changes the experience. It doesn't promote the kind of happy, healthy, relaxed, normal experience I think birth should be."
In 2002, midwives attended about 12,500 births in Maryland, Virginia and the District, according to the American College of Nurse-Midwives. Those accounted for almost 8 percent of all Maryland births, 3 percent of District births and 7 percent of Virginia births.
Nationally, 98 percent of midwife-attended births occur in hospitals, with 1 percent in birth centers and 1 percent in private homes.
Most midwives treat only healthy women with low-risk pregnancies. Anesthesia, such as an epidural block, and medications to speed up labor are available only in hospitals, and only physicians may perform C-sections.
Nationally, about a half-dozen birth centers have closed annually in recent years, according to the American Association of Birth Centers. But the opening of new centers provides "very slow growth" overall, said Executive Director Kate Bauer.
But most are feeling the financial squeeze of malpractice insurance costs rising faster than their incomes, Bauer said.
Those same pressures are felt throughout the health-care industry, but birth centers are hit particularly hard because they operate on slimmer profit margins than most physicians, midwives said. Several also cited problems unique to midwifery, including the growing popularity of C-sections, which they don't perform. Moreover, unlike obstetricians and gynecologists, midwives can't offset lower insurance reimbursements for office visits with higher-paying surgeries.
Some industry observers say the closings may simply mark the end of a natural cycle, as midwives who launched birth centers during their heyday in the 1970s and 1980s begin to retire. Many younger midwives don't want the financial strains of running a practice, they said.
Several midwives said they were surprised that the field's casualties now include the Bethesda birth center and Takoma Park midwives group. As two of the country's older and better-known practices, they helped midwifery reach beyond its traditional rural and inner-city roots, industry observers said. Both were among the first to cater to middle- and upper-class women.
At the Maternity Center's yellow and blue-shuttered, four-bedroom house off Democracy Boulevard, women deliver in regular double beds complete with decorative dust ruffles, ease their labor pains in whirlpool tubs and cook their own food. Nearly 300 babies were born there last year, said director Janet Lobatz.
But starting two years ago, clients increasingly opted for the center's midwives to deliver their babies at Shady Grove Adventist Hospital, Lobatz said. Many want epidurals and like the hospital's patient-friendly feel, she said. The Bethesda facility will continue to provide prenatal and gynecological care under a new name of Midwifery Care Associates. But Lobatz said continuing deliveries at the center became too costly, particularly after malpractice insurance premiums quadrupled over the past five years to $150,000 annually.
"It's very sad," Lobatz said. "It's like having your hands tied behind your back and you can't provide care that you know people want."
Some of Lobatz's clients are trying other birth centers, such as Birthcare & Women's Health in Alexandria, Northern Virginia's only accredited free-standing birth center. Though it has increased its client load, the center has had to send women elsewhere for prenatal care while putting them on a wait list for delivery.
"Our staff is getting calls from women crying," said the center's co-director, Marsha Jackson. "They're at the end of their pregnancy, and they're having to go somewhere else to find services. It's devastating."
Diana Jolles, general director of the Family Health and Birth Center in Northeast, said the practice survives primarily because it receives $500,000 in private donations and grants every year. Its primary expense is almost $300,000 in annual malpractice insurance premiums.
"We do it because we believe in it and love it," Jolles said, "and we know it's an option communities deserve."