Do you believe, I forgot to bring my camera? 3 new lenses going to waste, sitting at home........
For the majority of the time, I'm here attending the AABC "How to start a birth center" conference. It's actually rather exciting to me, to have this opportunity to learn about the various aspects of creating and running a birth center.
Where I live, we definitely need a birth center. The city I work in has none. There are pretty much two options if you want a natural, non-interventive birth: go to the hospital and hope you get one (come prepared, please!), or have a homebirth. There are NO birth centers within probably 75-100 miles. Sure, you can drive the distance, but should women have to do that?
I am deeply concerned about the lack of options to the lower income women. When I envision a birth center or homebirth, I see a middle class or higher woman. Basically, someone who can afford to pay out of pocket if need be, and someone with a high level of education. On the other side, perhaps I am biased, because I see a large number of the lower educated, low income women in the hospital who come to give birth. Very rarely do they attend childbirth education classes.
Now I'm off on a tangent: low income women need better access to childbirth education and need to be supported by their care providers about looking at choices and helping guide women in the direction in which they would like to see their birth go.
Furthermore: do low income women WANT more education on pregnancy and birth? Do they WANT to take control of their pregnancy and birth? Do they have desires for their birth options?
The 'normal' low income woman that I see on labor and delivery: no childbirth education classes, sometimes they have been at births of friends/sisters, gain knowledge of pregnancy and birth from their friends/sisters, no birth preferences other than wanting an epidural, some want to "try" to breastfeed, while others want to bottlefeed only.
**please note: I am only doing a generalization of many of my low income women who present to L&D**
Where to start? Where to start?
The more I reflect on what I see, the more I see that I want to gravitate towards working with low income women - to help improve education and birth options. Where it will take me? Who knows.
TTFN!
17 comments:
The class dynamic among homebirthers here in Maine is interesting. You have upper middle class folks and higher who have homebirths because they can afford them in addition to their private insurance. You have working class folks and lower doing a mix of hospital births or homebirths. Some use the state version of Medicaid to have a hospital birth paid for, and others pay for a homebirth out of pocket because it's so much cheaper than a hospital birth. It's folks in the middle who almost all have hospital births - because their paying for their insurance and insurance covers a hospital birth. It's these folks right in the middle who would love to have a homebirth but can't - because they can't afford both health insurance and a homebirth.
On top of that, the local birth center charges a facility fee on top of the normal fees the midwife charges, which puts a birth center birth even further out of the reach of lower income folks. I don't know whether they have taken advantage yet of the recent national changes for birth centers to be able to accept Medicaid.
Now, in our neighboring state of New Hampshire, Medicaid covers all CPM services, whether at a homebirth or a birth center. I'd love to know more about how that changes the dynamic of things by giving people another option that they can afford.
Interesting thoughts. I think bloodyshow hit the nail on the head. I think most of the time insurance and finances are a major influencing factor in women's choices for birth. I also think education is key. If more women had access to really good childbirth classes like Hypnobabies and such (NOT the classes offered at the local health dept or the hospital) then we might start seeing some different birth plans.
I know women who said they wanted a home birth but couldn't justify paying to do at home what they could do for much less in the hospital. I also know other women, myself included, who had access to excellent coverage for a hospital birth and paid out of pocket for the home birth they wanted. I think it comes down to what's most important and how much that birth plan matters to the couple.
I was able to observe a Hypnobabies course as part of my doula training, and that along with my previous childbirth experiences, the required reading for doulas, The Business of Being Born, and other factors helped me make the decision to plan a home birth. It was more important to me to have the home birth than to have a hospital birth that would be completely covered by insurance. I think this is where education is key.
I also prayed about my decision to give birth at home and felt complete peace through my entire pregnancy. That, to me, was more important than any other factor.
I have a question for you though. You say if you want an unmedicated birth in the hospital you need to come prepared. What are your recommendations to women on how to come prepared for a natural (prepared) birth in the hospital? With my 2 natural births in the hospital I had a birth plan and a doula to lay out my wishes and help ensure they were followed as much as possible. I also had a hospital and doctor who were very willing to work with me within those wishes. I've heard from other people whose birth plans were ignored, and from an L&D nurse who says the hospital staff tend to roll their eyes or make snarky comments when a patient comes in with a birth plan.
Are birth plans effective? Is it more effective to have your own support team (hubby, doula, etc.) to back you up in your birth wishes? Honestly, if it had only been my husband with me he might not have stood up like my doula did.
My doula helped me be prepared in several ways. She helped me figure out what I wanted to put on my birth plan (by helping me understand my options), she backed me up at the hospital and reminded staff of what I wanted, and she gave me the continuous labor support I needed to learn how to work with the contractions and gave me the coaching and encouragement all along the way to do it.
I'm thinking a doula can be a more effective tool than a birth plan. And what about women who can't afford to hire a doula? Is a birth plan enough?
One more thought: I really wish CPM services were covered by Medicaid in every state. They're covered in some areas and not in others. I think this would open up a lot more options for low income women.
I also considered birthing in a birth center, but the only one even remotely close to home is a freestanding center, and I figured it had all the same features as a home birth and I might as well be in the comfort of my own home and save on the birth center fee. I wish we had more birth centers in my state. There's only one that's a real birth center connected to a hospital.
I think some lower income women are interested in child birth education and giving birth somewhere other than a hospital; they just need to know the option is there. We were able to save the $300 for Bradley classes but could not spare the 5k-6k for the birth center. I was really hoping we could do it this time but about a week after I got pregnant my husbands engineer blew and with 2 babies we really need 2 cars and one that is more reliable. I really believe we could have been able to come up with 2k-3k for the birth but not 5k-6k so it will be a hospital birth for us again this time. I’m just glad I have a husband that is not shy and will speak up with the nurses and dr are trying to push their agenda.
Of course, since I don't live in the US, my take might be different. But I live in a neighborhood where most of the women have at most a high school education, many dropped out by 10th grade [the earliest one may legally do so], were married by 20 or before, and have husbands who are blue collar workers or in the semi- and skilled trades. Few of the women work at jobs which are more than minimum wage [supermarket clerks, etc.] However, since birth is free in Israel [the government picks up the tab], finding education and a suitable hospital is not a problem [all normal vaginal deliveries are done by midwives in hospitals, btw]
Just down the street was a hospital that specialized in natural childbirth, although epidurals were available on request, and I worked there for 12 years. I would ask neighbors, when seeing that they were expecting, if they didn't want to deliver there. "No way", I'd be told, " want to go to hospital X so I can get an epidural as soon as possible and not have someone try to pressure me into an unmedicated birth. I'm not one of those idiots who wants to suffer--my life is tough enough as it is, thank you!" It was almost impossible to convince them that they wouldn't "suffer" if they wanted analgesia, the hospital's reputation was so strong.
I wish you luck, but I think that first of all you will have to convince them that your sort of birth experience is what they want. You will have greater success in teaching mothercraft and breastfeeding postnatally, and advising on proper nutrition, etc. [which also costs money, btw] during the antenatal period. Remember too that low-income women often do not have the leisure or the ability to reorganize their schedules for childbirth classes, even if they are offered for free.
Reading the comments above, there is a real problem in the US with $$ which is why doulas, birth centers, etc. are geared to the middle class. You are not going to convince a woman who bags groceries for a living that a doula or a birth center is essential if she's having trouble buying food or paying the rent. Even one with a bit of a disposable income will think twice if insurance picks up the tab for a "standard" hospital birth but leaves her holding a bill for thousands of dollars if she makes other choices.
Is your seminar on starting a birth center discussing financing at all? A birth center, being an independent institution, needs to break even, at least. Factoring in staff salaries, materiel, maintenance, insurance, on an ongoing basis is big bucks, not to mention the initial outlay for equipment and the facility itself. If the center is connected with a hospital, hospital policies might well constrict your professional freedom, too.
Not to go into a whole lot in just one comment -- I want to say, I appreciate each and every one of your comments and input.
Antigonos - I especially appreciate your expertise and strong background in midwifery. The workshop is only for two days, and covers a very wide range of information about starting and operating a birth center, including the financial aspects. We go over finances in more detail on day 2 (tomorrow). I plan on making more posts in upcoming days/weeks/months about things that I am learning down here.
Referring to "bloodyshow"'s comment, in Germany a birth in the birth center costs about 500 Euro (which is paid by the insurance) plus 250€ out of your own pocket for the midwifes on-call-service. We liked the birth there, and I'd always do it again and pay for it even when it's a lot for a student. For having the calm atmosphere that actually makes a birth without strong meds possible, it's a good deal. (Except that the new high insurance rates might now force many free midwifes from working in birth centers).
Calculate it down to the months of pregnancy and you've got between 55 and 85 Euro per month to save up (in Germay). That's less than what many people spend on take-away coffee and cell phone bills - and you shouldn't drink too much coffee while pregnant anyway. ;-)
Oh and btw., I am a low income academic (student). Usually I wouldn't ever have gone to the BC, but was thinking between hospital or home (when H1N1 came out). The talk from friends didn't convince me, the nearly coincidental experience did (I just called up a BC one month prior to birthing and was lucky to get a free slot). In the hospital atmosphere, with hectic, I would have needed an epidural as my concentration would have been interrupted.
Also, I did not visit any birth prep classes. I trusted the midwifes would say what to do when it was necessary, which worked as expected.
In the Pasadena area of Southern California, the only birth center was shut down years ago. The nearest birth center is about 45 minutes away given that we have lots of traffic in this part of town. There are very few hospitals that allow midwives to deliver here, and home births with certified midwives are $4,000. Yep, you read that right(think: malpractice insurance because Los Angeles is the land of lawyers!)So, low income and middle class women don't have many birth choices because we have very few natural childbirth-friendly OB's in this area, either. It's a challenging situation, with home birth being viewed as "really weird." Tragic, and I'd love to see it change in the near future, but I doubt that will happen. Hey, you want to move to Pasadena and start a birth center? We'd love to have you! I'm not joking.
The poster above, Camille.thomas is my 12 year old daughter. I didn't notice that she was signed in and not I. So, I am a 40 year old mother of 6, not a 12 year old asking you to start a birth center in my town. Just needed to clarify that.
In the province I live, in Canada..it is mandatory for midwives to do a certain % of home births to keep up their license. It is all covered (hospital/MD or midwife/home or midwife/hospital) and you can choose which method you like. If it is a homebirth, for safety sake you must give birth within 1/2 hr of a hospital "in case of emergency"
No one here has ever heard of the "Bradley Method". The RNs I worked with in L&D here(5 different hospitals) were a little mystified by birth plans' demands brought in by moms-to-be because basically, most of the request on these birth plans were things we already did...so I had to explain to them that it wasn't the same in the USA. More than likely, these mom's with birthplans have been looking online and reading about those American mom's experiences. Most of the care plans were from US sites.
The worst thing was...(not all) some of the doulas and midwives would come in all hostile to the staff and create major problems with communication and actually did create unsafe situations with lies about what was actually happening. I was glad when they started licensing the Midwives and they had their own College because the educated ones were much safer.
I can tell you some pretty scarey stories.
Anyway....I feel that prenatal classes are a plus....new mom's do much better in labor when they have attended their classes, whether it be hospital based (in Canada I don't think these are the same as in USA giving the difference in actual labor care) or Lamaze or whatever. I really noticed a difference.
When I was working only as a doula, I worked a lot with a midwife (CNM owns a birth center) who had a huge amount of medicaid patients come through her doors. For self pay clients she would give them an option of home vs. center, but I think she got something like $800 extra from medicaid for a facility fee, so medicaid patients could only deliver at the center. It really is the only option in this area for an out-of-hospital birth paid for by medicaid.
AYC, you were in the right state to talk with midwives about serving low-income families. SC midwives have traditionally served the poor. Our regulations require reimbursement of prenatal midwifery care and prenatal testing for Medicaid families, as well as, the minimum of 2 physician prenatal visits required for all LM clients. Unfortunately, the expense of prenatal education or attending the actual birth isn't covered by Medicaid. So, many poor families work out payment plans with their LMs. The additional expenses are usually covered by $60-$75 co-pays at prenatal visits until the balance of approximately $500 (homebirth) or $750 (birth center) is paid in full. Most LMs also use a sliding scale to assess fees for their families facing financial hardships. As a low-income mom who's planned two homebirth here in SC, I fully understand that it can be difficult for many families to fulfill their payment agreements. But, I tell my friends that the quality of personalized care makes it so worth the potential sacrifices one makes to cover the attending fees.
Our state regulations do not extend to families with health insurance coverage. So, on an average day of prenatal visits a LM may see 3 Medicaid clients along with 3 affluent clients. The working/middle class families often think that midwifery care is out of their reach once they pay their health insurance premiums. Sad. Because, if those families just sat down and did a little math, they would discover that after the cost of deductibles, co-pays, and unplanned expenses--homebirth with a wonderful LM is so much more affordable.
As far as the desire of poor women to have prenatal education, all can say is, "you don't know what you don't know." My LMs addressed this need by including the cost of their 'prepared labor classes' into the $500 fee. Meaning if you paid in full, your attendance to their classes was free. They required all clients to attend some type of educational series, but didn't endorse any specific method. For clients who couldn't decide on local classes (in our area there's quite a selection offered, from Bradley to Hypnobabies) or couldn't afford the extra expense--the LMs 'prepared labor classes' are very informative and helpful. SC midwives also often assist families hoping to have successful natural births in hospital. In the hospital environment the LM's role changes into that of an experienced doula. My LMs required that all of their doula clients attend the 'prepared labor classes.' Side-by-side in these classes couples of varying socio-economic status prepare to meet their babies. Additionally, the March of Dimes, in conjunction with area hospitals carry out prenatal programs to educate expectant couples. These prenatal classes are geared toward families of little means. My husband and I utilized both the March of Dimes program and the LM's classes. Doing this allowed us access to a total of 20 hours of prenatal/labor education without any out-of-pocket expense.
A finally point about breastfeeding, I was unaware during my first pregnancy that lactation education/support (other than the classes offered at our regional health department) is covered fully by Medicaid. However, after my youngest daughter was born our backup physician and family doctor wrote out a referral to a certified lactation consultant based on medical necessity. Medicaid covered all of our LC visits because our physician stated that they were a medical necessity.
http://www.sc-midwives.org/directory.html
Here's a directory of LMs. If you contact any of the wonderful women with questions, I'm sure they could share tips on educating clients before childbirth.
What a GREAT comment! So relevant and informative. Thank you :)
I signed up for the workshop in Boston. I used to work with one of the midwifes who works there. Looking forward to it. Wish I could have taken the workshop when I took the birth center class. It would have been helpful.
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