Yes, I am still on the birth center "high" from last week's trip.
So, one of the things we all did as participants was talk a little bit about our own experience (or none) of birth centers. Having not had any exposure to birth centers, other than looking longingly at them online, I talked briefly about my ideas.
Women in my area have basically one choice for giving birth in a facility other than their own home: my L&D unit. There are other hospitals in other directions that offer obstetrics, but it can be quite the drive for women in the immediate area -- especially the lower income/poverty level women, which I tend to see a lot of on L&D.
Basically, women don't have a true choice in my city. We have the monopoly on birth. There is no competition or alternatives (other than homebirth).
I see plenty of low income women who come in to L&D, unprepared for their birth. No childbirth classes, minimal education. Never being educated on their options for birth, they hear about how horrible and painful labor is from their sisters/friends/cousins, etc. "Get the epidural" they tell the woman, as their only source of education.
Now, tell me, how is that providing high quality care, when they are never educated on pregnancy, labor, birth, and their options?
I also see several women on a weekly basis who come in with birth plans, hypnobirthing preparation, or just a general verbalization of wanting to go natural with their labor/birth. Some take childbirth classes. Some are highly educated, and know exactly what they want.
The problem? You're coming into a high risk OB unit and wanting to have a low risk birth. The L&D unit, in general, does not support natural childbirth/low risk birth. It's about turning over beds as quickly as possible. It's not about one-on-one nursing care. Your nurse has at least one other laboring woman she's taking care of while you are there laboring. The environment itself is loud, bright, and in general, not conducive to a more home-like, relaxed, non-interventive atmosphere. IVs, fetal monitoring, epidurals, pitocin, and c-sections are the norm on the high risk L&D unit. Add in anything that even smells like a pregnancy complication, and you add in more drugs and interventions.
Natural, no IV, intermittent doppler, one-on-one nursing support? Not finding it here.
These are just some of the reasons why we need a birth center in this area. We need a place where women who are low risk in their pregnancy can be cared for by nurse-midwives, educated on pregnancy/labor/birth, and supported throughout the process by a limited core group of nurses and nurse-midwives. Women deserve to have another option, other than the high tech, high risk L&D unit. Not all women fit the "cookie cutter" mold that is the flow of L&D. Women need to be treated with more respect than just being another one of the many coming through the unit that day.
High risk pregnancy/birth, desire for an epidural in labor, need for induction = go to the busy L&D unit.
Low risk pregnancy/birth, desire for little to no interventions in labor/birth, desire for natural childbirth, no medical need for induction = go to the Birth Center.
Can it get any simpler than that?
14 comments:
Who funds your hospital?
Who would fund a birth center?
I don't think it's simple at all, AYC. My guess is that your hospital is a teaching hospital, backed by a university, or charity, or both, to pick up the bill for those without insurance. A birth center would be private, and would have to break even.
I don't like the kind of L&D you describe--and I've worked in quite a few -- but the answer, to me, is to create a certain degree of change in the hospital, to alter some of the rooms to "homestyle" ones, to add CNMs, etc. rather than attempt the truly massive task of opening a freestanding birth center. Moreover, I remember well from my years at Beth Israel in NY, that roughly 65% of our patients were "clinic" [what used to be called in the Bad Old Days "charity"] patients who had minimal antenatal care [many avoiding care until the 9th month] and were far from low risk when they presented in labor. Even those with good antenatal care often had home and social issues which, unless your hypothetical birth center had a large social worker component, an unsuitable place for them to be.
Fear of childbirth isn't entirely dispelled by education, alas, nor is childbirth really made much easier by avoiding all forms of analgesia [this from a certified Lamaze instructor!]. You assume that every woman who is suitable for a low-risk birth WANTS a "birth experience" in preference to a painless birth and that "education" is all that is wanted. But who uses birth centers today? Not the low income woman.
Your view of the birth center is utopian. One on one nursing, for example. Forget it, any more than you have one-on-one nursing in your present unit. In your birth center, would your CNMs act as independent providers, in the way doctors do now, or would they be on staff? Doctors can undertake the care of a single patient at a time because someone else is at the bedside for much of the labor; a CNM either changes with the shift [which means the woman has multiple providers, most of whom she doesn't know well] or she is tied to the bedside and cannot accept many patients, which means you have to have a very large number of CNMs associated with your center. Since CNMs are fairly thin on the ground, this is one of the limiting factors of the size of the birth center, and the number of births = the income of the center. The type of unit you saw, and which you envision, is a luxury.
Your enthusiasm is laudable, and I am convinced there is a lot which needs changing in the world of maternity care, but I think you're being too idealistic. I keep wishing your program would stop messing around with a lot of theoretical nonsense and actually teach you what you need to know about midwifery. When you are the one REALLY managing a labor, and when its YOUR decisions which count, I think some of your attitudes will change. When the outcome of a birth can possibly endanger your license, or when you are going to be the one to confront unhappy parents, you tend to think differently. When you are a CNM, in hospital or out of it, the buck stops with YOU, not with a doctor.
I should point out, for those "not in the business", that "one on one" nursing means more than one nurse or CNM per patient: to have 1 on 1 coverage 24/7 actually means about 3 nurses per patient, assuming they are working 8 hour shifts.
I could write an entire essay on staffing, but I'll spare the Gentle Reader. A head nurse of mine, years ago, with a geek husband, asked him to make a computer program which would make it easier for her to work out the work schedule. After two weeks of trying, he told her he couldn't; the system was just too complex.
A busy high risk L & D unit doesn't have to work like yours does. It all comes down to the values of the institution and maybe of the entire health care system. I'm in Canada at a large teaching hospital that caters to all high risk women in Eastern Canada and also low risk women from about a 1-2 hour radius (there are other options but some women will drive 2 hrs to have a baby in our unit). We provide 1:1 nursing care in labour, have a very busy assessment area and run our own ORs. We are as high or low tech as we need to be depending on the medical indications.
Our facility receives a lot of money from the general public through various fundraising events put on by our hospital foundation and we give the kind of care the public wants/deserves. If our standard of care changed I think there would be a large public outcry and then the $$ would stop coming in, so our institution puts great value in the standards of care we give.
Good luck with this venture. Always a benefit to have a choice on how to deliver your child...
Jim
Antigonos: I am considering going to the head of our OB dept and talking to him, seriously, about an in-hospital smaller unit/section of L&D that would be a birth center type of environment. Our unit is in the planning stages of moving to a newly built unit (one that is still also in the planning stages), and this would be an opportune time to bring up the birth center concept.
Believe me, I have a very long way to go in my education - not just in midwifery itself, but also the whole concept of midwife-led birth centers, and the financial/operational aspects of running a business.
Insurance coverage of birth centers would be good. I have Blue Cross and it wouldn't cover the center in our area. I could not afford to pay cash up front. Hospital bill (with baby included) and midwife bill...and all labs about $10,000. Bill at the birth center something like $3000? It is sick really, makes no sense to me. If I had anesthesia, it'd be more. I was charged for every 15 minute time period I was in recovery after birth though I only used the room for 3 hours for the birth...and didn't use anything much extra. I don't know why you get a recovery charge for using the SAME ROOM that you labor and deliver in...and it wasn't up to me how long I was in there, the nurses decided that! Anyway, cost out of pocket for patients is something I want changed...coverage by insurance. It could save much money!
Blessings!
Dawn
I'm very interested to see your ideas on this as they develop. I'm a new CNM in a small practice. We don't have any birth center options in our city (medium-sized city). I would love to start one, but I think I'd have problems finding back-up (the medical model is very prevalent here) and I worry about keeping financially afloat. I'd be interested to attend one of the AABC workshops in the future.
I think our practice (my partner and myself) does a good job at providing an experience that is "in between" a hospital birth and a home birth. We do anywhere from 8-20 deliveries a month, and most (90%?) of our women intend to go unmedicated. We do a TON of labor sitting. No IV, intermittent monitoring, hydrotherapy, and waterbirth are all pretty common for us. We are the only practice in town that is doing this. I get worn down from working in the system and still seeing a lot of resistance to the normal process of birth, but I'm trying to provide other options to women in our community!
A birth center (even an in-hospital one) would be heavenly. I did part of my clinicals in a freestanding birth center and it was awesome!
Personally though, I would be anxious for my wife to deliver anywhere outside a hospital where she can get a crash section in minutes if she needs it.
ERP, I can understand your worries because we had the same thought - I'm a med student and fortunately my husband is an anesthesiologist with experience in emergency medicine and newborn treatment/ child anesthesia, so we went for the birth center, when the hype around H1N1 in hospitals was high - with the man and his whole emergency supply in tow, haha (the midwife was asked and would have been able to assist, since she'd worked in the hospital for many years).
Some of his colleagues warned him for the same worries you had. It was a totally uncomplicated birth btw. without anything (although I'll happily take the PDA or IV pain management the next time), and when there was the one and only moment of doubt - an early deceleration of 60 - it was unbeliveable how fast the midwife had the Partusisten (and the man the iv needle) in hand. Fortunately the decel disappeared and nothing was necessary, but they were extremely competent.
The main issue is to chose both a birth center and midwife you can trust, that will support you in your decisions to go into the clinic up to the last minute, and who won't play the hero. Same as with docs, actually.
Giving birth is a blessing given to women and they should be treated and educated well about their role as a mother. The place you are in has no difference with the situation of every Filipinas living in the barrios here in the Philippines.
http://www.nclexpinoy.com
The birth centers in my area (non-profit) work well, but yes, they do have to limit the number of patients they except so that they can provided that one-on-one care.
I'm glad that you're trying to work out solutions to something that has been on your mind for a good while.
I'm thinking way back here, but I once took an elective called Health Systems Planning. I'm wondering if a SWOT analysis (an assessment of strengths, weaknesses, opportunities and threats) of your community's maternal/child services might help you justify at least a need for change and present it to the powers that be.
Sounds like this could be your passion/calling... getting in on the ground level of creating a Birthing Center in your area! Good luck with shaping the future for those women who need your voice!
So many wonderful birth centers have closed down. Very few left. So many people's dreams and sweat and tears were involved, but ultimately, it's very hard to make a go of it. The reasons vary depending on the community, but in general, anyone who opens a birth center is committing herself to always being under attack. Plus having financial worries out the wazoo. Plus often having thorny disagreements with the other people involved in the project, so that your closest friends become your worst enemies.
Etcetera etcetera. Make sure you talk with people whose birth centers closed and get the whole picture.
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