Birth Center 4.0. What's different this time? 

The science, for starters. This time, what was often seen as an oddity has now become one potential answer to U.S. birth statistics that have raised deep concern from World Health Organization (WHO) to the National Institutes of Health (NIH). Those stats include:
  • A cesarean rate that even common sense says is out of whack. After all, few of us would be alive today if, 200 years ago, one out of three women required a C/S for the woman or her baby to live. Women and babies haven't changed that much. 
  • The depressing stats on U.S. birth costs and maternal mortality: While it costs three times as much to have a baby in U.S. than any other developed country, the U.S. mortality rate is the worst of any of those countries. And that rate more than doubled between 2000 and 2013--despiteAHRQ designation as a "never event"--one that should never occur. Even more concerning: The increase in maternal mortality over the last decade was in a demographics that previously had low rates: white and Asian women, not blacks. 
  • 11% of women who die during birth die from hemorrhage. The largest single cause of hemorrhage--about 75%--is over-stimulation of the uterus with pitocin, the drug used for induction of labor, which increased nationally from 10% of women to 26% during the last decade. In fact, by 2010, almost 40% of births in many areas were preceded by induction before the gestational age of 39 weeks--despite clear data that has shown for two decades that when a woman's uterus isn't ready for labor, the statistical probability of a cesarean birth radically increases.
  • The same inductions before 39 weeks stressed babies, with an annual neonatal care cost that escalated 7% per year and in total cost the U.S. an estimated $26B per year--just for preterm babies born after induction. Birth is, or course, the leading cause of hospitalization in the U.S; when birth costs rise like this, it affects all health care costs--including those impacting your personal wallet.
During the same period, there is no doubt that maternal and neonatal care for the sickest mothers and babies improved significantly. Processes improved: Testing for risk, vaccinations, and innovations in treatment. Importantly, by the end of the decade, insurances were required by ACA to provide prenatal care, long known to be the best and most basic way to prevent prematurity. 

While we improved many care processes, the outcomes of birth are statistically worse in the U.S. now than at the turn of the century. 

By the mid-2000s,  NIH, The Joint Commission (TJC), the Centers for Medicare and Medicaid Services (CMS), payors and multiple other organizations were weighing costs and outcomes. For birth, it had become clear that neither was justified.

At the same time, Gen Y moms were rewriting the book on pregnancy and birth. A generation that I call the Whole Foods Generation, these moms and families are much greener and more organic than the generations before them. Well-educated and cost sensitive because of the impact of the recession, they were not satisfied with the high intervention birth mentality of Gen X, and they were looking for answers.



The perfect storm: Outcomes and costs

For a detailed history of birth centers, go to AABC's "Birth Centers in the United States" by Ernst and Bauer.

During this period when U.S. perinatal stats were clearly deteriorating, multiple events occurredme, little noticed by mainstream health care. Hospitals and physicians were preoccupied with the jarring implementation of value-based purchasing (VBP), focused entirely on Medicare--heart, pneumonia and orthopedics. Among the events pertaining to perinatal care:
  • Around the same time, articles were published with the results of a type of prenatal care called "Centering." This group care model cut through the "wait forever for a 10 minute prenatal appointment in a cold room" process. Centering created an environment with very high patient engagement--even among historically high risk populations; lower cost than traditional prenatal care; and better outcomes for both mother and baby. The primary providers of this type of care were usually midwives, in and outside of birth centers. 
  • In 2010, NIH took the unusual step of calling a consensus development conference on vaginal birth after cesarean birth (VBAC), a way of decreasing at least repeat cesareans. The conference was followed by a remarkable consensus statement that outlined, in plain language, concerns about organizational, institutional, and legal barriers to VBAC. The document opened the door for risk-wary organizations to take a different stand on this alternative. At the time, the advocates for VBAC--and those with the most VBAC success--were often nurse-midwives. 
  • in April 2010, hospitals began collecting data for TJC's new perinatal core measures, the first of which was Early Elective Delivery (EED), aimed at decreasing elective births--either induction or cesarean--before 39 weeks gestation. Five more perinatal core measures rapidly followed. 
The American Association of Birth Centers defines a birth center as a home-like setting where care providers, usually midwives, provide family-centered care to healthy pregnant women. Most birth centers are located separately from hospitals...
  • By 2012, the number of birth centers in the U.S. had already increased more than 30% since 2007, and new corporations--both for-profit and non-profit--were looking at investment. Birth centers take on contemporary design, parting ways with the "little house on the prarie" design of earlier years. Large jetted tubs for pain relief and birth are de rigueur, and Centering is the preferred model of care. 
  • The same year, a Cochrane review--the Good Housekeeping Seal of Approval for medical research--compared traditional hospital births with alternative, home-like settings in or near mainstream hospital obstetrical services. In comparison with traditional hospital OB units, the home-like settings tended to have more spontaneous vaginal births, longer-term breastfeeding, higher patient satisfaction with care, and decreased incidence of medical intervention without increased harm to the mother or baby.
  • CMS adapted EED into its VBP program, previously only focused on Medicare. With a baseline year in 2012, and the performance year in 2014, hospitals reimbursement in 2016 for all Medicare dollars is at risk on this metric--not just dollars for rare Medicare OB patients.. Most importantly, with both TJC and CMS now requiring a focus on birth outcomes, leader hospitals and health systems began to connect the dots about how to successfully change poor outcome practices. 
  • In early 2013, a the second national study of birth center outcomes was published in the Journal of Midwifery and Women's Health as a follow-up to a 1989 study in the New England Journal of Medicine. Reporting on U.S. birth center data from 15,000+ births from 2007-2010, this study demonstrated significant outcome differences between birth centers and hospitals in the care of low risk women, summarized here. Among those differences were a four-fold difference in cesarean rates (birth centers 6%, hospitals 27%) for comparable low-risk populations. Hospitals, health systems and some investors began to connect the outcomes-TJC/CMS-birth center-midwife dots in earnest. 
  • Evidence mounts that supporting full-term gestation decreases costs and improves outcomes. Gen Y moms  read research potentially linking induction with autism, connect the dots, and wonder what other interventions may not have been in their best interest. Yoga, Centering, doulas, walking and eating/drinking during labor, epidural alternatives like Nitrous Oxide start to show up much more frequently on hospital birth plans. Certified Nurse-Midwife (CNM) salaries increase more than 10% as many health systems and physicians newly recognize a potential benefit.  
  • By 2013, with research continuing to document better outcomes with Centering, the March of Dimes initiated grants for Centering, and by 2014 CMS issued Strong Start grants to hospitals and provider practices for Centering and other patient-centered models.  
  • And in July 2013, Princess Kate and Prince William had their first child. The Princess was annoyingly (and uniquely) private about the details of labor and birth. However, it had been widely publicized that she prepared using hypnobirthing, planned to use only Nitrous Oxide for pain relief--if anything, and hoped to have a water birth. The birth announcement named the "supervising" physician, British-speak for he was there but the midwives "caught" the baby. The Princess herself walked out of the hospital the next day--causig cognitive dissonance among many in the U.S.--a feat the shet later topped after her second baby by leaving the hospital hours after the birth
  • Basically, Princess Kate experienced the British equivalent of a U.S. birth center birth. When a princess does it, 'group think' about the right way to give birth can turn on a dime. Add the newly legitimized concerns about U.S. birth quality and costs, and the time for birth centers had finally arrived. 



Back to the future: Birth Center 4.0

That brings us to "Birth Center 4.0." 

The first phase was the many small, office or home-based birth centers that started in the 1940s and 50s for either economic reasons, to avoid heavily medicated hospital deliveries, or out of traditional cultural beliefs. These were often for specific populations, and not well known. 
Each birth center phase involved the same components:
1.  Women searching for something different than conventional health care offered at the time.
2.  The birth center seen as an alternative to home birth.
3.  Passionate professionals who advocated for mom and baby--both midwives and their physicians care partners.
4.  Improved health care access for those most in need. And just as often, an answer for well-educated, affluent women seeking a more personalized, family-centered experience.
5.  Birth centers ultimately impacting conventional health care for the better.
The second phase--championed by indefatigable birth center pioneers Ruth Watson Lubic and Kitty Ernst, among others--started in the 60s and 70s as a natural outgrowth of the Lamaze and feminist revolutions and the times. Offering a safe alternative to home birth, birth centers were few and far between and there were few governing laws or regulations for either nurse-midwifery practice or birth centers. The barriers to entry were often formidable, and demanded as much passion as advocates could summon. This period was the first time I owned or developed a birth center.

This early birth center movement was surprising to many professionals, but perceived as safer than home birth, and ultimately these new centers were responsible for a revolution in appearance and comfort of hospital OB units. Both the LDR and LDRP models of care were inspired by birth centers. 
Birth Center 3.0 occurred during the 90s and 2000s as the American Association of Birth Centers (AABC) led nation-wide development of care standards, licensing laws and regulations, keeping the birth center environment safe and comfortable for low-risk mothers, versus an outpatient version of a hospital. The number of birth centers proliferated, and early centers garnered long-term respect in their communities. The number of midwives expanded during that period as well, with maturation of the specialty. While a comfortable, calm environment remained constant, birth center design matured as well with the constant changes in tastes of demographics accessing care. The care principles that prevented complications stayed the came, and no matter how beautifully designed a dream birth suite it, it still costs far less to furnish and equip than a conventional hospital birth room. 

Birth Center 4.0 is the newest phase. Once again, birth center growth is a response to medical intervention, concerns about increased numbers of home births, and an educated, inquisitive new generation of women--both Gen Y and the coming Digital Natives, the oldest of whom will be 15 this year. This time, birth centers are here to stay if we operate them carefully and well. Laws and regulations are in place in most states, and national accreditation standards are well established. Birth centers, health systems, midwives and physicians are working together now more than ever to ensure better access with the best possible experience and care no matter where birth occurs.

Most importantly, evidence continues to come in that birth centers offer a safe, higher quality, lower cost alternative for low-risk families, legitimizing an option that was once considered suspect. For health systems and providers, birth centers now offer the possibility of lowering costs of care and improving quality metrics as an alternative practice site. For all of us, however, the true opportunity is to create healthier pregnancies, births, families and communities.

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