Birth centers part of a study on cutting premature births

July 20, 2015

ST. LOUIS — At the Birth and Wellness Center in O’Fallon, Mo., women deliver babies in a low-tech, homelike setting with midwives. Yet it and other birth centers nationwide are being studied as an "innovative" approach to reducing preterm births among the poor.

"We’ve been trying to change how maternity care is delivered for 30 years," said Kate Bauer, executive director of the American Association of Birth Centers. "But when it’s such a small percentage of women receiving this care, it is still very much innovation."

Only 0.4 percent of all births take place in birth centers, yet those centers boast impressive health outcomes at a cost far less than hospital births, according to data compiled from over 15,000 birth center deliveries released three years ago.

When it comes to preterm birth, the rate is 3.75 percent among birth centers, compared to 11.4 percent of all births nationwide. Among African-Americans, the rate is even higher: 16.5 percent.

Babies born just a few weeks early are at risk of severe health problems and lifelong disabilities, statistics from the Centers for Disease Control and Prevention and the March of Dimes show. Premature birth is the leading cause of death of children under 5 — and a driving factor behind African-American babies dying at more than twice the rate of Caucasian babies.

With the costly and long-term consequences of preterm birth, the government is taking an interest in birth centers and the midwifery model.

Two years ago the Centers for Medicare and Medicaid Services launched Strong Start. The four-year initiative is studying how different approaches to prenatal care can improve health outcomes and reduce cost among pregnant women and newborns using Medicaid, the federal health care program for the poor.

As part of the initiative, the American Association of Birth Centers was awarded $5.35 million to measure outcomes and costs among its members. The Birth and Wellness Center recently joined more than 40 other birth centers across the country as a study site.

"Participating in the Strong Start program is validating the care that we already provide," said certified nurse midwife Jessica Henman, director of the center. "We, as an individual practice, and the American Association of Birth Centers want to demonstrate that low-cost, personalized care for women can vastly improve outcomes for mothers and babies."

About 40 percent of the patients at the Birth and Wellness Center use Medicaid. Nationwide, nearly half of all births are covered by Medicaid. Medicaid patients typically have twice as many adverse health outcomes as others, according to a report by the Medicaid Health Plans of America. Many face food insecurity, chronic unemployment, unstable housing, lack of transportation and low levels of education. Preterm birth alone accounts for 50 percent of all pregnancy costs, largely due to neonatal admissions, the Medicaid plans report found. Just one premature baby costs an extra $12,000.

Since it opened three years ago, the Birth and Wellness Center boasts a preterm birth rate of less than 1 percent and even fewer babies needing intensive care among its approximately 350 births.

Among patients who start labor at the center, only 3 percent end up needing a C-section at a hospital (nationwide birth center rate is 6 percent), while about 27 percent of low-risk hospital patients have surgical births. Four weeks after birth, 100 percent of the birth center’s clients are breast-feeding, Henman said.

Cost savings come from better health outcomes and a reduction in medical interventions that have become routine in hospitals — where studies show that most women receive continuous electronic fetal monitoring and intravenous fluids, and nearly half have their labor accelerated with medications. Most patients are also restricted to bed, not allowed to eat or drink and give birth lying on their backs. Evidence indicates that routine use of these practices, with no medical indication, has little benefit and increases risk for mothers and babies.

The midwifery model focuses on individualized care. The initial prenatal appointment lasts about an hour, and subsequent visits take 30 minutes. Midwives (advance practice nurses) assess nutrition, exercise habits, health history and stress factors in order to treat problems early and prevent complications such as high blood pressure or blood sugar that can require an early delivery. Questions are encouraged at any hour. The Strong Start initiative also pairs birth center patients with a peer counselor who meets with women three times during their pregnancy and provides another layer of support and guidance." Our whole model is based on education and prevention, not just the treatment of a disorder once it already occurs," Henman said.

Simple things at the birth center, like not having to spend too much time in the waiting room, make patients less likely to miss their prenatal appointment for fear of taking too much time off work or missing day-care arrangements. Missing prenatal visits can mean missing problems like bladder infections, cramping or low hormone levels.

Medicaid recipient Rachel Walker, 18, of Winfield, Mo., delivered a healthy baby girl just a few days shy of her due date last month at the birth center. Her first birth, three years ago, was a different story.

Walker said she had preterm contractions starting at 25 weeks and was placed on bed rest, a prescription that some experts say is unproven and could cause harm. Her baby was born at 37 weeks and suffered severe jaundice.

For her second pregnancy, Walker said she changed her diet, stayed active, learned coping skills for stress and took iron supplements her last trimester. "I definitely received a lot more information from them than I did from an OB (obstetrician) about how to take care of myself and my baby," she said. "I felt like I received more care and more personal care. They treated me like a person instead of just a number."

Birth centers still face many obstacles to becoming more accessible to women — especially in low-income areas — because of outdated state regulations and low Medicaid reimbursement rates for their more time-intensive care. The O’Fallon center is the only licensed and accredited freestanding birth center in Missouri. A second opened two weeks ago in Springfield, Mo., and expects licensing and accreditation in the coming weeks. Mercy Hospital St. Louis also has a midwife-staffed birth center. In Missouri, freestanding birth centers fall under the costly regulations of "ambulatory surgical centers" despite no surgeries taking place. A doctor is required to oversee the care of every three midwives; and midwives who are not nurses but credentialed as certified professional midwives can deliver babies in homes but not birth centers.

The Springfield center chose to open as a nonprofit so it can use grants and donations to care for the surrounding uninsured and low-income population, fearing Medicaid’s low reimbursement would force providers to focus on volume rather than care, explained the center’s board president, Mary Walsh.

"They are the people that need the one-on-one care that midwives provide, that extra time required through pregnancy to get to know them in personal way and provide the necessary support," Walsh said. "They need it more than other people."

Despite the obstacles, Henman said she is working to open another birth center in north St. Louis or North County, which sees the area’s worst preterm birth and infant mortality rates, but where many women are unaware of birth options or lack transportation.

"I want to get this model of care into this community that doesn’t Google natural childbirth on the Web, but for who it can make dramatic improvements," Henman said.

Bauer said she hopes the findings from the Strong Start initiative will lead to more friendly state regulations and higher reimbursements that will help birth centers proliferate.

"When you have that in place, you will have more birth centers that can help more women," the birth center association director said. "That’s ultimately what we want to do, we want to see care for moms and babies improve."



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