The Doctors Taking Birth Out of the Hospital
Dr. Steve Calvin was 25 years into a career as a high-risk obstetrician, and he was burning out. “I know virtually every bad thing that can happen to a mother and a baby because I’ve seen it and taken care of it,” he said. At the same time, his kids were starting to have babies, and he looked at the maternity care system and saw it was uncoordinated, expensive, and too quick to assume pregnancy was pathological. “I just realized, man, we are overdoing it.”
Convinced there was a better way, Calvin started thinking about opening a freestanding birth center, a place where women with low-risk pregnancies could give birth in the care of midwives. He approached the other doctors in his Minneapolis practice to see if they were interested in working with him on the project. “I might as well have opened up a dirty diaper on the table in front of them,” he said. “It was totally out of their ability to envision it, and they just said, ‘No, we’re not doing that. That’s dangerous.’” Calvin said the hospital system also had no interest in opening a birth center.
So, he did it himself. Calvin took a 70 percent pay cut, and he and his wife, Cindy, invested their retirement funds into renovating a run-down Victorian house across the street from Abbott Northwestern Hospital. They opened the Minnesota Birth Center in Minneapolis in 2012, followed by another in St. Paul in 2015. The centers cater to women with low-risk pregnancies who want a “physiologic birth,” without an epidural or other interventions. They offer long prenatal appointments with certified nurse midwives (CNMs), who focus on building relationships and preparing clients for birth and parenthood. If labor doesn’t progress normally, patients are transferred to the hospital, where their midwives can also deliver babies, and a local group of OB/GYN doctors is on call if needed.
Calvin is one of a small contingent of doctors who think taking low-risk births out of the hospital and into birth centers can achieve what’s known as the Triple Aim of obstetric care: simultaneously improving outcomes and patients’ experiences, while also lowering costs. The birth center model of care was primarily created by midwives, but physicians are investing in opening their own centers, hiring midwives to run them, and integrating them with the local medical system. In the process, they’re bridging a long-established divide between two approaches to caring for women in childbirth: midwifery and obstetrics.
At the turn of the 20th century, most babies were born at home, into the hands of general practitioners without specialized training or midwives trained through apprenticeship. But by the mid-1900s, childbirth had almost completely shifted to obstetricians and hospitals, which together offered women the promise of pain medication, a sterile environment, and experts trained in forceps-assisted and cesarean deliveries. While these advances were not without downsides, neonatal mortality dropped by a remarkable 89 percent and maternal mortality by 99 percent over the course of the century in the United States.
The shift to hospital birth was not just about medical progress, but also politics and power. In a 1915 paper, prominent obstetrician Joseph B. DeLee argued that his field would never gain the respect it deserved if birth continued to be viewed as a normal life event that could be attended by a midwife. “As long as the medical profession tolerates that brand of infamy, the midwife, the public will not be brought to realize there is high art in obstetrics and that it may pay as well for it as for surgery,” he wrote. He and others argued that midwives should be abolished, in part because they competed with physicians for business. Another obstetrician, Charles Edward Ziegler, wrote in JAMA in 1913 that eliminating midwives was also necessary to provide medical students with more childbirth cases for their training: “It is, at present, impossible to secure cases sufficient for the proper training of physicians in obstetrics, since 75 percent of the material otherwise available for clinical purposes is utilized in providing a livelihood for midwives.”
Thus, traditional midwives were essentially legislated and regulated out of practice in the U.S., and to the extent that they existed, they learned and practiced their trade underground. Things evolved differently in parts of Europe, where the emphasis was on training midwives to meet national standards, and bringing them into the hospital as appropriate providers of care for low-risk births.
Interest in midwifery reemerged in the United States in the 1970s, as more women sought alternatives to the hospital, where a pubic shave, episiotomy, sedative pain medication, and separation from their newborns were standard procedures. Midwives met this growing market by offering home births and opening birth centers, yet still relying on doctors and hospitals for a necessary safety net. Sometimes, what birth needs is not a cozy environment and supportive words but an anesthesiologist and a surgeon, a blood bank, or a NICU, and it’s up to the midwife to recognize this and transfer to the hospital quickly. In a 2013 study of accredited birth centers in the U.S., around 18 percent of women ended up transferring to a hospital either during labor or after the baby was born. Two percent of births resulted in emergency transfers for reasons like concerning fetal heart rate, postpartum hemorrhage, or newborn breathing difficulties.
These transfers can sometimes be tense and uncoordinated, in part because of variation in midwife training and birth center protocols. Certified nurse midwives have both a nursing degree and a master’s degree from a university midwifery program, and most attend births in hospitals. On the other hand, home births are most often attended by certified professional midwives (CPMs) or other types of midwives with variable training and education; they typically don’t have hospital privileges so must hand off a patient’s care if she is transferred. Both types practice at birth centers, though physician-owned centers tend to be staffed by CNMs. Birth centers themselves exist in a state-by-state patchwork of regulations. National accreditation sets standards for quality, but only 33 percent of the 370 birth centers in the U.S. are currently accredited.
“Almost all physicians have either been involved in an out-of-hospital birth disaster or walked into the room soon after one of their good friends were,” said Dr. Greg Eilers, an OB/GYN in Portland, Oregon. Because of this, it took time to convince his partners at Women’s Healthcare Associates that opening a birth center was a good idea. The company, jointly owned by 72 providers, mostly physicians but including some CNMs, opened a birth center in 2017, and Eilers serves as its medical director.
Physicians’ fears about out-of-hospital birth are well-founded. A 2014 study of U.S. birth certificate data found that, while safer than home birth, the risk of neonatal death was higher at freestanding birth centers (0.59 per 1,000 births) compared to midwife deliveries in a hospital (0.32 per 1,000 births). The study’s lead author, Dr. Amos Grunebaum, wrote in an email that he doesn’t believe the neonatal risk of out-of-hospital birth can be resolved, regardless of birth center ownership or integration, because the delay in emergency response is sometimes just too long.
Yet evidence from other countries and even the U.S. shows that birth centers can be safe. The study by Grunebaum and colleagues combined data from all U.S. birth centers, regardless of accreditation. In contrast, a 2018 systematic review of studies of birth centers meeting accreditation or similar standards did not find increased neonatal mortality at birth centers compared to low-risk hospital births, and the American College of Obstetricians and Gynecologists lists accredited birth centers, along with hospitals, as the safest settings for birth and appropriate for low-risk pregnancies. In the U.K., where midwifery-led units (similar to birth centers) are an integrated part of maternity care in the National Health Service, they have been shown to be just as safe for babies.
“I was actually astounded or astonished when I came for residency here and I found out I had to go to a normal delivery, because in England, those are done by the midwives, and physicians only handle instrumental deliveries or complicated deliveries,” said Dr. Dele Ogunleye, an OB/GYN who attended medical school in Nigeria before undertaking an obstetrics residency in England. In 2016, he and another local OB/GYN partnered to open a birth center in Bloomington, Illinois. He hopes to start at least two more in the state.
According to some experts, more birth centers that are well-integrated with the medical system might be just what maternity care in the U.S. needs. “Health care costs in the U.S. are incredibly high but we don’t have better outcomes, so there’s some kind of disconnect in what we’re doing,” said Dr. Victoria Woo, an OB/GYN at Kaiser Permanente in the San Francisco Bay Area and a former research fellow at Stanford’s Clinical Excellence Research Center. Woo has proposed an increase in hospital-affiliated birth centers to improve the value of maternity care in the U.S.
In the U.K., women who delivered in midwifery-led units were less likely to have a C-section, vacuum- or forceps-assisted birth, labor induction, or episiotomy. In the U.S., the Strong Start study, a federally-funded 5-year study of nearly 46,000 pregnant Medicaid beneficiaries found that women receiving accredited birth center care had fewer C-sections (18 versus 29 percent in a risk-matched comparison group), more vaginal births after cesarean (25 versus 13 percent), and were less likely to have preterm or low birthweight babies, all with $2,010 cost savings per patient.
Woo credits the birth center model of care, led by midwives, for these outcomes. “[A midwife’s] entire job is one-on-one care with you as the patient and to sit through the process of labor,” she said. This is in marked contrast to hospital care, where the emphasis can tilt toward getting a laboring woman in and out of the hospital as quickly as possible. “The way that current labor and deliveries are set up,” said Woo, “it would be really hard to go back to having that kind of slow, natural labor, because there’s too much pressure.”
At the Portland center, women can choose from several birthing suites, all of which include a queen-sized bed and a large bath tub. To build familiarity and comfort, prenatal appointments take place in the suite. Nora Tallman, one of the center’s certified nurse midwives, explained, “In a hospital, you put a woman in a room she’s never been in, ask her to sit on a toilet she’s never peed in, give her a nurse she’s never met before, and then say, ‘now continue.’ And even when she knows her provider who comes in, it’s very different.”
Giving birth at a birth center is also significantly less expensive than at a hospital, saving health care dollars for patients, insurers, and Medicaid, which pays for 43 percent of U.S. births. A 2013 analysis of childbirth costs in the U.S. reported the average total payment for a vaginal birth was $18,329 when paid by commercial insurance and $9,131 when paid by Medicaid, with 59 to 66 percent of both these amounts going towards the hospital’s “facility fee.” Giving birth at a less resource-intensive birth center reduces the facility fee significantly. For example, Calvin’s center charges a $4,900 maternal facility fee compared with an average of $11,693 for an uncomplicated vaginal birth in Minnesota hospitals.
The total amount billed to insurance at Calvin’s center is $13,287, including prenatal and newborn care. The 2013 study estimated the total charge for a woman with a vaginal delivery at a hospital: $32,093.
Lowering the cost of maternal care was a major factor motivating Eilers to open a birth center, and he said it made good business sense for his company, too. Owning their own birth center allows them to collect not only the provider fee, as they do for hospital deliveries, but the facility fee as well — a new source of revenue.
Still, starting a birth center is not a fast or easy way to make money. Start-up costs are estimated around $1 to $2 million, according to a 2017 book chapter written by Woo and Neel Shah, an assistant professor of obstetrics at Harvard Medical School, and long-term success hinges on negotiating adequate reimbursement from insurers and simply having enough births each year. Calvin said that his business is solvent, but he hasn’t yet taken any regular income from it. “I’m glad I did it, but it is easily as stressful as delivering one-pound babies,” he said.
Most birth centers in the U.S. are owned by midwives, but physician-owned centers have some advantages. For one, they’re in a better position to negotiate insurance contracts, essential both to their fiscal survival and their affordability to patients. “The biggest challenge to birth centers in the United States is that we have not been able to get reimbursed for the facility in a way that makes it sustainable,” said Kathryn Schrag, CNM, who opened and ran the Tucson Birth Center for 30 years along with fellow CNM Mariann Shinoskie, owned at times by midwives, physicians, or a combination of the two. “We live in a culture where physicians have the power and open a lot of doors,” she said. (Schrag has also watched physician-owned birth centers close when they weren’t profitable enough or lacked midwives’ passion for the model.)
Ogunleye, in Bloomington, Illinois, said his 15-year obstetric practice in the community gave him political capital to successfully negotiate insurance contracts. Eilers also said his company’s size and record of providing good care have given them leverage with insurance companies. At both centers, most patients have their care covered either through private insurance or Medicaid.
Meanwhile, Alma Midwifery, a midwife-owned birth center in business in Portland since 2005, has felt the competition of having the Women’s Healthcare Associates center open five miles away. “Places like WHA are awesome because they’re able to be in-network with a lot of insurance providers, but then that also means it takes business away from the birth centers that aren’t physician-run that haven’t been able to get those same pathways,” said Alma midwife Janelle Bandurraga-Rice. Alma is in-network with just two insurance carriers, and they don’t accept Medicaid payments. Many clients self-pay the $6,780 fee, with discounts for those eligible for Medicaid.
Tallman attended home and birth center births as an independent midwife for 26 years before becoming a CNM, and then worked in an academic hospital for seven years. She says she loved independent practice, but she was on call 24/7 with few vacations, and it was financially stressful. Now, she’s well-compensated and has more time to ride her horse, and she says it’s rewarding to practice within a larger organization, where midwives have autonomy but know they’re backed by supportive obstetric colleagues. She’s also enthusiastic about working with the hospital to improve care between the two settings. “This is really, potentially, the future of where out-of-hospital birth is going,” she said.
“There’s a sense that we’re in this together and that is such an exciting thing to me, to be bridging that gap and creating one system instead of two systems with this awkward space between,” Tallman added.
Eilers describes levels of care in their company as links in a chain, from the midwives to the obstetricians to the maternal-fetal medicine doctors who care for the highest risk patients. Everyone in the company must be comfortable with the criteria for which patients are appropriately low-risk for the birth center and with the protocols for transfers.
For all the opposition Calvin faced when he began this process, he says the medical community has warmed to the idea as they’ve worked with the midwives and seen their good outcomes. The same hospital that didn’t want to help with opening a birth center “now sees it as a real benefit,” Calvin said. In fact, he is currently discussing more formal integration with the hospital system, an arrangement Calvin would welcome — so long as midwives continue to lead the care. “It’s a balance between integration and independence,” he said.
Alice Callahan is a freelance journalist based in Oregon whose work has appeared in The New York Times, FiveThirtyEight, and The Washington Post, among other outlets. She is the author of “The Science of Mom: A Research-Based Guide to Your Baby’s First Year.”
Thanks for this informative article! What does it mean for a birthing center to be “accredited”? What is the organizational body that does that accreditation? Also, where can I find a list of physician owned birthing centers in the US?
I am an Ob/Gyn, and left my practice almost one year ago for a myriad of reasons, one of which I now think was due to the frustration with how we manage prenatal care and labor/delivery in the U.S. For low-risk pregnancies, the midwifery model is best. I would love to become involved in a birthing center, just need to figure out where and how to start.
Just a note for historical reference. The transition to hospitals was not necessarily the reason for improved maternal and infant mortality rates in the mid 1900’s. The increasing use of antibiotics helped to treat infection (particularly “child-bed fever”) and played a significant role in improving maternal/child health. Also note that at this same time the Frontier Midwifery Service headquartered in Hyden, Kentucky had excellent outcomes in rather primitive conditions.
Thank you for your comment, Bonita. This history is so interesting, and you’re right that the improvements in neonatal and maternal mortality were multifactorial. During the development of the field of obstetrics in the early 1900’s, its leaders openly admitted that women were at least as safe birthing with experienced midwives as with physicians, and part of the “midwife problem” they discussed was their own acknowledgement that medical students needed better training. (See the 1912 JAMA article by J. Whitridge Williams, for example – https://jamanetwork.com/journals/jama/article-abstract/450091)
The push towards hospitals likely made things worse before they made things better, because of increased infections, risky pain medications, and overuse of instrumental deliveries. The CDC link in the article mentions many other factors contributing to improving outcomes over the 20th century, including better nutrition, longer spacing between children (i.e. availability of contraception and safe abortion), antibiotics, creation of Medicaid and other federal aid programs, and advances in neonatology like use of pulmonary surfactant, in addition to improving obstetric care with better education, training, and advances in research.
And yes, nurse midwives were quietly working in Appalachia and in New York City as early as the 1920s, with excellent outcomes. La Casita in Santa Fe is thought to be the first freestanding birth center in the United States, started by Catholic missionary nurse-midwives in the 1940s. However, my understanding is that nurse midwifery was a small field focused on caring for under-served women (and not competing with obstetricians) until around the 1970s.
I am a CNM in a physician-owned free standing birth center. It really offers the best of everything! Midwives who believe in the normalcy of pregnancy and birth, but who are able to seamlessly provide care when things deviate from normal because of our fantastic collaborative practice MDs and our hospital privileges.
Please give Dr. Christina Sebestyen of Austin, Texas praise for being a proponent of safe out-of-Hospital births!
Nice to see some doctors in the USA are finally catching on to what midwives have been doing for ages in other places. Our two oldest were born in a birthing center run by midwives in Melbourne Australia in the 2000’s. So much better than the hospital birth for our third in a London Hospital 2012, which wasn’t terrible but just not nearly as ‘normal’. Fortunately we didn’t stay long…