Monday, November 16, 2009

More on birth centers and maternity centers

I'm currently reading Birth Territory and Midwifery Guardianship: Theory for practice, education, and research by Kathleen Fahy, Maralyn Foureur, and Carolyn Hastie (Butterworth Heinemann (Elsivier): Books for Midwives, 2008). Just today Science & Sensibility featured a review of the book by guest blogger Dr. Katharine Hikel. The review is worth reading--as is the book--but I wanted to highlight this particular excerpt when she discusses birth environments and brings up the idea of a freestanding maternity center: taking the entire birthing wing outside the hospital.
But what is the best birth environment? In a chapter called “Mindbodyspririt architecture: Creating birth space,” architect Bianca Lepori describes her designs for hospital-based birth rooms that are meant to enhance, not counteract, women’s abilities to give birth. She created suites of rooms with “Space and freedom to move; to be able to move to the dance of labor; to respond to the inner movements of the baby; to walk, kneel, stretch, lie down, lean, squat, stand, and be still.” The rooms have “Soft and yielding surfaces; or firm and supportive surfaces; different textures; the right temperature; soft curves; darkness or dim light.” A birthing woman can be ‘immersed in water, flowing or still; respected, safe, protected, and loved.” Access to the suite is through an antechamber; the bed is farthest away from the lockable door, and not visible from it, so that privacy is respected.

Lepori’s birth architecture reproduces the comforts of home. There is access to the outdoors, and private walking places. There are birth stools, exercise balls, bean bags, hooks for hammocks or ropes for stretching. Tubs and beds are large and accessible from both sides. There are accommodations for families. There are comfortable chairs for nursing. Medical equipment – supplies, oxygen – is tucked behind a screen or put in a closet. A refrigerator and light cooking equipment is available. This ‘birth territory’ certainly outshines the typical hospital OB floor; though it begs the question: Why not just stay home?

The answer, of course, is that, for those four to ten percent of births that truly need intervention, the OR is right there. It’s better not to have to transport a woman who’s labor has turned complicated; it makes sense – for many – to have all the birth territory under one roof.

This birthing-suite design indeed takes into account the all-encompassing, body-mind-spirit event of childbirth. It honors laboring, birthing women and families; it respects the process. It worked well for a designated maternity hospital in New Zealand – a facility already designed for childbearing. But most US hospitals are multi-use facilities; and though obstetrics is among the best money-makers for hospitals, childbirth is the only event that occurs there that is not related to illness or trauma.

The real question is, why not remove birth completely from the pathology-centered hospital model? Why not redesign birth territory to maximize best outcomes, minimize intervention, and replace the present medicalized view of birth as a disaster waiting to happen with the more normative, expectant-management, midwifery view? Move the whole shebang, from the waiting room to the surgical suite, out of the hospital and back into the community where it belongs.
The idea of a freestanding maternity center--one that has an OR and in-house OB and anesthesia, but that is completely separate from a hospital--is new. No one has ever done this before that I know of, and so no one knows how it would/should/could function. Would it be identical to hospital-style maternity care? Would women go there? Would being free from the confines of a hospital and all of its rules and regulations open up a space for a real change in maternity care?

One of the best ways to explore this new idea and offer up your own questions and ideas is to come to the Controversies in Childbirth Conference in Tampa, on February 19-21, 2010. The conference oragnizier, Alan Huber, just wrote more about the concept of freestanding maternity centers today, in a post called Birth Centers Versus Homebirth.


  1. I am very interested in hearing the answers to those questions. So far, at least to my knowledge, having one thing always means giving up have the comforts of home without the skill of the OR, or you have the skill of the OR without the comforts of home, and there never seems to be a way to make the two combine without ruining either one. Hmmmmmm! If this works, it would be revolutionary!

  2. Just imagine going to a free standing birth center knowing you are having a planned c-section for medical reasons. How much better could that be for a momma and baby? Still a surgery, but just like some other free standing surgical centers, the care is different...not being treated like you're in a factory?


  3. I'm not sure. Personally, if I had to have surgery, I'd want a skilled surgeon, and that means one who does a lot of surgeries. I'm not sure how that would integrate with a facility aiming for a low intervention rate.

  4. Another MAJOR plus (imo, especially since we're in flu season), is that since such a birthing center would not be a hospital where sick people are, then there would be fewer germs, less cross-contamination, fewer bugs for mamas and babies to be exposed to, etc.

    Sometimes I wonder how hospital clean-up crews work -- does one crew take care of all 4 floors? Might they accidentally drag some infectious diseases in mop water from a sick ward to a maternity ward? or from a maternity ward into the cancer ward? Or, could some diseases go airborne, and go through the ventilation system from someone with pneumonia into the NICU?

    Questions like that give me the heebie-jeebies. Surely, having no sick people in a birth center would have to be better, than being in a hospital that exists *so that* sick people can come in.


  5. to answer the hospital cleaning crew question. I found working in a huge world famous hospital, that everyone washed their hands way more often and many more folks were in complete precaution rooms. These hospitals know that infection control is a priority. Yes except for the BI. Then I migrated toward a rural hospital and the fear of bugs was smaller so I saw a lot less hand washing and more work being down without gloves. These days everyone is washing their hands or putting hand sanitizer on them. Long nails and fake nails are banned from most establishments.

    If someone comes in and we suspect they have an airborne illness, reverse precaution rooms are used. Masks are used, gowns and gloves. Equiptment specific to that room stays in that room.

  6. Oh and the cleaning staff. The wards I have worked on, cleaning staff is specific to maternity. In one hospital the RNs were the cleaning staff after a birth. We would wield the mops too.

  7. This is in some ways a comment to the last post on this topic as well! My comment there questioned whether freestanding maternity centers would just end up being rehoused L&D wards. Several people chimed in to say that wasn't the point - they would be low-intervention centers that had surgical services available for emergencies when needed. To those commenters - that's why I ended my earlier comment by saying I have nothing against emergency services under the same roof, but I did wonder whether those services would come in a package with the same birth-as-emergency attitude.

    Basically, I could see the freestanding maternity centers going 2 ways: 1) run by low-intervention practitioners who open freestanding maternity centers to attract patients who want low-intervention care, and are basically birth centers-with-ORs or 2) they're run by any kind of practitioners looking to cash in on one of the only profit centers left in hospital care - maternity services, and borrow the low-intervention facade of a "birth center" to bring in patients. Those would be L&D-wards-with-nicer-beds. (It already happens with hospital L&D floors who add some in-room fridges and nicer curtains, and call themselves "birth centers".)

    I know I sound like I'm raining on a potentially awesome parade. But I do think it's worth looking back at how the in-hospital "birth center" concept has been co-opted almost to the point of meaninglessness. I wouldn't want that to happen with maternity centers, should they come to pass.

  8. Rebecca, that would be my fear/assumption as well. If we're going to talk about "independent" then how will we get hospitals to sign on? They are not going to let go willingly of their L&D money.

    IF we could get measures pushed through that required evidence-based practice for birth, maybe we could build birth centers that were not just fancy L&D wards. In the American system at least, that is still a large "if".

    As per homebirth v. birth center, I think yes a birth center has a lot of appeal for many women who can't or don't want to homebirth. The trick is integrating such an animal into a system that is still largely hostile to midwifery model practices.

  9. Yes, why not just stay home? Yes, there will always be that small percentage that need emergency care, but anytime you set foot on someone else's territory, you either submit to their regulations or enter into an adversarial relationship in order to be granted your rights. When I had home births, my primary reason for staying at home was not comfort, although that was nice; it was having the birth on my own turf, and not having to fight with personnel over what their rules and regulations were.

    Additionally, there is always the risk of iatrogenic (hospital or provider-caused) complications caused by routine and needless interventions, for which reason I feel safer at home.

  10. I had the same idea/question a couple of years ago... why not create a birthing facility completely separate from the hospital, but equipped with all the necessary personnel and equipment for an emergency? I started talking with friends and midwives about it, and ran into some of the same concerns addressed in the comments here.

    I still think it would be feasible and a great option for women who don't feel comfortable giving birth at home.

    It would be cool if they could use of the concept of "small temples"--bringing the birthing facility to the people, lots of little facilities dotting the cities, close to their homes. But the tricky part, I think, would be having the surgical staff available 24/7 in so many little facilities.


Related Posts Plugin for WordPress, Blogger...