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.

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Pinky has a question about birth centers

Pinky, one of my blog readers and a L&D nurse (well, she recently switched and now is working as a psych nurse) and CNM-in-training, is doing a paper on freestanding birth centers. She's like to know why or why not you'd choose a birth center. Here are her questions:

Would folks who want a homebirth because of the restrictive nature of the hospital, come to a freestanding birth center? Is there a demand for Birth Centers? Especially a Birth center across the street from the hospital that has a large staff and 24 hour Ob and anesthesia folks so they can handle anything you throw at them. And a Nicu would be good too. I was thinking, if we did start up a birth center across the street from the hospital I worked at, would it be used? If we build it, will they come?

So for any home birth folks out there, could you please leave me a comment on your thoughts. What would you need in a birth center to make it attractive to birth at?

Here's my response: for me, a birth center is a less appealing option to me than a home birth. There isn't any inherent safety advantage of a freestanding birth center over a home birth, since the same equipment will usually be present in each setting (Doppler for intermittent monitoring, O2, IVs for dehydration/hemorrhage, antihemorrhagic meds, adult and neonatal resuscitation equipment, etc.) I'd much rather be in my own turf, rather than be at the mercy of an institution's rules, restrictions, or protocols. Of course birth center rules/protocols aren't anything like a hospital's, but still, it's not your house and you are the guest in someone else's territory. If I am going to get into a car and go somewhere else during labor, there better be a darn good reason for it--i.e., I need medical attention in a hospital setting.

On the other hand, someone else might choose a birth center over a home birth for a number of different reasons. Perhaps they just feel safer birthing in an institution/going somewhere to give birth, rather than staying in their own house. Perhaps they don't have a nice or safe home environment and the birth center is really awesome and luxurious and has a great labor tub. Perhaps they live too far away from their backup hospital for their own personal comfort (for some women, this might be 30 minutes, for others, 1 hour), but the birth center is right across the street from the hospital (pinky's ideal scenario, which I definitely can see the appeal of; I mean, if you're literally across the street from the hospital, you can't really argue from a safety perspective).

I wrote about this a while back in The Best of Both Worlds? I should note that I don't really feel that birth centers are the "worst of both worlds." It was more a train of thought that I was following at the time. I'd love to see more birth centers, especially ones really close to a hospital, because I think they would attract more women who are not thrilled about birthing in a hospital, but want the proximity to emergency care if needed.

And for a really fascinating idea that has started to gain momentum, read about freestanding maternity centers (my phrase; they don't really have an official name yet). It's basically a freestanding birth center with an OR and 24/7 OB and anesthsia coverage. Not part of a hospital, but instead owned and run by doctors and/or midwives directly.

Alan Huber explains his concept of a physician-owned birthing facility  in Why are pregnant women forced to choose between X and Y? and has more followup explanation in What's my hidden agenda?. Dr. Stuart Fischbein has also been working on this concept and thinks it might be a way to solve our maternity care crisis. Read A new type of birthing facility.

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