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Are outcomes compromised when mothers are assigned to birth centers for care?
'AREOUTCOMESCOMPROMISEDWHENMOTHERSARE ASSIGNEDTOBIRTHCENTERSFORCARE?
Anne Scupholme, CNM, and A. Susan Kamons, PhD
ABSTRACT A free-standing birth center was established in association with a tertiary care hospital that primarily served an indigent population. Initially, all patient assignments were voluntary. Fifteen months later, a change in policy occurred. In order to reduce the overcrowding in the obstetric suite, the hospital assigned low-risk women to the birth center for maternity care. A study was designed to test the null hypothesis that there would be no difference in outcomes between those who were assigned to the center and those who selected the center for care. One hundred forty-eight women from each group were matched for panty and demographic variables. The outcome results were analyzed and no differences in outcomes were found. The implications for the future of health care for low-risk women of poor socioeconomic status are discussed.
Birth centers have risen from the changes and controversies in obstetrical care during the past decade. Some consumers and health care providers became disenchanted with the technologically oriented style of hospital obstetrics. Accumulated data indicated that birth centers were safe, less costly settings for maternity care of low risk women.1-6 However, these data were derived primanly from populations of middleclass women who chose the birth center alternative. Would the same successful results be demonstrated if patients were from lower socioeconomic groups and were assigned to, as opposed to self-selecting, the outof-hospital system? The Birth Center of Jackson was developed as an alternative to the traditional hospital setting for childbearing families. Jackson Memorial
Address correspondence to: Anne Scupholme, CNM, Birth Center, Jackson Medical Towers, 10th Floor, 1500 NW 12th Avenue, Miami, FL 33136. Journal of Nurse-Midwifery
Copyright0
??Vol.
Hospital is a large tertiary care medical facility that serves a multi-ethnic population. The birth center is located on the 10th floor of a high rise building outside the hospital complex. The center consists of six large birthing rooms, each with an adjoining bathroom; two examination rooms; an education room; a waiting room; and staff offices and storage facilities. The center is staffed by certified nurse-midwives. Medical consultation and supervision are provided by obstetricians and pediatricians on the medical staff of Jackson Memorial Hospital. These physicians accept referral of any patients who develop complications that cannot be managed by the nurse-midwifery staff. All women who are cared for in the birth center program must first attend an orientation session. During the first visit, the nurse-midwife screens the client to ensure that no risk factors are present. Each woman must register for care before the 28th week of gestation. If prenatal care
32, No. 4, July/August
1987 by the American College of Nurse-Midwives
1987
has been obtained at another site, women are accepted up to 34 weeks gestation. A physician reviews the history and will examine the patient during the second prenatal visit and again around the 36th week of gestation. The remainder of the prenatal visits are managed by nurse-midwives. In the event of a complication, the patient is transferred to the highrisk clinics at the hospital. Nurse-midwifery management of labor, delivery, and postpartum is noninterventive with families assuming some responsibility for the care of mother and baby. No electronic fetal monitoring is available. Pitocin induction or augmentation is not performed in the center. Analgesia and intravenous hydration are available if necessary. Local anesthesia is available but there are no provisions for regional or general anesthesia. Any woman requiring an operative or assisted vaginal delivery (forceps or vacuum extraction) is transferred to the hospital. Complications that occur in labor 211 0091-2182/87/$03.50
require transfer to medical management in the hospital. Mothers with thick meconium in the amniotic fluid are transferred to the hospital at the time that the diagnosis is made. Clients with light meconium-stained fluid remain at the center provided that there are no fetal heart irregularities. After a delivery in which meconium is present in the amniotic fluid, the infant’s vocal cords are immediately visualized and endotracheal suctioning is performed. If meconium-stained is found below the cords, the infant is transferred to the hospital for observation. The safety and cost advantages of the program were demonstrated for clients who self-selected the birth center program.* The cost for care in the center was 30% less than the cost for low-risk women in the hospital. However, many mothers from the hospital’s specific population seemed reluctant to choose the outof-hospital setting, even though the obstetric floor was tremendously overcrowded. A system was established, therefore, to assign low-risk
Anne Scupholme
BA, CNM, is presently
the director of nurse-midwifery at Jacksor Florida.
Memorial
Hospital
These include a hospital based
service and a free-standing She completed education Bachelor
services in Miami,
birth center.
her nurse-midwifery
in England
and obtained a
of Arts degree in religious
studies from Florida International Uniuersity in Miami. She is presently studying for her master’s degree in Public Health at the University of Miami. She is Chairperson of the Clinical
Practice Committee of the American College of Nurse-Midwives. A. Susan Kamons, PHD, is presently an Assistant Professor at Florida International University. She obtained her doctorate and masters’ degrees in public health from Columbia
University, New York. She has also held a post as Research Associate at the Harvard Medical School and School of Public
Health.
212
women to the center for obstetrical care in order to relieve the overcrowding within the hospital obstetric department. In association with this policy change, a study was designed to evaluate the safety and effectiveness of the birth center program for mothers assigned to the center for care. During the period of the study, 494 women were admitted to the birth center in labor; 213 had self-selected the center and 281 had initially chosen the hospital setting but had been assigned to the center for care. One hundred forty-eight women from each group were matched for parity and demographic variables. The results were analyzed for comparisons and differences and the implications for the future of health care were determined. STUDY POPULATION
During the study period, May 1984 through April 1985, 1054 women presented for care at the birth center. Fifty-five percent of them were assigned to the center; 45% of them selected the program. Of these 1054 women, 70 (7%) were not admitted to the program and a further 42 (4%) dropped out of the program after admission for care. Two hundred twelve women (20%) were transferred to medical management during the antepartum period. Four hundred ninety-four women (47%) were admitted in labor to the birth center; 281 were assigned and 213 had selected the center. The remaining 236 women (22%) were undelivered at the completion of the study. The study group was comprised of these 281 low-risk women who were assigned to the birth center. The control group included the 213 lowrisk women who had self-selected the birth center instead of the traditional hospital setting. Although the study and control groups were similar in parity, they differed with regard to age, race (ethnic@), financial
status, and years of schoJjl corn-, pleted. The assigned group was younger, had a lower proportion of white mothers, a lower proportion of self-pay patients, and was less educated than the self-selected group (Table 1). This study employed a matched sample design to control for these demographic differences. It was possible to obtain 148 pairs of assigned. women and self-selected women matched for age, ethnic group, parity, financial status, and level of education. STUDY RESULTS
The study was designed to test the null hypothesis that there are no differences in outcomes of pregnancy between those who were assigned to the birth center and those who chose to seek maternity care at the birth center. The chi square analysis was applied to the results based on the McNemar test7 (Table 2). Labor characteristics were compared between the two groups; 26% of the assigned group and 33% of the self-selected group were admitted in active labor while the remainder were admitted in the latent phase. These results showed that there was no significant difference in the cervical dilatation on admission. There was also no significant difference in the length of labor of the mothers from each group with 47% of the assigned group and 37% of the self-selected group encountering labors that were over 12 hours in length. Labor was timed from the mother’s report of the onset of regular contractions. Analgesia was required by 39% of the assigned group and 43% of the self-selected group. (Demerol used alone or in combination with Vistaril or Phenergan are the only forms of analgesia that are available for use in the center.) Meconium was present in the amniotic fluid when the membranes ruptured in 18% of the assigned group and 20% of the self-selected
Journal of Nurse-Midwifery
??
Vol. 32, No. 4, July/August 1987
TABLE 1
Characteristics
of the study population Patient classijication Self-selected n %
Assigned Total Age (years) 16-19 20-29 30-34 35 or more
n
%
281
WO)
58 183 37 3
(21) (65) (13) (1)
Total n
%
(100)
213
(100)
494
33 141 28 11
(15) (66) (13) (6)
91 324 65 14
101 33 79
(48) (15) (37)
159 2;;:
129 84
(60) (40)
289 205
(59) (41)
143 57
(27)
13
‘4:;
3:; 61
I::; (13)
39 93 68 13
(18)
117 228 132 17
(24) (46) (27) (3)
1Ei; (13) (3)
x* = 8.93, .Ol < p < .05
Ethnic distribution White Black Hispanic
58 64 159
(21) (22) (57) p < .OOl
x2 = 39.81 Parity Primipara Multipara
160 121
(57) (43)
x* = 0.66 Financial status Self-pay County Medicaid
2:: 48
p > 0.1 I::; (17) p < .OOl
x* = 31.14 Education level ~12 Grade 12 Grade Co11 1-4 Yr Co115 + yr
78 135 64 4
(28) (47) (24) (1)
;y* = 16.58
I:; (6)
p < .OOl
group. These rates are high for a low-risk population but seen to be consistent with other unpublished findings from a personal survey of some South Florida hospitals. The rate of intrapartum transfers was nearly the same for both study group and controls; 24% for the assigned group and 26% for the selfselected group. The national average
delivey, be considered septic and, therefore, be subjected to a full septic workup, including a spinal tap. Consequently, if a mother is not in active labor within 18 hours after spontaneous rupture of the amniotic sac, she is transferred to the hospital for oxytocin augmentation. Modes for delivery were similar in each group; 93% of the assigned group and 90% of the self-select group experienced normal spontaneous vaginal deliveries. The outcomes of all those women who were transferred to the hospital were included in these results. No cesarean sections, vacuum extractions or forceps deliveries were performed in the center. The overall cesarean section rate for both groups was 5%. Table 3 shows the reasons for the intrapartum transfers. These were similar for both assigned and self-selected patients. The most common cause for transfer was arrested labor. There were no acute emergencies during the study period. All of the mother’s and babies experienced good outcomes. There were no significant differences between the study and control groups in Apgar score, birth weight or rate of transfer for neonatal problems. All babies had Apgar scores greater than 8 at 5 minutes. One baby from the assigned group weighed less than 2500 g. Nine percent of the babies in the assigned group and 7% of the babies in the self-select group weighed over 4000 g. One baby from the self-select group had a fractured clavicle that did not require any treatment.
for intrapartum transfers from centers serving a low-income population, where all women would be classified as self-selected, is 20%.5 There may be many reasons for the higher rate but it is most likely explained by the pediatric policy in the hospital that requires that any baby, whose mother had ruptured membranes for 24 hours or more prior to
TABLE 2
Assigned and self-selected mothers, labor and outcomes for 148 matched pairs McNemar test >4 cm dilated on admission in labor Labor >12 hr Use of analgesia Meconium presence Intrapatum transfer Normal spontaneous vaginal delivery
Assigned
%
Self-select
%
38 70 58
(26) (47)
49
(33)
z 29 38 133
g; (20) (26) (90)
;: 138
Journal of Nurse-Midwifery??Vol. 32, No. 4, July/August 1987
I?‘81 (24) (93)
?ESUltS
x* = x2 = x2 = )(* = x* = x2 =
1.70 3.21 0.27 0.02 0.02 0.76
p>O.l 0.1 >p > .05 p > 0.1 p > 0.1
p>O.l p > 0.1
213
TABLE 3 Reasons for intrapartum
transfers of assigned
and self-selected
mothers
Assigned
f%o)
Self-select
Preeclampsia Fetal distress Arrested labor 2nd stage >2 hr Maternal fever > 101 Thick meconium in fluid Breech
3 1 19
(9) (3) (56) (18) (5) (9) (0)
2 2 24 5 1 :
(5) (5) (67) (14) (3) (3) (3)
Total
34
(100)
36
(100)
: 3 0 -
Five percent of babies from each group had to be transferred to the hospital for medical management of neonatal problems (Table 4). The rate of neonatal transfer of 5% is higher than the national average of 2.7% that was reported by the National Association of Childbearing Centers in 1984.5 This is probably explained by the fact that only nurse-midwives examine the babies in our center, whereas in the majority of centers the babies are examined at least once by a physician. Any baby who has a problem that requires a physician evaluation must be transferred to the hospital. DISCUSSION
Concerns had been raised that the mothers in the assigned group would demonstrate different outcomes from those who self-selected the center. The demographics of the assigned group implied a potential difTABLE 4 Reasons for infant transfer from birth center assigned and self-selected mothers Assigned
Selfselect
Tachypnea Fractured clavicle Weight ~2500 g Hypoglycemia Anomalies Bradycardia
: 1
;
:, 0
: 1
Total
6
9
214
4
Cw
ference in outcomes; as mentioned previously, they were younger, more heavily nonwhite, poorer, and less educated than the self-selected mothers. Furthermore, it was felt that any residual anxiety concerning the safety of a birth center for delivery would be demonstrated in an increased rate of arrested labor and complicated deliveries. Birth centers, as noninterventive alternatives to traditional hospital obstetric practice, were developed in the early 1970s in response to the growing disenchantment with hospital care. Indigent families, however, typically have been served through traditional hospital-based practices. Nontraditional forms of health care have not been part of their culture because such options have not been available to them. The Birth Center of Jackson experienced some reluctance of the population to change during the development of the birth center and to accept the idea of out-of-hospital birth. Not all women who were assigned to the center were knowledgeable about the concept and about their responsibilities for self care. A high rate of noncompliance in the form of missed appointments was expected but this did not prove to be the case during the study period. Although the overall rate of antepartum transfer had increased since women were assigned to the center, there was a decrease in the rate for transfer for missed appointments. The safety of birth center care lies in strict on-
going screening during the prenatal period. Some anxiety has been expressed concerning the postdischarge visit to the center. All mothers must return with their infant within 36 hours for a physical examination and for the infant metabolic screening tests. The birth center has experienced total compliance with this aspect of the program. The cost at the birth center for labor, delivery, and postpartum care was $982 during the study period and was 30% less than care for a comparable patient in the hospital. This included professional and facility costs as well as laboratory fees for mother and baby. The cost of prenatal care, including laboratory tests, but not ultrasound if indicated, was $484. A comparable figure is not available from the hospital as outpatient services are all billed separately. Since the conclusion of the study period, many patients from the assigned group have chosen the birth center for care during a subsequent pregnancy. They also have been referring other family members to the birth center for care. This seems to demonstrate their satisfaction with their birth center care. With the current limitations on health care funding, available systems for providing maternity care are insufficient to meet the demand. The current malpractice crisis is serving to reduce the number of physicians and nurse-midwives who are in private practice, thereby increasing the demand on public services. Hospitals and technologicallyoriented systems serve a vital role in the care of high risk pregnant women who need this special care. In order to maintain the availability of that level of care for those who need it, physicians, nurse-midwives, and consumers must collaborate to develop alternative systems that are less expensive, accessible, and safe. Although the study sample is small, it demonstrates that women assigned
Journal of Nurse-Midwifery
??
Vol. 32, No. 4, July/August 1987
‘,
to. a bix?h center for care can be as succ&ful in using that care as women who are motivated to select the birth center. We feel that the
birth center, where it is part of an integrated obstetric care system, is one answer to contain escalating costs and increase client satisfaction with their health care. REFERENCES 1. Lubic RW Evaluation of an out-ofhospital maternity center for risk patients,
Journal of Nurse-Midwifery
??Vol.
in LH Aiken (ed), Health Policy and Nursing Practice. New York, McGrawHill, 1980. 2. Faison JB: The childbearing center: An alternative birth setting. Obstet Gynecol54:527-532,1979. 3. Goodlin RC: Low risk obstetric care for low risk mothers. Lancet i:10171019,198O. 4. Scupholme A, McLeod AGW, Robertson EG: A birth center affiliated with a tertiary care center: Comparison of outcomes. Obstet Gynecol 67(4): 1986.
32, No. 4, July/August 1987
5. National Association of Childbearing Survey 1984, N.A.C.C. News, Perkiomenville Penn. Vo12, Nos 3 and 4 1984. 6. Bennetts AB, Lubic RW The freestanding birth center. Lancet i:378-380, 1982.
7. Fleiss JL: Statistical methods for rates and proportions: Wiley series in probability and mathematical statistics. New York, J. Wiley & Sons, 1982.
215
Anne Scupholme, CNM, and A. Susan Kamons, PhD
ABSTRACT A free-standing birth center was established in association with a tertiary care hospital that primarily served an indigent population. Initially, all patient assignments were voluntary. Fifteen months later, a change in policy occurred. In order to reduce the overcrowding in the obstetric suite, the hospital assigned low-risk women to the birth center for maternity care. A study was designed to test the null hypothesis that there would be no difference in outcomes between those who were assigned to the center and those who selected the center for care. One hundred forty-eight women from each group were matched for panty and demographic variables. The outcome results were analyzed and no differences in outcomes were found. The implications for the future of health care for low-risk women of poor socioeconomic status are discussed.
Birth centers have risen from the changes and controversies in obstetrical care during the past decade. Some consumers and health care providers became disenchanted with the technologically oriented style of hospital obstetrics. Accumulated data indicated that birth centers were safe, less costly settings for maternity care of low risk women.1-6 However, these data were derived primanly from populations of middleclass women who chose the birth center alternative. Would the same successful results be demonstrated if patients were from lower socioeconomic groups and were assigned to, as opposed to self-selecting, the outof-hospital system? The Birth Center of Jackson was developed as an alternative to the traditional hospital setting for childbearing families. Jackson Memorial
Address correspondence to: Anne Scupholme, CNM, Birth Center, Jackson Medical Towers, 10th Floor, 1500 NW 12th Avenue, Miami, FL 33136. Journal of Nurse-Midwifery
Copyright0
??Vol.
Hospital is a large tertiary care medical facility that serves a multi-ethnic population. The birth center is located on the 10th floor of a high rise building outside the hospital complex. The center consists of six large birthing rooms, each with an adjoining bathroom; two examination rooms; an education room; a waiting room; and staff offices and storage facilities. The center is staffed by certified nurse-midwives. Medical consultation and supervision are provided by obstetricians and pediatricians on the medical staff of Jackson Memorial Hospital. These physicians accept referral of any patients who develop complications that cannot be managed by the nurse-midwifery staff. All women who are cared for in the birth center program must first attend an orientation session. During the first visit, the nurse-midwife screens the client to ensure that no risk factors are present. Each woman must register for care before the 28th week of gestation. If prenatal care
32, No. 4, July/August
1987 by the American College of Nurse-Midwives
1987
has been obtained at another site, women are accepted up to 34 weeks gestation. A physician reviews the history and will examine the patient during the second prenatal visit and again around the 36th week of gestation. The remainder of the prenatal visits are managed by nurse-midwives. In the event of a complication, the patient is transferred to the highrisk clinics at the hospital. Nurse-midwifery management of labor, delivery, and postpartum is noninterventive with families assuming some responsibility for the care of mother and baby. No electronic fetal monitoring is available. Pitocin induction or augmentation is not performed in the center. Analgesia and intravenous hydration are available if necessary. Local anesthesia is available but there are no provisions for regional or general anesthesia. Any woman requiring an operative or assisted vaginal delivery (forceps or vacuum extraction) is transferred to the hospital. Complications that occur in labor 211 0091-2182/87/$03.50
require transfer to medical management in the hospital. Mothers with thick meconium in the amniotic fluid are transferred to the hospital at the time that the diagnosis is made. Clients with light meconium-stained fluid remain at the center provided that there are no fetal heart irregularities. After a delivery in which meconium is present in the amniotic fluid, the infant’s vocal cords are immediately visualized and endotracheal suctioning is performed. If meconium-stained is found below the cords, the infant is transferred to the hospital for observation. The safety and cost advantages of the program were demonstrated for clients who self-selected the birth center program.* The cost for care in the center was 30% less than the cost for low-risk women in the hospital. However, many mothers from the hospital’s specific population seemed reluctant to choose the outof-hospital setting, even though the obstetric floor was tremendously overcrowded. A system was established, therefore, to assign low-risk
Anne Scupholme
BA, CNM, is presently
the director of nurse-midwifery at Jacksor Florida.
Memorial
Hospital
These include a hospital based
service and a free-standing She completed education Bachelor
services in Miami,
birth center.
her nurse-midwifery
in England
and obtained a
of Arts degree in religious
studies from Florida International Uniuersity in Miami. She is presently studying for her master’s degree in Public Health at the University of Miami. She is Chairperson of the Clinical
Practice Committee of the American College of Nurse-Midwives. A. Susan Kamons, PHD, is presently an Assistant Professor at Florida International University. She obtained her doctorate and masters’ degrees in public health from Columbia
University, New York. She has also held a post as Research Associate at the Harvard Medical School and School of Public
Health.
212
women to the center for obstetrical care in order to relieve the overcrowding within the hospital obstetric department. In association with this policy change, a study was designed to evaluate the safety and effectiveness of the birth center program for mothers assigned to the center for care. During the period of the study, 494 women were admitted to the birth center in labor; 213 had self-selected the center and 281 had initially chosen the hospital setting but had been assigned to the center for care. One hundred forty-eight women from each group were matched for parity and demographic variables. The results were analyzed for comparisons and differences and the implications for the future of health care were determined. STUDY POPULATION
During the study period, May 1984 through April 1985, 1054 women presented for care at the birth center. Fifty-five percent of them were assigned to the center; 45% of them selected the program. Of these 1054 women, 70 (7%) were not admitted to the program and a further 42 (4%) dropped out of the program after admission for care. Two hundred twelve women (20%) were transferred to medical management during the antepartum period. Four hundred ninety-four women (47%) were admitted in labor to the birth center; 281 were assigned and 213 had selected the center. The remaining 236 women (22%) were undelivered at the completion of the study. The study group was comprised of these 281 low-risk women who were assigned to the birth center. The control group included the 213 lowrisk women who had self-selected the birth center instead of the traditional hospital setting. Although the study and control groups were similar in parity, they differed with regard to age, race (ethnic@), financial
status, and years of schoJjl corn-, pleted. The assigned group was younger, had a lower proportion of white mothers, a lower proportion of self-pay patients, and was less educated than the self-selected group (Table 1). This study employed a matched sample design to control for these demographic differences. It was possible to obtain 148 pairs of assigned. women and self-selected women matched for age, ethnic group, parity, financial status, and level of education. STUDY RESULTS
The study was designed to test the null hypothesis that there are no differences in outcomes of pregnancy between those who were assigned to the birth center and those who chose to seek maternity care at the birth center. The chi square analysis was applied to the results based on the McNemar test7 (Table 2). Labor characteristics were compared between the two groups; 26% of the assigned group and 33% of the self-selected group were admitted in active labor while the remainder were admitted in the latent phase. These results showed that there was no significant difference in the cervical dilatation on admission. There was also no significant difference in the length of labor of the mothers from each group with 47% of the assigned group and 37% of the self-selected group encountering labors that were over 12 hours in length. Labor was timed from the mother’s report of the onset of regular contractions. Analgesia was required by 39% of the assigned group and 43% of the self-selected group. (Demerol used alone or in combination with Vistaril or Phenergan are the only forms of analgesia that are available for use in the center.) Meconium was present in the amniotic fluid when the membranes ruptured in 18% of the assigned group and 20% of the self-selected
Journal of Nurse-Midwifery
??
Vol. 32, No. 4, July/August 1987
TABLE 1
Characteristics
of the study population Patient classijication Self-selected n %
Assigned Total Age (years) 16-19 20-29 30-34 35 or more
n
%
281
WO)
58 183 37 3
(21) (65) (13) (1)
Total n
%
(100)
213
(100)
494
33 141 28 11
(15) (66) (13) (6)
91 324 65 14
101 33 79
(48) (15) (37)
159 2;;:
129 84
(60) (40)
289 205
(59) (41)
143 57
(27)
13
‘4:;
3:; 61
I::; (13)
39 93 68 13
(18)
117 228 132 17
(24) (46) (27) (3)
1Ei; (13) (3)
x* = 8.93, .Ol < p < .05
Ethnic distribution White Black Hispanic
58 64 159
(21) (22) (57) p < .OOl
x2 = 39.81 Parity Primipara Multipara
160 121
(57) (43)
x* = 0.66 Financial status Self-pay County Medicaid
2:: 48
p > 0.1 I::; (17) p < .OOl
x* = 31.14 Education level ~12 Grade 12 Grade Co11 1-4 Yr Co115 + yr
78 135 64 4
(28) (47) (24) (1)
;y* = 16.58
I:; (6)
p < .OOl
group. These rates are high for a low-risk population but seen to be consistent with other unpublished findings from a personal survey of some South Florida hospitals. The rate of intrapartum transfers was nearly the same for both study group and controls; 24% for the assigned group and 26% for the selfselected group. The national average
delivey, be considered septic and, therefore, be subjected to a full septic workup, including a spinal tap. Consequently, if a mother is not in active labor within 18 hours after spontaneous rupture of the amniotic sac, she is transferred to the hospital for oxytocin augmentation. Modes for delivery were similar in each group; 93% of the assigned group and 90% of the self-select group experienced normal spontaneous vaginal deliveries. The outcomes of all those women who were transferred to the hospital were included in these results. No cesarean sections, vacuum extractions or forceps deliveries were performed in the center. The overall cesarean section rate for both groups was 5%. Table 3 shows the reasons for the intrapartum transfers. These were similar for both assigned and self-selected patients. The most common cause for transfer was arrested labor. There were no acute emergencies during the study period. All of the mother’s and babies experienced good outcomes. There were no significant differences between the study and control groups in Apgar score, birth weight or rate of transfer for neonatal problems. All babies had Apgar scores greater than 8 at 5 minutes. One baby from the assigned group weighed less than 2500 g. Nine percent of the babies in the assigned group and 7% of the babies in the self-select group weighed over 4000 g. One baby from the self-select group had a fractured clavicle that did not require any treatment.
for intrapartum transfers from centers serving a low-income population, where all women would be classified as self-selected, is 20%.5 There may be many reasons for the higher rate but it is most likely explained by the pediatric policy in the hospital that requires that any baby, whose mother had ruptured membranes for 24 hours or more prior to
TABLE 2
Assigned and self-selected mothers, labor and outcomes for 148 matched pairs McNemar test >4 cm dilated on admission in labor Labor >12 hr Use of analgesia Meconium presence Intrapatum transfer Normal spontaneous vaginal delivery
Assigned
%
Self-select
%
38 70 58
(26) (47)
49
(33)
z 29 38 133
g; (20) (26) (90)
;: 138
Journal of Nurse-Midwifery??Vol. 32, No. 4, July/August 1987
I?‘81 (24) (93)
?ESUltS
x* = x2 = x2 = )(* = x* = x2 =
1.70 3.21 0.27 0.02 0.02 0.76
p>O.l 0.1 >p > .05 p > 0.1 p > 0.1
p>O.l p > 0.1
213
TABLE 3 Reasons for intrapartum
transfers of assigned
and self-selected
mothers
Assigned
f%o)
Self-select
Preeclampsia Fetal distress Arrested labor 2nd stage >2 hr Maternal fever > 101 Thick meconium in fluid Breech
3 1 19
(9) (3) (56) (18) (5) (9) (0)
2 2 24 5 1 :
(5) (5) (67) (14) (3) (3) (3)
Total
34
(100)
36
(100)
: 3 0 -
Five percent of babies from each group had to be transferred to the hospital for medical management of neonatal problems (Table 4). The rate of neonatal transfer of 5% is higher than the national average of 2.7% that was reported by the National Association of Childbearing Centers in 1984.5 This is probably explained by the fact that only nurse-midwives examine the babies in our center, whereas in the majority of centers the babies are examined at least once by a physician. Any baby who has a problem that requires a physician evaluation must be transferred to the hospital. DISCUSSION
Concerns had been raised that the mothers in the assigned group would demonstrate different outcomes from those who self-selected the center. The demographics of the assigned group implied a potential difTABLE 4 Reasons for infant transfer from birth center assigned and self-selected mothers Assigned
Selfselect
Tachypnea Fractured clavicle Weight ~2500 g Hypoglycemia Anomalies Bradycardia
: 1
;
:, 0
: 1
Total
6
9
214
4
Cw
ference in outcomes; as mentioned previously, they were younger, more heavily nonwhite, poorer, and less educated than the self-selected mothers. Furthermore, it was felt that any residual anxiety concerning the safety of a birth center for delivery would be demonstrated in an increased rate of arrested labor and complicated deliveries. Birth centers, as noninterventive alternatives to traditional hospital obstetric practice, were developed in the early 1970s in response to the growing disenchantment with hospital care. Indigent families, however, typically have been served through traditional hospital-based practices. Nontraditional forms of health care have not been part of their culture because such options have not been available to them. The Birth Center of Jackson experienced some reluctance of the population to change during the development of the birth center and to accept the idea of out-of-hospital birth. Not all women who were assigned to the center were knowledgeable about the concept and about their responsibilities for self care. A high rate of noncompliance in the form of missed appointments was expected but this did not prove to be the case during the study period. Although the overall rate of antepartum transfer had increased since women were assigned to the center, there was a decrease in the rate for transfer for missed appointments. The safety of birth center care lies in strict on-
going screening during the prenatal period. Some anxiety has been expressed concerning the postdischarge visit to the center. All mothers must return with their infant within 36 hours for a physical examination and for the infant metabolic screening tests. The birth center has experienced total compliance with this aspect of the program. The cost at the birth center for labor, delivery, and postpartum care was $982 during the study period and was 30% less than care for a comparable patient in the hospital. This included professional and facility costs as well as laboratory fees for mother and baby. The cost of prenatal care, including laboratory tests, but not ultrasound if indicated, was $484. A comparable figure is not available from the hospital as outpatient services are all billed separately. Since the conclusion of the study period, many patients from the assigned group have chosen the birth center for care during a subsequent pregnancy. They also have been referring other family members to the birth center for care. This seems to demonstrate their satisfaction with their birth center care. With the current limitations on health care funding, available systems for providing maternity care are insufficient to meet the demand. The current malpractice crisis is serving to reduce the number of physicians and nurse-midwives who are in private practice, thereby increasing the demand on public services. Hospitals and technologicallyoriented systems serve a vital role in the care of high risk pregnant women who need this special care. In order to maintain the availability of that level of care for those who need it, physicians, nurse-midwives, and consumers must collaborate to develop alternative systems that are less expensive, accessible, and safe. Although the study sample is small, it demonstrates that women assigned
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to. a bix?h center for care can be as succ&ful in using that care as women who are motivated to select the birth center. We feel that the
birth center, where it is part of an integrated obstetric care system, is one answer to contain escalating costs and increase client satisfaction with their health care. REFERENCES 1. Lubic RW Evaluation of an out-ofhospital maternity center for risk patients,
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in LH Aiken (ed), Health Policy and Nursing Practice. New York, McGrawHill, 1980. 2. Faison JB: The childbearing center: An alternative birth setting. Obstet Gynecol54:527-532,1979. 3. Goodlin RC: Low risk obstetric care for low risk mothers. Lancet i:10171019,198O. 4. Scupholme A, McLeod AGW, Robertson EG: A birth center affiliated with a tertiary care center: Comparison of outcomes. Obstet Gynecol 67(4): 1986.
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5. National Association of Childbearing Survey 1984, N.A.C.C. News, Perkiomenville Penn. Vo12, Nos 3 and 4 1984. 6. Bennetts AB, Lubic RW The freestanding birth center. Lancet i:378-380, 1982.
7. Fleiss JL: Statistical methods for rates and proportions: Wiley series in probability and mathematical statistics. New York, J. Wiley & Sons, 1982.
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