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Development and experience of a University based, freestanding birthing center
Development and Experience of a UniversityBased, Freestanding Birthing Center T H O M A S J. GARITE, M D , B. J. SNELL, C N M , PhD , D E B O R A H L. WALKER, M B A , A N D VICKI C. D A R R O W , M D Objective: To describe our experience w i t h a f r e e s t a n d i n g birthing center established in c o n j u n c t i o n w i t h a university m e d i c a l center, a n d to d e t e r m i n e the safety a n d effectiveness of such a program. Methods: The U n i v e r s i t y of California | r v i n e Medical Center o p e n e d a f r e e s t a n d i n g b i r t h i n g center 2 miles from the hospital. The u n i t p r o v i d e s prenatal, labor, delivery, p o s t p a r t u m a n d w e l l - b a b y care 24 hours/day. All direct p a t i e n t care is p r o v i d e d by certified n u r s e - m i d w i v e s . Data were collected prospectively to p r o v i d e a descriptive account a n d to evaluate m a t e r n a l a n d p e r i n a t a l m o r b i d i t y a n d mortality to d e t e r m i n e the safety a n d efficacy of this approach. Results: D u r i n g the first 20 m o n t h s of operation, the U n i v e r s i t y of California Irvine B i r t h i n g C e n t e r cared for 1830 patients. A p p r o x i m a t e l y 90~ were i n d i g e n t , 85% were Hispanic, and 35% were nulliparas. Of the total patients, 12% were transferred a n t e n a t a l l y for h i g h - r i s k c o n d i t i o n s a n d 19% were t r a n s f e r r e d i n t r a p a r t u m . The cesarean rate for all p a t i e n t s was 10% (6.5% for those w h o s e i n t r a p a r t u m care began at the birthing center). The perinatal mortality rate was six p e r 1000. N e o n a t a l m o r b i d i t y rates, n e o n a t a l intensive care u n i t a d m i s s i o n s , a n d m a t e r n a l c o m p l i c a t i o n s were not greater t h a n expected. Conclusion: T h e first 20 m o n t h s of experience w i t h a u n i v e r s i t y - b a s e d , f r e e s t a n d i n g b i r t h i n g center suggests that this alternative is safe for d e l i v e r i n g obstetric a n d n e w b o r n care to low-risk patients. (Obstet Gynecol 1995;86:411-6)
Changes in health care demand that more economic methods of health care delivery be developed and evaluated. Two important trends, outpatient services previously provided to inpatients and the use of nonphysician providers, hold promise for decreasing costs. In obstetrics, there is an opportunity to provide both such solutions in the form of outpatient, freestanding birthing centers with certified nurse-midwives providing obstetric and newborn care. Recent reports have From the Department of Obstet,'i~ > and G!nlecology. Lhtiver
V()L. 86, NO. 3, SEPTEMBER It~u'~
suggested that such centers can provide a safe alternative to traditional in-hospital care. ~ 3 Most information on such systems comes from outside the traditional health care system and has not made a notable impact on the attitudes or practices of most obstetric care providers. Consequently, only a small percentage of births in this country are delivered in such settings. It is incumbent on the obstetric community to evaluate critically the safety, efficacy, and costeffectiveness of such new health care delivery systems.
Materials and Methods The purpose of this paper is to provide a descriptive account of a university experience with the development of a freestanding birthing center with obstetric care for low-risk patients administered by faculty certified nurse-midwives. A freestanding birthing center was opened jointly by the Department of Obstetrics and Gynecology of the University of California Irvine and by the University Medical Center, assisted with state and local support. An existing two-building outpatient facility located 2 miles from the medical center was converted. One building provides the office suite for prenatal and postpartum care. The adjacent birthing center consists of ten rooms in which labor, delivery, postpartum, and immediate newborn care are delivered. The functional capacity of this unit is 150 deliveries per month. An ambulance and driver based at the birthing center at all times allows rapid emergency transport of laboring patients when required. The birthing center is staffed by seven certified nursemidwives who each see prenatal patients 2 d a y s / w e e k in the office suite and who each cover one 24-hour shift per week in the birthing center. No direct patient care by physicians is provided, and no physicians are routinely on-site at the birthing center, except to provide administrative and consultative support. Consulting physicians provide 24-hour telephone and electronic
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support. Weekly conferences are conducted to review" both recent statistics and management of ongoing patients. The intent of the birthing center is to provide total obstetric and newborn care to low-risk patients. Patients are screened initially with a simple questionnaire at the time of the first telephone or in-person encounter. Those who meet low-risk criteria are given appointments to the birthing center for prenatal care. Patients are registered from those enrolling for prenatal care at the university medical center, from local public health and community clinics, and by self-referral. Patient enrollment at the birthing center is voluntary. Patients are free to transfer care to any other provider, including the university medical center clinic, at any time. Prenatal care is provided by nurse-midwives at a frequency as outlined in the Guidelines for Periuatal Care. 4 The nurse-midwives adhere to a detailed set of practice guidelines that defines complications or risk factors. Patients with complications are either transferred to the medical center for care or the physician director is called upon for consultation. No patient is accepted after 34 weeks' gestation. Contracts with local clinics and providers allow additional eligible patients to deliver at the birthing center. These patients are seen, evaluated, and oriented at the birthing center at least once during the third trimester. Evaluation on admission for anticipated labor and delivery includes clinical evaluation, an initial 30minute electronic fetal heart rate (FHR) strip, and an ultrasound examination for fetal presentation if there is either a reason to defer the pelvic examination given on admission (eg, premature rupture of membranes [PROM]) or uncertainty as to the presentation. Subsequent FHR monitoring is bv intermittent auscultation, but continuous electronic FHR monitoring is an option and is used routinely to clarify any abnormalities of the FHR detected by auscultation. Clinical practice guidelines carefully define criteria for intrapartum transfer to the medical center, and telephone consultation with physician staff is available at all times. Narcotic and nonnarcotic analgesia are offered. Conduction anesthesia is not available. Local or pudendal anesthesia may be provided for delivery. Patients are informed of analgesia and anesthesia options during prenatal care, and a letter of understanding in this regard must be signed by the patient. Patients who cannot tolerate labor can be transferred to the medical center for this indication. No operative deliveries are performed at the birthing center. Patients with fourth-degree perineal and large vaginal lacerations are transferred to the medical center for repair. Patients are discharged postpartum in 12
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hours or less. Criteria for postpartum transfer to the medical center are detailed in the practice guidelines. Newborn evaluation is performed by a nursemidwife. Criteria for newborn transfer to the medical center are also detailed in the practice guidelines, and physician consultation is available. The patient is instructed to return 48 hours after discharge for routine newborn assessment and a review of maternal condition. Subsequent newborn care is provided by referral to local providers. Mothers return 6 weeks postpartum for final evaluation and family planning. A computer data base was developed and implemented at the opening of the center. All patients initially seen in the birthing center clinic were included, and location of delivery, route of delivery, complications, and outcomes for both mothers and newborns were tracked prospectively. A small percentage of patients elected to deliver elsewhere or transferred care without notification, and these data were lost. All data reported here were collected prospectively.
Results For the purpose of this descriptive study, we provide the first 20 months of experience at the University of California Irvine Birthing Center. The majority of patients were Hispanic (85%), with 11% white, 3% Asian, and 1~ African-American. Thirty-five percent were nulliparous. The mean age of all patients was 23.5 years (range 13-41). Most received prenatal care at the birthing center (60%), but 30% had prenatal care at the Public Health Department, and the remainder at other local clinics. These factors are all similar to those of patients delivered at the medical center. One thousand sixty-six births occurred at the birthing center during this time period, for an average of 53 births per month. After the initial growth period of the center, a relatively steady rate of 60-70 births per month was achieved. We saw 1830 patients for their initial prenatal visit at the birthing center. Two hundred twenty-eight patients (12%) were transferred to the medical center at some point during their antenatal care for a variety of risk factors or complications, as shown in Table 1. Ninety-two patients (5'~) moved or chose to transfer care to other health care providers. One hundred three patients (6%) presented to the medical center for delivery, almost all in the first 6 months after the center opened, mainly because the instructions on where and when to present were unclear. During this time period, 1407 patients presented to the birthing center for delivery, and there were 341 intrapartum transfers (Table 1). This represents 19% of the total population registered and 24% of those whose intrapartum care began at the birthing center. The
Obstetrics & Gynecology
i n t r a p a r t u m transfer rate was 46~:,~ for n u l l i p a r a s and 13% for multiparas. The i n t r a p a r t u m transfer rate declined steadily from 29~7~ in the first 6 m o n t h s to 22% in the last 6 months. All patients who delivered at the b i r t h i n g center delivered vaginally w i t h o u t i n s t r u m e n t a t i o n . There was one u n e x p e c t e d b u t u n c o m p l i c a t e d vaginal breech delivery. The route of delivery for i n t r a p a r t u m transfers was 54% s p o n t a n e o u s vaginal, 19~ operative vaginal, a n d 27% cesarean. This represents an overall cesarean rate of 6.5% for patients whose i n t r a p a r t u m care b e g a n at the b i r t h i n g center (10% if all patients whose prenatal care began at the birthing center are included). Of the patients transferred i n t r a p a r t u m , three required u r g e n t (crash) cesarean delivery (two a b r u p t i o placentae and one p r o l o n g e d FHR deceleration). All three cesareans were accomplished in less than 3(I m i n u t e s from decision for transfer to deliverv of the neonates. N o n e had a n y significant neonatal complications and all survived w i t h o u t a p p a r e n t damage. There were 24 p o s t p a r t u m transfers to the medical center d u r i n g the s t u d y period (2.29~) for the following reasons: laceration repair (ten; seven fourth-degree perineal a n d three vaginal), p o s t p a r t u m fever (nine), postp a r t u m h e m o r r h a g e (two), retained placenta (one), vaginal h e m a t o m a (one), a n d u n e x p l a i n e d m a t e r n a l tachycardia (one). There were no maternal deaths; with one exception, all of these p o s t p a r t u m transfers resolved their complications w i t h o u t sequelae. The one major complication involved a severe p o s t p a r t u m hemorrhage d u e to m u l t i p l e vaginal lacerations. A delay in this patient's transfer to the hospital m a y have contributed to the degree of her tnorbidity. The perinatal mortality for all patients whose care b e g a n at the b i r t h i n g center d u r i n g this time period was
Table 1. indications for Maternal Transfer Antepartum transfers ( 2 2 8 ) Post-dates Preeclampsia Preterm labor Gestational diabetes Spontaneous abortion Suspected macrosomia Fetal anomaly Other medical complication Other
lntrapartum transfers (341)
27 (12V, 24 (1 IV, 16 (79;) 16 (7~) 15 (79;) 13 (6(~) 10 (4q:~) 10 (4~)
Failure to progress 126 (37'",) I'ROM/no labor 71 (27'/, ) Nonreassuring FllR 41 {12V,) Thick meconiunr 26 {89;} Preeclampsia 20 (6~) I'ain intolerance 11 (3~/;1 Preterm labor l0 (39~ Malpresentation 8 (2~,';) Antepartmn bleeding 5 (1~ ) 97 (429~) l'reterm PROM 3 Pust-dates 2 Suspected macrosomia 2 Active herpes 2 Other* 14 (7',;)
PROM premature rupture of membranes; FltR * Includes patient request, security risk. etc.
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fetalheart rate.
Table 2. Perinatal Deaths Type/delivery site Weeks Ii~trapartum Amepartum Hospital Hospital Hospital Hospital Hospital Neonatal Birthing
Cause
Autopsy confirmation
None 31 34 37 40 40 40
qenter
Birthing center Birthing center Neonatal ffospital*
40
Hospital* HospitaP
40 40
40
40
Cytomegaluvirus infection Unknown Unknown Anencephaly Unknown Congenitalheart disease Diaphragmatic hernia Congenitalh e a r t disease Perinatalasphyxia
Meconiumaspiration syndrome Perinatalasphyxia Pottersyndrome
Confirmed Declined Declined Declined No definitive cause
Declined Endocardial Fibroelastosis Confirmed/basal Ganglia infarcts Declined Declined Renal agenesis
* Both cases transferred intrapartum from birthing center for inadequate labor progress with normal fetal heart rate tracing at time of transfer. Care transferred intrapartum for abnormal fetal heart rate tracing.
six per 1000 (11 deaths) excluding those patients who self-transferred to other providers. This i n c l u d e d five fetal deaths (all a n t e p a r t u m deaths) a n d six n e o n a t a l deaths (Table 2). Of the neonates born at the b i r t h i n g center, three had low A p g a r scores (less than 7) at 5 minutes. There were 12 infants w e i g h i n g less than 2500 g (all more than 2000 g) a n d 60 w e i g h i n g more t h a n 4000 g (5.6%). All neonates with complications were transferred to the medical center. There were 44 n e o n a t a l transfers (4%). Reasons for n e o n a t a l transfers i n c l u d e d possible or suspected sepsis (20 transfers), tachypnea or respiratory distress (13), feeding difficulties (seven), a n o m a l i e s (two), jaundice (two), n e o n a t a l d e p r e s s i o n at birth (two), p r e m a t u r i t y (one), suspected heart disease (two), m e c o n i u m a s p i r a t i o n (one), a n d t h r o m b o c y t o p e n i a (one). Except for three patients, all complied with instructions to have their neonates seen at the b i r t h i n g center 24 hours after discharge. Sixty-six n e w b o r n s were a d m i t t e d to the n e o n a t a l intensive care u n i t (NICU) from the 1407 patients who presented to the b i r t h i n g center for delivery (4.7%). This includes all 44 neonatal transfers (4.1% of n e w b o r n s delivered at the birthing center) a n d 22 of the 341 i n t r a p a r t u m transfers (6.5%). These N I C U a d m i s s i o n rates from the b i r t h i n g center c o m p a r e quite favorably with the rate of 15.3% for NICU a d m i s s i o n s of neonates
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born at the medical center, which does not in(lude maternal or neonatal transfers. Because charges are often arbitrarily assigned, we endeavored to calculate the costs of care when possible. For the birthing center, the average total cost for prenatal, labor, vaginal delivery, postpartum, and newborn care was $2183 per patient for both the provider and the facility. The costs are extremely volume dependent; total costs per patient decrease to $1543 at 75 deliveries per month and $1390 for 100 deliveries per month. For this birthing center, these volumes are achievable with minimal increases in nursing staff support and without any change in nurse-midwife or physician-supervisor support. For similar care at the medical center, costs are considerably higher. Although physician costs are not possible to calculate, total obstetric care contracts for physicians average $1500 for vaginal deliveries. The hospital charge averages $120{) per day for an average stay of 1.5 days, or $1800 per vaginal delivery. In addition, savings are even greater because there is no pediatrician's charge for newborn examinations and no epidurals are given. Even with the costs incurred as a result of antenatal and intrapartum transfer, the savings are more than $1500 per patient. Because of the large proportion of fixed costs, the savings exceed $2000 per patient at a delivery volume of 100 patients per month.
Discussion The cost of health care has become an overriding concern. Two practices have great potential for reducing cost: outpatient care and the use of nonphysician providers. Freestanding birthing centers combine both of these cost-saving practices. It is incumbent on the obstetric community to determine systematically the safety of such alternatives. In the words of Eakins, 5 a freestanding birthing (or birth) center is "an adaptation of a home environment to a short-stay, ambulatory health care facility with access to in-hospital obstetrical and newborn services; designed to safely accommodate participating family members and support people of the woman's choice; and, providing professional preventive health care to women and the fetus/newborn during pregnancy, birth and puerperium." Although many community hospitals have redesigned or set aside areas within the hospital that they often call "birthing centers," these should not be confused with freestanding birthing centers because they are not likely to provide similar cost savings, reductions in technology use or reduced cesarean rates. Over the last 2 decades, freestanding birthing centers have been slowly but steadily gaining acceptance in this country. The first such birthing centers w e r e developed to serve rural areas. In 1975, the first urban birthing
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center was established in New York City, and by the late 1980s there were over 240 centers opened around the country) However, this approach has not gained widespread acceptance; in 1989, Declercq ~ reported that only 0.4% of all births in this country occurred in freestanding birthing centers. Certified nurse-midwives are licensed registered nurses who have had 1 (certificate programs) or 2 years (masters programs) of additional postgraduate training and certification in obstetric, gynecologic, and newborn care. The American College of Nurse-Midwives accredits the training and provides certification of nursemidwives. Candidates are required to pass a written examination to receive certification. Certified nursemidwives are now licensed in all 50 states. An estimated 4500 nurse-midwives are certified at present, and about 3% of all births in the United States are attended by certified nurse-midwives. ° Although freestanding birthing centers have great potential for cost savings, this practice has not gained widespread acceptance. Safety appears to be the main concern because most bodies of organized medicine have not endorsed such practices, discouraging their use until better data on safety are available. 4 Several studies have evaluated the safety of freestanding birthing centers. In general, low perinatal mortality rates of 1.0-4.2:1000 have been reported, with zero to one per 1000 intrapartum fetal death rates and very low rates of neonatal depression) '2: Cesarean rates were also reported to be reduced substantially, with most reporting rates of 4-8~. compared with average in-hospital rates of 20%. 1'2'7 Recently, Rooks et al ~ reported on the experience of 11,814 women admitted for labor and delivery to 84 freestanding birthing centers around the United States; they found an overall perinatal mortality of 1.3 per 1000 and a cesarean delivery rate of 4.4% with no maternal deaths. Our descriptive study is unique in several respects. It includes data on the experience of a freestanding birthing center that is related exclusively to a university medical center. Patient data were collected prospectively from its inception. Complete data are available on all patients cared for and delivered at the birthing center; in addition, this is one of the few studies of freestanding birthing centers that also reports on data from patients transferred antenatally. Such complete information is essential in comparing data with inhospital births. Accurate comparison is important not onlv for safety but for determining the actual total transfer rates of patients out of the system, the true cesarean rates, and the overall cost savings of such programs. Unfortunately, there are limited data that compare safety and cesarean delivery rates for truly comparable
Obstetrics & Gynecology
populations. Because only low-risk, often more highly educated and wealthier patients deliver at freestanding birthing centers, it is difficult to k n o w what the expected mortality, morbidity, and cesarean rates w o u l d be in truly similar populations delivered in-hospital. H o w ever, even if such data were available, the rates of such complications are so low that it would take large sample sizes to demonstrate any statistically significant difference. A c k n o w l e d g i n g this limitation, several statements can be made. First, intrapartum death rates are low in all reports from freestanding birthing centers. The best data on realistically and optimally achievable intrapartum death rates come from those reported in r a n d o m i z e d trials of intrapartum FHR versus auscultation done in hospital settings, with an average rate of 0.5 per 1000, similar to the rates reported in this and other reports of freestanding birthing centers.l'2'7 u~ Another w a y of evaluating perinatal mortality is to examine specific cases and see how m a n y might have been preventable. In our study, there were 11 perinatal deaths. Of the fetal deaths, none was intrapartum; of the five antepartum deaths (five per 1830, or 2.7 per 10001, two were unpreventable (cytomegalovirus infection and anencephaly). The three deaths of u n k n o w n causes did not have risk factors that would have indicated antepartum testing. This antepartum death rate is similar to that of untested patients without risk factors (four per 1000) in our institution. ~ For the neonatal deaths, of the three delivered at the birthing center, two had major cardiac anomalies and one had perinatal asphyxia. Of the three deaths that occurred a m o n g patients w h o were intrapartum transfers, one was a major anomaly and the other two m a v have been related to perinatal asphyxia, but both were transferred for reasons other than fetal distress and had normal FHR tracings after transferring from the birthing center; these subsequently deteriorated at the hospital. Therefore, only the one case of asphyxia-related neonatal death occurring in a n e w b o r n delivered at the birthing center could be identified as preventable and attribtttable to the birthing center, out of 1061~ deliveries and 1830 total patients cared for prenatally. Regarding cesarean deliveries, at least one study ~2 controlled for risk factors and concluded that births attended by nursem i d w i v e s result in lower cesarean rates. The cost savings that occur as a result of such an outpatient setting staffed bv certified nurse-midwives is substantiated by our calculations of cost. These calculations m a y be conservative because lower utilization of ancillary tests and decreased cotnplications, such as infections, could lower costs even further. However, freestanding birthing centers do have limitations. Not all patients will accept this alternative. The lack of conduction anesthesia is a deterrent to m a n y
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women. The high transfer rate, especially for nulliparous patients, is of particular concern. O u r s t u d y found intrapartum transfer rates s o m e w h a t higher than most others. Most of these w e r e for i n a d e q u a t e labor progress and PROM in patients w h o failed to enter labor spontaneously within 12 hours. O u r study includes data on a n t e p a r t u m transfers as well. This antep a r t u m transfer rate (12%) is similar to rates reported in the exceptional studies that have also looked at this issue. 3'~3 The total transfer rate m a y be i m p r o v e d by learning which risk factors can be safely liberalized and by adopting new procedures, such as amnioinfusion. O n g o i n g efforts are required, but we must all avoid the temptation to change without being sure that safety is not compromised. Those involved in mainstream medicine m u s t carefully scrutinize and report on medical practices that might result in substantial reductions in health care cost. This goal is intrinsically important, but we must test the safety and effectiveness of such alternatives before some third party m a n d a t e s such new practices based on cost-savings alone. We have reported on our experience with a freestanding birthing center associated with a university medical center with care delivered primarily by certified nurse-midwives. Using strict guidelines for risk assessment and delivery of care, we have demonstrated that such a p r o g r a m appears to be safe and effective; however, limitations are present, such as the high frequency of transfers of care for nulliparous patients. We encourage the obstetric communitv to explore such programs further.
References 1. I~.o~)ks JP, Weatherby NL, Ernst EKM, Stapleton S, Rosen D, l;:osentield A. Outcomes ot care in birth centers--The National I:~irth Center Study. N Engl J Med 1989;321:1804 ll. 2. I akins PS Free-standing birth centers in California: Program and medical outcome. J Reprod Med 198g;34:960-7f1. 3. I)elong RN Jr, Shy KK, Carr KC. An out-of-hospital birth center using university referral. Obstet Gynecol 1981;58:703-7. 4. Freeman RK, Poland RL, eds. Guidelines for perinatal care. 3rd ed. Washington: American Academy of Pediatrics and American (_otlege of Obstetricians and Gynecologists, 1992. 5. Eakins PS. The rise of the freestanding birth center: Principles and practice. Women ttealth 1084;9:49 64. 6. l)eclercq ER. Where babies are born and who attends their births: Findings from the revised 1089 United States standard certificate of live birth. Obstet (;ynecol 1993;81:997 1i11"14. 7. Acheson I,S, Harris SE, Zvzanski SJ. Patient selection and outc~mles for out-of-hospital births in one tamily practice. J Faro Pract It,tOO;31:128 36. 8. I laverkamp AD, Orleans M, Langendoerfer S, McFee J, Murphy J, l h o m p s o n HE. A controlled trial of the differential effects of intrapartum tetal mt~nitoring. Am J Obstet Gynecol 1979;134:399412.
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9. Leveno K/, Cmmingham F(;, Nelson S, et al. A prospectixe comparison of selective and universal electronic fetal monitoring in 34,995 pregnancies. N EngI I Med 1980;315:~15-9. 10. Freeman RK, Garite TJ, Nageotte MP. Fetal heart rate monitoring. 2nd ed. Baltimore: Williams & Wilkms, 1991:~1}. 11. Garite TJ, Freeman RK, Hochleutner l, Linzey EM. Oxvt~cin challenge test achieving the desired goals. Obstet Gynecol 1978;51: 614- 8. 12. Butler JB, Abrams B, Parker l, Roberts JM, Laros RK. Supportive nurse midwife care is associated with a reduced incidence of cesarean section. Am I Obstet (~wlecol 1~L)3;168:1407 13. 13. Faison JB, l'isani BJ, Douglas RG, Cranch GS, Lubic RW. The childbearing center: An alternatixe birth ,erring. Obstet Gynecul 1979;54:527" 32.
Address reprint requests to:
'ltlomas 1. Garite, MD Departmellt of Obstetrics and Gynecology University of Californh7 lrvim' Medical Center 101 The City Drive Orau~e, CA 92668 Received October 31, 1994. Reteived l~z revised h~rm April 25, 1995. AcLcpted May ~, 1995.
Copyright © 1995 by The American College of Obstetricians and Gynecologists.
ANTEPARTUM A N D INTRAPARTUM ASSESSMENT
November 30--December 2, 1995 T h e A m e r i c a n C o l l e g e of O b s t e t r i c i a n s a n d G y n e c o l o g i s t s is s p o n s o r i n g a c o u r s e o n t h e a s s e s s m e n t of c o m m o n a n t e p a r t u m a n d i n t r a p a r t u m d i s o r d e r s , to b e h e l d a t t h e W a l d o r f - A s t o r i a H o t e l , N e w Y o r k City. T h i s c o u r s e h a s b e e n a p p r o v e d for 16 c o g n a t e h o u r s ( F o r m a l L e a r n i n g ) b y T h e A m e r i c a n C o l l e g e of O b s t e t r i c i a n s a n d Gynecologists. For further information, contact the Registrar, The American College of O b s t e t r i c i a n s a n d G y n e c o l o g i s t s , 409 1 2 t h S t r e e t SW, W a s h i n g t o n , D C 2 0 0 2 4 2188; (202) 863-2541.
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Changes in health care demand that more economic methods of health care delivery be developed and evaluated. Two important trends, outpatient services previously provided to inpatients and the use of nonphysician providers, hold promise for decreasing costs. In obstetrics, there is an opportunity to provide both such solutions in the form of outpatient, freestanding birthing centers with certified nurse-midwives providing obstetric and newborn care. Recent reports have From the Department of Obstet,'i~ > and G!nlecology. Lhtiver
V()L. 86, NO. 3, SEPTEMBER It~u'~
suggested that such centers can provide a safe alternative to traditional in-hospital care. ~ 3 Most information on such systems comes from outside the traditional health care system and has not made a notable impact on the attitudes or practices of most obstetric care providers. Consequently, only a small percentage of births in this country are delivered in such settings. It is incumbent on the obstetric community to evaluate critically the safety, efficacy, and costeffectiveness of such new health care delivery systems.
Materials and Methods The purpose of this paper is to provide a descriptive account of a university experience with the development of a freestanding birthing center with obstetric care for low-risk patients administered by faculty certified nurse-midwives. A freestanding birthing center was opened jointly by the Department of Obstetrics and Gynecology of the University of California Irvine and by the University Medical Center, assisted with state and local support. An existing two-building outpatient facility located 2 miles from the medical center was converted. One building provides the office suite for prenatal and postpartum care. The adjacent birthing center consists of ten rooms in which labor, delivery, postpartum, and immediate newborn care are delivered. The functional capacity of this unit is 150 deliveries per month. An ambulance and driver based at the birthing center at all times allows rapid emergency transport of laboring patients when required. The birthing center is staffed by seven certified nursemidwives who each see prenatal patients 2 d a y s / w e e k in the office suite and who each cover one 24-hour shift per week in the birthing center. No direct patient care by physicians is provided, and no physicians are routinely on-site at the birthing center, except to provide administrative and consultative support. Consulting physicians provide 24-hour telephone and electronic
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support. Weekly conferences are conducted to review" both recent statistics and management of ongoing patients. The intent of the birthing center is to provide total obstetric and newborn care to low-risk patients. Patients are screened initially with a simple questionnaire at the time of the first telephone or in-person encounter. Those who meet low-risk criteria are given appointments to the birthing center for prenatal care. Patients are registered from those enrolling for prenatal care at the university medical center, from local public health and community clinics, and by self-referral. Patient enrollment at the birthing center is voluntary. Patients are free to transfer care to any other provider, including the university medical center clinic, at any time. Prenatal care is provided by nurse-midwives at a frequency as outlined in the Guidelines for Periuatal Care. 4 The nurse-midwives adhere to a detailed set of practice guidelines that defines complications or risk factors. Patients with complications are either transferred to the medical center for care or the physician director is called upon for consultation. No patient is accepted after 34 weeks' gestation. Contracts with local clinics and providers allow additional eligible patients to deliver at the birthing center. These patients are seen, evaluated, and oriented at the birthing center at least once during the third trimester. Evaluation on admission for anticipated labor and delivery includes clinical evaluation, an initial 30minute electronic fetal heart rate (FHR) strip, and an ultrasound examination for fetal presentation if there is either a reason to defer the pelvic examination given on admission (eg, premature rupture of membranes [PROM]) or uncertainty as to the presentation. Subsequent FHR monitoring is bv intermittent auscultation, but continuous electronic FHR monitoring is an option and is used routinely to clarify any abnormalities of the FHR detected by auscultation. Clinical practice guidelines carefully define criteria for intrapartum transfer to the medical center, and telephone consultation with physician staff is available at all times. Narcotic and nonnarcotic analgesia are offered. Conduction anesthesia is not available. Local or pudendal anesthesia may be provided for delivery. Patients are informed of analgesia and anesthesia options during prenatal care, and a letter of understanding in this regard must be signed by the patient. Patients who cannot tolerate labor can be transferred to the medical center for this indication. No operative deliveries are performed at the birthing center. Patients with fourth-degree perineal and large vaginal lacerations are transferred to the medical center for repair. Patients are discharged postpartum in 12
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hours or less. Criteria for postpartum transfer to the medical center are detailed in the practice guidelines. Newborn evaluation is performed by a nursemidwife. Criteria for newborn transfer to the medical center are also detailed in the practice guidelines, and physician consultation is available. The patient is instructed to return 48 hours after discharge for routine newborn assessment and a review of maternal condition. Subsequent newborn care is provided by referral to local providers. Mothers return 6 weeks postpartum for final evaluation and family planning. A computer data base was developed and implemented at the opening of the center. All patients initially seen in the birthing center clinic were included, and location of delivery, route of delivery, complications, and outcomes for both mothers and newborns were tracked prospectively. A small percentage of patients elected to deliver elsewhere or transferred care without notification, and these data were lost. All data reported here were collected prospectively.
Results For the purpose of this descriptive study, we provide the first 20 months of experience at the University of California Irvine Birthing Center. The majority of patients were Hispanic (85%), with 11% white, 3% Asian, and 1~ African-American. Thirty-five percent were nulliparous. The mean age of all patients was 23.5 years (range 13-41). Most received prenatal care at the birthing center (60%), but 30% had prenatal care at the Public Health Department, and the remainder at other local clinics. These factors are all similar to those of patients delivered at the medical center. One thousand sixty-six births occurred at the birthing center during this time period, for an average of 53 births per month. After the initial growth period of the center, a relatively steady rate of 60-70 births per month was achieved. We saw 1830 patients for their initial prenatal visit at the birthing center. Two hundred twenty-eight patients (12%) were transferred to the medical center at some point during their antenatal care for a variety of risk factors or complications, as shown in Table 1. Ninety-two patients (5'~) moved or chose to transfer care to other health care providers. One hundred three patients (6%) presented to the medical center for delivery, almost all in the first 6 months after the center opened, mainly because the instructions on where and when to present were unclear. During this time period, 1407 patients presented to the birthing center for delivery, and there were 341 intrapartum transfers (Table 1). This represents 19% of the total population registered and 24% of those whose intrapartum care began at the birthing center. The
Obstetrics & Gynecology
i n t r a p a r t u m transfer rate was 46~:,~ for n u l l i p a r a s and 13% for multiparas. The i n t r a p a r t u m transfer rate declined steadily from 29~7~ in the first 6 m o n t h s to 22% in the last 6 months. All patients who delivered at the b i r t h i n g center delivered vaginally w i t h o u t i n s t r u m e n t a t i o n . There was one u n e x p e c t e d b u t u n c o m p l i c a t e d vaginal breech delivery. The route of delivery for i n t r a p a r t u m transfers was 54% s p o n t a n e o u s vaginal, 19~ operative vaginal, a n d 27% cesarean. This represents an overall cesarean rate of 6.5% for patients whose i n t r a p a r t u m care b e g a n at the b i r t h i n g center (10% if all patients whose prenatal care began at the birthing center are included). Of the patients transferred i n t r a p a r t u m , three required u r g e n t (crash) cesarean delivery (two a b r u p t i o placentae and one p r o l o n g e d FHR deceleration). All three cesareans were accomplished in less than 3(I m i n u t e s from decision for transfer to deliverv of the neonates. N o n e had a n y significant neonatal complications and all survived w i t h o u t a p p a r e n t damage. There were 24 p o s t p a r t u m transfers to the medical center d u r i n g the s t u d y period (2.29~) for the following reasons: laceration repair (ten; seven fourth-degree perineal a n d three vaginal), p o s t p a r t u m fever (nine), postp a r t u m h e m o r r h a g e (two), retained placenta (one), vaginal h e m a t o m a (one), a n d u n e x p l a i n e d m a t e r n a l tachycardia (one). There were no maternal deaths; with one exception, all of these p o s t p a r t u m transfers resolved their complications w i t h o u t sequelae. The one major complication involved a severe p o s t p a r t u m hemorrhage d u e to m u l t i p l e vaginal lacerations. A delay in this patient's transfer to the hospital m a y have contributed to the degree of her tnorbidity. The perinatal mortality for all patients whose care b e g a n at the b i r t h i n g center d u r i n g this time period was
Table 1. indications for Maternal Transfer Antepartum transfers ( 2 2 8 ) Post-dates Preeclampsia Preterm labor Gestational diabetes Spontaneous abortion Suspected macrosomia Fetal anomaly Other medical complication Other
lntrapartum transfers (341)
27 (12V, 24 (1 IV, 16 (79;) 16 (7~) 15 (79;) 13 (6(~) 10 (4q:~) 10 (4~)
Failure to progress 126 (37'",) I'ROM/no labor 71 (27'/, ) Nonreassuring FllR 41 {12V,) Thick meconiunr 26 {89;} Preeclampsia 20 (6~) I'ain intolerance 11 (3~/;1 Preterm labor l0 (39~ Malpresentation 8 (2~,';) Antepartmn bleeding 5 (1~ ) 97 (429~) l'reterm PROM 3 Pust-dates 2 Suspected macrosomia 2 Active herpes 2 Other* 14 (7',;)
PROM premature rupture of membranes; FltR * Includes patient request, security risk. etc.
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fetalheart rate.
Table 2. Perinatal Deaths Type/delivery site Weeks Ii~trapartum Amepartum Hospital Hospital Hospital Hospital Hospital Neonatal Birthing
Cause
Autopsy confirmation
None 31 34 37 40 40 40
qenter
Birthing center Birthing center Neonatal ffospital*
40
Hospital* HospitaP
40 40
40
40
Cytomegaluvirus infection Unknown Unknown Anencephaly Unknown Congenitalheart disease Diaphragmatic hernia Congenitalh e a r t disease Perinatalasphyxia
Meconiumaspiration syndrome Perinatalasphyxia Pottersyndrome
Confirmed Declined Declined Declined No definitive cause
Declined Endocardial Fibroelastosis Confirmed/basal Ganglia infarcts Declined Declined Renal agenesis
* Both cases transferred intrapartum from birthing center for inadequate labor progress with normal fetal heart rate tracing at time of transfer. Care transferred intrapartum for abnormal fetal heart rate tracing.
six per 1000 (11 deaths) excluding those patients who self-transferred to other providers. This i n c l u d e d five fetal deaths (all a n t e p a r t u m deaths) a n d six n e o n a t a l deaths (Table 2). Of the neonates born at the b i r t h i n g center, three had low A p g a r scores (less than 7) at 5 minutes. There were 12 infants w e i g h i n g less than 2500 g (all more than 2000 g) a n d 60 w e i g h i n g more t h a n 4000 g (5.6%). All neonates with complications were transferred to the medical center. There were 44 n e o n a t a l transfers (4%). Reasons for n e o n a t a l transfers i n c l u d e d possible or suspected sepsis (20 transfers), tachypnea or respiratory distress (13), feeding difficulties (seven), a n o m a l i e s (two), jaundice (two), n e o n a t a l d e p r e s s i o n at birth (two), p r e m a t u r i t y (one), suspected heart disease (two), m e c o n i u m a s p i r a t i o n (one), a n d t h r o m b o c y t o p e n i a (one). Except for three patients, all complied with instructions to have their neonates seen at the b i r t h i n g center 24 hours after discharge. Sixty-six n e w b o r n s were a d m i t t e d to the n e o n a t a l intensive care u n i t (NICU) from the 1407 patients who presented to the b i r t h i n g center for delivery (4.7%). This includes all 44 neonatal transfers (4.1% of n e w b o r n s delivered at the birthing center) a n d 22 of the 341 i n t r a p a r t u m transfers (6.5%). These N I C U a d m i s s i o n rates from the b i r t h i n g center c o m p a r e quite favorably with the rate of 15.3% for NICU a d m i s s i o n s of neonates
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born at the medical center, which does not in(lude maternal or neonatal transfers. Because charges are often arbitrarily assigned, we endeavored to calculate the costs of care when possible. For the birthing center, the average total cost for prenatal, labor, vaginal delivery, postpartum, and newborn care was $2183 per patient for both the provider and the facility. The costs are extremely volume dependent; total costs per patient decrease to $1543 at 75 deliveries per month and $1390 for 100 deliveries per month. For this birthing center, these volumes are achievable with minimal increases in nursing staff support and without any change in nurse-midwife or physician-supervisor support. For similar care at the medical center, costs are considerably higher. Although physician costs are not possible to calculate, total obstetric care contracts for physicians average $1500 for vaginal deliveries. The hospital charge averages $120{) per day for an average stay of 1.5 days, or $1800 per vaginal delivery. In addition, savings are even greater because there is no pediatrician's charge for newborn examinations and no epidurals are given. Even with the costs incurred as a result of antenatal and intrapartum transfer, the savings are more than $1500 per patient. Because of the large proportion of fixed costs, the savings exceed $2000 per patient at a delivery volume of 100 patients per month.
Discussion The cost of health care has become an overriding concern. Two practices have great potential for reducing cost: outpatient care and the use of nonphysician providers. Freestanding birthing centers combine both of these cost-saving practices. It is incumbent on the obstetric community to determine systematically the safety of such alternatives. In the words of Eakins, 5 a freestanding birthing (or birth) center is "an adaptation of a home environment to a short-stay, ambulatory health care facility with access to in-hospital obstetrical and newborn services; designed to safely accommodate participating family members and support people of the woman's choice; and, providing professional preventive health care to women and the fetus/newborn during pregnancy, birth and puerperium." Although many community hospitals have redesigned or set aside areas within the hospital that they often call "birthing centers," these should not be confused with freestanding birthing centers because they are not likely to provide similar cost savings, reductions in technology use or reduced cesarean rates. Over the last 2 decades, freestanding birthing centers have been slowly but steadily gaining acceptance in this country. The first such birthing centers w e r e developed to serve rural areas. In 1975, the first urban birthing
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center was established in New York City, and by the late 1980s there were over 240 centers opened around the country) However, this approach has not gained widespread acceptance; in 1989, Declercq ~ reported that only 0.4% of all births in this country occurred in freestanding birthing centers. Certified nurse-midwives are licensed registered nurses who have had 1 (certificate programs) or 2 years (masters programs) of additional postgraduate training and certification in obstetric, gynecologic, and newborn care. The American College of Nurse-Midwives accredits the training and provides certification of nursemidwives. Candidates are required to pass a written examination to receive certification. Certified nursemidwives are now licensed in all 50 states. An estimated 4500 nurse-midwives are certified at present, and about 3% of all births in the United States are attended by certified nurse-midwives. ° Although freestanding birthing centers have great potential for cost savings, this practice has not gained widespread acceptance. Safety appears to be the main concern because most bodies of organized medicine have not endorsed such practices, discouraging their use until better data on safety are available. 4 Several studies have evaluated the safety of freestanding birthing centers. In general, low perinatal mortality rates of 1.0-4.2:1000 have been reported, with zero to one per 1000 intrapartum fetal death rates and very low rates of neonatal depression) '2: Cesarean rates were also reported to be reduced substantially, with most reporting rates of 4-8~. compared with average in-hospital rates of 20%. 1'2'7 Recently, Rooks et al ~ reported on the experience of 11,814 women admitted for labor and delivery to 84 freestanding birthing centers around the United States; they found an overall perinatal mortality of 1.3 per 1000 and a cesarean delivery rate of 4.4% with no maternal deaths. Our descriptive study is unique in several respects. It includes data on the experience of a freestanding birthing center that is related exclusively to a university medical center. Patient data were collected prospectively from its inception. Complete data are available on all patients cared for and delivered at the birthing center; in addition, this is one of the few studies of freestanding birthing centers that also reports on data from patients transferred antenatally. Such complete information is essential in comparing data with inhospital births. Accurate comparison is important not onlv for safety but for determining the actual total transfer rates of patients out of the system, the true cesarean rates, and the overall cost savings of such programs. Unfortunately, there are limited data that compare safety and cesarean delivery rates for truly comparable
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populations. Because only low-risk, often more highly educated and wealthier patients deliver at freestanding birthing centers, it is difficult to k n o w what the expected mortality, morbidity, and cesarean rates w o u l d be in truly similar populations delivered in-hospital. H o w ever, even if such data were available, the rates of such complications are so low that it would take large sample sizes to demonstrate any statistically significant difference. A c k n o w l e d g i n g this limitation, several statements can be made. First, intrapartum death rates are low in all reports from freestanding birthing centers. The best data on realistically and optimally achievable intrapartum death rates come from those reported in r a n d o m i z e d trials of intrapartum FHR versus auscultation done in hospital settings, with an average rate of 0.5 per 1000, similar to the rates reported in this and other reports of freestanding birthing centers.l'2'7 u~ Another w a y of evaluating perinatal mortality is to examine specific cases and see how m a n y might have been preventable. In our study, there were 11 perinatal deaths. Of the fetal deaths, none was intrapartum; of the five antepartum deaths (five per 1830, or 2.7 per 10001, two were unpreventable (cytomegalovirus infection and anencephaly). The three deaths of u n k n o w n causes did not have risk factors that would have indicated antepartum testing. This antepartum death rate is similar to that of untested patients without risk factors (four per 1000) in our institution. ~ For the neonatal deaths, of the three delivered at the birthing center, two had major cardiac anomalies and one had perinatal asphyxia. Of the three deaths that occurred a m o n g patients w h o were intrapartum transfers, one was a major anomaly and the other two m a v have been related to perinatal asphyxia, but both were transferred for reasons other than fetal distress and had normal FHR tracings after transferring from the birthing center; these subsequently deteriorated at the hospital. Therefore, only the one case of asphyxia-related neonatal death occurring in a n e w b o r n delivered at the birthing center could be identified as preventable and attribtttable to the birthing center, out of 1061~ deliveries and 1830 total patients cared for prenatally. Regarding cesarean deliveries, at least one study ~2 controlled for risk factors and concluded that births attended by nursem i d w i v e s result in lower cesarean rates. The cost savings that occur as a result of such an outpatient setting staffed bv certified nurse-midwives is substantiated by our calculations of cost. These calculations m a y be conservative because lower utilization of ancillary tests and decreased cotnplications, such as infections, could lower costs even further. However, freestanding birthing centers do have limitations. Not all patients will accept this alternative. The lack of conduction anesthesia is a deterrent to m a n y
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women. The high transfer rate, especially for nulliparous patients, is of particular concern. O u r s t u d y found intrapartum transfer rates s o m e w h a t higher than most others. Most of these w e r e for i n a d e q u a t e labor progress and PROM in patients w h o failed to enter labor spontaneously within 12 hours. O u r study includes data on a n t e p a r t u m transfers as well. This antep a r t u m transfer rate (12%) is similar to rates reported in the exceptional studies that have also looked at this issue. 3'~3 The total transfer rate m a y be i m p r o v e d by learning which risk factors can be safely liberalized and by adopting new procedures, such as amnioinfusion. O n g o i n g efforts are required, but we must all avoid the temptation to change without being sure that safety is not compromised. Those involved in mainstream medicine m u s t carefully scrutinize and report on medical practices that might result in substantial reductions in health care cost. This goal is intrinsically important, but we must test the safety and effectiveness of such alternatives before some third party m a n d a t e s such new practices based on cost-savings alone. We have reported on our experience with a freestanding birthing center associated with a university medical center with care delivered primarily by certified nurse-midwives. Using strict guidelines for risk assessment and delivery of care, we have demonstrated that such a p r o g r a m appears to be safe and effective; however, limitations are present, such as the high frequency of transfers of care for nulliparous patients. We encourage the obstetric communitv to explore such programs further.
References 1. I~.o~)ks JP, Weatherby NL, Ernst EKM, Stapleton S, Rosen D, l;:osentield A. Outcomes ot care in birth centers--The National I:~irth Center Study. N Engl J Med 1989;321:1804 ll. 2. I akins PS Free-standing birth centers in California: Program and medical outcome. J Reprod Med 198g;34:960-7f1. 3. I)elong RN Jr, Shy KK, Carr KC. An out-of-hospital birth center using university referral. Obstet Gynecol 1981;58:703-7. 4. Freeman RK, Poland RL, eds. Guidelines for perinatal care. 3rd ed. Washington: American Academy of Pediatrics and American (_otlege of Obstetricians and Gynecologists, 1992. 5. Eakins PS. The rise of the freestanding birth center: Principles and practice. Women ttealth 1084;9:49 64. 6. l)eclercq ER. Where babies are born and who attends their births: Findings from the revised 1089 United States standard certificate of live birth. Obstet (;ynecol 1993;81:997 1i11"14. 7. Acheson I,S, Harris SE, Zvzanski SJ. Patient selection and outc~mles for out-of-hospital births in one tamily practice. J Faro Pract It,tOO;31:128 36. 8. I laverkamp AD, Orleans M, Langendoerfer S, McFee J, Murphy J, l h o m p s o n HE. A controlled trial of the differential effects of intrapartum tetal mt~nitoring. Am J Obstet Gynecol 1979;134:399412.
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9. Leveno K/, Cmmingham F(;, Nelson S, et al. A prospectixe comparison of selective and universal electronic fetal monitoring in 34,995 pregnancies. N EngI I Med 1980;315:~15-9. 10. Freeman RK, Garite TJ, Nageotte MP. Fetal heart rate monitoring. 2nd ed. Baltimore: Williams & Wilkms, 1991:~1}. 11. Garite TJ, Freeman RK, Hochleutner l, Linzey EM. Oxvt~cin challenge test achieving the desired goals. Obstet Gynecol 1978;51: 614- 8. 12. Butler JB, Abrams B, Parker l, Roberts JM, Laros RK. Supportive nurse midwife care is associated with a reduced incidence of cesarean section. Am I Obstet (~wlecol 1~L)3;168:1407 13. 13. Faison JB, l'isani BJ, Douglas RG, Cranch GS, Lubic RW. The childbearing center: An alternatixe birth ,erring. Obstet Gynecul 1979;54:527" 32.
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'ltlomas 1. Garite, MD Departmellt of Obstetrics and Gynecology University of Californh7 lrvim' Medical Center 101 The City Drive Orau~e, CA 92668 Received October 31, 1994. Reteived l~z revised h~rm April 25, 1995. AcLcpted May ~, 1995.
Copyright © 1995 by The American College of Obstetricians and Gynecologists.
ANTEPARTUM A N D INTRAPARTUM ASSESSMENT
November 30--December 2, 1995 T h e A m e r i c a n C o l l e g e of O b s t e t r i c i a n s a n d G y n e c o l o g i s t s is s p o n s o r i n g a c o u r s e o n t h e a s s e s s m e n t of c o m m o n a n t e p a r t u m a n d i n t r a p a r t u m d i s o r d e r s , to b e h e l d a t t h e W a l d o r f - A s t o r i a H o t e l , N e w Y o r k City. T h i s c o u r s e h a s b e e n a p p r o v e d for 16 c o g n a t e h o u r s ( F o r m a l L e a r n i n g ) b y T h e A m e r i c a n C o l l e g e of O b s t e t r i c i a n s a n d Gynecologists. For further information, contact the Registrar, The American College of O b s t e t r i c i a n s a n d G y n e c o l o g i s t s , 409 1 2 t h S t r e e t SW, W a s h i n g t o n , D C 2 0 0 2 4 2188; (202) 863-2541.
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