By Angela Bowman
Nurse-midwife Carrie Hansen had a client this spring who was preparing to give birth to her second child. She had delivered her first in the hospital, and Hansen asked her about her experience there. It was fine, said the client. It was normal. Hansen asked her, as she asks all her clients, whether she had ever thought about giving birth at home, and showed her some photos.
The mother in the pictures had spent the majority of her labor in the bathtub and the shower to ease labor pains. It was her fourth baby, and her young children and husband were all present during the labor. Photo after photo showed the woman's four-year-old daughter at her side, rubbing her back, holding her hand, and finally, stroking her new little brother's head.
As Hansen's client looked at the photos, she began to cry. "I never knew it could be like this," she said. For her first child, she told the midwife, she'd been confined to bed throughout her labor so as not to disturb the electronic fetal monitor. The hospital staff hadn't allowed her to eat and had required her husband to leave as soon as the baby was born. She'd had no idea that it was even possible to give birth in any position besides flat on her back.
Hansen was surprised by her client's reaction, "because she had said she was satisfied with the hospital birth."
Hansen works at Alivio Medical Center, a health clinic in Pilsen that serves the Latino community's poor and underinsured. Alivio's nine nurse-midwives--nurses who've completed a master's program in prenatal care, childbirth, and mother-baby care--have been delivering their clients' babies (600 just last year) at Mercy Hospital since 1992. Last September they started a home birth program, which has delivered about six children a month since. What they'd like now is to offer another option, a middle ground between home and hospital. Unfortunately what they want--and what hundreds of others in Illinois want--is illegal.
Thirty-four states already have what are known as freestanding birth centers--facilities that offer natural childbirth in just such a setting. But in Illinois, if two or more unrelated women give birth in a place that is not a hospital and not home, that place would be charged with violating the Illinois Hospital Licensing Act, which requires any facility that cares for pregnant women and delivers babies to be licensed as a hospital.
This year, birth center advocates tried for the seventh time in eight years to overturn the prohibitive legislation. State representatives Barbara Flynn Currie (D-Chicago), David Phelps (D-Eldorado), and Suzanne Deuchler (R-Aurora) sponsored House Bill 1828, which would have amended another law, the Alternative Health Care Delivery Act, to set up ten freestanding birth centers throughout the state to be operated as test facilities.
Run primarily by midwives but occasionally by obstetricians, birth centers reflect midwives' guiding philosophy: that birth is a natural event rather than a medical emergency. Proponents say the centers are not only cozier and more intimate than hospitals but also free of some hazards introduced by unnecessary medical intervention. They point to studies that show centers in other states to have as good or greater success with low-risk births than hospitals do. They also point to the lower price of birth centers--where a birth costs about one-third less than in a hospital--and to the access they can provide for women in rural and underserved urban areas. (Forty Illinois counties have no hospital obstetrical services; 26 of them have been designated by the federal Department of Health and Human Services as health-professional shortage areas.)
Most of the country's 125 freestanding birth centers operate on the east and west coasts, with an especially high concentration in the southwest and California. New York City has two. These state-licensed facilities--often set up in renovated houses, with about ten beds--follow guidelines developed by the 800-member National Association of Childbearing Centers. Insurance companies recognize them, as does Medicaid. All have collaborative agreements with nearby hospitals, where women and newborns are sent in the event of complications.
In 1989 the New England Journal of Medicine published the National Birth Center Study, which gave statistics on 11,814 women who delivered in 84 freestanding birth centers around the country. The women were all judged to have a lower-than-average risk of complications. About 16 percent of the women were transferred to a hospital, 2.4 percent for emergency reasons. No mothers died; 15 infants did, either during or after delivery, 7 because of lethal congenital birth defects. At 1.3 deaths per 1,000 births, this compares favorably to the rate of 2.1 deaths per 1,000 low-risk births reported in a study of 12 Illinois hospitals published in 1987 in Obstetrics and Gynecology.
In fact the World Health Organization regards outside the hospital--either at home or in birth centers--as the preferred location for childbirth. Twenty of the world's developed nations have better infant mortality rates than we do, among them western European countries where midwives deliver 70 percent of all babies, as opposed to 4 percent of American babies. Many women in these countries give birth at home or in birth centers.
But opponents--foremost among them the Illinois State Medical Society, the state's most prominent doctors' organization--question the safety of freestanding birth centers. They say it's too hard to predict labor complications, and that in emergencies, birth centers cannot be counted on to get women to the hospital in time. They find the studies unconvincing, citing small sample sizes, poor study techniques, and in one case lack of a control group. Even a low risk of maternal or child death is too high, they say, especially when hospitals are there expressly for the purpose of managing that risk.
Birth center advocates say there's more to it, that doctors and hospitals are as concerned with power and money as they are with safety, and that options for healthy women are being compromised to subsidize high-risk cases. But if the outcome of the most recent birth center battle is any indication, doctors' clout is in little danger. On April 25, the last day of the house legislative session, the sponsors of HB 1828 decided not to call for a vote, afraid that its imminent failure would hurt their efforts next session. They had been holding out in hopes of endorsement--or at the least, neutrality--from the Illinois chapter of the American College of Obstetricians and Gynecologists, the leading national authority on obstetrical medicine. But ACOG here has close ties to the Illinois State Medical Society, and despite a change of heart on the issue last summer by its national body, Illinois ACOG maintained its opposition to the bill till the very end.
To be sure, Illinois tends to be conservative in most medical matters. Some people attribute this to generally conservative midwestern values, others pin it on Chicago's status as home to the great bastion of the medical establishment, the American Medical Association. In any event, change comes slowly here.
As far as freestanding birth centers are concerned, "no other state has had to go through a legislative hurdle like this," says Gayle Riedmann, head of the Illinois Birth Center Task Force. "No other state has had ACOG involved. They haven't had to, but because of the very old and unusual wording [the 'two or more unrelated women' clause] of this hospital licensing act," Illinois has. Efforts began downstate in 1987 when the Southern Illinois Birth Center Committee, motivated by a lack of hospital access for rural women, petitioned for a waiver to the Hospital Licensing Act. The Illinois Department of Public Health rejected the petition, but set up a task force to evaluate birth centers' merits. Its report, issued in 1989, supported the idea.
In that year, Barbara Flynn Currie sponsored the first of six birth center bills to be proposed almost annually until 1995. The bills were voted down year after year, always with the approval of the Illinois State Medical Society and almost always with the approval of the Illinois Hospital and HealthSystems Association, which had raised concerns about the economic impact of birth centers on hospitals. Other sticking points included concerns about the possibility of abortions being performed at birth centers and vague legislative wording. By 1993, the margin of dissent had narrowed and the bill lost by seven votes in the house and just three in the senate.
Though today most Americans think of hospital birth as the norm, only in the last 50 years has it become the default, a situation spurred as much by social change as by medical technology. At the turn of the century women gave birth at home with midwives or doctors, unless they were unwed or indigent, and then they went to disease-infested maternity, or "lying-in," hospitals. Today, more than 99 percent of Illinois women give birth in hospitals, in a variety of settings that range from traditional delivery areas to more family-centered, less interventionist birthing rooms.
In a standard hospital birth, a woman is kept in bed, or more often on a delivery table, with her feet in stirrups. She gets fluids and often medication through an IV, and the activity of the fetus is electronically monitored through an array of electrodes placed on the mother's belly. Obstetricians use the monitor in addition to standard criteria such as dilation, timing of contractions, and vital signs to assess the progress of the labor. Women generally receive pain medication, including normal analgesics and epidurals--injections to the base of the spinal cord that numb the patient from the pelvis down. If the practitioner judges that the labor is progressing too slowly, he or she may also administer a labor-inducing drug called pitocin.
Most women are not allowed to eat during labor, as a precaution against choking under general anesthesia, which they might need in the case of a cesarean section. They're also commonly given an episiotomy, an incision to the rear of the vagina intended to prevent vaginal tears or pelvic damage from the passage of the baby's head; it's stitched up after delivery. The baby is then examined and brought to the nursery for observation. Mother and child generally remain in the hospital for one or two days; the mother can breast-feed her baby during that time and receive limited visitors.
The cost of all this varies depending on the amount of medicine administered and technology used. The fee generally breaks down into a provider's bill, which runs about $3,000, and a hospital bill, which can be as low as $1,800 but usually runs between $3,000 and $5,000.
Like so many other institutions, hospitals have had to scramble in the past few decades to keep up with the challenges of a more critical public. In response to consumer demand, some have developed more family-friendly birthing areas. At the very least, these bedroomlike rooms offer homier furniture, and at best, they allow women greater freedom of movement during birth and encourage personnel to refrain from unnecessary intervention in healthy, uncomplicated births. Most fall somewhere in between, and few practitioners actually have dropped the habit of reliance on the hospital's many tools.
How did these tools become so dear to physicians? There was a time when doctors and laypersons alike regarded childbirth as frightening and dangerous. Infections and labor complications claimed many lives; in 1915, almost 70 out of every 1,000 American babies died during or within a month of birth, according to Richard W. and Dorothy C. Wertz's book Lying-In: A History of Childbirth in America--13 times the current rate. In the same year, more than 60 of every 10,000 childbearing women died in childbirth--more than 75 times today's rate.
In the early 1900s, the hospital began its evolution into the locus of medical expertise and learning--in other words, doctors stopped making house calls. Instead, they brought women into the hospitals, where they could follow a more efficient, industrial model of care, and where their tools lay at arm's reach. In 1926 one doctor compared a laboring woman to a broken-down automobile, himself to a trained mechanic, and the hospital to a garage.
Hospitals served as the training grounds for residents and as laboratories for the study of new practices, including surgeries. Maternal and infant mortality rates remained high throughout the 20s, due to inadequate prenatal care, infections, and excessive, improperly performed medical intervention. In fact, the number of infant deaths due to birth injuries actually rose more than 40 percent between 1915 and 1929, as the percentage of babies born in hospitals shot up to almost 25. In the 30s, physicians took on the task of developing rigorous accreditation standards for specialists and for hospitals, and in 1936 mortality rates began to drop sharply.
Women did not necessarily resist or object to hospitalization; on the contrary, many welcomed the advances in pain management and the opportunity to turn over the work--the labor--to someone else. During the first two decades of this century, feminists campaigned for the American acceptance of Twilight Sleep, a German technique for painless birth involving morphine and an amnesiac called scopolamine, plus chloroform or ether. It became very popular during the 30s, drawing more mothers to hospitals. In 1942 chloroform and ether were found to be dangerous and were replaced by the epidural.
By 1960, more than 90 percent of American babies were born in hospitals. Mortality rates had dropped further, apparently because of increased prenatal care, improved medical practices, and the discovery of antibiotics. Women learned to put themselves in the hands of physicians as soon as they became pregnant.
But the doctors, of course, did not know everything. Some scolded their pregnant patients for failure to stick to dietary regimens, some of which were later found to be unhealthy. The Wertzes note that some seemed to regard poor women especially as morally weak and incompetent. Many women complained of feeling dehumanized in the maternity wards and of cruelty on the part of hospital staffs.
In 1957, Ladies' Home Journal published a brief letter from a Chicago nurse who called for an expose of "the tortures that go on in modern delivery rooms." She told of women being strapped to the delivery tables for hours at a stretch with their legs held apart (or worse, tied together), and of one doctor who cut and sutured patients without anesthetic because he'd almost lost one to an overdose in the past. The magazine received hundreds of letters in response. Some writers took issue with the charges but the majority, including a number of delivery nurses, confirmed them.
"The doctors dropped by at 6:45, cast me a scornful glance and went out to make house calls," wrote one woman from California. "One hour later my legs were released from the stirrups and held together by a nurse, who sat on my knees, up on the delivery table, mind you, because the baby was coming too fast. A few minutes after 8 o'clock the doctor arrived and allowed my baby to be born."
Another reader, from Saint Louis, wrote, "When the doctor began to cut, I screamed. It was the final indignity of so many. The doctor snapped at me, 'You may as well shut up; we've run out of Novocain."
Still others complained of being left alone for hours at a time: "My first child was born in a Chicago suburban hospital. I wonder if the people who ran that place were actually human. My lips parched and cracked, but the nurses refused to even moisten them with a damp cloth. I was left alone all night in a labor room. I felt exactly like a trapped animal and I am sure I would have committed suicide if I had had the means. Never have I needed someone, anyone, as desperately as I did that night."
It was around that time that the idea of "natural childbirth" began to gain popularity. Promulgated by British doctor Grantly Dick-Read in the 30s and 40s, the concept was most famously developed by French doctors Fernand Lamaze and Pierre Vellay in the 50s and 60s. Women seeking to regain control of childbirth took Lamaze classes to learn to manage labor pain through breathing and physical exercises rather than medication. Women began to view birth as consumers, and started to shop around for options. Some turned back to midwives--who by then were often licensed by the state--and a few (including my mother) chose to give birth at home.
Since then, more and more women have turned to midwives, a trend that seems motivated by an increased awareness of birth as a natural event, greater desire for family involvement, and concern about the rising costs of health care. There are now more than 40 schools of nurse-midwifery in the country, including the one at the University of Illinois at Chicago's College of Nursing; many of those have sprouted up just in the last decade.
But in Illinois, the trend has been bucked every step of the way by the powers that be. This year, the Illinois Nursing Act of 1987, which licenses nurses and defines the scope of their practice, came up for renewal, as it will every ten years. Among the proposed changes was the state's first-ever definition of "advanced-practice registered nurses," a category that includes certified nurse-midwives, nurse practitioners, nurse-anesthetists, and clinical nurse specialists, all of whom hold master's degrees and national board certification in their fields. This amendment, House Bill 1076, would have given such nurses more autonomy, including the ability to prescribe medicine--something they can already do in every state except Illinois.
The Illinois State Medical Society initially opposed this measure, then in May, shortly before the bill was to come to the senate, agreed to a compromise that would recognize and license advanced-practice nurses as such, but wouldn't grant prescriptive rights or otherwise increase the scope of their practice. After a few days, the ISMS changed its position again, and renewed its complete opposition to the bill. As with the birth center bill, the sponsors withdrew it rather than suffer certain defeat.
When Gayle Riedmann, the Illinois Birth Center Task Force chairwoman, practiced as a registered nurse in Nebraska in the early 1980s, there were no midwives in that state. But through her experience as a childbirth educator, she learned about natural childbirth, and as a regular labor-and-delivery nurse, she didn't much like what she saw--for instance, how the physicians always came in at the last minute to deliver the child.
"How can you know what a woman needs if you haven't labored with her?" she asks. Now a nurse-midwife at Female Health Associates, at the West Suburban Center for Women's Health in Oak Park, she delivers babies at West Suburban Hospital. She attends to a woman throughout her labor and knows a lot about her by the time she begins to push. "I have been very tuned in through several hours of laboring with this woman. I know what her fears are, what her hopes are, what her pain tolerance is," she says. With midwife-attended births, she adds, there's none of the "frantic, tear-the-room-apart" rush that often occurs when an obstetrician appears on the scene at delivery time.
From Nebraska, Riedmann went to California to train as a nurse-midwife. While in San Diego, she learned for the first time about freestanding birth centers. She made her own contacts and worked at a birth center in addition to her formal training. She came to Chicago in 1986 to start a midwifery service at Northwestern Memorial Hospital, where she worked for seven years with patients at its Prentice Women's Hospital. (Northwestern's four midwives have recently left for Weiss Memorial Hospital at the U. of C., which offered them better space and other benefits.) She stopped working for a while to take care of her own three children, the first two of whom were born at Prentice.
"While Northwestern and West Suburban and many hospitals go to great efforts to provide a homelike environment, it's still in a hospital," she says. "By the third one I wasn't going back to the hospital anymore." With her last child, she had a planned home birth with a midwife.
"I've become very invested in finding that middle ground," she says. "There are very small risks that an individual might take in having a home birth and there are risks in having a hospital birth. But the relative risk of choosing to give birth out of the hospital is often one that women are willing to accept in order to avoid the iatrogenic problems that can occur in the hospital."
"Iatrogenic" means "caused by medical action." "The very things that obstetrical providers do to help women are actually increasing their complication rate," Riedmann continues. "I'm not badmouthing OBs, because that will happen--sometimes you find out that what you are doing to try to help someone may cause other problems."
Actually, Riedmann says, obstetricians and gynecologists have done a very thorough job of challenging their own practices. She cites an OB-run study on the effects of electronic fetal monitoring that determined that the practice does not improve birth outcomes--and that it was related to a fourfold increase in the rate of cesarean sections. (Critics of electronic fetal monitoring suggest that this is because physicians often overreact to monitor readings that they don't understand.)
Another study investigated the benefits of episiotomies, which are intended to prevent lacerations of vaginal tissue during the passage of the baby. "In fact, women with episiotomies have larger problems with lacerations," she says. The trouble with these studies, she says, is that the results came back only after these practices had become entrenched in hospital protocol. "Now you have to go back and train people" to deliver babies without episiotomies and fetal monitors. Some habits die hard.
About pitocin, which is used to induce labor in some 40 percent of Illinois mothers, she says, "When used appropriately, it's a magnificent drug that has probably saved many a woman from having a C-section [when her uterus has become tired after working for too long]." But the drug can also cause overstimulation of the uterus and hamper the placenta's ability to provide adequate oxygen and nutrition for the baby. This in turn can decrease the baby's heart rate. And babies born with pain medications in their bloodstreams can have trouble breathing and sucking.
"There are many things we can do to help aside from medication," Riedmann says. She thinks of pain management as a step-by-step process: you start with the least interventive measures, such as massage, showers, hot cloths, and TLC. "If the initial noninterventive efforts don't work, then you press on.
"Safety is what all of us are concerned with," she says. "We've established and would like to continue to establish that birth centers are safe and viable options for women giving birth."
One argument against birth centers is that they duplicate services already available. But there are actually few options for women who want noninterventive childbirth but can't or don't want to do it at home.
Forty-eight of Illinois' 225 hospitals now have family birthing rooms of some sort, but many of them keep high-tech equipment behind an armoire. The Alternative Birthing Center (ABC) at Illinois Masonic Medical Center is the only one in Chicago that does not use electronic fetal monitors or epidurals: if the need for technical intervention should arise, staff will transfer a woman down the hall to the standard labor, delivery, and recovery unit. About 23 percent of women who begin labor in the ABC end up giving birth in the main delivery area, and around 9 or 10 percent end up delivering by cesarean section (the national rate of C-sections stands at around 20 percent.) The center screens out high-risk patients and charges a flat fee, which is a little more than $2,000. If a woman completes her labor in LDR, she pays the usual rate instead.
In the opinion of certified nurse-midwife Betty Schlatter, who has worked at the center for 16 years, the absence of the monitors is "the biggest difference between delivering in the birth center" and delivering in a traditional labor and delivery unit.
Schlatter explains the "cascade effect" that monitoring has on the actual events of a birth: "You put the monitor on and that puts the woman in bed. Therefore she can't walk around. She can't walk around, therefore you've gotten rid of the effect of gravity on helping the baby go into the birth canal." Take away the effect of gravity and you slow the progress of the contractions, introducing the need for pitocin. Pitocin, Schlatter says, increases the risk of too-frequent contractions, fetal distress, and ultimately, a C-section.
"If someone says they have an alternative birth center," says Schlatter, "but they still put a monitor on the woman, to me that's just a fancy labor and delivery room. You know, you put wallpaper on the walls, you make it look really nice, but you haven't changed the philosophy."
Critics of the ABC complain that too many women who want to deliver there end up in labor and delivery, both because of a high rate of transfer and because the center only has two beds. The 23 percent rate of transfer exceeds that of out-of-hospital birthing centers (about 16 percent), raising the question of whether the Illinois Masonic staff is too quick to give up on natural childbirth. "My response to that has always been that because we are an in-hospital birth center we have probably been a little bit more relaxed on the numbers of people that we allow to start out in the birth center," Schlatter says. But although women are sometimes diverted to the main delivery area because the ABC is full, the facility is actually somewhat underused, she adds.
As for home births, though the majority of obstetricians and even nurse-midwives don't do them, there are practice groups who specialize in them, including Chicago Community Midwives, Women's Health Limited, and Homefirst. They all screen their clients for risk factors like high blood pressure, diabetes, or other complications, accepting only healthy women at low risk for complications. All have emergency agreements with hospitals. In addition to nurse-midwives and obstetricians, a few "direct-entry" midwives, also known as lay midwives, practice home delivery in Illinois. Direct-entry midwives are trained by apprenticeship and are not nurses. They're licensed in some states, including Florida and Tennessee, but they're illegal here.
Home birth affords women the greatest amount of control over their environment and care. It also ensures them the complete attention of the provider--they don't have to compete with other laboring patients. But not all women feel comfortable or confident with home births; others, particularly poor women, would like to give birth at home but lack the necessary space or privacy. It's these women Alivio Medical Center--where Carrie Hansen works--wants to help by opening its own birth center.
Under the direction of community activist Carmen Velasquez, Alivio offers a range of community-based care, including maternity care, to its clients, primarily immigrant and second-generation Latinas and their families. The clinic's name comes from the Spanish verb aliviar, which translates as "to get well." In Mexican idiomatic Spanish, it also refers to giving birth: when a woman is pregnant, people ask her, "ÀCuando va a aliviar?"
Ceal Bacom, a certified nurse-midwife, started Alivio's midwifery program in 1992. She says that many of her clients would like to use the home birth service, but that "home is not an option for them": they may lack privacy because they live with neighbors or relatives.
"I think that choice is a big issue and that if [birth center birth] is a documented safe option, which we know it is, then it should be legal," she says. "I think it's restraint of trade that it's not, frankly."
Mary Sommers came to Alivio in 1992, shortly before Bacom. She helped to bring Bacom on board, and shortly after the beginning of the midwifery program, Sommers started a home visiting program for pregnant women and new mothers. She and her colleagues do whatever is necessary to bridge the gap between immigrant women and the American medical system, including speaking to clients in their own language and integrating themselves into the home and family life as much as possible. "Birth needs to be a very private event that you have control over as a client," she says, and control quickly eludes those trying to navigate a foreign health care system.
Sommers, who has five children of her own, actually prefers home birth to birth centers. But as a provider, she says she thinks birth centers provide a happy medium. "It's definitely still provider turf," she admits. "But it's better than a hospital, which is even more removed."
And for midwives, a hospital's not even really provider turf, she says. In a hospital setting, midwives are following protocols that are part of a more interventive model of care. Birth centers, on the other hand, allow midwives to follow their own philosophy.
Within the next two years, Alivio plans to open a brand-new, $5.2 million facility at 21st and Morgan. It'll house an expansion of existing services, including primary and dental care, and when the OK for birth centers comes through, Velasquez says, "we'll have enough land to do what we need." Despite recent setbacks she is quite confident that the Illinois legislature will have caught up by the time Alivio is ready to move ahead. "We just keep moving forward. If I had taken the attitude that, well, it's not a law in Illinois, so I'm not gonna do anything, that would have been foolish, don't you think so?"
Two years ago, both Alivio and the UIC Medical Center petitioned for exemption from the Illinois Hospital Licensing Act to open birth centers. Alivio cited its location in a federal empowerment zone and the university its status as a government institution. UIC succeeded.
"We don't have to get licensed by the state because we are the state," says Dr. Joyce Roberts, who heads the nursing college's maternal and child nursing department, and is the clinical chief of the hospital's Women's Family Health Care Services. Roberts is also a certified nurse-midwife. Basically, she says, UIC has official permission to open a birth center and treat it as a giant research project.
As proposed, it would be built somewhere in the neighborhood of the hospital, perhaps only a tunnel's length away. Roberts says the idea of the tunnel has appealed to those who want an "umbilical cord" to the hospital's labor and delivery unit.
But not long after beginning preliminary work on it, Roberts says, she put the birth center on hold. The university was looking for state approval on a couple of other large projects, including an ambulatory care center, and the birth center's controversial nature "could have encumbered these initiatives."
What Roberts means is that the university didn't want to cross the Illinois State Medical Society. The ISMS, according to a study by Kent Redfield, a professor at the University of Illinois' Springfield campus, has for the past three election years been the single largest source of campaign contributions, giving well over a million dollars each time to legislative leaders and candidates. Senate president James "Pate" Philip has received $678,000 in ISMS support, and house Republican leader Lee Daniels $973,000 over the past 15 years. The ISMS has been Jim Edgar's number one benefactor over the past 20 years, contributing $349,000 to his career; Roberts notes that some of the society's members advise the governor. "We know that they were unenthusiastic about, if not in opposition to, a birth center," she says, and it was not in the university's best interest to challenge the ISMS on this topic while looking for state support on other matters.
Lately Roberts is hopeful, especially in light of some new developments at UIC. In mid-March the university endorsed a new line of women's and children's services, and she thinks a birth center would fit in well with these plans. But the new service line is really only just getting started, and it may be some time before its directors can even address the birth center.
Roberts knows of other institutions that would like to open birth centers once the legislation passes. "If U. of I. doesn't decide it's in their best interest, then they could lose out," she says. "We have a unique opportunity that I keep saying is our responsibility."
Dr. LeRoy Sprang has practiced as an obstetrician and gynecologist for 22 years. He has witnessed significant changes in maternity care, and has precipitated some of these changes as well. "I was the first person to set up a birthing room at Evanston Hospital," he says, where mothers can move around and shower during labor. "We're very open-minded," he says. "We have nurse-midwives, doulas, all the things that people have been asking for." (A doula offers comfort and support to a woman in labor.)
Still, Sprang firmly believes hospitals are the best place for a woman to give birth--"I think home birth is the earliest form of child abuse," he says. And unfortunately for birth center advocates, he's the chairman of the board of trustees of the Illinois State Medical Society.
Sprang says he objects to freestanding birth centers solely on the basis of their out-of-hospital location. "If it's totally freestanding, how far away is it from that extra help? It's taking another risk, which, as I see it, is probably unnecessary.
"Sometimes you're going to need more help, and if it's not there, then it could be a disaster for the mother and baby," he says. Anyone who's delivered children, he says, knows that there are occasions when "if you don't act, the baby's going to die." He says he's seen situations like this only two or three times in his 22 years of practice, but that those were enough to convince him the risk's not worth taking. He has a patient whose first baby died at home, and says he's seen "nearly dead" women in the emergency room who'd been allowed to push for 12 hours at home. "I don't think home birth is in the best interest of the mother or the baby," he says. "And if I don't think it's in the best interest of the patient, I can't support it."
He supports the idea of birthing centers immediately adjacent or connected to a hospital but argues that "anything else is an experiment. They should be in continuity with a hospital that has the ability to do a cesarean section." He says it's important to be able to do a C-section within 30 minutes, and sometimes within 5 or 10.
When confronted with advocates' claims that in-hospital birthing centers frequently do not in fact offer natural childbirth, he concedes that this may be true for many of them. "But then let's build one," he offers. "Especially with hospital occupancies being down, a lot of hospitals would devote a wing" to a birthing center on the premises. He likes the idea of a birth center at UIC--as long as it's somehow adjacent to the hospital. "Obviously I think that would be an excellent location," he says. "It's a teaching hospital, and they serve a very needy population. I think that would be a very reasonable thing."
Sprang is not impressed by the studies that show freestanding birth centers to be statistically as safe or safer than hospitals. "When I was a resident someone told me, 'If you read a study and it's not consistent with your experience, you'd better question it.'" To be convinced, he says, he'd have to see at least three studies done with very large and statistically significant numbers. The National Birth Center Study followed more than 11,000 women but compared their figures to existing figures about low-risk in-hospital births instead of using a control group; Sprang says any study without a control group is invalid. And you have to be careful how the data is collected, he says. He says he was observing at Illinois Masonic's ABC when it first opened and tried to get an open view of a laboring mother's vagina to check for tears. "The nurse-midwives weren't looking. I said, 'How do you know there are no tears?' The nurse-midwife said, 'Well, she's not bleeding.' So they say in these studies that there are no tears but they're not even looking. That makes me leery."
Sprang denies the suggestion of birth center proponents that the debate has more to do with "turf" than with safety. "Why do I care whether the hospital has competition or not? I think that's a poor argument," he says. "Doctors don't work for hospitals, or many of them don't."
But if the doctors don't consider this a turf war, it seems the hospitals might. The Illinois Hospital and HealthSystems Association has traditionally opposed freestanding birth centers. "We think they're unnecessary, and that the current system can't handle them," says spokeswoman Karen Porter. Even in rural areas where hospitals lack OB/GYN services and birth center advocates say the centers would provide a much needed service to low-risk mothers, "the capacity exists to deliver babies," she says. "A delivering woman is simply treated as an emergency and delivers in the emergency facilities." Besides, she says, the problem in rural areas isn't so much the lack of facilities as the lack of people: if the population is so sparse, who will staff the birth center? And finally, the IHHA shares the ISMS's concerns about safety.
Publicly, in fact, the birth center debate revolves almost exclusively around safety. Critics of birth centers tend not to bring up the issues of economics, competition, or control. As a cheaper alternative to hospitals, however, birth centers could pose a threat to established obstetrical providers. Chicago, especially the north side, already has an overabundance of hospital maternity beds. As it is, says Betty Schlatter of Illinois Masonic's ABC, hospitals are competing heavily for obstetrical patients, because "if you get the patients in there to deliver they're more likely to bring their kids back there, they're more likely to bring their family there....It carries out throughout a lifetime."
She concedes that the situation on the south and west sides may be different. But on the north side, she predicts that out-of-hospital birth centers would draw "the cream of patients" away from hospitals. This would leave hospitals floundering with higher-risk, nonpaying patients, "because unfortunately you pay for technology by the numbers of patients that you take care of. And it costs an arm and a leg. From a hospital perspective it's a matter of dollars and cents."
This is not to say that hospitals are motivated by greed: "You know, we may sit back and say, 'Oh, all they're interested in is money,'" Schlatter says. "Well, they are interested in money, but they're also interested in taking care of people. And you have to have money to do that."
Karen Porter of the IHHA says she's not convinced that freestanding birth centers could actually deliver low-risk births more cheaply than hospitals (although they do all across the country). But she concedes that if they could, "it stands to reason that costs are going to go up for people who use hospitals."
As far as the Birth Center Task Force's Riedmann is concerned, hospitals don't necessarily stand to lose business to freestanding birth centers, because they could open their own.
Not all Illinois doctors are in agreement with the ISMS's official stance. Practicing internist Dr. Quentin Young is the president-elect of the American Public Health Association, a national group that includes nurses and other health care professionals as well as doctors. He's also the chairman of the board of the Health and Medicine Policy Research Group in Chicago, which has housed the Birth Center Task Force since 1989. He describes the task force as having "this single issue of trying to make Illinois join the rest of the human race and the majority of the United States. They have, of course, heretofore failed," he says. "There's no question why--the science is there, the studies are there, the mothers are there. The reason it hasn't been legalized is opposition from the Illinois State Medical Society."
Young, who's been a member of the ISMS since 1952, says the battle is about more than safety or money. Because obstetricians' time costs so much more than that of nurse-midwives, freestanding birth centers generally don't have them on staff, and "it would be inefficient and too expensive to have OBs sitting around, maybe delivering only two or three babies a day," he says; the emergence of midwife-run facilities poses a challenge to doctors' authority.
Until last year, the ISMS had been able to point to the stance of the American College of Obstetricians and Gynecologists, which opposed birth centers on the basis of safety, says Young. "That's been the scientific bulwark" of the ISMS position. "ACOG is the definitive body to identify obstetrical standards in this country; no one challenges that."
Last summer, members of the Illinois Birth Center Task Force tried to negotiate with the ISMS's Dr. Sprang, and according to Margie Schaps, a task force member and the executive director of Health and Medicine, Sprang said then that there was nothing to negotiate until ACOG changed its position. So the task force turned its attention to the national body. On August 7, ACOG's director of practice activities wrote them a letter saying that ACOG had deemed it appropriate to develop "approved, well-designed research protocols" to assess the "safety, feasibility, and outcomes" of freestanding birth centers. This amounted to a tacit acceptance that birth centers must exist, if only in order to be tested. Young characterizes the decision as a long-awaited "moment of truth."
The task force went back to Sprang, who told them that he thought the Illinois chapter of ACOG should weigh in as well. Young then approached Dr. Pedro Poma, who is the chair of the Illinois chapter, proposing a transition period in which ten centers would be opened and tested. Poma said that he would poll his executive board. After doing so, he told Young that board members were a little reluctant, because they didn't know what the bill would say.
"That's illogical," says Young. He regards this as bureaucratic game playing, noting that seeing a bill beforehand will never tell you what it will actually say once legislators are done with it. To his mind, the point is not the bill but the basic principle--either they support it or they don't. "In the world of medicine that I inhabit, there are national standards," he says, "not state by state or county by county."
On March 18, at a small benefit for the task force, Gayle Riedmann showed me a letter Poma had written on Illinois ACOG's behalf, urging the members of the Committee on Human Services to vote against HB 1828. The letter was dated March 19, the day on which the committee was to vote, even though the advisory committee of Illinois ACOG wasn't scheduled to discuss its official position on birth centers until the evening after the legislative committee's vote.
On the 19th, the bill made it out of committee with the necessary six of nine possible votes. The house then had until April 25 to read the bill three times and vote on it. If the house approved the bill, it would move on to the senate to be voted on in May. If the house voted it down, that would be the end of it, until next year.
That evening the ACOG advisory committee met and, according to Poma, the members agreed almost unanimously not to support the bill. Poma explained that the committee had some arguments with the bill's language and was not satisfied that the bill met the standards of the national office of ACOG or the American Academy of Pediatrics.
As it was written, the Department of Health had nine months to establish its operation and research protocols for this project, which it would do in cooperation with obstetrics departments and related institutional review boards. So ACOG's concerns seem slightly disingenuous considering that ACOG, as the state's foremost obstetrical authority, would certainly have had input on their development.
Throughout March and April, the Birth Center Task Force kept after the ten members of the ACOG advisory committee, hoping that the group might change its stance at least to a neutral position. By the beginning of the final week of the legislative session (April 21-25), Riedmann says, "We knew who our supporters were, and we talked to those individuals. They said that when they were polled, that they would voice that." The task force thought it had the necessary support to reach a tie. But "Poma finally informed us on the 22nd that we did not have enough votes to have a support position," she says, "and we were not allowed to know who had voted for or against the measure."
"Unless we could get them to be neutral or positive, we didn't feel there was any way that the bill would pass," says Schaps. So the task force decided with the sponsoring legislators not to call the bill for its final reading. "Some people think it's worth getting the vote, just so you know who your supporters are," she says. "Other people think it's bad to get people in the habit of voting 'no' on something," because when it comes up again next year, they won't bother to re-evaluate it.
Poma has agreed to have the ACOG advisory committee meet this summer with the task force to see if they can hammer out the issues and reach a compromise. "We'll try and get a bill drafted together," says Riedmann. "They have said that they're willing to work with us on this." o
Art accompanying story in printed newspaper (not available in this archive): Carmen Velasquez/ LeRoy Sprang/ Gayle Riedmann/ all photos by Randy Tunnell.