Birth Center Delivers Women New Options

San Diego’s newest site for having babies won’t feature the stainless steel ambience of an operating room, but neither will its rooms look like those of a Rancho Bernardo resort.

Its primary birth practitioners will be highly trained professionals with lengthy medical backgrounds, but they won’t be obstetricians.

And some of the 100 to 150 babies born there each month will have poor mothers, but they won’t have lacked for medical care during their pregnancies.

Indeed, if the idea for The BirthPlace works, this Hillcrest alternative birth center could show the private sector how to help solve the problem of women who cannot obtain health care during their pregnancies.

The secret, believes Dr. William H. Swartz, is to minimize technological intervention, maximize efficiency of medical services and use certified nurse-midwives to assist with normal deliveries.

“The concept is that low-risk patients deliver in a low-technology environment, but not at home,” said Swartz, who left the UC San Diego faculty in July to set up The BirthPlace. He remains a clinical associate professor.

“Out-of-hospital birth centers used to exist in the United States. They exist throughout areas of Europe, and I believe they’re the wave of the future in the United States,” he said.

Swartz suspects that cost-savings pressures will hasten the day when--just as outpatient surgery centers mushroomed over the last decade--out-of-hospital birth centers attended by midwives will become the norm rather than the exception.

Already, the largest health maintenance organization in San Diego, Kaiser Permanente, is using nurse-midwives for 45% of its births. Naval Hospital San Diego also has a midwifery service that is undergoing expansion.

Kaiser’s births are done in the hospital, but building an out-of-hospital birth center nearby is “an option that we’re investigating,” said Dr. David Preskill, chief of obstetrics and gynecology at Kaiser.

“I think we have very reasonable control on our costs, but there are still good reasons to consider out-of-hospital birth centers,” Preskill said. “They are less expensive to build, and they offer a potential for providing a setting which is perhaps more comfortable for low-risk patients.”

Swartz agrees. But the real fuel for his dream has come from many years of attending to San Diego’s “no-cares”--women who show up in the emergency room to deliver their babies, having had no prenatal care. There were nearly 4,000 such births in San Diego last year.

“I believe that every person has a right to be born under warm, friendly, healthy circumstances,” he said recently. “The basics of childbirth should be available to all before the luxuries are given to a few.”

But normal, uncomplicated births don’t belong at high-technology hospitals, he says: “You don’t build a neighborhood market in the middle of Horton Plaza, because the fruit is going to be quite expensive.”

It was Swartz who wrote the proposal a decade ago to address San Diego’s no-care problem by beginning the Comprehensive Perinatal Program, or CPP, at UCSD.

UCSD’s Reproductive Medicine Department announced in mid-October that it was ending the program. After controversy, the hospital and medical school administration began negotiating to continue it under the auspices of community clinics. No final plan has been announced. His experience with CPP gave him the basic structure for the new birth center: using midwives both for education-oriented prenatal care and for low-technology deliveries. Obstetricians will deliver only high-risk or Caesarean-section babies.

“You begin with the fact that in 80% or 90% of pregnancies the outcome can be expected to be perfect for mother and baby. Perfect. You can’t improve on perfect,” Swartz said. “It is this group of low-risk women with which the midwife rolls up her sleeves and gets to work.

“Her job is to provide a natural, culturally sensitive, noninterventionist type of experience which attends to the personal, emotional needs of that particular family unit.

“And at the same time she is a highly trained birth attendant. She is an constant and careful observer for safety, to make sure that this isn’t one of the patients who falls into the 10% or so in whom the outcome might not be perfect without some obstetric intervention.”

In those latter cases, the women can be transferred to UCSD or Mercy hospital for Caesarean-section deliveries, he said. The center’s location, on two floors of a building at 4094 4th Ave., is intended to allow a 10-minute transfer to either facility.

Kaiser’s Preskill said 10 minutes is short enough to meet most obstetricians’ concerns about safety of nonhospital births. “Even if you’re just down the hall from an operating room in a hospital, it can take that long,” Preskill said.

On the other hand, birth centers remain controversial with many obstetricians, who say they worry about deaths among babies and their mothers if they aren’t in a hospital, said Dr. Michael Rosenthal, an Upland obstetrician and birth center operator.

A study published last December in the New England Journal of Medicine provided the first large-scale comparison between childbirth outcomes at birth centers and at hospitals. Looking at 11,814 women admitted to 84 free-standing birth centers, the study concluded that infant mortality was no higher than in hospitals.

“The results are so good that I don’t believe we can continue to dismiss this idea,” Swartz said of the study.

The BirthPlace’s planned structure is a blend between a private medical practice and the CPP that Swartz helped found. Currently, Swartz and two other obstetricians, Dr. John Sanchez and Dr. Christopher Lafferty, see patients in an office building sandwiched between fast-food restaurants in Mission Valley. A fourth obstetrician, now at Harvard University, is to join the practice early next year.

But the 30-member staff also includes a variety of specialists, some drawn from the CPP model:

* A nurse-midwife, Cindy Dickinson, who is overseeing licensing and birth services to be given by eight to 10 midwives.

* Two nurse-practitioners, Melinda Bender and Victoria Tueros, whose duties respectively will be to give well-baby care of the children until age 1, and family planning information to their mothers.

* An administrator, Janice Bluemer, who formerly helped administer Medi-Cal for the county.

* A nutritionist, a health educator, a social worker, a patient advocate, and a staff member whose sole duty it will be to help women negotiate Medi-Cal red tape.

After remodeling that begins this month, The BirthPlace is scheduled to open Feb. 1 in a Hillcrest office building. The medical offices will occupy one floor, and another floor will have homelike labor-delivery-recovery rooms able to handle 100 to 150 births a month, a much larger capacity than usual for an out-of-hospital birth center.

Swartz said he is aiming for half the patients to be funded through Medi-Cal, and the rest through cash or private insurance.

Like every other program aimed at helping the poor, however, The BirthPlace’s biggest problem may be its financial underpinnings. Swartz admits that he knows of no other birth center in the state, all of them smaller than his, that takes Medi-Cal.

Swartz said he and the other obstetricians have put perhaps $200,000 of their own money into the start-up, and said the practice is “breaking even” with about 50 deliveries a month, now done at UCSD. Funding also has come from small foundation grants, and further grants are being sought.

“In principle, I think you need birthing centers. The problem is you can’t fund it through Medi-Cal,” Rosenthal said.

Rosenthal said he doesn’t take Medi-Cal patients, or even patients from health maintenance organizations, because these sources don’t reimburse enough to keep a birth center operating.

Total reimbursement for Medi-Cal birth was raised over the last two years to $2,155 for prenatal care plus the delivery. The BirthPlace also will be able to collect a facility fee allowance from the state.

Rosenthal said he wonders, too, if the plan’s finances could be further skewed if private-insurance patients succumb to class snobbery.

“It is very difficult to run a practice that is a mix of middle-class clientele and people who are using Medi-Cal. The Medi-Cal tend to drive the middle class out of the waiting room,” Rosenthal said. “I’m not in favor of this. It’s simply what I’ve observed in my own practice.”

Still, Swartz and colleagues hope a homey, relaxed childbirth atmosphere will attract privately insured patients. They will be competing against luxurious, high-technology facilities recently opened at Grossmont Hospital and Alvarado Hospital Medical Center, and another being built at Sharp Memorial Hospital.

“If you’re having a baby, you want to have it in a nice environment. However, there is a certain level of niceness which is beyond that and gets into luxury,” Swartz said. “I don’t think stained oak floors are necessary, or add to the childbirth experience.”

In an indirect way, he added, such features add to the problem of no-care deliveries by eating health care dollars that could be better spent elsewhere.

“I don’t want to knock Grossmont and Alvarado. I think they have truly beautiful facilities, and I believe in LDRs (single labor-recovery-delivery rooms) and the direction they’re heading,” Swartz said. “But if you try to insist that all patients deliver in that environment, the health care system can’t pay for it. Only the wealthy can pay for it.”