Breach Birth

After 20 years, financial woes close birth center, leaving pregnant women in the lurch.

It was an odd sort of press conference. Sunlight poured through the big windows of a cheerful medical waiting room where a lone male TV reporter stood out conspicuously in a sea of about 75 women. Many of the women had the dramatically swollen belly of advanced pregnancy, and most of those who didn't held nursing infants to their breasts or bounced babies on their hips. Toddlers were running around with signs proclaiming, "Tucson Needs Its Birth Center," and up the hall a woman reportedly was in labor in a hot tub.

Kathryn Schrag, the nurse-midwife who founded the Birth and Women's Health Center almost 20 years ago with Mariann Shinoskie, could barely be heard above the din of the babies' coos and cries. But her message came through anyway: the much-loved birth center, the only such freestanding center in Tucson, will close June 1.

"It breaks my heart to tell you this but the decision was made to cut the midwives," Schrag told the distraught crowd. "It's very sudden, but it's a long story. It's all about money."

The board of Associates in Women's Health Care, which controls the center, cited financial difficulties caused by declining insurance reimbursements when it voted May 14 to close the center, Schrag said. Formerly independent, the birth center joined forces in 1998 with doctors who had worked at the now-defunct GHMA and Thomas-Davis clinics. But the merger meant that midwifery represented only one-fourth of the new practice. Schrag said she pleaded with the physician-controlled board to keep the center open, but to no avail.

"What's behind it is managed care," she said. "This is absolutely a symptom of what is going on with managed care."

Roy Gilbert, CEO of the Associates group, said the physicians have been "supportive philosophically and financially" of the center, but that the managed-care money crunch had begun to threaten the entire practice. "The doctors have gone without paychecks many times to help bolster the birth center," he said. "Financially it's been killing us."

No births will take place at the center after June 1, and the team of six midwives will be laid off in mid-June. Over the years, some 5,300 women have received prenatal care and delivered their babies with the center's midwives, either at the freestanding birth center or at a hospital. Last week's decision leaves more than 200 pregnant women scrambling to find a place to give birth to their children.

"I'll probably have a home birth," said Christine Parlia, 25, whose first child is due July 13. "Money is an issue for me." Parlia said she had signed on at the birth center because of the "quality of care of the midwives, the constant contact, taking so much time with me."

Those are exactly the reasons that the center ran into difficulties, Schrag said. Midwife is an Old English word meaning "with woman," and the time the midwives spend with women is time not reimbursed in these days of managed care. Typical prenatal visits with midwives run 30 minutes, and midwives stay with a woman in labor as long as it takes for the baby to be born. Obstetricians, by contrast, offer office visits of just several minutes' duration, and typically arrive in the labor room shortly before the baby emerges from the womb.

"We get paid the same if we spend five minutes with you or 30 (in a prenatal visit)," Schrag explained. "And we get paid the same if we spend eight hours with you or just come in at the last minute and catch the baby."

Doctors have responded to declining insurance reimbursements by squeezing more and more patients into their day, but midwives by definition cannot. So while the Associates doctors continue to bring in profits, the midwives are losing money.

"The practice of midwifery is time- and education-intensive," Schrag said. "We can't see women every five minutes. Midwifery is not profitable."

The immediate crisis was precipitated last fall. The managed care company Health Net offered Associates in Women's Health Care a contract that would have slashed reimbursements by 15 percent. At $1,500, the cost for an unmedicated vaginal delivery at the birth center is already substantially less than the typical $3,000 hospital birth, but the center usually collects only about $1,000 a birth from the insurance companies. With costs only going up, Schrag said the practice had no choice but to turn the contract down. Since Jan. 1, they've lost 20 percent of their patients.

"We were hoping to make it up, but at present we have more capacity than patients. So something had to happen. Somebody had to go and the decision was made to let the midwives go."

Managed care and physican control were not an issue in the heady early days of the birth center, which had been gearing up for a 20th birthday celebration this September. Schrag and Shinoskie founded the freestanding center in a little house on Pima Street at the height of the movement for natural childbirth. The push for a new kind of woman-controlled childbirth was a reaction not only against skyrocketing rates of a Cesarean section, but against the highly medicalized births of the 1950s and 1960s. In those days, doctors put mothers in a drug-induced "twilight sleep" and women never saw their own children born. Fueled by feminism and idealism, midwifery had a strong resurgence in the 1970s.

The idea was that "childbirth was not a disease," said Shinoskie, now an attorney with the University of Arizona. Instead it could be an experience that empowered a woman and "taught her about her capacity as a female, that she can overcome obstacles, and that she has tenacity and resolve."

Nevertheless, the changing medical climate induced the nurse-midwives in 1986 to affiliate with Thomas-Davis, in an effort, Schrag said, to gain "credibility, an entrée into the managed care system and malpractice insurance." In 1990, Thomas-Davis split to join with a University of Arizona practice, and the birth center moved out of what Shinoskie called that "funky little building" into a glittering, much larger building near Tucson Medical Center. Eight years later came the fateful decision to join forces with the physicians who have now voted to shut the midwives down.

The natural childbirth movement itself lost some steam, and epidural births - in which the mother is anaesthetized but awake - nowadays account for the bulk of hospital deliveries. Cesarean rates in hospitals have stayed at 20 percent, while the nurse-midwives at the center still boast a much lower rate of fewer than 10 percent. But though there may have been a generational shift away from natural childbirth, the birth center mothers are still fierce proponents of its philosophy.

"Births here are natural and drug-free," said Jody Carver, cradling her infant daughter Kristen. "Women have total control. You're calling the shots, and it's less stressful for the babies. They're born in dim light and they go right to the mom."

Carver and her husband John knew they would have to pay out of pocket for Kristen's birth at the center 13 weeks ago because their insurance refused to cover it. But they decided the expense was worth it after they toured a local hospital late in her pregnancy and learned that newborns were routinely separated from their moms for monitoring. "We want people to know that our community needs a birthing environment such as the birth center," she said.

Meg Hagyard, an official at the Tucson Children's Museum, credits the center's attentive staff with noticing a medical problem in her newborn son that her pediatrician had overlooked. "It's tragic that this place is closing," she said.

Schrag told the gathering of women that she hopes the birth center can experience a rebirth in a new form. CEO Gilbert said that Associates physicians stand ready to help the midwives and might be able to sublease the current building back to the midwives at advantageous rates.

The worst-case scenario, Shrag said, is that the center will permanently close, expectant mothers will make other plans - even deliver babies with Associates' obstetricians--and the midwives will have to find new jobs. Another possibility is that a hospital, attracted by the revenue stream represented by those 200 pregnant women, could affiliate with the center. But her dream, Schrag said, is to reconstitute the birth center as an independent nonprofit. The center has already spun off an educational nonprofit that specializes in menopause education, and that might serve as a model for a new birth center that could look a lot like the old one.

"The power of passionate women is not to be underestimated," she told the cheering crowd.

Meantime, the immediate future is uncertain. Tina Hastings, 26, arrived for a prenatal visit after the press conference and was greeted with the bad news. She's already delivered two children at the center and had planned to give birth there to her third, due in November.

"I like the atmosphere here, the closeness, it feels more like family," she said. "I don't feel like a patient ... I just heard about it when I walked in and I'm just kind of in shock. I don't know what I'm going to do now."

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