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APPENDIX C Freestanding Birth Centers Anita B. Bennetts and Eunice K. M. Ernst A DESCRIPTION OF THE ADMIRIS'l'RATION AND SERVICES OF ELEVEN BIR'l'B CENTERS As of February 1982 there were 130 freestanding birth centers (I'BCs) in the United States in which prtmary care was provided by certified nurse midwives (CRMa). Bow many additional such facilities exist in the United States is not known. Description of 11 of the freestanding birth centers is provided below. This information was obtained from a survey of FBC directors conducted by Ernst in 1979 and then broadened and updated by Bennetts in 1980 (Bennetts, 1981). At these centers low-risk obstetrical clients received care primarily from CRMa. Phy- sicians and hospitals provided backup services for medical emergencies. Five criteria were used to determine the eligibility of the centers for inclusion in the study. Each center was required to have& • nine •study-eligible labors,• i.e., nine women who had begun labor in the center by December 15, 1979 (labor is defined as the onset of regular contractions as noted by the patient) • structural and administrative separation from a hospital • only patients at lowest risk for obstetrical or neonatal co.plications, as defined by criteria siailar to those described by Lubic (1980) • primary care provided by CRMB with physician and hospital backup • a philosophy of minimal obstetrical or neonatal intervention, such as not using either forceps or oxytocin induction or augmentation of labor Tables 1 and 2 indicate the basic services provided and the obstetrical technologies available within each center. This Appendix also contains a review of the literature on free- standing birth centers and suggests the types of information that should be obtained if useful comparisons are to be made among free- standing birth centers and other types of birth settings. 91

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92 TABLB 1 Services Offered by Childbirth Centers (care is Provided by Certified Nurse Midwives) BnUy Routine Pl'ecJII&ftCY Pl'enetal Pl'epal'ed Self- liatpal't• llo. Childbil'th Centel' Cal'a ..... t Cal' a Childbil'th Cal'a Follow (1) Su Clinica Paailial' Ray.ondville, ...... + + + + + (2) Southweat Matel'nity Cantel' Albuquel'que, R.N. + + + + ! + (3) Bil'th Cantel' Lucinia Cottage Gl'ove, Ol'IICJ· + COM + + + + (4) Bil'th Cantel' Meleah Rauiabul'g, Ol'IICJ. + COM + + + + (5) 'l'he Bil'thplace Seattle, lluh. COM + + + + + (6) Childbeal'ing Cantel' (Matel'nity Centel' Aaaociation) Mew Yol'k City COM COM + + + + (7) Stol'k Stop Jackaonville, Pla. ! + + COM + + (8) Childbil'th Cantel' of o.ytona Daytona Baach r Pla. + + + COM ! + (9) 'l'he Bil'thplace Gaineaville, Pla. + + + + + + (10) Rhoa4a Paaily Health Bal'vicea Qual'l'yaville, Pa. + + + + + + (11) Mc'f-ny llurae-llidwivery Canter Reading, Pa. + + + + + + IIO'l'Ba+ • yea, by cel'tified nul'ae •idwifer COM • .. l'vicea available in the co.aunitYr ! • yea, but li•itedr PRP • pediatric nu~tae p~tactionel'r - • not offel'ed by cacr liD • doctol' of ~iciner +( ) • yea, by cal'e provide~ Uated in pal'entheaear PIDI • public health nul'aa. !wiC • WO..n, Infanta, and Children--a federal nutl'itional prograa. !!up to and including 6 - k exaaination. 80UJICB1 Bannetta, 1981. CBARAC'l'BRISTICS OF STUDIES EXPLORING FREESTANDING BIRTH CENTERS ~e freestanding birth centers exaained in the studies su.aarized below all fulfilled certain criteriaa ~ey were all homelike facilities in which five or more births occurred each year, and they had no adainis- trative or physical connections to a hospital (other than the possible provision of backup services). !he studies fall into four categoriesz

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93 Bntey AdoleiiCUt Social General '!be VIC!. PuUy Routine Infant .,.. .,.. Routine Parenting Pediatric llo. Progru Service• Oouneeling Progru Planning Car~ Viaiting Birtha Cla•••• Service• (1) + + + + + + CC»> + ! (2) COM + COM ! + ! COM + +(PIIP) (]) CC»> + + + + + + + COM (4) COM + + + + + + + COM (5) COl CC»> + COl + COl + CC»> + CClll (S) + + COM + COM (+PIIII) COM ! (7) ! + CC»> ! + + CC»> + COM (8) COM + COM + + + CClll CC»> +(MD) (9) + + COl + CC»> + COl + CC»> (10) COM + COM + + + + ! + (11) CClll + CC»> + CC»> + + CClll COM • descriptive case studies of patients receiving FBC care (Bennetts, 1981J·•aiaon et al., 1979J Lubic, 1977, 1980J McCallum, 1979J Murdaugh, 1976J Neilson, 1977J Scott and Pittenger, 1981J van Aalten, 1979) • studies of freestanding birth centeraa hospital and FBC versus home birth case-comparison studies, with and without controls for various intervening factors (Bennetts 1981J Bennetts and Lubic, 1982J Beman and Beman, 1978J Balle, 1980J Shy et al., 1980) • out-of-pocket coat analysis of FBC care (Lubic, 1979)

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TABLE 2 Obstetrical Technology Available at Various Childbearing Centers! Narcotics Forceps Vacuum Electronic Antepartum Infant on on Extractor Fetal Oxytocin, I~ Resuscitation Childbearing Centers Premises Premises on Premises Monitor or oral Equipment Su Clinica-Familiar, Raymondville, Tex. Yes Yes£ No No Yes£ Yes Southwest Maternity Center, Albuqurque, N.M. Yes No No No Yes£ Yes Birth Center Lucinia, Cottage Grove, Oreg. No No Yes Yes No Yes Birth Center Meleah, Harrisburg, Oreg. No No Yes Yes No Yes The Birthplace, Seattle, wash. Yes No Yes, but No No Yes never used Childbearing Center (Maternity Center Association), New York, N.Y Yes No No No No Yes .. \D Stork Stop, Jacksonville, Fla. No Yes£ (by Yes, but No IV with M.D. Yes M.D. only) never used present Childbirth Center of Yes Yes£ (by Yes, but No IV with M.D. Yes Daytona, Fla. M.D. only) never used present The Birthplace, Gainesville, Fla. Yes No No No No Yes Rhoads Family Health Services, Quarrysville, Pa. Yes No Yes, but No No Yes Never used McTammany Nurse-Midwivery Center, Reading, Pa. No No No No No Yes !Prom Bennetts, 1981. ~ntravenous. £Extremely rare, used in less than 2 percent of all cases and priaarily in early years of operation.

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95 • studies of situational and attitudinal variables related to choice of birth site (Fullerton, 19821 Mather, 1980). All of these studies have limitations, but each one has contributed to our understanding of the maternity care option called the freestanding birth center. 1he formats of these studies are summarized in Table 3 and are organized by category, type of study, primary care provider, and year of study completion. ROW ROUTINE DATA COLLECTION CAN AID MEDICAL, SOCIODEMOGRAPRIC, AND ADMINISTRATIVE COMPARISONS OF BIRTH SETTINGS The following observations and suggestions for research on birth set- tings are based on a review of the literature on freestanding birth centers. 1hese comments derive as much from the types of data an FBC collects as from the types it fails to collect. There is considerable variability in data collection procedures across the FBCs studied. The same variability might be found for hospital units as well. Neverthe- less, without some uniformity, even the most basic descriptive studies within and across different types of birth settings will be impossible. In the 11 FBCs examined by Bennetts (1981) certain variables were routinely recorded. For comparative rather than descriptive studies, the following demographic and medical information should be considered as providing potential research variables: a. Demographic 1. patient age 2. patient race 3. marital status at initial visit 4. patient education s. patient occupation at initial visit 6. age of baby's father 7. primary payment method 8. patient address with zip code b. History of previous pregnancies 1. gravidity 2. parity 3. number of live births 4. number of children now alive 5. number of stillbirths 6. number of infant deaths 7. number of spontaneous abortions 8. number of induced abortions 9. number of small-for-gestational-age infants 10. number of low birth weight infants 11. number of preterm infants 12. month of last delivery 13. year of last delivery 14. month of last stillbirth

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TABLB 3 Characteristics of Studies on Freestanding Birth Centers PriMry care Suple DeiiCription and Reference Type Of Study Provider Location Study Period Suple Siae Method of Selection Typee of Variable• Murdaugh, rae deiiCriptive Certified nuue Ra)"'IIO\dv ille, July 1, 1972, to 754 754 birthe occurring Medical~tetrical 1976 caae etudy aidwife Texae June 30, 1976 during atudy period IHelaon, rae deiiCriptive Certified nurM Cottage Grove, May 21, 1976, to 152 100 percent of woaan Medical-obatatrical 1977 caae atudy aidwife Dragon apring 1977 ragiatered for care \0 0\ Lubic, rae deiiCr iptive Certified nurM New York City 1975 to 1977 All woaan 100 percent of woaan Deaographic, aedical- 1977 caee etudy aidwife uaing center ragiatered for care obatetrical, patient eatief~~etion raiaon et al., rae deiiCriptive Certified nurM • - York City October 1, 1975, 714 100 percent of woaen Medical-obatetrical 1979 caae etudy aidvife to April 30, ragiatered for care 1978 Lubic, rae deiiCriptiYe Certified nurM Raw York City October 1975, to 1,166 100 percent of woaen Medical-obatetrical 1980 caae atudy aidvife July 1, 1979 ragiatered for care Bennette, DeiiCripti ve Certified nurM See Table l May 1, 1982 to 1,938 Stratified eyat...tic Deao9raphic, aedical- 1981 caM etudy of aidwife thie Appendix Deceaber 15, eaaple of all "etudy- obatetrical u rae. for centere 1979 eligible labora• and location• occurring i.n 11 aelected center• during etudy period Van AAlten, rae. hoae. and Lay aidwife, Inn Diatr let, October 1969 to 2,277 riret 2,277 woaan Medical-obatetrical 1979 hoapital phyaician the hther- Deceaber 1972 ragiatered for care (unpubliahed) de~~eriptive land a vith gynecologiet caae atudy in Inn Diatrict llcCallua, rae deiiCriptive Lay aidwife El Paao, 'fexaa Auguat 1976 to 560 Firat 560 woaen who Medical~tetrical 1979 cue atudy Deceaber 1978 ragietered for care at rae Scott and PIIC, hoae , and Certified nurM Sviae lloae, 1976 to 1981 300 riret 300 birthe Medical-obltetrical Pittenger, hoepital aidvife, phyaician Dragon at center 1981 deiiCripti ve ( unpubliehedl caM etudy Ber-n and rae and hoepital Nurae, phyeician Lo8Angelee, 1974 to 1976 I'1IC • 160 Medical-obetetrical a.r . .n, coaparatlve CalUornia hoepital • lll lt71 etudy \

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HAlle, nc and boepital Celttified nuue to. Angelea, January U78 to nc • 43 100 percent of wo.en Madical•obatetrical 1910 pit~pective aidwife, pbyaician C.Ufornia Much 1971 hoapital • U regiatered for rae. ( unpubliabed) •tched- Hoapital cOII()Uter padaon atudy printout ueed for contltole July·AU4. 1971 and Peb, 1979 Shy et al., rae, ' - • and Varied waehington 1975 to 1977 PBC • 1, 247 100 paitcent infante Deaographic, aedicel- 1910 h~pital State ' - . 1,614 born outaide hoepi- obetetrical COIIpeltatiVe tale in waehington etudy State Bennette, rae and boepital Ce~ttified nultee See Table 1 May 1, 1972, to nc • 1,n1 Stratified eyet ... tic Medical-obetetrical 1911 cont~tolled caM aidwife of thie Deceaber 15, hoepital • e.-ple of all •etudy· c.-pu i eon Appendix for 1979 4,790 eligible labon" etudy centere, loca- occun ing in 11 tion, and eelected race and folt deacription the e011perieon group: 1972 u.s. birth cer- tificatee and follow- back queetionnairee Lubic, OUt-of-pocket Ce1ttified nune Mev York City 1979 Not Not applicable Pee for eeltvices 1979 c~t coapar ieon aidwife applicable rendered of rae to local boepitale Pulleitton, Bx poet facto Celttified nuree Reading, 1971 Hoae/PBC • 33 Convenience el8plee Attitudinal variablee 1911 analytical de- aidwife Penneylvania hoepital • 33 of prenatal voeen, related to choice of ecriptive etudy i.e. thoee actually birth eite (unpubliebed) regietering for a hoae/PBC or hoepital birth Mather, s. Field Survey Not applicable Salt Lake Late 1978 100 Rlndoa clueter eaa- l~rtance and value 10 1910 County, Utah pling of voaen lS-39 of childbirth ..... yeare intending to optione about pro- beceae pregnant cedure and eite within the next 10 year e. Fifty of the voeen eelected had previoue birth experience

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98 15.year of last stillbirth 16.month of last spontaneous abortion 17.year of last spontaneous abortion 18.month of last induced abortion 19.year of last induced abortion 20.month when last small-for-gestational-age infant was delivered 21. year when last small-for-gestational-age infant was delivered 22. month when last preterm infant was delivered 23. year when last preterm infant was delivered c. History of current pregnancy 1. week of gestation when first antepartum visit was made 2. number of antepartum visits 3. weight gain during current pregnancy based on reported weight prior to pregnancy 4. childbirth education course taken during pregnancy 5. tobacco use during current pregnancy 6. list of antepartum conditions 7. hospitalization required during pregnancy before onset of labor 8. rupture of membranes: how and when in relation to delivery 9. method of initiation of labor: with or without the use of drugs or artificial rupture of membranes 10. type of fetal presentation during delivery 11. drugs administered to induce labor 12. episiotomy, if so, type 13. method of delivery 14. month of delivery 15. day of delivery 16. year of delivery 17. weeks of completed gestation at birth 18. day of last menstrual period 19. month of last menstrual period 20. year of last menstrual period 21. perineal state following delivery 22. list of intrapartum conditions 23. length of first stage of labor in hours 24. length of second stage of labor in minutes 25. length of third stage of labor in minutes 26. type of attendant at deliveryJ if none present, so state d. Neonatal and postpartum data 1. birth weight in grams 2. sex of infant(s) born at this delivery 3. birth order and type of gestation 4. Apgar score at 1 minute 5. Apgar score at 5 minutes 6. list of postpartum conditions 7. list of fetal/neonatal conditions 8. infant status at 28 days of life: if dead, how many hours after delivery did death occur and why, including autopsy findings

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99 9. transfer data: was mother ever transferred? 10. transfer data: if mother transferred, when? 11. transfer data: was infant ever transferred prior to PBC discharge? 12. method of infant feeding at discharge 13. postpartua visit kept? 14. infant supervision visit kept? SOme potentially important information was ~routinely recorded by most of the PBCs studied as well as some hospitals: a. transfer data: who, when, where, why, before or after discharge from PBC or physician-hospital up to four to six weeks postpartum b. variables reflecting innovations in delivery of maternity care ~ allow valid comparisons, the obstetrical and medical risk status of patients at the onset of PBC and physician-hospital care should be similar and well defined. 1he use of a published risk screening instru- ment to define risk is suggested--e.g., Maternity Center Association's (MCA) Risk Screening ~1 (Lubic, 1980) or Robel's Problem-Oriented Perinatal Risk Assessment Systa (Bobel et al., 1973). J«:A's Risk Screening ~1 is widely used with and without modification in many PBCs today. 1hroughout the United States, the populations used to establish obstetrical and medical risk screening criteria may be too restricted to warrant generalizing the use of risk screening instru- ments or weights to all individuals receiving hospital care. Similarly, socioeconomic and demographic status of coaparison groups should be st.ilar. In particular this includes: a. race b. neighborhood by zip code c. length of the interconceptual interval d. family income The length of the observation period(&) during which subjects are compared should be similar within and among PBCs and hospitals. Complete follow-up data on patients transferred from PBCs (when, where, why, outcome) should be obtained. Currently, data on transfers are available only for PBC patients transferred after the onset of labor. care providers may improve with experience. Likewise, consuaers may, with exposure to the PBC in the com.unity, improve their general health-oriented behavior. 1bus, PBCs being compared should have been in operation for the same length of tt.e. ~e availability of technology may vary disproportionately over tt.e and thus may influence the transfer rate from PBCs to a hospital setting. ~ere fore, data on PBC& being compared should all have been collected during the same calendar year. ~ make valid assessments of health care delivery across PBCs, one must have access to accurate data within the PBCs. care should be taken to ensure that no counts are duplicated. Whether collected for a

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100 calendar year or for year of operation, the following data are necessary: a. number of patients who registered for care (demand for service) b. number of patients who withdrew c. number of patients who terainated care antepartum due to pregnancy loss d. number of patients who were transferred to hospital antepartum before labor onset e. number of patients who were transferred to hospital intrapartum f. number of mothers who were transferred to hospital froa FBC before discharge g. number of patients satisfied with care per total number of patients served (a standard patient satisfaction instruaent or scale should be used) h. number of patients seen for well-women gynecological services i. number of patients seen for routine infant care exclusive of postnatal infant exaaination j. number of women breastfeeding four to six weeks postpartua REFERENCES Bennetts, A. B. 1981. Out-of-hospital childbearing centers in the United States: A descriptive study of the demographic and aedical- obstetric characteristics of women beginning labor therein: 1972-1979. Ph.D. thesis. The University of Texas Health Science Center at Houston. Bennetts, A. B., and R. w. Lubic. 1982. The freestanding birth centre. Lancet 1:378-380. Beraan, s., and v. Beraan 1978. Teaa approach to obstetrics and natural childbirth. In Current Practice in Obstetric and Bynecologic Nursing, Vol. 2, Leota K. McNall and Janet Trask Galeener, eds. St. Louis: Mos trt. Faison, J. B., B. J. Pisani, R. G. Douglas, G. s. Cranch, and R. w. Lubic. 1979. The Childbearing Center: An alternative birth setting. Obstetrics and Gynecology 54:527-532. Fullerton, J. D. T. 1981. The choice of in- or out-of-hospital birth environment as related to selected issues of control. Ph.D. thesis. Teaple University, Philadelphia. Halle, J. N. 1980. Elective birth center delivery for low risk pregnancy: Effect on perinatal outcome. M.S. thesis. california State University at Los Angeles. Bobel, c. J., M.A. Hyvarinen, D. M. Okada, and w. Oh. 1973. Prenatal and intrapartua high risk screening: I. Prediction of the high risk neonate. American Journal of Obstetrics and Gynecology ~17:1-9. Lubic, R. w. 1977. Ooaprehensive aaternity care as an aabulatory service--Maternity Center Association's birth alternative. Journal of the New York Nurses Association 8(4):19-24.

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101 Lubic, R. w. 1979. Boonamic aspects of the Childbearing Center. Unpublished report. Maternity Center Association, New York. Lubic, R. w. 1981. Bvaluation of an out-of-hospital maternity center for low-risk patients. ~ Health Policy and Nursing Practice, Linda Aiken, ed. Hew York: McGraw Bill. Mather, s. 1980. Women's interests in alternative maternity facilities. Journal of Nurse-Midwifery 25(3):3-10. McCallua, w. T. 1979. The Maternity Center at El Paso. Birth and the Family Journal 6:259-266. Murdaugh, s. A. 1976. Experiences of a new aigrant clinic. women and Health 1(6):25-29. Neilson, I. 1977. Nurse-aidwifery in an alternative birth center. Birth and the Family Journal 4:24-27. Scott, J., and J. Pittenger. 1981. Unpublished data on the first 300 births in a freestanding birth center in Sweet Home, Oregon. Paper presented at the Western Regional International Childbirth Education Association Conference, August 8, 1981. Shy, K. K., F. Frost, and J. Ulloa. 1980. Out-of-hospital delivery in Washington State, 1975-1977. American Journal of Obstetrics and Gynecology 137:547-552. Van Aalten, D. 1979. '.l'be obstetrical center at Woraerveer 1 '.l'be Netherlands •. Unpublished paper.