Pregnant mother Courtney sat on a bed in a birthing room at the Geneva Woods Birth Center in Anchorage. We’re just using her first name to protect her family’s privacy. Courtney was three days past her due date, and her water broke about a half hour ago. She was still early in her labor.
Her midwife, Barbara Norton, took out a small beige plastic machine called a fetal doppler, dabbed some gel on Courtney’s belly and rubbed the wand across it to find the baby’s heartbeat.
The machine crackled like an intercom, then revealed a regular beat, faster than an adult’s. Norton said it sounded good.
Courtney had been preparing with her midwife for months for this day.
“When you get a really seasoned midwife, there's something about them that makes you feel so calm,” she said. “And it just leads you to kind of have that little bit of anxiety knocked off of a potentially really anxiety-riddled experience.”
But now there will be fewer options for pregnant women, like Courtney, who want to deliver their babies at a birth center with midwives. Geneva Woods, one of just three independent birth centers in Anchorage, stopped delivering babies at the end of December. Instead, it’s shifting to postpartum, sexual health and menopause care. Nationwide, more and more birth centers are closing.
“It's a loss on all fronts,” said Kate Bauer, who’s been executive director of the American Association of Birth Centers for almost 30 years. “It's disheartening to see, because this model works and you know that if there were systemic changes, birth centers could flourish.”
An alternative to hospital births
Courtney was one of the last women to give birth at Geneva Woods. The birthing room she labored in looked like a bedroom, with taupe walls, dim lighting, tasteful artwork and a big birthing tub in the corner.
This was Courtney’s third birth. Her first was at a hospital and her second was with a midwife when she was in Alabama, and she said she prefers the deep relationship she developed with both of her midwives. Courtney is a registered nurse who used to work in delivery and there, she said, she saw births with seemingly unnecessary medical interventions.
“I really appreciate the midwifery approach of, ‘Let's just intervene if we really, really need to,’” Courtney said.
Midwives only medically intervene, or leave with a laboring mother for a hospital setting, when absolutely necessary. It’s a model that is in demand, both in Alaska and across the country. Over the past decade, independent birth centers have doubled in the United States.
Barbara Norton co-founded the Geneva Woods center in 2002. She said, since then, they’ve delivered almost 2,000 babies. They’ve offered an alternative to hospital births for mothers with low-risk pregnancies.
“There's minimal intervention in the process, and they go home early,” Norton said. “There's no epidurals. Women labor and give birth in whatever way they want to. So, it's a pretty empowering experience for many women who want to make that choice.”
If a birth becomes high-risk during labor, the mother and her midwife go to a nearby hospital. Norton said the center’s services are in demand, but there has been increasing trouble keeping it staffed. After losing several midwives to hospital jobs or who moved out of state, they decided to shift their practice away from births.
And the center is not alone. Bauer, head of the American Association of Birth Centers, said keeping birth centers open can be challenging.
“It's a culmination of several intersecting factors, including staffing, in particular midwifery staffing,” said.
Insurance payments and staffing pose challenges
Since hospitals are larger organizations, Bauer said, they can often offer better salary and benefits, and better work-life balance.
“The other area is when we look at sustainable payment for birth center services,” Bauer said. “And too often, birth centers are paid only a fraction of what the hospitals are paid for the same services.”
Bauer also said insurance payments are higher for medical interventions, which means preventative care, a core focus of midwifery, isn’t compensated as well, and neither is care with few or no medical interventions. The rate of cesarean or C-section births for low-risk pregnancies in the U.S. is about 25%, the rate at birth centers is only 6% and the ideal rate, according to the World Health Organization, is 10 to 15% of all births.
Bauer said there’s been a spike in U.S. birth centers closing in the last few years for staffing and financial reasons. Alaska hasn’t had a higher rate of closures than other states. But Bauer said because the state is underserved, communities may feel the impact more.
Birth centers are not the only businesses closing in the birth field. Two hundred obstetric units have closed across the country over the past decade, because of declining birth rates, staffing shortages and increased costs. It’s created more maternal health care deserts and has exacerbated birthcare inequalities, especially for rural areas.
The White House has recommended opening more birth centers as a way to close those gaps in maternal health care, and Bauer said it’s an evidence-based solution.
“But we can only make this work if we have the midwives to work in the birth centers,” she said.
Norton said she struggled with the decision to shift her practice away from delivering babies partly because she knows mothers in the area will have fewer choices about where to give birth.
“It makes me very sad,” Norton said. “I'm hoping somebody else wants to open a business and start another birth center… there's probably some young person out there who has the energy.”
A baby is born
Back at the Geneva Woods Birth Center in the middle of the night in late December, Norton coached Courtney through intense labor. Courtney breathed through contractions.
“It needs to be quick,” Courtney said. “I can't do this much longer.”
Her husband was at the end of the bed, ready to catch their son.
“Court, push,” he said. “Oh, great job, honey.”
After six hours of labor, the baby was born.
“He needs to be stimulated,” Norton said.
The baby was stunned and not yet breathing or crying. Norton asked Courtney’s husband to step aside and she massaged the baby’s tiny body.
Then the baby cried out, and everyone yelled in relief.
Norton laid the baby on Courtney’s chest, and guided her husband to cut the umbilical cord. She stepped away to let the parents rest with their child.
Then another midwife stepped in to deliver the placenta, so Norton could rush off to another mother in labor. Before the end of the year, she’d deliver three more babies. Then she’ll also get to rest, from the unpredictable schedule, and rewarding work, of a labor and delivery midwife.
