Bellevue, Birth Center No More

A few weeks ago, I attended a birth at Bellevue Hospital in downtown Manhattan. A warm, smart, and unassuming couple from Queens, Regina and Jason (names changed, of course) were incredibly knowledgeable about their options for their prenatal care and birth. They had decided early in her pregnancy that Regina would deliver their first daughter in Bellevue Hospital's Birthing Center, a section of the hospital staffed by midwives and equipped with queen-sized beds, bath tubs, birth balls, and birthing stools, all in the name of allowing the process of birth to unfold undisturbed. Now, this couple didn't choose the birthing center because it was the delux suite, the "spa" version of birth. (Although, I'm not denying that it is better to cuddle with your husband on a queen-sized bed than a regular hospital twin). They choose it because its outcomes for low-risk women were incredible, with a c-section rate of 4%. Because it was an incredibly safe place to give birth.

Regina and Jason also chose the birthing center because, like Elan McAllister of Choices in Childbirth said (in the GritTV link I introduce below), it was a "culture of faith." When midwives and nurses allow birth to progress undisturbed, as they do in the birth center, they are displaying to mothers their faith in birth, their faith that birth can progress undisturbed. Their actions proclaim their faith that it is actually possible for a woman to have a baby without an IV line, constant fetal monitoring, and supplemental hormones. With every touch, every glance, they are telling these women that they can do it.

Now, this is what happens when you, a woman with a low-risk pregnancy, like the vast majority of pregnant women, enter your delivery room for the first time in a traditional labor and delivery ward. Your nurse brings over an IV line and begins examining your veins before you can even say you don't need it, you're low-risk and you won't be receiving any extra medications through the line. Simultaneously, another nurse applies the fetal monitors to your belly, before you can ask that you only be monitored occasionally, because again, you're low-risk and your baby doesn't need constant monitoring. Then a nurse asks, "Do you want an epidural?" when the thought of pain relief hadn't even crossed your mind yet. Three very simple actions. But these three simple actions send a strong message: we don't think you can do this. So, Regina and Jason chose the birthing center, because, well, they thought Regina could do it.

If you noticed earlier that I was speaking about the Bellevue Birthing Center in past-tense, good job! Bellevue Birth Center officially closed on October 1st, 2009, without much warning or explanation. Its closing received the attention of the New York Times, WNYC, and GritTV, and not to mention, Regina and Jason, about five weeks before Regina's due date. In their response, the media highlighted something about the birth center that I think is the most important: the birth center at Bellevue was the only in-hospital birthing center in Manhattan to accept patients with Medicaid or without any insurance whatsoever. So this notion of birth centers and undisturbed birth as a celebrity trend, or only for those who can want the "spa" birth? Not at Bellevue. Like the New York Times article says, the birth center at Bellevue "was the only one of its kind dedicated not to Manhattan's trend-conscious set, but to poor, mostly immigrant women on Medicaid."

Why did it close? HHC, Bellevue's parent company, is suffering a staggering deficit. So cost is probably the first problem that would come to mind. But undisturbed birth is CHEAP. No meds to pay for, no expensive monitoring machines. No epidurals, which cost the hospitals anywhere from $1000-$2500, plus no staffing the extra anesthesiologist who must be there to administer it. And, with a 4% c-section rate, Bellevue is saving $10,000-$20,000 on each c-section the birth center avoids.

Decreased demand? Elan says that yes, Bellevue was experiencing a decrease in demand for maternity services, but ONLY on the traditional labor and delivery ward, NOT for the birth center. What was changing however, was how many women were cleared as low-risk and could use the birthing center. And this, ladies and gentlemen, is where we enter the dreaded field of medical-legal practice. In a survey conducted by the American College of Obstetricians and Gynecologists in September, 29% of obstetricians agreed that they are conducting more c-sections out of fear of liability issues, not out of safety needs. In other words, as the report of the survey says, "As the negative state of the medical liability environment continues, OBGYNs across the US are forced to make changes across their practice that ultimately hurt patients" (quoted from the WNYC report above). Because when you get sued for malpractice, and you didn't document that you did everything, monitored constantly, gave her every medicine possible, that you were constantly waiting for and expecting the birth to go wrong, you lose a staggering amount of money.

So it actually is about cost: the cost of malpractice insurance, the anticipated cost of some staggering malpractice suit lost. (But let's not forget, Bellevue was actually saving money by allowing more of their patients to use the inexpensive birth center). So the closing had a lot to do with cost, but it's more about fear. Fear that birth almost always goes wrong, fear that women can almost never do it, and fear that the hospital will be punished for trusting birth and women's abilities. But in this case, the hospital survives as if nothing happened, and women, mostly low-income women, are punished.

Regina and Jason decided to stick with Bellevue Hospital, and gave birth on the labor and delivery floor. They walked in and were greeted with an IV, a fetal monitor, and an offer of an epidural. But Regina was already doing it. Fully dilated once she entered the hospital, Regina began pushing and, with the gentle assistance of her fantastic midwife, gave birth to a completely gorgeous little girl only a few hours later. She did it.