Experts of Normal
After co-authoring a landmark study demonstrating the safety and effectiveness of birth center care, Cara Osborne, SD, CNM, took the data published in the Journal of Midwifery and Women’s Health (JMWH) in 2013 one step further. She put the findings right into practice.
With the help of a financial backer, Osborne opened a birth center in Rogers, Arkansas, and founded Baby+Company—the name behind a group of boutique birthing centers that offer highly personalized care. One in Cary, North Carolina, came next in 2014, followed by centers in Denver and Nashville, where she earned her MSN in Nurse-Midwifery from Vanderbilt University School of Nursing (VUSN) in 2001. A center in Charlotte, North Carolina, will be opening this fall.
“It’s been a bit of a wild ride,” Osborne said. “Our study (in JMWH) replicated the original national birthing center study, published in the New England Journal of Medicine in 1989, and confirmed that safety and efficacy hadn’t changed over the period of time.”
The JMWH study, “Outcomes of Care in Birth Centers: Demonstration of a Durable Model,” examined the records of 15,574 women who planned and were eligible for giving birth at a birth center at the onset of labor. Eighty-four percent gave birth at a birth center, 4 percent were transferred to a hospital prior to birth center admission, and 12 percent were transferred in labor after admission. Ninety-three percent of those women had a spontaneous vaginal birth; 1 percent, assisted vaginal birth; and 6 percent, a cesarean birth.
The results of the study, also called National Birth Study II, were “particularly remarkable in an era characterized by increases in obstetric intervention and cesarean birth nationwide,” the authors wrote.
Osborne, who had her two sons at birth centers, said she stands behind birth center care “both personally and professionally. It’s a great option for women.”
The Business Model
Baby+Company offers a unique birth experience, combining highly personalized clinical care delivered in a home-like environment with the benefits of partnership with academic medical centers with a long history of excellence in women’s services.
In Nashville the business model operates like this: Baby+Company builds, equips and manages the facility. Vanderbilt University Medical Center (VUMC) provides the faculty CNMs and seamless patient transfer to VUMC when a higher level of care is needed.
Baby+Company delivers the type of care that the data in the study heralded. Maternity care is provided by certified nurse-midwives, who offer personalized support and clinical care from the first prenatal appointment through birth. After birth, the midwives even visit the new mother’s home to check on the mother and baby and are available for consultation as needed, through the standard six-week postpartum office visit. While the centers operate independently, they are each located very close to those partnering medical centers.
“I believe, and midwives at birth centers do too, that birth is normal physiology,” Osborne said. We should approach it with the expectation that things will proceed normally and that the body will do its work. Then we can recognize when things are not going well and intervene accordingly; rather than approaching it from the standpoint of expecting complications, for things not to go normally, and being surprised when they do.”
Baby+Company Nashville is located in a renovated commercial site on West End Avenue, just over 1 mile from VUMC. It’s currently the only freestanding birth center in Nashville.
Each center has several comfortable and beautifully decorated birth suites with spacious showers and tubs, classrooms for prenatal education, yoga and new mom groups. There’s also a communal kitchen and living room available for the laboring mom’s family who are awaiting the birth of a new family member.
Margaret Buxton, DNP, MSN (VUSN ‘98), CNM, and a nurse-midwife with the West End Women’s Health Center (Vanderbilt University School of Nursing’s nurse-midwifery practice group that deliver women at Vanderbilt University Medical Center) for the past 12 years, is now the clinical director of Baby+Company Nashville.
She said that a thriving nurse-midwifery program at Vanderbilt—both an educational program at VUSN and the 20-year-old West End Women’s faculty practice with more than 20 midwives delivering more than 1,000 births a year—was a perfect breeding ground for a company like Baby+Company to offer women another option.
“Eighty percent of pregnancies are normal health events,” Buxton said. “The birth center offers a participatory model of care where we get to know our patients over time. Vanderbilt recognizes nurse-midwives as valuable team members, experts of normal (pregnancy and delivery). And there’s been a huge growth of women seeking care at Vanderbilt who aren’t high risk. In fact, they’re very low risk,” she said.
“Vanderbilt, the tertiary hospital for the region’s high-risk cases, recognized that they have this thriving nurse-midwife practice (West End Women’s) and they want to keep it going. But for women looking for a low-intervention approach to childbirth, Vanderbilt saw the value of the midwifery model of care, saw the demand in the community and began thinking about a birth center, not as an alternative, but in addition to, hospital-based care.”
The cesarean section rate for women receiving care in birth centers averages 6.1 percent. By comparison, the CDC’s vital statistics report indicates the state of Tennessee has a cesarean rate of 26.8 percent among low risk women who deliver at a hospital.
Joining Buxton at Baby+Company are VUSN faculty nurse-midwives Lauren Drees, CNM, and Taneesha Reynolds, CNM. The medical director is Richard Lotshaw, MD, professor of Clinical Obstetrics and Gynecology at VUMC. Under the agreement, if complications arise or a patient wants an epidural, she will be transferred to VUMC.
The birth center will be staffed by at most five nurse-midwives, delivering 400 to 500 babies a year. “Research shows that birth centers don’t really feel like birth centers when you get above 500 births a year. You lose the intimacy,” Buxton said. “The birth center model targets the woman who believes in the importance of education and who wants to participate in her health care. The midwife builds a trusting relationship that’s collaborative.”
The cost of a Baby+Company birth is about half of the cost of a hospital birth. The fee includes the birth, all prenatal care, the required prenatal classes and all postpartum care up to 6 weeks, including a postpartum home visit. The specific out-of-pocket cost for patients will depend on the specifics of their health care plan. Clinical services available at Baby+Company include prenatal, labor and delivery, postpartum, and newborn care, as well as annual exams, pre-conception and birth control. More than 90 patients signed up for prenatal care prior to the center’s opening.
Educating the Next Generation of Nurse-Midwives
VUSN has one of the largest nurse-midwifery educational programs in the country. It’s ranked No. 3 by U.S. News & World Report. The doctorally prepared, practice-active faculty uses a mix of traditional classroom settings, simulated experiences and clinical training to fully prepare nursing students for a career in this field.
VUSN nurse-midwifery students benefit from low faculty-to-student ratios, mentoring and personalized attention. Now, in addition to clinical training at West End Women’s, the students will also be able to rotate through Baby+Company for an additional training experience.
“It is crucial for all of our students to get valuable, hands-on clinical opportunities as part of their education. Our relationship with Baby+Company opens up several more preceptorships for our nurse-midwifery students and in a setting that is growing in popularity as an option for women,” said Mavis Schorn, PhD, CNM, RN, senior associate dean for Academics at VUSN.
Consistent with the patient-centered approach of the nurse-midwifery model, women in Nashville who want to be delivered by Vanderbilt certified nurse-midwives have several options. They can receive care from VUSN Faculty Practice nurse midwives located at a variety of community sites and deliver at Vanderbilt University Hospital or receive care and deliver at Baby+Company. In addition, nurse-midwives practicing with Vanderbilt University School of Medicine work with physicians to care for high-risk patients. These patients are also delivered at Vanderbilt University Hospital.
“Vanderbilt has long been a supporter of nurse-midwifery care, and now there are midwives at every level,” said Sharon Holley, DNP, CNM, and clinical director at West End Women’s Health. “The birth center focuses on low risk and low intervention, while the VUSN Faculty Nurse-Midwife practice on West End cares for women who have low- to medium-risk pregnancies. These two practices will be working very closely together and support one another if patients desire to transfer.”
Last year, West End Women’s Health delivered about 25 percent of the births at Vanderbilt Hospital. There continues to be a strong commitment to midwifery care within the hospital setting. The group’s cesarean rate ranged from 13 to 15 percent, compared to the national cesarean section rate of 32.8 percent, and the epidural rate was about 40 percent, compared to national rates between 60-70 percent. Now with the addition of Baby+Company there is midwifery care available outside the hospital as well.
Osborne’s passion for the birth center model of care started early in her career. After earning her MSN degree in Nurse-Midwifery at Vanderbilt in 2001, she worked at a birth center in Wellesley, Massachusetts, and began working on her doctorate in maternal and child health at Harvard with a focus on perinatal epidemiology. While at Harvard she was part of a research team looking at birth outcomes in hospital and birth center settings, and worked for the Clinton Foundation in Jamaica, helping the government build a program to manage perinatal transmission of HIV.
In 2005, she joined Vincent Obstetrics at Massachusetts General Hospital, a Harvard training site. She took a break from clinical practice in 2007, joining the midwifery training program at Frontier Nursing Service in Kentucky, and ultimately accepted an academic appointment at Eleanor Mann School of Nursing at the University of Arkansas.
“I like being a clinically practicing midwife,” Osborne said. “When someone asks me what I do, (instead of saying she’s the owner of five birth centers) I say I’m a midwife. I have also really enjoyed taking on the academic part of it. I’m driven by the evidence-base in my own clinical practice. Trying to do what I can to help show the value of midwifery in the American health system, and to demonstrate the outcomes that are possible with a low intervention model of care, is rewarding. It’s been a step-by-step evolution and I couldn’t have imagined when I was a brand new student midwife that all this was down the road.”
The business side of things is still new for Osborne.
“The size of the business remains to be seen. The important part for me is having centers that deliver exceptional clinical care, working with strong hospital and physician partners. Our focus, for now, is on these five centers and making sure that we run them safely, effectively and efficiently.”
“I truly believe this is an option that women all over the U.S. would like to have. I hope that we can replicate and grow, but we are taking it one step at a time.”
Osborne said that national data from Listening to Mothers, a national survey of women’s expectations and satisfaction around the birth experience, shows that about 25 percent of women would like to have a birth center option, if available. “But the regulatory environment in a lot of states makes it hard to get one off the ground,” she said.
“I’m struck by how important it is to have this skill set (regulatory and business knowledge). If we are going to expand access to this model of care, it has to pay for itself and be a viable business. It’s been a challenge for birth centers, because as a high-value, low-intervention model, the model of care doesn’t do well under a fee-for-service framework, which is how most payers operate. Figuring out how to overcome that is an important part of making this model work. You don’t necessarily learn that in school,” Osborne said.
“Vanderbilt’s School of Nursing had a great focus on critical thinking and on decision-making skills. There’s an acknowledgement that you can’t learn everything, and that everything isn’t in the book. You’ve got to be able to problem solve and work your way through whatever presents itself. I feel like my education prepared me well. But instead of just solving problems in my personal clinical practice, I now have a different set of problems to solve.”