Public Address - Busytown (Home)

Liable to collapse | Aug 30, 2003 08:52

Another New York birth centre, the Brooklyn Birthing Center, has fallen victim to the same catastrophic rise in insurance costs that scuttled the Elizabeth Seton Childbearing Center: read about it here. As that article notes, only one birth centre remains in the wider New York metropolitan area: the Morris Heights Childbearing Center, which is federally funded and insured and thus insulated from the upheavals in liability insurance (and vulnerable only to the whims of government funding and policy).

Nothing is ever certain, particularly when it comes to the well-understood but individually mysterious process of birth. You can hope and plan all you want, and get something completely different. Both you and the baby are at the mercy of forces literally beyond the control of either of you, although your first task as a mother is to prepare yourself as best you can to navigate the uncharted rapids ahead. At the same time, in a very important sense, birth is the baby's journey. It is the baby who is making its way into the world, and acquiescing to the process is a preliminary lesson in accepting the invigorating chaos - and the utter otherness - that a child brings into your well-ordered life. Among my friends, I've heard of (and in a couple of cases witnessed) labours that were serene, chaotic, sudden, long-awaited, traumatic, ecstatic; labours that were over as quickly as they began, that lasted longer than seemed bearable at the time, that ended in emergency C-sections, that consisted entirely of planned, absolutely necessary C-sections. I know people who've had difficult birth-centre births, and perfectly fine hospital births. Nothing is ever certain.

Nonetheless, it was sobering the other night to visit Elizabeth Seton for what will be the last time and sit in a room full of women due to have their babies any day now, as they absorbed the news that their carefully chosen birth context -- the one thing of which they could be certain, until labour began -- had been extinguished by the stroke of a pen at some insurance company HQ. Some of these women will choose home-birth, which is the closest one can get to a birth center birth. Others will move with some of the Elizabeth Seton midwives to the temporary rooms at St Vincent's, or seek out other hospitals, where they will be subject to the hospital protocols that limit the number of supporters in the room, define visiting hours, accelerate the speed with which artificial methods of induction are applied when labour slows down, and mandate the frequency of internal exams (see a list here of the major differences in St Vincent's birth protocols).

For those interested in learning more about the dubious rationales and cascading effects of these apparently minor differences, Henci Goer's must-read The Thinking Woman's Guide to a Better Birth is a partial (pro-natural birth) but impeccably researched and annotated guide to studies of the impact of various medical interventions.

More reading: an older article in the New York Post that lists the Soho Midwives Center as another casualty of the insurance rise. And although my focus here has been on midwifery in New York, it's not just New York, and it's not just natural-birthing facilities that are feeling the pain -- the crisis is a much, much wider one and it's been coming for a while.

Obstetricians all over the country are finding it too expensive to renew their insurance policies, leaving some areas - especially rural areas - without any pregnancy-related services at all. The profession as a whole is suffering. (These last two links were found at Overlawyered, which fair froths at the mouth detailing particularly outrageous liability suits in every field -- their medical section is here). So which medical or diagnostic practice will disappear next? Mammograms?

Tort reform -- limiting the circumstances and dollar amounts of liability suits -- seems to be the only answer, although funnily enough the trial lawyers don't necessarily agree... At MedPundit, an anonymous doctor replies, and links to this fascinating story of one woman's experience with ambulance-chasing lawyers. None of this is news, of course. But none of it is good news either. And don't even get me started on the latest news about the alarming concentration of harmful substances in the breast milk of North Americans... it'll just make me want to sue someone, dammit.

Digg this Scoopit!

The birth (and death) of the clinic | Aug 28, 2003 11:08

I'm back! Back here at Public Address, as well as back in the USA, the land of big bad food and lots of other big bad things. I have tons of blogs about the New Zealand trip stacked up like circling planes just ready to land, but I'm going to hold them all back in favour of a distressing bit of news that greeted me on my return to New York.

If I write "the Elizabeth Seton Childbearing Center is closing on September 1st" that probably won't mean much to most readers. So try this instead: the only place in Manhattan – short of having a home-birth -- where you can have a baby without being automatically hooked up to the machine that goes "ping", the only place where you will be attended by expert midwives and loving nurses who assume that you can handle labour pain without the services of an anaesthetist, the only place where you are allowed to give birth in the bath if you want to, the only place where you can have as many people in the room with you as you want (including one woman who famously had her entire church choir singing throughout the labour and greeting the baby with a song), the only place where, after the birth, you and the baby and your partner and anyone else you like can snuggle up in a king-size bed on fresh sheets and sleep and get to know each other, the only place where you can order in pizza or scones or pad thai or whatever you like from your favourite little place in the Village for that first, ravenous post-birth snack… In short, the only place I would have considered having Busytot, and the place where he made his first appearance nearly two years ago – this place is shutting its doors.

With two weeks notice. Which is distressing enough for me, but even more so for the many women who expected to give birth there in the next few months, including my friend (and Busytot's first babysitter) Aline. Like me, she's a long way from home; like me she comes from a place that still believes women's bodies can do more or less what they're designed to do; like me, she wants to have her first baby in a place that has all the love, comfort and care of a home-birth but also the necessary equipment and access to a hospital if needs be.

For thirty years, the Elizabeth Seton Childbearing Center has been offering all of this to New York women -- three or four hundred of them a year -- including those on public assistance, and non-citizens like me, as long as we have health insurance. It's a lovely wee place down on 14th St: three nicely appointed birthing rooms with big beds, patchwork quilts on the walls, rocking chairs and big spa baths for labouring in. It's also home to an ob/gyn practice, and to a set of meeting rooms where parents and babies come to talk and organize: it hosts breastfeeding workshops, post-natal depression support groups, baby development seminars, bilingual playgroups, mother and baby yoga. And tonight, it will host a meeting – possibly the last -- about what, if anything, can be done to keep the centre open. St Vincent's Hospital, just around the corner (where you transfer if things aren't working out) has picked up the ball and are converting a couple of rooms for use by Elizabeth Seton clients due over the next few months. But after that, it's anyone's guess.

What's closing it down? Money. Specifically, liability laws and the correspondingly exorbitant insurance charges. For the last few years, the centre has been paying half a million dollars a year in liability insurance. That's somewhere between one and two thousand dollars per birth, just in case something goes wrong. It's horrifically expensive, but granted, any birth involves two potential victims of medical malpractice, and the statute of limitations is something like 21 years so these things can catch up with you long after the fact. There's a twisted capitalist logic at work: without an adequate social safety net of any kind, your only hope of recovering from what they call medical misadventure is to sue the pants off someone – no matter how many other people suddenly find themselves chilly around the nether regions as a result.

(On a side note, I had a moment of culture shock, while I was home, reading an update on the young woman who was badly burned during a routine C-section in a New Zealand hospital last year. She was sanguine about the experience, sympathetic to the medical staff, insisted that it was an accident that could have happened to anyone, and was thrilled by the support she'd received from the hospital – including a birthday cake and some rosehip oil – as well as the wider public. No plans to sue. That's a story you would never, ever, ever read in an American newspaper, not in a million years).

So, half a million dollars constituted a massive chunk of the annual budget, probably more than what the midwives themselves cost. Weeks ago, the insurer informed the centre -- out of the blue -- that the insurance bill for out-of-hospital births would more than double [Note added 3/9/03: according to a letter from the Center, this was a two-stage process -- first the existing insurer informed them that it would cease to cover out-of-hospital births, then enquiries to other insurance companies produced the following figures]. For the Elizabeth Seton Center to stay insured would cost $1.2 million a year. That's about $4000 per birth; a totally unsustainable amount of money. [Figures updated 31/8/03; an earlier report had mentioned a $2 million premium but $1.2 million is equally unaffordable] I don't know if or how these increases will apply to home-birth midwives too; if they do, women here – in the largest city in what we are constantly told is the greatest country in the world – will have no option but to give birth in hospitals, which is very convenient for the highly paid obstetricians and anesthesiologists, and promises a corresponding increase in C-sections, episiotomies, and all those other interventions that add up to money for the doctors and extended recovery time for birthing women and their babies. Let me repeat: no option. Talk about tyranny in the land of the "free".

What will be lost? Not just a functional group of five talented midwives and their support staff, and the three beautifully equipped birthing rooms with extra space for pacing around in. It's also the very existence of a place that assumes birth to be a largely uncomplicated experience, and which has helped shift hospital practices to a more woman-friendly model, including the construction of special birthing suites, the re-introduction of rooming-in as an option, and permitting midwives to practice on the premises. It's the loss of a middle option that has made hospital birth more humane and home-birth more thinkable (that's my plan for next time). At a time when home-birth is the norm in Holland, and is being encouraged as a matter of public health policy in Wales, once again the United States is swimming against the tide. This feels like the end of an era that has hardly begun.

Some background reading: there are articles about the closure in both the New York Times (free registration required) and Newsday. The last chapters of Peggy Vincent's excellent midwife memoir Babycatcher give an overview of how the insurance industry has ravaged the business of homebirth in America. Also check out Ayun Halliday's book The Big Rumpus, her hair-raising account of child-raising on a budget in the big city: the chapter on the waterbirth of her son Milo is a raucously engaging tribute to the Elizabeth Seton Center and its midwives, as well as a nail-bitingly exact depiction of an ordinary and miraculous birth. And Naomi Wolf, in Misconceptions: Truth, Lies, and the Unexpected on the Journey to Motherhood -- a no-holds-barred indictment of the American way of birth -- set aside a chapter for a warm and eloquent description of the Center and its activities, concluding that what this country needs is more places like Elizabeth Seton. Alas, it's even less likely to get them now.

I remember trekking down to the Center for the first of our birth classes on the Saturday after September 11, 2001. It was the first train I'd taken in several days, and the first time I'd been outside our immediate neighbourhood since that too-blue Tuesday. Any major exertion led to premature contractions, something I was eager to avoid with six weeks still to go, so I was moving carefully and deliberately. We came up out of the subway to a wall of posters of missing people, and a cluster of police officers marking the edge of the frozen zone. A gap in the skyline down Seventh Ave. A smoky bitter smell. The mood was somber, morose, nervous, dissociated. Walking, or I should say waddling, the hundred feet or so to the door of the birth centre, I tripped and fell. No one moved to help me, least of all the armed policeman standing a few feet away.

At the birth centre, a kind nurse found a band-aid for my bleeding knees, and we joined the class. The tutor was barely able to hold herself together, but led us through the basics of breastfeeding and handed out realistic life-sized baby dolls so we could practice holding them properly. I felt stupid, but I clutched my little brown doll for dear life and tried to concentrate on the class, tried not to think about how far from home I felt, how difficult it would be to get on a plane and flee. The next day, the same journey downtown, a different teacher, a different group, and we prepared to talk about the mechanics of labour and how best to comfort oneself through it without resorting to drugs. The mood was tremulous, brittle; we were all pulling ourselves along some sort of mental handrail to get through these last weeks. I found myself thinking in clichés. What kind of a world was this to bring a child into? A child who hadn't asked to be born? The hospital round the corner treated exhausted rescue workers and burned survivors of the twin towers, and we were busy talking about hot water bottles and ice cubes and cups of tea.

As we went round the circle introducing ourselves, one of the other heavily pregnant women said that she'd been stopped on the street that morning by a man who told her she was beautiful, that a pregnant woman was "a walking sign of hope." Under other circumstances we might have scoffed at this greeting-card turn of phrase, but in that moment it had a ring of authenticity and, strangely, salvation. It was all right to be pregnant. It was more than all right, it was necessary. Erica, our tutor, wrote down the phrase and put it up on the noticeboard out the front of the center, where it was still hanging six weeks later as we tucked Busytot into his baby carseat and carried him out to the taxi.

I don't know if the notice is still there. But if pregnant women are walking signs of hope, then the Elizabeth Seton Birth Center is the Grand Central Station of hope. I'm just not sure that hope alone will save it. If you're a New York state resident, you can sign this online petition. And if not, do you know of a kind millionaire who can help keep the centre open, while the rest of us scramble to lobby for changes to the insurance industry and the liability laws, so that the welfare of mothers and babies can be the bottom line?

Digg this Scoopit!