Birth Center vs Hospital Birth - Which Is Right for You

0:00Hi, I'm Sarah Trott, and welcome to the fourth trimester podcast. I'm a new mama, and this podcast is all about postpartum care for the first few months following birth. The time period also known as the fourth trimester. My postpartum doula Esther Gallagher is my co-host. She's a mother, grandmother, perinatal educator, birth, and postpartum care provider. Fourth trimester care, our topic, is about the practical, emotional, and social support parents and baby require. And importantly, it helps set the tone for the continuing journey of parenting. Hello, and welcome back to the fourth trimester podcast. I'm your host, Sarah Trott. I'm joined by my co-host, Esther Gallagher, hi Esther. Welcome and today's episode is a special one. This conversation is part of podcast thon, which is a global movement where podcasters around the world dedicate an episode to highlight nonprofit organizations that are making

1:01a meaningful difference in their communities. And for this episode, I'm honored to shine a big spotlight on the San Francisco Birth Center Foundation, a nonprofit that helps expand access to community-based midwifery and birth center services for families in the Bay Area. And many parents are spending a lot of time thinking about their birth plan, of course. But one of the most important decisions happens even earlier, which is to answer the question of where they are going to give birth. So for most families in the US, the vast majority choose a hospital birth. In fact, it's about 98% of births happen in hospitals, but there is growing evidence and awareness that's getting some attention around birth centers. So according to the American Association of Birth Centers, they're roughly double the number across the United States, and there were a couple of decades ago. The number is still under 500, but its progress is movement. And there are some very good reasons for this attention and this growth.

2:03One of the stats that I see highlighted often around this story is, for example, accessory and birth rates. So in birth centers, that stands around maybe six or eight percent, and that's compared to a national average of about a third in hospitals, which is a significant difference. And we can talk more about the data and evidence as we have our conversation today. But we're going to talk about what it's actually like to give birth to the birth center, how to families decide what's right for them, what role in the community birth centers play in improving maternity care in the US and elsewhere. And to help answer our questions today, I'm joined by our guest, Nancy Myrick, certified nurse midwife and co-founder of the San Francisco birth center. Nancy is also the co-founder of the San Francisco birth center foundation. And joining her, our additional guest is Monica Levine, who is the president of the San Francisco birth center foundation and on the floor. And she is here with us to talk all about the amazing work that they've been doing.

3:08Both Nancy and Monica believe that having meaningful choices in childbirth really helps families begin that journey, every single healthy, happy, thriving families. So we're super excited about this conversation today. We're going to talk about so much valuable information for parents who are considering where to have birth. So let's just dive right in, Nancy, do you mind giving us an introduction in your own words? Sure. I've been attending births for over 30 years now. I was just at a birth with a dear friend and midwife, Sue Bailin, and we realized that we had met 33 years ago at a study group to be midwives. So that's how long I've been in the birth world now. I was a home birth midwife for a long time, and then about 10 years ago, myself and Sarah Van Acker and Julie Birdsong decided San Francisco needed a birth center, and we worked really, really hard and opened it up, and it's been fantastic. A couple of years ago, we decided to make a big shift and create a nonprofit organization

4:13to help support the work of the birth center. It's been really phenomenal to work with this amazing board of people to really open access to the birth center to a broader population and focus on sustainability. I'm going to pop in, Nancy. Would you say there was anything that maybe was brewing that pushed you in the direction of the need for a nonprofit status? Would you like to drill into that just a little bit for us? Because I think it's significant in the culture. Yeah, so excellent birth care is not cheap. What you often get at the hospital is the kind of care that insurance pays for, which is short prenatal visits, a doctor or midwife popping into your birth, most commonly I've never met them before. It is fractured, it is impersonal, it is what I think of as really minimalist care, and

5:17it's not good. I believe in wrap around holistic care during pregnancy and birth, where it's not just about what's going on in your uterus, it is what's going on in your whole life. And I really believe that this is what people need in pregnancy, birth, and postpartum. So in order to give that kind of care, we cannot survive on the measly reimbursement that insurance companies offer. And because of this belief and because of the belief of the other board members, they have now supplemented the care we offer so that we can actually offer this wrap around care. There you go. Yeah. And sustainability means we need, we all need to be able to pay our rent and our child care and our food bill and all the things and it says, though, we're just, it doesn't

6:18matter. Yeah. So I'm 100% with you on that. You guys, me, teachers, it's all in there, right? Yeah. And San Francisco is a difficult place to live. You know, we've relied upon midwives taking a cut in salary because of their passion to do this work. And it's really hard to retain staff in San Francisco where it just costs so much to live. I know we're going to come back to a lot of this. I want to give a moment to ask Monica to give herself a little bit of an introduction as well. Hi. I first came to the San Francisco birth center as a client. I had both of my beautiful births with my two daughters there. Nancy attended my birth with my second and really it's the kind of care that every human being deserves to have, especially in birth, but in all health care, I wish that, you know, there were birth centers for everything was just really so inspired by the care that

7:22I got that I wanted to make sure that everybody has access to this. And so that's what has called me to be on the board of the foundation and helping to expand that access. It's hard work, but it's beautiful work to bring more families into the birth center. Yeah. I mean, you're drawn to it because you're on personal experience. So what is drawn testament that is to your ongoing participation in your professional work now leading the group? So tell us more about your own birth story and your own fourth trimester experience. Awesome. Yeah. I was pregnant with my first kiddo in 2020, sick of the COVID pandemic, and we might remember there were all these stories about your partner even be allowed in the delivery room with you. Can you have a doula people that didn't know the story was always changing? What first drew me to the San Francisco birth center was that not only were they going to guarantee that I was going to get my partner and a doula in the room with me when I was giving birth, my partner could come to all my prenatal appointments with me. And as a first time pregnant person going into a hospital by yourself for prenatal appointments

8:28was so scary and knowing that I could come instead to this home like friendly welcoming environment where I'd be cared for by midwives who I knew personally and my husband could come with me was like immediate cell. I didn't need to know anything more about it. As I learned more about childbirth and about what the options are really the whole birth center model and experience really spoke to me before I had my baby I did not know anybody who had had an unmedicated childbirth and I did not know anybody who had felt good about their childbirth experience. Everybody that I knew all my friends had gone into the hospital with these plans or their hypno-birth thing or their their natural birth and they had gotten on that conveyor belt hospital and ended up with their epidural and like healthy mom, healthy baby, everything is fine, right? But it was not the experience that they wanted and then they came home to postpartum to be completely unsupported and meeting with five different lactation consultants who told them five different things and nobody knew what they were doing and wasn't worth getting

9:30any sleep and trying to figure it out. And the birth center model of care like really resolves all those things. Of course labor and coming home with a new baby is always going to be hard. It's not going to be a complete cakewalk for anybody but when you have the support of this team behind you who are coming to your home in the postpartum, teaching you how to breastfeed your baby while you sit in your own bed. The whole experience is worlds different and I was really lucky to have a very medically uncomplicated birth. If there was nothing I would have needed to be an hospital for, so I'm so grateful for the care that I got at the birth center. So I came back for my second baby, did it all again, yeah, and your postpartum was probably starkly different. Yeah, even with COVID restrictions that meant that I couldn't have a lot of help and visitors in my home. I still had so much more education, so much more support, knew that there was a midwife I could call any time if I had any questions about anything.

10:34And then just because the care never ends, Nancy continues to lead a new parents group that you can attend really forever. She never kicks. People come mostly with little babies and then they go back to work after maternity leave. But you've got a crawler or a walker and she still welcomes you and so much of my parenting advice and wisdom from those sessions. So it's really a full spectrum. Yeah, you know, we have two primary, I would say, philosophies that drive the whole way we give care to people. And the first is relationship-based care, which means us getting to know our clients and our clients getting to know us. And the way we do that is we spend time together. Many of our visits are an hour long, our prenatal visits. We really want to get to know you so that when we are in the birth room, there is a connection there. There is a knowledge, there is a trust that really rarely exists in a hospital-based setting.

11:39The second philosophy is building community around birth. And I think this is very true in San Francisco, which is a city of migrants, like people are coming from Iowa or Canada or India to live here and work here. And often without the kinds of connections that traditionally families will have, we really want to connect people because otherwise parenting can be really lonely. And partly we do that through our group prenatal care. We have eight classes which cover pregnancy and labor and birth in the postpartum and breast feeding. And you get to know this cohort of people who are all giving birth around the same time as you. And then afterward we have what Monica mentioned is our new parents group where you can continue to expand and deepen those connections and have a lot of fun listening to the babies. So for anyone who is listening to this and they're hearing about birth centers perhaps for the first time where they're just kind of scratching the surface with their research, would it be possible to give a little bit of context around just what exactly a birth

12:42center is? Maybe the finer points around how it's different from hospital birth? Yeah, you bet. So birth centers are really designed for healthy people having normal pregnancies in birth. And we always have a backup plan, of course, because things can be unpredictable. We have great relationships with the hospitals in town. There are a couple that are very close to us. And we'll transfer there if complications arise. It is really about agency in birth that this is not care that's directive, but this is care based on you and your needs and your belief systems. It's midwifery led care midwives in the United States and really all over the world are the primary caregivers for healthy people in the United States. It's a little differently mostly default to going to an OBGYN for our pregnancy care versus in much many parts of the world. You go see a midwife unless you're sick, unless you have a complication and then you go see a doctor.

13:43I do think that model is what we should be striving for because there is ample evidence that when you start care with a midwife outcomes are better. And while we know this on paper and we know this is how it is in many countries, it has been a very difficult system to institute the United States. But in those places that have done it, for example, in birth center care, we have the kind of outcome Sarah that you mentioned a little bit earlier where we have about a third of the C-section rate that they have in hospitals. We have a 90 plus breastfeeding success rate. We have a low to non-existent infection rate. Really, it's just a model that is based in health and well-being. I just also want to pop in and say that both Monica and Nancy's descriptions are excellent descriptions of what's going on and I want to add both from personal and, of course, professional

14:44experience over all these years. Let's not forget that midwives are highly trained and experienced people and they are very well prepared to intervene when appropriate and or necessary and will do so on behalf of somebody that they've created an actual relationship with. That's the wiffery, that's the difference people. This is the big secret in America is that somehow, you know, midwives aren't quite up to speed and it's BS, it's just such BS and I get real passion about this as you know from previous podcasts and right now, but it's really when next door to us in Canada, they have such better birth statistics where all over the first and second world, they have better statistics than us. Why the heck can't we get a clue?

15:45And as Nancy mentioned, get this model that works all over the world to be part of the American model of perinatal care and life care. I circled back to my midwifery team many times in my whole life for things and have been part of that same culture for people who I worked with during their births and postpartum. So, you know, I think it's a much more integrated model of care for women and children. Let's not forget, right, while I, of course, always put women in the center of all this, I think the kinds of care that those babies and then, you know, toddlers, tweens, teens on up are going to get in their life because their moms have such a different experience is going to be phenomenal in culture changing. So, that actually reminds me of something, Esther, that there is lots of confusion about what is an OBGYN do, what is a midwife do, what is a nurse do, what is a doula do?

16:47There's a lot of confusion about what's a doula versus a midwife. So OBGYNs by their primary training are surgeons and they can do a C-section. I'm not trained to do surgery. That is not a part of my job. They are trained really to manage the complications of birth. As a midwife, I say, I'm a specialist in normal birth and I think outcomes really reflect those two perspectives. That if you are trained that birth is kind of a complication waiting to happen, you're going to respond differently than if your center is, birth is a natural event. Sometimes things go off the rail a little, be prepared for that. I do want to jump in, Nancy, and add this based on something you said the other day. Ironically, when those complications do arise, the midwife is going to spot them quicker than the doctor because the midwife is in the room. Knows that patient very intimately and is going to direct you so much more quickly to

17:49that higher level of care that you need when the complication arises than the doctor or nurse who's busy and taking care of six other patients at the same time and running in and out of the room. And so there is absolutely space for doctors and medical teams in birth because things happen and they really can provide incredibly important life-saving care, but you're not going to necessarily be directed to that care in the way that you need to be, especially in the postpartum when they send you home and don't check on you again for six weeks. Yeah. Thanks, Monaco. It is that intimacy, that connection that helps us to see when things shift. Now, I want to address the difference between a midwife and a doula because this question comes up all the time. We are huge fans of doula's at the birth center, including our friend Esther Gallagher here, is that you? And I would say about maybe three quarters of our clients actually have doula's in addition to our care. A doula is trained to offer physical and emotional support and education to support the

18:52birthing family. They are not medical care providers. So as a midwife, I went to school for three years. In my case, I became a nurse first. I'm a nurse midwife. Some midwives do what we call direct entry midwifery where they don't go to nursing school first, but it is an intensive extended, deep dive education into being the primary care provider for people during normal pregnancy, birth, and the postpartum. It's just a whole different role. In our scope of work, we are more similar to an OBGYN and that we do the full care of pregnancy, birth and postpartum. That's a really important distinction. Midwives are medical professionals. And I think it's important to highlight that in part because a lot of what we're talking about and certainly from a decision making standpoint is safety. So I just want what's going to be safest for me and safest for my baby, often the concerns that are top of mind, but what we were actually saying is that safety is actually potentially

19:52higher or as high at least in a birth center scenario. Yeah. And let's not forget there's such a thing as emotional social safety, which we could do a whole show on. Yeah, by way of comparing midwifery and obstetric care. Yeah. I mean, Esther, that is so core in our model. You know, I'd like the metaphor of the deer who goes into labor in the forest and a lion comes by, her labor shuts down, right? This is not the bright time to have a baby. And I think that it can sometimes feel like that at the hospital, not that it's full, necessarily of horrible, dangerous people, but it is full of strangers. And when someone you've never met before walks into your labor, there's this kind of pause of like, oh, am I safe with you? And that can really disrupt your labor. And if that person does prove to be unconnected or feels that they have a different agenda

20:55than you do, or is just brusque, it can be really scarring. It can be traumatic in a way that maybe that person never even knew. And in some models of care, it's not just one person walking in. It could be three to four, or even more sometimes the team shows up. I mean, yeah, I was just going to say we have the birth plan template that we have on our website. And so what we advise actually is that when people use it, first of all, we call it birth intentions, because it might not go to plan, right? So there's that mindset part. But we say print out five or six copies of this, not one, because you're going to need to hand them out to a lot of different folks or coming in and out, right? So just to that point, yeah, I had a client one say, you know, when they told me they took a team approach, I didn't realize I was going to be the football man. Yeah. And I want to have a balanced conversation here.

21:56There are a lot of people who have really beautiful, successful, it's like, logically, safe hospital bursts, like it is possible to do that. So we're not like just, you know, like completely disregarding that option. I mean, it's the vast majority and that it is what it is. What we're saying is there are reasons why birth centers and the shift is there's some movement here and it's getting a lot of attention, right? For positive reasons. And so what said that, you know, I have a lot of dear friends who work in hospitals and give phenomenal care. I think that my challenge is not with the amazing people that work there. It's with the institutionalization of birth and almost the industrialization of birth. The way things are monitored, the way things are managed is much more of machine oriented. Yeah. And I didn't want to quite go that far, but yeah, it really is. You know, Eltebates Hospital in the East Bay has, I think, 28 labor rooms. There are some enormous hospitals around there. And I mean, it's like if you have one kid, you can kind of be flexible.

22:59But if you have five children, you've got to have a schedule. It has becomes management rather than personalized care. And by the way, I would just like to infold home birth into the same rubric as birth center birth. We're talking about the same model of care and you get to stay in your home and that is a viable, healthy, normal, if you're healthy, a normal option for people to choose in this country, where there are direct entry and CNMs who attend home births. But you'd think that they don't exist. People don't even know when they come to have their first baby. So it's a question whether having a hospital birth is actually a choice if people don't even know what the choices are. So again, thank you, thank you, thank you, Nancy, for creating yet another alternative. We haven't given birth at the birth center as I come into our house to give birth. It really is designed based on my many years of home birth experience to be this warm,

24:03welcoming space really designed for natural childbirth where people have the opportunity to move and walk around and be on hands and knees or squatting or in our big beautiful tubs or dancing or whatever it is that's working for you in your labor. It's not the bed with the monitor where it's kind of perched there. I mean, there's not more options in the hospital, but you walk in the door and it's like it kind of funnels you into that and we're like, here's the room, what do you want to do? Yeah. Yeah. Well, I'm wondering if we should shift at this point to a little more talking about the foundation. Monica, do you want to tell us more about why and how the foundation exists? Yeah. Now that we've convinced you that everybody should be having a birth center birth, why aren't it? Birth centers is the question and the answer is that it's almost impossible to get insurance companies to pay for birth center birth.

25:06It is real healthcare as we've told you and in fact, it's safer and cheaper than hospital care, but the system is so biased against it. Nancy has spent 10 years beating her head against a wall trying to get people's health insurance to cover their birth at the birth center and there's just no good outcome right now. Either the midwives take a big pay cut or families have to pay a lot out of pocket and is not within reach for a lot of families. So the birth center foundation's primary function is to subsidize the cost of that care through donated funds, be able to make sure that the midwives are getting paid and the families are able to have their babies without it being a huge financial burden on anybody. That doesn't mean that we are letting the insurance companies off the hook. We are continuing to work as hard as we can to get them to recognize this care for what it is and start paying for it. But in the meantime, as a board, we just made the decision to start funneling the majority

26:12of our funds towards really just subsidizing that care so that people can have access. I would also say that they're committed to paying for some specific programs that fit into their mission beyond that and one is really looking at the communities that have been really impacted by the worst birth outcome. So obviously, front and center black women have three times the complication rates and not just complications, but death rates of other people in labor and San Francisco is right there as bad if not worse than other parts of the country. It's a really important thing to keep in mind and words subsidizing some specific programs for that and also this belief in the importance of education and birth and subsidizing our classes so that people can really be good decision makers in their care during pregnancy, the birth and the postpartum period.

27:13Nice. Another big part of it is education for new midwives. In the same way that a doctor goes to residency in a hospital, midwives need to do a lot of hands-on training and traditionally that has relied completely on the generosity of existing midwives to educate them. There is no formalized, I was called preceptorship, teaching a new midwife about midwifery. They're not compensated for that or whatsoever and so that is another goal of the foundation is to compensate midwives for that work, training new midwives so that this can continue. Right. Because what is the future that's going to look like if we don't have an F-Train professionals to help support? It seems like there are a lot of needs. We know about the data coming out around maternity care deserts where a third of counties in the U.S. don't even access to a hospital, let alone birth center so there's also that. There's access to care and part of the picture that you're highlighting is access to care

28:13professionals. Right. So building the foundation helps also create the future path for additional professionals to take the reins for the next generation. Sarah, that's really, that brings to mind something really exciting in many parts of the world where we have nationalized healthcare unlike the United States. There is a distribution of care that matches need and that is not true in the United States. There's been a real centralization of care leaving as you describe these maternity care deserts. There is an interesting model being worked on in the northeast corner of California, Caliburus County, I believe it is, where the local maternity ward closed down and people need to drive 100, 200 miles to get to a hospital that has maternity care. There is a birth center there and what they want to do is be the primary caregivers for the lowest people. There is a hospital round. It just doesn't have a maternity ward, but it has an emergency room.

29:15Getting up the emergency room to be the receiver of those more sudden onset complications. And then if you are someone who actually has an existing complication, the plan is, you know, go to the hospital 150 miles away to get your care. And I think that's a really interesting model for the country to use. But until recently in California, the only way for a birth center to get licensed was if they were within a 30 minute drive of a hospital that with the labor and delivery ward. Right. And so the birth center is able to operate without a license, but the license is required in order to be able to accept health insurance in order to be able to accept patients with public insurance. And so luckily we have some great legislators in state of California who are working on changing those rules in a bill that's just passed last year that removes that requirement of being within 30 minutes of a hospital. There's so many moving parts of this too, because what is it? There's a significant percentage of births in the U.S. that are Medicare and Medicaid.

30:17And the reimbursement rates there are also lower than what would be needed to get out of quick care. And that's part of the picture around a lot of these labor and delivery rooms closing. It's just, it's lost making for hospitals, which ultimately are businesses. 50% of the births in California are paid for by medical. And the reimbursement rates are significantly below the cost needed to pay people to do this work. And it is a constant frustration, I think, for all of the hospitals. There are reasons why private hospitals avoid it. Yep. Yep. Well, we're so excited to be able to shine a spotlight on what birth centers are, what midwives are, how they work, how you've got this foundation here that is helping support more people in getting the care that they require. This is amazing work that you're doing. Thank you so much, Sarah. Yeah. Thank you, Eth. It's great to see you. Yeah. It's great to see you too.

31:18I just want to mention Nancy Myrick has a beautiful singing voice. Whenever I see her, we were at a function at Natural Resources here in town, and we were doing a circle, and we were singing, and I had the good fortune to be near Nancy, and I was just like, wow, there's an angel in the room singing. I don't know if you ever sing at those births, but that's an added bonus. But also, yeah, thank you so much for coming on the show, Nancy and Monica, and the work he's been doing all these years has just been phenomenal and necessary and needed, and you are just the gal for the job. I can't overstate how grateful I am for this Board of Directors of the foundation. And it is these people who are so deeply dedicated. They're all volunteers, and they all work incredibly hard to do this. And I think a lot of nonprofits really suffered last year, and we net and exceeded our fundraising

32:18goal. And it was through the hard work of this team. That's incredible. That's incredible. The generosity. Let me be clear. The generosity of our donors. They were great. Yeah. Well, we've had a prior episode with you, which we'll link to in the show notes, featuring both you, Nancy and one of your other board members, Lita Bashi. So we'll make sure people can go and learn more and listen to that episode as well. And I'll give you the opportunity now to leave us with any final thoughts, Monica and Nancy. Sure. I think we have Sarah and Esther, you shared so much of our message as well. So great to talk to people who really get it. And we just really hope that in the future of birth care, birth centers are one of a menu of options. It's not a fringe, different thing to choose. It's just one of your choices. And it's really, really all about choice and reproductive care, which is something that I know we all believe in and feel passionately about.

33:19Yeah. If you don't know what your choices are, then you don't have any. Truth. Where can people learn more about the birth center and the foundation? Well, the birth center is at sfpercenter.com, and we have infosessions every month, the first Friday of the month at 1130 that you can sign up for. And I tell you in depth about all of the care that we have. Monica, you want to talk about the foundation? sfbirthcenterfoundation.org is our website, which has a little bit more information about our board and our programs, and we are always happy to connect and chat with people who are interested in learning more or getting involved. Yep. And so people who are interested in making a donation can go to the foundation site. Great. We'll have links for that as well. Thank you so much. And again, thank you for being wonderful guests on the show. Thank you so much. Thank you. Thank you. You can subscribe to this podcast in order to hear more from us. Thank you for listening, everyone, and I hope you'll join us next time on the fourth

34:20trimester. The theme music on this podcast was created by Sean Trot. Hear more at SoundCloud.com slash Sean Trot. Special thanks to my true loves, my husband Ben, daughter Penelope, and baby girl Evelyn. Don't forget to share the fourth trimester podcast with any new and expecting parents. I'm Sarah Trot. Goodbye for now. No, you're doing all that you can. I wrote the song, simple and true. I wrote the song, all singing song for you. You got your wheels, you got your gears, you ride around town with out any fear. You got your pedals, you got your brakes, you always wear your helmet for safety's sake.

35:47Hello again, bicycle man, I know you're doing all that you can. I wrote the song, simple and true. I wrote the song, all singing song for you. Hello again, bicycle man, I know you're doing the best that you can. I wrote the song, simple and true. I wrote the song, all singing song for you. I wrote the song, simple and true.