I. Statement of the Problem
Some women are seeking alternatives to the acute care hospital for normal pregnancy and birth.1,2
Birth centers in and out of hospitals can offer this alternative to women and families.3-6
Births to healthy mothers can occur safely in birth centers outside the setting of an acute care hospital.3,7-9
These births can be safely and competently attended by professionals trained specifically in the conduct of normal, uncomplicated childbirth,3,10-14 and early recognition of complications or abnormalities and labor.
Birth centers have a potential for reducing the costs of maternity care.15,16
The American Public Health Association adopted a position, in October 1979, that endorsed family-centered maternity care, demonstration projects for alternatives in maternity care, and research in this area.17
State and local jurisdictions have been called upon to regulate birth centers.18-21
APHA has a public responsibility and an organizational commitment to ensure that standards exist to protect the health, safety, and welfare of mothers and infants.
To make available to state and local health agencies, health planners, maternity care providers, and professional organizations general guidelines for licensing and regulating birth centers.
APHA's adoption of the following positions on licensing and regulating birth centers is directed at promoting the health of mothers and infants by assisting state and local health agencies to achieve safe, quality care for mothers who choose to give birth outside the setting of the acute care hospital.
IV. Actions Desired
APHA endorses the guidelines below as representing a reasonable approach to ensure that births occurring outside of hospitals are as safe as possible while providing pregnant women with the maternity care alternatives they seek.
- Birth Center—Any health facility, place, or institution which is not a hospital or in a hospital and where births are planned to occur away from the mother's usual residence following normal, uncomplicated pregnancy.
- Low Risk—Normal, uncomplicated prenatal course as determined by adequate prenatal care and prospects for a normal, uncomplicated birth as defined by reasonable and generally accepted criteria of maternal and fetal health.22-26
- Licensed Birth Attendants—Individuals licensed and/or registered to provide care at childbirth and practicing within the scope of their training and experience.
- Administration—Birth centers should have a governing body which is responsible for: the overall operation and maintenance of the center; the provision of personnel, facilities, equipment, supplies, and services to mothers and families; adopting administrative policies regarding patient care; appointing an administrator or director responsible for implementing the adopted policies; establishing and maintaining a written organizational plan; appointing a clinical staff and assuring its competence; and documenting all of the above.
- Clinical—The clinical staff should develop and adopt bylaws which are subject to the approval of the governing body and which should include requirements for clinical staff membership, delineation of clinical privileges, and the organization of the clinical staff. All clinical staff members should hold current licenses in the state, and physicians should have hospital obstetrical privileges.
- Staff, Volunteers, and Personnel Providing Patient and Other Services—The governing body must ensure that there are adequate numbers of qualified and, where required, licensed personnel to provide services needed by mothers and families and to provide for safe maintenance of the center.
- Advisory Council—The governing body must establish an advisory council, a portion of the members of which represents the population served and which includes, in addition, representatives of the clinical disciplines practicing at the center. This council will advise the governing body on community and clinical matters.
- Design—The center may be an adaptation of a house and should include birthing rooms; toilet facilities for staff, mothers, and families; bath facilities; storage facilities; examination areas; laundry facilities; sterilizing area; areas for laboratory and emergency equipment; kitchen facilities; and reception and family areas. If office-based prenatal or other health care is provided at the facility, consultation and examining rooms should be separate from the birth center itself. Hand washing facilities should be immediately available to all examining and birth rooms. The center should meet codes for ordinary construction and for water supply and sewage disposal. It should be maintained in a safe, clean, and orderly manner. Residential, professional, or commercial zoning regulations, rather than hospital regulations, should apply to the birth center.
- Fire and Safety—Local fire and safety codes for ordinary construction should apply with specific attention to demonstration of adequate ingress and egress of occupants, placement of smoke alarms, fire extinguishers or sprinkler systems, and fire escape routes. Fire reporting systems and evacuation programs with appropriate drills should be outlined in the policies and procedures manual.
- Equipment—The facility should be equipped with those items needed to provide low-risk maternity care and the equipment and readiness to initiate emergency procedures in life threatening events to mother and baby including but not limited to: cardiopulmonary resuscitation (CPR) equipment, oxygen, positive pressure mask, suction, intravenous (IV) equipment, equipment for maintaining infant temperature and ventilation, blood expanders, and medications identified in protocols drafted by professional staff and consultants to meet emergency needs of mother and baby in the center and during transport to an acute care setting. Equipment for performing standard screening, laboratory tests, and for sterilizing instruments and other materials should be provided in the facility. A program for regular inspection and staff competence with resuscitation and other equipment should be outlined in the policies and procedures manual to be available on site at all times.27
- Selection of Clients—The policy and procedures manual of the center should specify criteria by which risk status will be established. These should be applied for each woman at admission and during labor.8,22-26 The medical and social risk factors which exclude women from the low-risk intrapartum group should be clearly delineated and annually reviewed. Only those mothers for whom prenatal and intrapartum history, physical examination, and laboratory screening procedures have demonstrated a normal, uncomplicated course of pregnancy and labor should be accepted into the center for childbirth.
- Orientation and Education—Women and families registering for care at the birth center should be fully informed and provide written consent on the benefits and risks of the service available to them at the center. They should be fully aware and supportive of the risk criteria as defined above. The birth center should include a program of education which prepares women and their families for self-care and self-help, for psychoprophylaxis of pain, and which outlines the importance of good nutrition and prenatal care in pregnancy outcome. In addition, the adverse effects of smoking, alcohol, drugs, and poor nutrition should be explained. Plans for medical evaluation, feeding, and care of the newborn should be made.
- Prenatal Care—The center and its clinicians should ensure that patients have adequate prenatal care by generally accepted definitions.28 Records of this care should be available in the center at the time of admission. When, in the course of prenatal care, risk factors are identified which preclude childbirth at the center, the woman should be referred for care in a hospital setting and her prenatal records made available to the attending clinicians.21
- Surgical Services—The birth center is not an ambulatory surgical center. Surgical procedures should be limited to those normally accomplished during uncomplicated childbirth, such as episiotomy and repair, and should not include operative obstetrics or cesarean section. Other surgical procedures such as tubal ligation and abortion should not be performed in birth centers unless they are specifically licensed for such.
- Laboratory Services—The birth center should have the capacity to perform on site routinely necessary tests such as hematocrit and urinalysis for glucose, protein, bacteria, and specific gravity.
- Intrapartum Care—That labor should not be inhibited, stimulated, or augmented with chemical agents during the first or second stage of labor.
- Analgesia and Anesthesia—General and conduction anesthesia should not be administered at birth centers. Local anesthesia for pudendal block and episiotomy repair may be performed if procedures are outlined by the clinical staff. Systemic analgesia may be administered, but pain control should depend primarily on close emotional support and adequate preparation for the birth experience.
- Postpartum Care—Mothers and infants should be discharged within 24 hours after birth in accordance with standards set by the clinical staff and specified in the policy and procedures manual, including laboratory tests required by state laws. A program for prompt follow-up care and postpartum evaluation after discharge should be ensured and outlined in the manual of policies and procedures. This program should include assessment of infant health including physical examination, laboratory screening tests at the appropriate times, maternal postpartum status, instruction in child care including immunization, referral to sources of pediatric care, provision of family planning services, and assessment of mother-child relationship including breastfeeding.29,30
- Food Services—It is recommended that the center have the capacity to provide mothers and families with nutritious liquids and snacks as required. Food may be prepared by the family, catered, or prepared in the center's kitchen. Meals that are prepared and served by the center will be subject to local regulations for food preparation and service.
- Other Services—It is recommended that services not provided by the birth center be made available to clients by referral to other community service agencies and that a list of these agencies be maintained at the center.
E. Policies and Procedures
- Organization—The birth center should develop and display a table of organizations showing the structure, and identifying the governing body, the advisory council, the center director, the medical director, the clinical staff, and the medical consultants.
- Consultation—The center must maintain and document a consultation agreement with board-certified obstetricians or physicians who have completed obstetrical training within the prior three years and pediatricians who have hospital privileges in their specialties at an appropriate referral (level 2 or 3) hospital. This consultation may be by telephone as required by the clinical and geographic situation. The policy manual should outline consultation, transfer, and hospital admission procedures.
- Transportation—Arrangements with an ambulance or other appropriate transport must be documented in the policies and procedures manual, and periodic assessments of the transport system should be made and documented.
- Transfer of Patients—The policy and procedures manual should list criteria for transfer of patients to a hospital. Transfer should be to acute care institutions capable of providing obstetrical and neonatal services, usually meaning level 2 or 3 perinatal centers, and which agree to accept emergency patients without regard to their ability to pay.
- Health and Medical Records—These should be developed according to procedures outlined in the policy and procedures manual as a legal record and an instrument for continuity of care, and as a visual aid in teaching about and providing pregnancy care. Appropriate preservation and storage procedures should be documented. The records should be immediately available in the center at the time of admission and when transfer of care is necessary.
- Program Evaluation—The policy and procedures manual should outline a process for gathering statistics from medical records to provide an analysis of maternal and perinatal morbidity and mortality by maternal risk status and attending clinician for all patients whether completing birth in the center or at a referral hospital.
- Quality Assurance—The policy and procedures manual should document a program for medical record audit to evaluate periodically the care process and outcome. The results of program evaluation and quality assurance should be regularly examined by the governing body and be available for inspection in the center.
- Policies and Procedures Manual—The governing body is responsible for developing and making available to staff, clinicians, and licensing authorities a manual which documents the above mentioned policies, procedures, and protocols.
- Professional Accreditation—The center should apply for and obtain approvals of other professional accrediting groups in addition to acquiring a license.
V. Methods for Implementation
- Distribute guidelines to Directors of Maternal and Child Health at state and local health departments.
- Make guidelines available to providers who are considering establishing a birth center.
- Distribute guidelines to concerned professional organizations.
- Dingley EF: Birthplace and attendants: Oregon's alternative experience, 1977. Women and Health 1980; 4:239-251.
- Shy KK, Frost F, Ullom J: Out-of-hospital delivery in Washington State. Am J Obstet Gynecol 1980; 137(5):547-552.
- Bennetts AB, Lubic RW: Alternative health services: the free standing birth centre. Lancet 1982; 1:378-380.
- Ernst EKM, Forde MP: Maternity care: an attempt at an alternative. Nurs Clin North Am 1975; 10:241-249.
- Faison JB, Pisani BJ, Douglas RG, Cranch GS, Lubic RW: The childbearing center: an alternative birth setting. Obstet Gynecol 1979; 54:527-532.
- Lubic RW, Ernst EKM: The childbearing center: an alternative to conventional care. Nurs Outlook 1978; 26:754-760.
- Browne H, Isaacs G: Frontier nursing service. Am J Obstet Gynecol 1976; 124:14-17.
- Lubic RW: Evaluation of an out-of-hospital maternity center for low risk patients. In: Aiken L (ed): Health Policy and Nursing Practice. New York: McGraw-Hill, 1980.
- Paxton NF, Franklin JB: The first 1,000 deliveries at the Booth Maternity Center in Philadelphia. Trans Amer Assoc Obstet Gynecol 1974; 85:152.
- Burnette CA, Jones JA, Rooks J, Chen LH, Tyler CW. Miller A: Home delivery and neonatal mortality in North Carolina. JAMA 1980; 244(24):2741-2745.
- Chalmers I, Lawson JG, Turnbull AC: Evaluation of different approaches to obstetrical care: Part I. Brit J Obstet Gynecol 1976; 83:930-933.
- Chalmers I, Lawson JG, Turnbull AC: Evaluation of different approaches of obstetrical care: Part II. Brit J Obstet Gynecol 1976; 83:930-933.
- Disbrow M (ed): Meeting Consumer Demands for Maternity Care: Conference for nurses and other professionals. Seattle, Washington: University of Washington, 1973.
- Slome C, Wetherbee H, Daly M, Christensen K, Meglen M, Thiede H: Effectiveness of certified nurse-midwives. Am J Obstet Gynecol 1976; 124:177-182.
- Lubic RW: Effect of cost on patterns of maternity care. Nurs Clin North Am 1975; 10:229-239.
- Lubic RW: Impact of technology on health care—the childbearing center: a case for technology's appropriate use. J Nurs Midwifery 1979; 14:6-10.
- American Public Health Association: Position Paper 7924: Alternatives in Maternity Care. APHA Public Policy Statements, 1948 to present, cumulative. Washington, DC: APHA, current volume.
- Cooperative Birth Center Network: Recommendations, rationale, and sample regulations for licensure of birth centers, October 1981. CBCN, Box 1, Route 1, Perkionmenville, PA 18074.
- Kansas State Department of Health and Environment: Maternity center, regulations for licensing, May 1981. Topeka, KS: Dept. of Health & Environment, 66620.
- Oregon State Health Division: Alternate birthing center: draft regulation, April 1981. OSHD, 1400 Southwest 5th Avenue, Portland, OR 97201.
- Washington State Board of Health and the Health Services Division: Laws, rules, and regulations governing childbirth centers, April 1980. WSBH/HSD, Olympia, WA 98504.
- Aubry RH, Pennington JC: Identification and evaluation of high risk pregnancy: the perinatal concept. In: Osofsky HJ (ed): High Risk Pregnancy with Emphasis on Maternal and Fetal Well-being. Clin Obstet Gynecol 1973; 16:3-27.
- Committee on Perinatal Health: Toward improving the outcome of pregnancy. White Plains, NY: National Foundation, March of Dimes, 1976.
- Hobel CJ, Hyvariner MA, Okada DM, Uh W: Perinatal and intrapartum high risk screening: I. prediction of the high risk neonate. Am J Obstet Gynecol 1973; 117:1-9.
- Hobel DJ, Youkeles L, Forsythe A: Prenatal and intrapartum high risk screening: II. risk factors reassessed. Am J Obstet Gynecol 1979; 135:1051, 1056.
- Sokol RJ, Rosen MG, Stofkor JR, Click L: Clinical application of high risk scoring on an obstetric service. Am J Obstet Gynecol 1977; 128:652-661.
- Abramson H (ed): Resuscitation of the Newborn Infant, 3rd Ed. St. Louis: C.V. Mosby, 1973.
- American College of Obstetricians and Gynecologists: Standards for obstetrical and gynecological services. Chicago: Am College of Ob/Gyn, 1974.
- American Academy of Pediatrics Committee on Fetus and Newborn: Standards and recommendations for hospital care of newborn infants, 5th Ed. Evanston, IL: American Academy of Pediatrics.
- Yanover MJ, Jones D, Miller MD: Perinatal care of low-risk mothers and infants: early discharge with home care. N Engl J Med 1976; 294:702-705.
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