When Tricia Branson moved to Cincinnati from Michigan, she had two children, both of whom had been delivered with the help of midwives. She was surprised by how difficult it was to locate a midwife in her new town. She didn't know that Ohio certified nurse-midwives (CNMs) attend only 6 percent of births (compared to a national average of more than 9 percent) or that Ohio was the last state in the nation to allow CNMs, and all other advanced nurse practitioners, to write prescriptions.
Branson's search eventually led her to CNM Jackie Gruer, who opened the state's first and only nationally accredited birth center in Cincinnati in 1997. On a pear-tree-lined street just minutes from the city's major hospitals, the Midwives Care, Inc., birth center is still a largely unknown resource for women's health and wellness, maternity care, and childbirth. Branson selected it for the births of her fifth and sixth children, Samuel and Olivia, and she couldn't be happier about her choice.
"We're lucky to have Jackie here," says Branson. "The staff of the birth center is so wonderful. They all worked in harmony, like a well-oiled machine. I've never been so spoiled in my life. I would travel anywhere to have that experience."
Jackie Gruer is a native of St. Louis and trained to be a midwife in Kentucky, the home of Mary Breckenridge's Frontier Nursing Service, which brought nurse education and professional midwifery to the Appalachian Mountains. An activist by nature, Gruer admired Breckenridge but did not see herself as a modern-day counterpart to the midwife pioneer. Yet that is just what she has turned out to be.
For years after she moved to Cincinnati in 1983, Gruer shuttled between doctors' offices, hospitals, and homebirths, partnering with receptive ob-gyns who would give insured patients access to her care. When her principal doctor lost liability coverage for homebirths in 1986, Gruer and several other midwives formed their own business so they could continue to assist women who wanted to birth at home.
Even though Gruer's practice had been financially independent, in many ways it did not appear that way because of her close collaboration with doctors. "I always felt the physical presence of our business in a doctor's office gave people the idea that we were employees of the physicians," she says. Gruer knew she needed her own space, and she figured that establishing a freestanding birth center might eventually make reimbursement for out-of-hospital births more palatable to insurance companies.
"I've never really liked offices," Gruer says with a smile as she sits in the front room of the circa-1897 Victorian house that is now the birth center and home of Midwives Care. "And I love old houses." However, although Gruer was no stranger to home renovation, she knew that it would take a lot more than new oak floors, drywall, and fresh paint to create a successful birth center.
Keeping a Watchful Eye
"A birth center is a very politically charged operation," says Kate Bauer, executive director of the National Association of Childbearing Centers (NACC), which accredited Gruer's facility in 1997. "You have to be involved in the politics of your state."
"Ohio is not a trailblazer," adds Gruer, who is still continuing a years-long effort to have births in her center reimbursed by Medicaid. In support of her case, she has gathered evidence from 40 other birth centers, representing 20 states, that receive Medicaid funds for their services.
"CNMs in all states encounter difficulty in getting jobs, hospital privileges, prescriptive privileges, and reimbursement," says CNM Joyce Roberts, president of the board of the American College of Nurse Midwives (ACNM). Roberts, who teaches at Ohio State University and the University of Illinois, sees Ohio's laws as representative of outdated legislation that does not provide for widespread use of nurse-midwifery care. "The Northwest, Northeast, and Southwest seem more progressive," she adds. "States in those regions have more CNMs because their laws are less restrictive regarding nurse-midwifery practice, especially about reimbursement and prescriptive privileges."
Gruer knows a lot about Ohio's healthcare policies and laws and the limitations they put on her career. She began attending legislative hearings in Columbus, the state capital, in the early 1990s, when she feared that changes in maternity licensure laws might be aimed at making homebirths illegal. However, what she found in Columbus was a refreshing surprise. CNMs and nurses on staff at the Ohio Department of Health were working with birth centers in mind, in part because two centers in Amish communities were already in operation in the state. One promising aspect of the new policy clarified that "direct supervision" of midwives by physicians meant phone, not physical, contact.
In 1996 the Ohio legislature approved a bill establishing standards for freestanding surgical centers, a category that included birth centers. Gruer, who volunteered to help write the rules and regulations for Ohio birth centers, saw all the pieces she needed to open her own facility coming together.
Finding the Right Home
Gruer's vision of a viable birth center crystallized when she took a house tour in her northside Cincinnati neighborhood. A stately Victorian home that had once been used as a doctor's office caught her eye. She knew the house well--she lives just a few blocks away, and her dentist works out of the house next door. "I came through here and immediately knew how I would lay it out," she says.
Gruer bought the building in 1996 and worked with architect Neena Judd to determine the massive changes that would turn the house into a licensed and accredited birth center. Some of the additions are invisible, such as the minilab in a former coat closet and the metal conduit tubing placed over electrical wires to meet code requirements. Others, like a separate air-conditioning unit in the attic for the upstairs birthing rooms and two 80-gallon hot water heaters to service the rooms' soaker tubs, have a more immediate impact on laboring mothers.
"Every weekend for a year I was over here painting, cutting shrubs, thinking," Gruer remembers. She enlisted an army of enthusiastic rehabbers--other midwives, trainees, doulas, birth assistants, mothers, fathers, and children. Pictures of their efforts fill a before-and-after scrapbook, which Gruer points to with pride. "I met so many wonderful people doing this. They really gave me boosts when I needed them."
The first floor of the center, with exam rooms, a kitchen, and a solarium, opened for business in 1996. A year later the two upstairs birthing rooms were operational and the center was licensed by the state and accredited by NACC. Since then, 60 babies have been born at the center in Adelaide and Al, the birthing rooms named for Gruer's paternal grandparents. The bright, airy center is filled with pieces of Gruer's past, from the chair in which her grandfather rocked her to sleep to his oil paintings above the birthing rooms' fireplaces. Decorating other walls are quilts handmade by Amish patients who used them as barter for prenatal care.
Paving the Way for Success
Despite the relative speed with which Gruer had the center up and running, like all savvy small business owners, she was realistic about her prospects for success. "I knew that it was going to be a struggle," she says.
To help her cause, she traded in her swinging gray cornrows for a more conservative bob and wore pumps instead of Birkenstocks for meetings with physicians, lawmakers, and insurance providers. "You put on the costume that's appropriate," Gruer says, though her deep, throaty laugh belies her practicality.
"We're in an area with a ninety to ninety-five percent epidural rate," she continues, "but I don't know that that's a barrier so much as it is a sign that people need to be educated. I think our main challenge is direct insurance reimbursement and being available to people who have insurance, and that includes Medicaid. You have to be able to provide your services to people before they can even consider you."
Alyson Reed, a former policy analyst specializing in state law for ACNM, agrees. "We have been struggling to access the managed-care system and become full-fledged partners in the delivery of care," Reed explains. She points to research showing that midwives are safe and highly effective and that their care can cost more than 20 percent less than ob-gyn care.
"As midwifery practice by CNMs has become more accepted and desirable, it has also become more competitive," agrees ACNM's Roberts. "In the managed-care area, where doctors are threatened at the most basic level of their practice--their revenue and their autonomy--there is somewhat more resistance to midwifery practice."
"The bottom line is that there are a lot of people with an economic interest in keeping nurse-midwives out of the market," says Reed. "It becomes very cutthroat."
Even with a growing number of births attended by nurse-midwives every year and with more midwives in training, the future of birth centers has as much to do with business as it does with quality care. "I would say I'm cautiously optimistic," says Reed. "We have to continue to struggle. Hopefully, our slice of the pie will get a little bit bigger."
"I think that birth centers are resilient," says Bauer of NACC, which has accredited 45 birth centers nationwide. "We have already in our short life span faced a lot of obstacles, and we're still here."
Welcoming Babies and Progress
For Gruer and the two other full-time CNMs at Midwives Care, Leah Terhune and Karen McGirr, maintaining the birthing rights of local women is a labor of love. They have clients from Ohio, Kentucky, and Indiana--women like Tricia Branson and others who will travel great distances to meet with midwives who can offer safe, comfortable alternatives to hospital births.
When the cost of liability insurance for homebirths became prohibitive, Gruer and her partners persevered, and today they are among the very few CNMs in Ohio who attend homebirths. Gruer maintains that being able to attend homebirths has always been an integral part of Midwives Care. "All our births work together to support our practice," she affirms. With more than 700 active clients on file, Gruer, Terhune, and McGirr attended more than 200 births in 2000; 20 of these took place at the birth center, 20 in homes, and the rest in hospitals.
For its families, the birth center symbolizes a very important freedom of choice. "We want to make it as a birth center," Gruer says emphatically. "You just cannot sit back and wait for the people to come to you. You have to facilitate a successful venture. I don't think of midwives as passive people anyway. The midwives and the people that we're working with are making the changes."
Hopes for greater clout with legislators are brightening, too, thanks to successful lobbying on a national level and letter-writing campaigns by midwifery proponents. US Representative Steve Chabot (R-Ohio) visited Midwives Care in 1999 after meeting with Gruer in Washington, DC. She hopes he will support midwifery-friendly legislation.
But even though the Ohio Department of Health and Human Services anticipated that Medicaid would reimburse the birth center by the beginning of 2000, Gruer and her staff are still waiting.
Like the legendary pioneer Mary Breckenridge, Gruer continues to work to extend the reach of midwifery, though she promotes her services in the middle of an urban neighborhood instead of climbing mountains to reach laboring mothers. "You can't control other people's minds, but you can help to open them," she says. "And the fact that we even exist can show a woman that pregnancy and birth are normal, healthy events."
For additional information about birthing centers, you can see the following article in a past issue of Mothering: "We've Come a Long Way, Babies," no. 9