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Please remember to call Senator Feinstein 202-224-3841 and Boxer202-224-3553 asking them to introduce a senate version of HR2358, Medicaid reimbursement act. Please tell them "HR2358 is needed so women have access to prenatal and other care in birth centers. High quality health care is the goal of this legislation. Birth centers will not be able to exist without Medicaid reimbursement." Thank you for your support!

Link to trailer. Coming out next month
http://www.reducing infantmortality. com/

http://www.latimes.com/business/la-fi-cover-birth17-2009may17,0,7665456.story

HEALTHCARE: ROADS TO REFORM
Childbirth: Can the U.S. improve?
Christine Cotter / Los Angeles Times

Ruby Wales holds her newborn, Carson. Her first doctor worried more about the risks of vaginal delivery than of cesarean, so she found a different one.

C-sections are expensive. Doctors ask if we are doing too many.
By Lisa Girion
May 17, 2009

After an emergency cesarean with her first baby, Ruby Wales was holding out for a vaginal birth with her second one.

With a toddler underfoot, the 33-year-old Mission Viejo woman wanted a faster recovery. But finding a physician to deliver her second child wasn't easy. Her first obstetrician turned her down flat. "She said, 'No -- no way,' " Wales recalled.

Once reserved for cases in which the life of the baby or mother was in danger, the cesarean is now routine. The most common operation in the U.S., it is performed in 31% of births, up from 4.5% in 1965.

With that surge has come an explosion in medical bills, an increase in complications -- and a reconsideration of the cesarean as a sometimes unnecessary risk.

It is a big reason childbirth often is held up in healthcare reform debates as an example of how the intensive and expensive U.S. brand of medicine has failed to deliver better results and may, in fact, be doing more harm than good.

"We're going in the wrong direction," said Dr. Roger A. Rosenblatt, a University of Washington professor of family medicine who has written about what he calls the "perinatal paradox," in which more intervention, such as cesareans, is linked with declining outcomes, such as neonatal intensive care admissions. Maternity care, he said, "is a microcosm of the entire medical enterprise."

As the No. 1 cause of hospital admissions, childbirth is a huge part of the nation's $2.4-trillion annual healthcare expenditure, accounting in hospital charges alone for more than $79 billion.

Because spending on the average uncomplicated cesarean for all patients runs about $4,500, nearly twice as much as a comparable vaginal birth, cesareans account for a disproportionate amount (45%) of delivery costs. (Among privately insured patients, uncomplicated cesareans run about $13,000.)

Pregnancy is the most expensive condition for both private insurers and Medicaid, according to a 2008 report by the Childbirth Connection, a New York think tank.

"The financial toll of maternity care on private [insurers]/employers and Medicaid/taxpayers is especially large," the report said. "Maternity care thus plays a considerable role in escalating healthcare costs, which increasingly threaten the financial stability of families, employers, and federal and state budgets."

The cesarean rate in the U.S. is higher than in most other developed nations. And in spite of a standing government goal of reducing such deliveries, the U.S. has set a new record every year for more than a decade.

The problem, experts say, is that the cesarean -- delivery via uterine incision -- exposes a woman to the risk of infection, blood clots and other serious problems. Cesareans also have been shown to increase premature births and the need for intensive care for newborns. Even without such complications, cesareans result in longer hospital stays.

Inducing childbirth -- bringing on or hastening labor with the drug oxytocin -- also is on the rise and is another source of growing concern. Experts say miscalculations often result in the delivery of infants who are too young to breathe on their own. Induction, studies show, also raises the risk of complications that lead to cesareans.

Despite all this intervention -- and, many believe, because of it -- childbirth in the U.S. doesn't measure up. The U.S. lags behind other developed nations on key performance indicators including infant mortality and birth weight.

And in at least two areas, the U.S. has lost ground after decades of improvement: The maternal death rate began to rise in 2002, and the typical American newborn is delivered at 39 weeks, down from the full 40. Public health experts view the trends with alarm.

At a recent conference held by Childbirth Connection, physicians, employers, insurers and hospital operators wrestled with the disappointing data and discussed thorny questions, such as whether insurers should stop paying more for cesareans than for vaginal births.

"Cesarean birth ends up being a profit center in hospitals, so there's not a lot of incentive to reduce them," said Dr. Elliot Main, chief of obstetrics for Sutter Health, a Northern California hospital chain.

But there is a lot that hospitals can do to reduce them, as illustrated by the wide variation in cesarean rates. Among California hospitals, cesareans range from 16% to 62% of births.

Such variation means a lot of women are getting unnecessary cesareans, Main said. "There's no justification for that kind of variation."

The surge in cesareans may owe more to celebrity magazines than medical journals. After word got out that Victoria "Posh Spice" Beckham had three, physicians reported a surge in requests for such deliveries, dubbed the "too posh to push" bump.

Physicians, too, have been blamed for failing to make women fully aware of the consequences of cesareans, and for promoting them for convenience.

But change is underway. The Institute for Healthcare Improvement's Strategic Partners program trains hospitals to implement a set of guidelines, such as the careful use of oxytocin, and a ban on elective deliveries before 39 weeks. In four years, 60 hospitals have signed on.

"It's a culture change," program director Frank Federico said. "We're at a tipping point. . . . It used to be that we spent more time defending the 39-week rule. Lately, there's no question about that. It's, 'How can we improve the process to support that?' "

WellPoint Inc. and UnitedHealthcare Services Inc., the nation's largest health insurers, also are trying to curb cesareans.

In an analysis of its claims, United found that 48% of newborns admitted to neonatal intensive care units were from scheduled deliveries, many of them before 39 weeks.

United targeted a group of Texas obstetricians with particularly high rates of deliveries before 39 weeks.

An analysis showed that the babies these doctors delivered were admitted to neonatal ICUs twice as often as the national average.

After being notified of the correlation, the physicians changed their practices and reduced neonatal ICU admissions by 46% in three months.

The rise in avoidable first-birth cesareans has had a multiplier effect. Most U.S. physicians discourage vaginal deliveries after a cesarean because of some widely publicized cases several years ago in which the uterus split disastrously along the prior incision.

That's why Ruby Wales' first obstetrician refused.

"She said it was because there is a 1% chance of a uterine rupture," Wales said. "And I thought that was weird because there's more chance of things going wrong with a cesarean section."

But some obstetricians believe that new evidence supports allowing some women the option of trying for a vaginal birth.

"If the old incision was a vertical, then a trial of labor is not a good idea," said Dr. David Lagrew, medical director for the Women's Hospital at Saddleback Memorial Medical Center in Laguna Hills. "But what happens now in the United States is the low transverse, an incision in the bottom part of the uterus, from side to side. Those heal better. All the studies say, in those types of incisions, the risk is less than 1%, probably a half percent, that it will open during labor."

Saddleback delivers about 3,000 babies a year. In March, it joined a few hospitals nationwide that are pioneering the "hospitalist" approach to maternity care, which adds a measure of safety to attempted vaginal births after cesareans. A hospitalist is a doctor who cares only for hospitalized patients.

Hospitalist obstetricians staff the maternity ward 24 hours a day, seven days a week. They are there to deliver babies when an attending obstetrician gets stuck in traffic, to monitor lengthy labors and to assist in emergencies.

Saddleback supported Wales' desire for a vaginal birth. Nine days after her due date and after 30 hours of labor, she gave birth -- the way she wanted -- to an 8-pound, 11-ounce boy.

"I was so glad nothing happened at the last minute to have an emergency C-section because I'd gone through all this work," said Wales, resting in her hospital bed with baby Carson in her arms. "I'm so relieved that I don't have to deal with a [cesarean] recovery because I have a 2 1/2-year-old at home who is very active."

TO SIGN THE LETTER CLICK HERE!!!

Dear Friends,
You can help support birth centers one of maternity care choices that should be widely available to all women simply by signing an on-line letter.
The American Association of Birth Centers (AABC) is asking for your help.
Rep. Susan Davis (D., CA) will soon introduce a bill to include birth centers as eligible providers for Medicaid payment. To clarify, when a Medicaid-covered birth takes place in a hospital, the doctor gets paid, and the hospital is paid too -- a facility fee. A judge recently ruled that Medicaid may not pay the 43 birth centers in Texas, because birth centers are not specifically listed in the federal statute for Medicaid. This ruling would apply nationally. But hospitals can still get paid if women who are Medicaid recipients give birth in hospitals. When birth centers are not reimbursed for a facility fee, they cannot survive economically, and Medicaid-eligible women are denied this excellent (and cost-saving) choice.

If you think this is wrong and bad public policy, please sign the AABC letter. The letter supports enactment of legislation, ie Rep. Davis’ bill, that would correct this inequity.

Please pass this on to everyone you know and all birth-related or women's health elists that you belong to so others can sign too. PLEASE both sign and pass it on. AABC's goal is 1,000 signatures in the next week.
TO SIGN THE LETTER CLICK HERE!!!

Sincerely,
Susan Hodges, “gatekeeper”

Congresswoman Susan Davis will be visiting Best Start Birth Center on December 15, Monday at 11:30 AM. This momentous visit is in support of high-quality, affordable, women’s healthcare and normal birth through midwifery care and free-standing birth centers.

Representative Davis, a strong supporter of women’s health, is exploring the impact on health care reform of Midwifery care and free-standing birth centers which are included in many healthcare plans including Medi-Cal.

Best Start Birth Center is the only facility in San Diego which offers waterbirth, an alternative delivery method proven to reduce the mother’s discomforts and shorten labor. The midwives of Best Start Birth Center have been providing high-quality prenatal care and births to the women of San Diego County for over 25 years. Best Start Birth Center also offers Nutritional Counseling Services, Psychosocial Counseling Services, and Childbirth Education.

Best Start Birth Center is state licensed and is the only nationally accredited birth center in Southern California. Roberta Frank, CNM, the center’s Founder and Clinical Director, is nationally acclaimed and is the 2008 American Association of Birth Centers' Professional Awardee.

Sigma Theta Tau International, Gamma Gamma Chapter is awarding the grant to Best Start Birth Center, enabling the purchase of a second much-needed Neopuff Infant Resuscitator. We greatly appreciate their generousity.

SPECIAL BENEFIT SCREENING OF “THE BUSINESS OF BEING BORN”
Directed by Abby Epstein, Executive Produced by Ricki Lake

ON: Sunday, February 10th
LOCATION & TIME: Best Start Birth Center, (10am, 12pm, 2pm, 4pm, 6pm, & 8pm)
TICKETS: $5 in advance, $10 at the door, ($5 for pregnant women at the door)

Best Start Birth Center is pleased to announce a special sneak preview of:

"THE BUSINESS OF BEING BORN"
A DOCUMENTARY FILM DIRECTED BY ABBY EPSTEIN AND EXECUTIVE PRODUCED BY RICKI LAKE

In 2001, actress Ricki Lake gave birth to her second child with the assistance of a midwife in her home bathtub. She made the choice for a home birth after she experienced unwanted medical interventions while delivering her first child at a hospital birthing center. Ricki succeeded in giving birth on her own terms and the experience was so unexpectedly empowering and life-changing that she felt every woman should know what they could be missing out on.

Ricki approached filmmaker Abby Epstein to collaborate on a film that would examine birth culture in America, and ask questions about the way American women have babies.

Footage of women having babies punctuates THE BUSINESS OF BEING BORN. Each experience is unique; all are equally beautiful and equally surprising. Giving birth is clearly the most physically challenging event these women have ever gone through, but it is also the most emotionally rewarding.

Along the way, Epstein conducts interviews with a number of obstetricians, experts and advocates about the history, culture and economics of childbirth. The film’s fundamental question: should most births be viewed as a natural life process, or should every delivery be treated as a potential medical emergency?

As Epstein uncovers some surprising answers, her own pregnancy adds a very personal dimension to THE BUSINESS OF BEING BORN, a must-see movie for anyone even thinking about having a baby!

This film premiered at New York’s Tribeca Film Festival and is due to be released in select theaters in January 2008. It will then be available on Netflix in February 2008. The filmmakers are allowing these local screenings to help raise awareness on the topic and support birth organizations on a local level. All proceeds from this advance screening will go to benefit Best Start Birth Center.

For more information go to www.thebusinessofbeingborn.com or www.Beststartbirthcenter.com
For advance registration, call France Wilson: 619-964-1971

Prize package includes:

~Network Spinal Analysis Consultation, Exam, Report of findings, & 2 Adjustments
~Hypno- Birthing Classes
~Positive Change Counseling session
~Customized facial
~Chiropractic Analysis package, (consultation, exam, & X-rays)
~Cranial Sacral Session
~Acupuncture and Herbal Medicine treatment
~$25 credit towards services at Premium Birth Services
~ 3 “Mommy and Me” Yoga classes

Prize package includes:

~Network Spinal Analysis Consultation, Exam, Report of findings, & 2 Adjustments
~Hypno- Birthing Classes
~Positive Change Counseling session
~Customized facial
~Chiropractic Analysis package, (consultation, exam, & X-rays)
~Cranial Sacral Session
~Acupuncture and Herbal Medicine treatment
~$25 credit towards services at Premium Birth Services
~ 3 “Mommy and Me” Yoga classes

So, with so much going on these days, we thought a quarterly newsletter was in order...We were considering waiting for January 2008 to begin but with the recent fires burning through our beautiful city, we think now seems as good a time as any for some uplifting news…First on the agenda, the long awaited upstairs birth suite is complete! Come by to view! We are happy to give you a tour!

~We’d like to welcome the newest addition to our Best Start family. On August 26,2007 @12:26PM , one of our own midwives, Sarah Khorram and her husband, Saul Alarcon Farfan gave birth to a healthy baby girl, named Zyanya Alarcon Khorram, She weighed 7lbs/4oz and was 19 inches long. We are thrilled for them! We hope to have Sarah back with us part time in January of ’08. She is currently on maternity leave, enjoying time with her baby. In Sarah’s absence, Brooke Ray is taking her place as our part-time Certified Nurse Midwife. She has clinic each Friday. Hopefully you will get a chance to visit with Brooke, as she may be “on-call” when you deliver!

~Kel Shields, CNM took a week off to further her education in pharmacology…This means she is on her way to becoming certified to write prescriptions. Great job Kel!

~Roberta Frank, Medical Director and CNM; Bonnie Everett, Insurance Billing Specialist; and Karen Roslie, Exec. Administrator, were recently away to Anchorage, Alaska for the annual AABC convention. We happened to be gone on Roberta’s 39th wedding anniversary. Since we each brought our husbands, we found it most appropriate to visit Homer Alaska, where coincidentally Roberta and her husband Bill, were married and lived 39 years ago!

While there, wouldn’t you guess it….We ran into a woman who had her first child at Best Start 13 years ago…and yes, Roberta was her midwife!

Needless to say, this was a very magical trip. AABC conventions are always a great way to meet up with other Nationally Accredited birth centers to share information and knowledge… But this trip was especially memorable.

~More good news...Many of you remember Ruth Goldberg who has previously worked at Best Start many years as an RN and Birth Assistant. Ruth is now back with us as a Student Nurse Midwife, interning to complete her preceptorship to become a Certified Nurse Midwife. Once she has graduated, Ruth plans to come back to work at Best Start as one of our midwives. We know you will find her as much a joy to work with as we do!

~ Also interning with us are Tuesday Benivediz, (SNM) and Tamara Herald, (SNM). Both these interning students will complete their internship in early November of 07’.

~We also want to welcome Michelle Reynolds to Best Start. She is an RN with experience working in birth centers not only nationally but internationally as well…Michelle will be working part-time at Best Start as a birth assistant. Welcome Michelle!

~Best Start is partnering with Project Concern International and several other health care institutions in San Diego, on a grant program called "Healthy Start". This program focuses on under-served high risk women and babies. It has been proven very successful in other states in providing much needed prenatal and postnatal care. Trained "Promotora's" (pregnancy counserlors) and doulas, (birth coaches) will be utilized to guide moms-to-be through pregnancy and up to age two for the children born in the program. The goal is to create a model in San Diego which links all the current resources so women have easier access to quality care.

We are honored and excited to be part of this endeavor! If you or anyone you know would be interested in becoming a volunteer doula for this program, we would love to hear from you…
No Experience Needed!
Please contact Karen Roslie:
kroslie (at) beststartbirthcenter.com

~In closing, we would like to thank those who help support Best Start in our efforts…
Amongst those are the physicians and hospitals that provide back up for the birth center. This network of support allows Best Start Birth Center to provide natural child birth services to our clientele: Larry Flickinger, MD and Karl Evelyn, MD provide care for our clients at Scripps Mercy Hospital; Resident Physicians under the Supervision of Thomas Moore, MD at UCSD Medical Center; Our long time consultant, Gary Blake MD who accepts our transfers at Sharp Mary Birch Women's Hospital. Together, these physicians and hospitals have provided "back up" for over 20 years. In the unlikely event of a hospital transfer, you can rest assured the care you receive will be in your and your baby’s best interest.

Best Start Birth Center would like to express its heartfelt thanks all our “Support Services” for their continuing support and contributions to Best Start Birth Center and its patients. We recently had a successful fundraiser event, in which Jonathan Olow, RE agent, generously provided Best Start the use of his incredible home in Mission Hills, (photos can be viewed on our website). This and the donations of time and services from all of our collaborating supporters made this the success it was. Please view our “Thank you” page for more information on these individuals/ organizations.

Finally, We'd also like to thank Bobbie Oudinarath, Vice President of Washington Mutual Bank, for sponsoring us an ad campaign which ran the month of October, 2007. It encompassed more than 50 radio commercials, and 2 half page color print ads in the SD Union Tribune, (10/9/07), as well as the SD Business Journal, (10/8/07.)

Hopefully you got to hear and see them…Thank you, Bobbie for being such an incredible support for Best Start. We are truly grateful!

Best Start to be featured in advertising campaign sponsored by Washington Mutual Bank

Washington Mutual is sponsoring Best Start Birth Center in an ad campaign and will be featured the week of October 8th, 2007, and the campaign has been extended all will also be running from October 29th to November 2nd:

Radio Ads: 35 radio spots total on these stations:


Paper Ads: SD Union Tribune, 6colx7" Color on 10/9/07; SD Business Journal 1/2 Page, Color on 10/8/07

Keep your eyes and ears open for for our ads!

We'd like to give credit to Bobbie Oudinarath, Vice President of Washington Mutual, for getting us the ad campaign. She has been an incredible support for Best Start.

Best Start Birth Center is pleased to announce its 2,000th birth. Our lucky baby was born June 28th, 2003, and was delivered by Roberta Frank. Congratulations to our honored parents!

Recently at the Annual Meeting of the American College of Nurse-Midwives, Roberta Frank was honored for her pioneering work in the field of nurse-midwifery. She was introduced at the opening meeting in Palm Desert, California May 31, 2003, and recognized for her contributions to the establishment of nurse-midwifery in California. Because of her early efforts, nurse-midwifery was born and has grown strong. Roberta was thanked for her dedication to women and newborns. Roberta graduated from the UCSD School of Medicine in 1978, and began practice in San Diego County in 1979. She then opened Best Start Birth Center. Best Start was the first birth center in the county. Best Start then became the first birth center to be licensed by the state. Best Start was later used as a model for licensing future birth centers as they opened in the State of California. 18+ years later, Best Start remains the model for new centers as it is the oldest, largest, and only continuously operating birth center in the state.

THE SAN DIEGO UNION-TRIBUNE • SATURDAY OCTOBER 23, 1999
By Devorah Knaff
Photography by Laura Embry


Hair apparent: Six-week-old Joselin Rodriguez gets a checkup.


It's a boy: Derek Finley and his wife, Tammy, hold their son, Collin, moments after his birth, as nurse midwife Roberta Frank gives Tammy a drink of water at the Best Start Birth Center in Hillcrest. Using a midwife, Tammy Finley said later, helped her feel “more in control.

Roberta Frank's experience with her first child is typical of many women who eventually seek out midwives. "It wasn't that I didn't have a good doctor, because I did," said Frank "But the whole environment of giving birth in a hospital is not a very soothing one. "What I wanted in giving birth was really something that all women want. You want to feel that your emotional needs will be met. "Giving birth is exhausting and painful and it can be dangerous, but it's also a time of joy. When I went to my midwife (for her second child), I felt that I was being taken care of physically as well as emotionally." With more women seeking environments where birth is treated as a natural experience, as something that should be celebrated. San Diego's midwife community is flourishing. And the medical establishment is beginning to embrace a practice once associated with the counterculture.


Caring attitude: Roberta Frank checks Rocio Ramirez during a prenatal visit at the San Diego County Medical Center. In addition to helping during labor and delivery, midwives provide a range of health services.


"When I was practicing in the Midwest we had midwives in the hospital, and so it was definitely very different for me when I came to California," said William Simpson, one of the obstetricians who oversees labor and delivery services at UCSD. "I was used to working only with other doctors and nurses. "But as I've gotten used to working with midwives. I've come to see that they have a great deal to offer women ... that doctors and midwives can serve as complementary health-care providers. We each have something valuable to give to women who are pregnant or in labor."



Finishing up: Nurse Anne Allen, (left) and nurse midwife Roberta Frank help Tammy Finley to deliver the placenta while Derek Finley holds his just delivered son, Collin, at the Best Start Birth Center in Hillcrest.


Breaking Stereotypes:
Midwifery still accounts for a minority of births in the United States - but the percentage is rising steadily, according to Lauren Hunter, director of UCSD Nurse-Midwifery Clinical Services. In 1973, 1 percent of American babies were delivered by midwives. In 1989, 3.6 percent of births were performed by nurse-midwives, midwives who have a formal nursing degree and generally help give birth in a hospital or birth center.

In 1996, that figure rose to 6.5 percent, according to Hunter- and these newer figures do not include births performed by certified midwives, midwives who are trained by another midwife (before a 1993 state law took effect, they were called "lay midwives"). They are licensed by a national organization, the Midwives Affiance of North America, and required to have an association with a doctor. "I think that people may have had this stereotype of the kind of women who go to midwives as all being sort of late-blooming hippies," said Paula Tipton-Healy, a certified midwife in Encinitas who has worked in the field for over 20 years. "But in fact what you see - what I see in my own practice - is that a wide variety of women come to see midwives. A lot of them have had bad experiences with a previous birth and they are looking for a more personal, more caring, more supportive environment A lot of them are concerned that they have some measure of control that they can be equal partners.

"Many of them come from countries that have much stronger midwifery traditions than the United States has, and so it just seems natural for them to seek out a midwife. And some of them are relatively poor women, and the formal medical community has never been as receptive as many would like to the poor. About 10 certified midwives practice in San Diego County, and scores of nurse-midwives practice at the naval hospital, at Kaiser facilities, at clinics and at UCSD. This year, UCSD has begun to allow nurse-midwives not employed by the university to bring patients into its hospitals, a first for Southern California.

Midwifery is essentially the provision of assistance during pregnancy and especially during labor and delivery. This includes everything from giving back rubs and telling a woman how far she is dilated to providing emotional support and suggesting positions that may be more comfortable during labor. They also offer other services, from family-planning advice to gynecological checkups and nutritional counseling.

For American midwives and their clients, midwifery is also an attitude about pregnancy and labor. They approach pregnancy and birth as a natural process that does not usually require high levels of medical intervention or treatment, but rather support and education, according to women who have used midwives. "You could almost look at me as a test-case study, because I had one of my sons in the hospital with a doctor, one with a midwife in a birth center and one with a midwife in a hospital, and the experience was very different each time," said Lynne Anne Baker, whose children are now 7, 5 and 2 months. "And what I found was that midwives are more supportive. Doctors look at labor from an interventionist point of view. They're trained to see what might go wrong and take steps to remedy that."



Weighty Questions: Frank reweighs Cintia Reyes, who was surprised she had gained so much weight since her last visit.


Active Roles:
Roberta Frank - who, after having her second daughter, entered UCSD and graduated in its first class of nurse midwives 20 years ago - sees the difference between doctors and midwives as curing vs. caring.

“The doctor looks for trouble," said Frank. "That’s not meant as a criticism. That’s what doctors are trained to do. That's what allows doctors to save lives.” But it is also an attitude that is really the most useful when someone is sick, and of course pregnancy is not a disease."

Frank is now a nurse-midwife at the Best Start Birth Center in San Diego, where her clients and those of other midwives at the clinic are a cross-section of the kind of women who are likely in the 1990s to seek out midwives: well-educated women, poorer women, immigrants, women concerned with taking an active role in the births of their children.

"I'm not sure that we have a typical client," Frank said. "We have clients who are in their teens and in their 40s, those giving birth to their first child or their fifth, all different levels of education and income, all different races." One of her clients, Tammy Finley, points to the empowerment she felt when Frank helped her give birth to her two­ month-old son at the Best Start center. "One of the things that was most important to me in choosing to have a midwife was that I felt that I was much more in control," said Finley, who also has a 2-year-old son. "When I talk with doctors, they tell me what the procedure is going to be. What they're going to do to me. When I talk to midwives, they ask me what I want. I am the one who determines what is going to happen to me and to my baby, and that's very important"

Greater Options: Giving women greater health-care choices was one of the recommendations of a report issued earlier this year on midwifery by the Pew Health Professions Commission and the University of California San Francisco Center for the Health Professions. It urged insurance companies and health maintenance organizations to include a full range of midwifery services in their offerings describing midwifery as an "essential element of comprehensive health care for women and their families."


This old house: Frank in the renovated house that is the Best Start Birth Center. Photos of children born there decorate the walls.

Health-maintenance organizations have responded, and insurance companies are also more inclined to cover midwifery services than they were 20 or even 10 years ago, according to Bonnie Everett, the chief financial officer for the Best Start clinic. "I think that American women really aren't aware of the options open to them. I think that a lot of women think that they really don't have any other options other than to go to a doctor, but of course that's not true," said Andrea Melin, Tipton-Healy's partner at Birth, Babies & Beyond in Encinitas. "And I think that it’s also true that women may think that it’s more dangerous to have a midwife than a physician but that's not true either." The Pew notes that in 1994, 24 countries had lower infant-mortality rates than the United States and that in the last 15 years, maternal death rates in the United States have stayed the same despite the fact that half of those deaths are classified as avoidable (and even though 93 percent of births in the United States, according to the report, are attended by a physician).

Still, midwives in the United States have generally not had an easy time, being accepted by the medical community.

“There are a lot of reasons-that doctors have not worked hand-in-hand with midwives," said Robin DiMatteo, a psychologist at UC Riverside who studies medical institutions and patient-doctor relationships. "In part, its because they risk their malpractice insurance if they do. But it's also clear­ly in large part because the two groups represent very different cul­tures - on the one side a male-dominated, scientific-based group; on the other, a lay-trained, humanistic, female group. It's not surprising that the two groups would have an uneasy relationship. But what you see now is some coming together of the two groups in the recognition that they both have something to offer women, which is good for everyone. It offers women more health choices and it allows these two groups of professionals to work together and learn from each other."

Devorah Knaff is a Riverside-based writer.