Nevada looks to birth centers, midwives as alternatives to hospitals

The first baby born at Serenity Birth Center was named Hope.

It seemed an apt name.

Not just for the 7 lbs, 13 ounce newborn girl. But for Serenity, which became Nevada’s only freestanding birth center when it opened its doors last month.

Freestanding birth centers are facilities where midwives provide maternity care and birthing services in a family-focused, home-like environment. Advocates of birth centers describe them as a “maxi-home” (rather than a “mini-hospital”) — a place where someone who is not comfortable with the idea of a home birth can go to give birth.

In 2018, there were 384 freestanding birth centers in 37 states across the country, according to the American Association of Birth Centers. They welcomed nearly 20,000 babies. That represented just 0.5% of all U.S. births that year, but also a 200% increase in the past decade.

Nevada until recently was not one of those states, due to strict requirements that proved prohibitive to the midwives who attempted over the years to open one. But those requirements have been updated over several legislative cycles to remove barriers.

That work continues this current legislative session with Assembly Bill 287, a bill that solidifies the definition of freestanding birth centers and aligns their requirements with the American Association of Birth Centers. Sponsored by Assemblywoman Daniele Monroe Moreno (D-Clark), the bill cleared the full Assembly on a 30-12 vote on April 20 and on Thursday advanced out of its Senate committee.

April Clyde, an advanced practice registered nurse and certified nurse-midwife, is the owner of Serenity Birth Center. She believes the alignment with AABC will make it easier for birth centers to open and operate.

Serenity opened under existing requirements following something called the Facility Guidelines Institute, which creates guidelines for hospitals and other health care facilities. The low-tech birthing practices used by midwives make much of their guidelines unnecessary, says Clyde.

“All of these requirements we’ve been asked to do are important if you’re doing surgeries, if you have IV equipment and anesthesia and medical equipment,” she added. “None of those things are happening here.”

Clyde, who first studied the possibility of opening a birth center in Las Vegas in 2002 as part of her graduate education, said each step toward opening was difficult because officials from the city, the health district and the fire marshal had no template to work from and felt like more was needed. Stuck in their minds — and in a lot of people’s minds — is the image of pregnancy as a distressed woman screaming uncontrollably in labor.

“For me, it’s the opposite,” she said. “It’s fierce and powerful.”

Wanting a positive, empowered experience is common motivation for choosing a birth center over a hospital. That motivation is pronounced among people of color, who seek client-focused providers after experiencing first hand systemic racism within the medical community.

Monroe Moreno in a Senate committee hearing said she almost died giving birth to her daughter because medical professionals didn’t believe her symptoms. Knowing that, Monroe Moreno’s own daughter sought a midwife and home birth as an alternative.

“Her care with her midwife, she had more visits than I ever had in my pregnancy,” said Monroe Moreno, adding that many doctors offices are simply too busy to provide holistic care.

U.S. Rep. Cori Bush of Missouri and others recently spoke out during a congressional hearing about the high rate of Black maternal deaths in the United States. Nevada is studying the issue through its own maternal mortality review committee.

Many midwives believe birth centers could be a part of the solution.

But the birth center industry has internal equity issues it needs to address too. Only 11 of the 384 birth centers in the U.S. are Black owned, according to AABC data.

Birth centers are also being pitched as a cost-saving measure. Pre-pandemic around half of births in Nevada were covered by Medicaid. Post-pandemic that number is expected to be closer to 70%.

The U.S. hospital system has a high rate of induced labor and cesarean birth. Midwives argue that many of these costly medical interventions are unnecessary and would safely be avoided with a midwifery model of care, which typically involves longer visits and more relationship building with medical providers. Birth centers then could potentially save the state millions, say advocates.

The Nevada chapter of the American Academy of Pediatrics supports AB287, writing in a letter they believe accredited birthing centers are a safer alternative to home births for parents who do not wish to visit a hospital.

Dignity Health-St. Rose Dominican opposes the birth center bill, arguing that the state’s regulations don’t take into consideration medical emergencies that only hospitals would be equipped to handle.

The hospital suggested freestanding birth centers in urban areas should be required to be located within five miles of and have written transfer agreements with a hospital. Those suggestions would likely be prohibitive for birth centers, said Monroe Moreno.

Geneivieve Burkett of Serenity Birth Center told the Senate committee the birth center has reached out to its nearest hospital, University Medical Center, to establish a formal transfer agreement but has not received a response. But Burkett noted that, if an emergency transfer needed to happen, UMC would be required to accept the patient, as is the nature of emergency rooms.

She added that, even absent any formal agreement, the birth center has a good relationship with the hospital’s labor and delivery and NICU units.

According to Burkett, approximately 12% of Serenity’s clients do wind up transferring to a hospital, but almost all are voluntary. A typical scenario is a woman in prolonged labor who decides she wants an epidural after all. Some women transfer in the weeks before the onset of labor because their blood pressure or some anomaly was discovered that triggered a transfer.

“Every step, every prenatal visit, before admission into the birth center requires a risk assessment that is outlined,” said Burkett. “We follow state of Nevada recommendations for women who risk out of birth center care, because you must be low risk. We have gone above and beyond that.”

Inclusive language

AB287 has drawn criticism for replacing in NRS dozens of references to “mother” and “father” with inclusive terms like “birthing person” and “other person.”

Critics in hearings for the bills and on social media called it a denigration of the roles of mothers and fathers.

Assemblywoman Monroe Moreno acknowledged those critics during the bill’s Senate committee hearing, saying, “The world we lived in has changed.”

She acknowledged circumstances wherein mother and father might not apply, such as birth involving trans people, same-sex couples or surrogacy. The assemblywoman also noted that her own parents are listed on her birth certificate but did not give birth to her because she is adopted.

“The world has changed,” she said again.