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ANFSCD: Checking in on #BirthCenterNWA

And Now For Something Completely Different…


As a lot of original blog readers know, I am a huge fan of birth centers and midwifery care. The difference in quality of care between the hospital where I gave birth the first time and the birth center I used for my second birth was striking enough to, you know, propel me to start this blog.

When I moved to Arkansas two years ago, the state’s first freestanding birth center, Birth Center of Northwest Arkansas or BCNWA, was just opening. I had the chance to help them on various projects and I don’t think I fully realized until later on what an enormous undertaking opening a birth center, let alone a birth center in Arkansas, was. If I can say that I personally know all of the Certified Nurse-Midwives catching babies in Arkansas (not because I’m popular but because I can count them all on one hand), that gives you a good idea of the founders’ starting point while trying to work with the state and various payers on licensing and reimbursement.

I visited BCNWA recently and it was great to see that not only is the Rogers, Arkansas, location going strong but another site is open in Cary, North Carolina, under the umbrella of the same parent company, Baby+Co. Three more birth centers are opening soon in Denver, Nashville and Charlotte.

My visit to the birth center was aptly timed, and not just because it reminded me that I need to schedule my overdue well-woman visit with the midwives there. In researching cost and pricing transparency along with rates of procedure utilization and quality metrics in maternity care, I keep happening upon mentions in articles of birth centers as potentially high-quality, low-cost alternatives to hospital care. The gist of a lot of it is global billing for the perinatal episode, like a prix fixe for patients whose birth occurs at the birth center (as opposed to those who risk-out or must transfer to a hospital for care), which keeps costs down and encourages coordination of care.

Check out this excerpt from a 2013 Integrated Healthcare Association policy brief:

There is a compelling need to improve how we pay for and deliver maternity care in the United States. Evidence indicates that reducing the number of medically unnecessary obstetric interventions, currently rewarded by the fee-for-service payment system, would reduce maternity care costs while improving care and outcomes for mothers and babies.

Bundled payment has the potential to realign incentives in maternity care. Combining all costs into a single, episode-based payment creates financial incentives for providers to enhance care coordination and increase efficiency, which in turn should lead to lower costs and improved health outcomes.

Beyond the obvious benefits and perks of high-quality health care in absolutely gorgeous settings, the care model that Baby+Co is implementing across the country— a scalable, turnkey model of a freestanding birth center with a close relationship to a local hospital— is worth watching as a maternity care reform innovator.

While Baby+Co is off changing the landscape of maternity care in the U.S., their midwives are available for a free consultation for people considering giving birth at the birth center and will take care of your well-woman visits, too!


Still curious about the Birth Center of Northwest Arkansas? This video gives a great overview:



Issue 4, May 15, 2015



The intersection of maternity care, data transparency, health care costs and patient safety in a weekly curated list of articles of interest.

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In terms of Internet virality, this was by far the article of the week:

How One Hospital Brought Its C-Section Rate Down Fast

Faced with the possible loss of an important insurer, one California hospital rapidly reduced excessive cesarean section rates in part by sharing each physician’s rate with everyone in the obstetrics department.




Study: CA hospitals waste money by ignoring ‘big data’

The idea floated by advocates of the Affordable Care Act — that the U.S. government could change the “cost curve” of medicine to achieve major savings — wasn’t well-explained by many Washington reporters. Encouraged by official reports, they often focused on the idea that preventive care would be the change agent.

But as the C-section research shows, the change agent could be the “big data” approach. It may have the potential to bring U.S. health care costs more in line with those seen in other advanced countries — so long as there are incentives to encourage physicians and hospital administrators to try to do what’s most sensible, not what’s easiest.




Cesareans following shift toward patient-centered care




Various Reasons for High Maternal Mortality in US

According to Dr. Anita Kuriya from McGill University Health Centre “The increase in caesarean rate has lead to deaths due to haemorrhage”.





White House Moves to Fix 2 Key Consumer Complaints About Health Care Law

The White House is moving to address two of the most common consumer complaints about the sale of health insurance under the Affordable Care Act: that doctor directories are inaccurate, and that patients are hit with unexpected bills for costs not covered by insurance.




Crowd-Sourcing Healthcare Costs

Clearhealthcosts.com is an experiment in crowd-sourcing with the goal of bringing transparency to healthcare costs by sharing real costs with real people: patients and clinicians.




What do high deductible health plans really mean for hospitals?

As consumers become responsible for a greater portion of their healthcare costs, hospitals will see their role as collection agent grow.




Watchdog: HHS program lacks transparency

The Department of Health and Human Services lacks transparency in how it makes approval decisions about billions of dollars in experimental projects in the Medicaid program, the nonpartisan Government Accountability Office said Wednesday.




Surprise medical bills are costing consumers

Nearly one third of privately insured Americans have dealt with medical bill shock in the past two years




U.S. News Health Care Index Shows Massive Increase in Consumer Costs

But deductibles – the out-of-pocket costs consumers must pay before their health insurance benefits kick in – are the components that have seen the most growth from 2002 to 2013. In 2002 – the earliest year for which data about deductibles were available – less than half of private-sector health insurance plans had a deductible. By 2013, more than 80 percent had a deductible, and the amount paid by consumers was skyrocketing.

“Premiums were steadily rising,” says Douglas Holtz-Eakin, president of the American Action Forum and former director of the Congressional Budget Office. “Employers tried to manage this expanding price tag by shifting costs to their employees in the form of higher deductibles and increased co-pays. This is one of the factors – in addition to the Great Recession – that contributes to the slowing of health care spending growth in the latter part of the period.”




Healthcare providers and consumers both stung by rising costs, report shows

As providers face declines in reimbursement from commercial plans, they are seeing more patients covered under Medicaid and Medicare.




Should Malpractice Settlements Be Secret?




Centers for Disease Control and Prevention (CDC)’s New FAQ’s on Birth Control Coverage




I’m still amazed that someone at The Onion satirized hospital cost reporting!

Report: U.S. Hospitals Spend $2 Billion Each Year Replacing Gowns Taken By Escaped Patients




Anatomy of Error

Marsh isn’t interested in the usefulness of error… he writes about his errors because he wants to confess them, and because he’s interested in his inner life and how it’s been changed, over time, by the making of mistakes.




Cesarean rates of hospitals  |   Where can I VBAC?  |  Maternity Data Reports



Issue 3, May 8, 2015



The intersection of maternity care, data transparency, health care costs and patient safety in a weekly curated list of articles of interest.

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This week’s collection of articles is brought to you by BabyLove. Are you in Minnesota near the Mall of America? Veronica Jacobsen and the whole team at BabyLove, an independent childbirth education center, have a lot to offer! Check out the class schedule and pass on the good word about BabyLove to pregnant friends in or around Eagan, MN.



An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?




In case the above article in the New Yorker was on your TL;DR list, Vox.com summarizes it…

McAllen, Texas, used to be everything wrong with American health care. Not anymore.



Here is the poster that Neel Shah and the team at Ariadne Labs presented at the 2015 ACOG Annual Meeting this week. Click on the image to open a PDF.

RESULTS: Processes that take place on the labor floor are highly resource-intensive as a result of the level and number of personnel required, whereas postpartum processes are less resource-intensive. On average, vaginal deliveries require more than 700% more labor floor time compared with cesarean deliveries. Within the bounds of our sensitivity analyses, we found that vaginal deliveries are approximately 200% more expensive than cesarean deliveries until the birth takes place and cost equivalent to cesarean deliveries when summed over the entire length of stay. (Read the abstract in the Green Journal)



The U.S. Is Still a Terrible Place for Maternal Health




Paying People To Use Lower Cost Health Care Providers Saves Money




For Breech Births, C-Sections May Be the Safest Choice




New Evidence Updates C-Section Techniques




The Mom’s Beat: Care, not childbirth, is the measure of a mom




Celebrate International Day of the Midwife




From the archives:

Did Tort Reform in Texas Lower the State’s Total Cesarean Rate? (2012)



Cesarean rates of hospitals  |   Where can I VBAC?  |  Maternity Data Reports



Issue 2, May 1, 2015



The intersection of maternity care, data transparency, health care costs and patient safety in a weekly curated list of articles of interest.

Tne Unnecesarean in your inbox? Yes, please! Enter your email address:


Want everyone to see your product or service here? Find out how!


This week’s collection of articles is brought to you by BabyLove. Are you in Minnesota near the Mall of America? Veronica Jacobsen and the whole team at BabyLove, an independent childbirth education center, have a lot to offer! Check out the class schedule and pass on the good word about BabyLove to pregnant friends in or around Eagan, MN.


CMQCC’s OB Hemorrhage Toolkit 2.0 is available for download. The Toolkit includes care guidelines (in checklist, flowchart or table chart formats) and a slide set for professional education in PDF format.

More than 2000 have been downloaded worldwide since March 24. Have you downloaded the toolkit for your hospital?



April was Cesarean Awareness Month and someone at Society for Maternal Fetal Medicine put a lot of time into creating a month-long social media campaign that ended up being a fantastic cheat sheet of recommendations for preventing a primary cesarean. See all of their tweets at the end of this article.


UCHealth aims to lower C-section rates



Women with epilepsy face tough choices over their medication

Review on how treatments for epilepsy in pregnancy may affect the unborn child, and the dilemma facing young women making decisions about their treatment. (Cochrane)



The battle for better maternity care shows the limits of the Amazon warehouse approach to medicine

“The issues around maternity care are a microcosm of the bigger battles in the NHS – centralisation, protocols and “efficiency savings” v making a space for common sense, professional judgement and personal relationships.”



Hospitals work to fast-track C-section’s

“Hospitals rework C-section policies to promote quicker bonding between mothers, babies”



Aid for consumers; Data helps health-care decisions


(Subscriber access only but I wrote it so I’m including it here anyway. PDF here.)


A Cluster-Randomized Trial to Reduce Cesarean Delivery Rates in Quebec

Audits of indications for cesarean delivery, feedback for health professionals, and implementation of best practices, as compared with usual care, resulted in a significant but small reduction in the rate of cesarean delivery, without adverse effects on maternal or neonatal outcomes. The benefit was driven by the effect of the intervention in low-risk pregnancies.



Pediatricians Issue New Guidelines for Hospital Release of Newborns

The decision to allow a healthy newborn to go home is made after careful review by health providers, but there can be wide variation in the degree of an infant’s readiness to leave the hospital, and a number of factors need to be considered, according to the AAP.



Continuing to Help Low-Income Women Access Primary Care

“…ACOG has launched the nationwide advocacy initiative, All-in for Women’s Primary Care. Regardless of whether your state has expanded its Medicaid program under the Affordable Care Act, your state can raise Medicaid primary care rates to Medicare levels for ob-gyns.”



A very cool interactive infographic from IOM that accompanies the report titled “Vital Signs: Core Metrics for Health and Health Care Progress”



A Big Step Forward for Health Care Transparency in New Mexico

One major reform to come out of the 2015 legislative session was a law that will dramatically increase the transparency of hospital prices and quality data.

The new statute, which passed both the Senate and House unanimously and was signed by the Governor, updates the existing Health Information System Act to allow the Department of Health to release hospital-specific quality and cost information. Much of this data has been collected from hospitals for the last two decades, but the old law prohibited the Department of Health from releasing it in a way that identifies specific hospitals.



From the archives: Inés Ramírez Pérez and the Mythical Self-Cesarean (2009)


The oddball start-up that shows how ObamaCare has made a friendlier insurance market

“It’s got a user-friendly website that offers providers after you type in your symptoms, along with free 24/7 internet consultations with doctors. It lets you compare prices from different providers and refill prescriptions with one click. It’s even partnering with CVS to build care locations throughout the state, and it’s hiring nurses to offer in-home follow-up services, especially for new moms.”


“Before the health reform law, all the incentives encouraged insurers to exploit consumers rather than help them. Most people who weren’t on government-provided insurance got their private coverage through their employer. (And still do.) In that case, insurers have an incentive to make employers happy, but little reason to offer customers transparency or quality service.”



Future of health care: innovation and personalized medicine

A very perky article on the impact of the fee-for-value approach



Commonwealth Fund’s Health Policy quiz

I failed this. Really badly.



Canadians unaware about the full cost of health care



From the archives: Defending Ourselves against Defensive Medicine (2011)

Can Transparency Tools Further the ACA’s Goals of Reducing Costs?



What Hospital Websites of the Future Will Look Like

Leapfrog’s Leah Binder thinks that “[t]he hospital (and its website) of the 21st century will look very little like the ones we encounter today. And that will be a good thing for its customers—the patients.”



Hospitals Provide a Pulse in Struggling Rural Towns

Rural hospitals face huge challenges; nearly 50 of them have closed in the last four years, according to the North Carolina Rural Health Research Program. But the many successful hospitals, beyond providing an array of jobs from the bottom to the top of the economic ladder, also stimulate local spending and help attract new businesses that offer a stable of insured patients.




Cesarean rates of hospitals  |   Where can I VBAC?  |  Maternity Data Reports

A Month of Cesarean Awareness Month Tweets from the Society for Maternal Fetal Medicine, 2015:

Results for #prevent1stcs


Apr 30

Thanks for all you do to keep #mothers and #babies safe!  #Prevent1stCS #CAM2015 is part of this! http://ow.ly/KUj64

Apr 29

Advise on short/long-term risks of the surgery for both woman and baby- in present and future #Prevent1stCS #CAM2015 http://ow.ly/KUj63

Apr 28

Intermittent auscultation acceptable in low-risk patients without #FHR abnormalities #Prevent1stCS #CAM2015 http://ow.ly/KUj61

Apr 27

Repeated #cesarean increases risk of #accreta- a major safety concern for mom and baby #Prevent1stCS http://ow.ly/KUj5z

Category II tracings don’t mean CS - they mean evaluation and continued surveillance are needed #Prevent1stCS #CAM2015

Apr 26

Unless indicated, avoid elective induction with bishops score <8. Ripen if you must induce #Prevent1stCS #CAM2015 http://ow.ly/KUj5B

Apr 25

1st cs may slightly decrease neonatal risk, difference through lifespan increasingly smaller #Prevent1stCS #CAM2015 http://ow.ly/KUj5Z

Apr 24

#cesarean does have a place in modern practice and can be lifesaving for some moms and babies #Prevent1stCS #CAM2015 http://ow.ly/KUj5A

Apr 24

1st cs only small risk maternal morbidity, difference increases throughout reproductive life #Prevent1stCS #CAM2015 http://ow.ly/KUj5Y

Apr 23

Repeated #cesarean increases risk of #accreta- a major safety concern for mom and baby #Prevent1stCS #CAM2015 http://ow.ly/KUj5z

Apr 23

Counsel appropriately that elective cs 1st increased risk major maternal morbidity 10% by 4th #Prevent1stCS #CAM2015 http://ow.ly/KUj5y

Apr 22

Encourage policy changes at your hospital within NICHD and SMFM guidelines to help #Prevent1stCS #CAM2015 http://ow.ly/KUj5X

Apr 20

Excessive weight gain increases cs! Help women keep weight gain in IOM recommendations to #Prevent1stCS #CAM2015 http://ow.ly/KUj5V

Apr 19

EFW late gestation imprecise, counsel, reserve cs >4500 grms diabetics >5000 grms non-diabetics #Prevent1stCS #CAM2015

Apr 18

Document fetal presentation at 36 weeks to allow discussion and attempt of external version #Prevent1stCS #CAM2015 http://ow.ly/KUj5U

Apr 17

When inducing, don’t call failure til latent phase >24 hrs and >12-18 hrs of oxytocin after AROM #Prevent1stCS #CAM2015

Apr 16

Don’t forget cervical riping! Riping reduces risk of #cesarean when inducing unfavorable cervix #Prevent1stCS #CAM2015

Apr 15

If there are no maternal/fetal indications- hold off on induction of labor until 41 weeks #Prevent1stCS #CAM2015 http://ow.ly/KUj5T

Apr 15

@WHO proposes Robson system for comparing #caesarean rates between facilities/countries/regions.http://ow.ly/LCyqg  @Lancet #Prevent1stCS

Apr 15

#Caesarean sections should only be performed when medically necessary says @WHO http://ow.ly/LCjFo  #Prevent1stCS

Apr 14

Category 2 tracing?  Consider scalp stim to assess fetal acid-base status as a safe alternative to #Prevent1stCS #CAM2015

Apr 13

#amnioinfusion for repetative variables may help #Prevent1stCS #CAM2015 http://ow.ly/KUj5S

Apr 12

Consider manual rotation for fetal malpresentation in #secondstage before #operativedelivery #Prevent1stCS #CAM2015 http://ow.ly/KUj5P

Apr 11

#Operative delivery by experienced and well-trained physicians is safe alternative to #Prevent1stCS #CAM2015 http://ow.ly/KUj5O

 Apr 10

Diagnosis of arrest 2nd stage is >2 hour muliparous and >3 hours nulliparous women #givewomantime #Prevent1stCS #CAM2015

Apr 9

There is no absolute maximum for the #secondstage, allow for variation with progression #Prevent1stCS #CAM2015 http://ow.ly/KUj5M

Apr 8

Active phase arrest should be reserved for >6cm for >4 hours with adequate uterine activity #Prevent1stCS #CAM2015 http://ow.ly/KUj5L

Apr 7

Protracted latent phase >20 hrs #nulliparous >14 hrs #multiparous not a indication for cs #Prevent1stCS #CAM2015 http://ow.ly/KUj5J

 Apr 6

Options for latent phase include time, #AROM or #oxytocin to achieve active labor #Prevent1stCS #CAM2015 http://ow.ly/KUj5I

Apr 5

6 cm is the new 4! Don’t call active labor protraction or arrest til adequate time elapsed! #Prevent1stCS #CAM2015 http://ow.ly/KUj5H

Apr 4

Each cs increases risk in next - #Prevent1stCS can improve outcomes for a lifetime  #CAM2015 http://ow.ly/KUj5F

Apr 3

10 fold variation #cs across US from 7.1% to 69.9%- how does your hospital rate? #Prevent1stCS #CAM2015 http://ow.ly/KUj5E

Apr 2

Severe maternal morbidies increase risk #cs 3 fold- prevention and early treatment can help #Prevent1stCS #CAM2015 http://ow.ly/KUj5x

Apr 1

Experts agree #cesareanrate too high in US @mySMFM committed to lowering safely follow for tips #Prevent1stCS #CAM2015


Issue 1, April 24, 2015


The intersection of maternity care, data transparency, health care costs and patient safety in a weekly curated list of articles of interest.

Tne Unnecesarean in your inbox? Yes, please! Enter your email address:


Want everyone to see your product or service here? Find out how!


The Connection Between Evidence-Based Medicine and Shared Decision Making

Journal of the American Medical Association




National Healthcare Quality & Disparities Report 2014

Agency for Healthcare Research and Quality




Oregon Doctors Try To Reduce Number Of C-Section Births

Oregon Public Broadcasting




Why are C-section rates still so high?

San Diego Union-Tribune




Beyond SGR: Aligning The Peanut Butter Of Payment Reform With The Jelly Of Consumer Engagement

Health Affairs Blog




Why Maternal Mortality Is Rising In The U.S.





Women in the World ‏ April 23, 2015

“When we launched #MerckforMothers“…we weren’t expecting to work in the U.S.” @priya__agrawal#WITW




From the Archives:


A Tale of Two Cities: Unwarranted Variation in Tonsillectomy Rates in Vermont



Video of Human Childbirth in an MRI



Cesarean rates of hospitals  |   Where can I VBAC?  |  Maternity Data Reports