UPDATE: DHEC now says it does not plan to shut down birth centers. Read more here.
A North Charleston natural birth center and other birth centers around the state have been in danger of closing since September, when the S.C. Department of Health and Environmental Control began investigating them for compliance with state law.
According to Lesley Rathbun, owner and director of the Charleston Birth Place, the state agency is reinterpreting its regulations for birth centers and could end up shutting down non-hospital birthplaces across the state.
"We're in limbo right now. I don't really know what's going to happen," says Lesley Rathbun, owner and director of the Charleston Birth Place.
While birthing centers are able to provide midwifery services and alternative childbirth arrangements like water birth (where the mother sits in a large tub and gives birth underwater), they are not equipped to perform Caesarean sections, give epidural anaesthesia, or deal with certain high-risk pregnancy conditions, including multiple births, breech births, severe anemia, and fetal birth defects. Because of these restrictions, under state Regulation 61-102 (PDF), all birthing centers are required to take certain precautions in case a mother requires emergency services at a hospital.
The law requires every birthing center to have a transfer agreement with a nearby hospital, and it also requires that "a physician must be on call and available to provide medical assistance at the birthing center at all times that it is serving the public."
According to Rathbun, around 10 to 15 percent of mothers who come to the Birth Place end up having to be transferred to nearby Trident Hospital for delivery, but only about 1 percent are for emergencies. The birthing center has collaborating agreements with two obstetricians, Dr. James Martin and Dr. Christine Case, who can be reached immediately by cell phone and can meet laboring mothers at the hospital during a delivery — but who do not actually set foot inside the Charleston Birth Place.
Since Charleston Birth Place opened in 2007, the lack of physicians inside the facility has never been a problem for state regulators. But on Sept. 6, Rathbun and administrators of birthing centers around the state received a letter from Gwen Thompson, chief of DHEC's Bureau of Health Facilities Licensing, that said it was "a reminder to the regulated community" about the on-call physician requirement. "The Department interprets [Reg. 61-102, Sec. D.6.a.1] to mean that at any given time the birthing center is serving the public, there is an on-call physician who, if called, would be able to come to the birthing center to provide medical assistance."
This, Rathbun says, is a new interpretation. "So if I have a mother that is having a complication, I have to call a doctor, the doctor has to come to the birth center, then the mother can be transferred to the hospital — which is just ludicrous," Rathbun says. "It would only delay care for the mom. If she needs an obstetrician, she needs to be at a hospital. There's nothing an obstetrician can do at a birth center that a midwife couldn't have already done."
A few days after she received the letter from DHEC in September, Rathbun says an inspector from the agency arrived at the Charleston Birth Center and demanded to see copies of the center's written agreements with physicians. Rathbun says she provided the documents and was told she would find out whether the center was in compliance within two weeks. It has now been 10 weeks since that visit, and Rathbun has not received an answer from DHEC. She says that when she called to check on the status of the response, she was told it was tied up in DHEC's legal department.
This week, Rathbun says her attorney met with DHEC attorneys, who stated that "every birth center who had a visit will get a letter of citation within the next few days, and we would have 15 days to come up with a plan of correction." Rathbun was told that if birth centers do not give a satisfactory plan of correction within 15 days, their licenses will be suspended.
Since September, three national groups have written letters to DHEC Director Catherine Templeton protesting the change in interpretation of Regulation 61-102: The American Association of Birth Centers (of which Rathbun is also the president), the Commission for the Accreditation of Birth Centers, and the American College of Nurse-Midwives. In the letter from the ACNM, Director Jesse Bushman writes that "an overly stringent interpretation that this regulation requires a physician to be physically present at a birth center in emergencies would hinder rather than promote appropriate transfer of care by mandating unnecessary delays."
The Sept. 6 letter from DHEC did not state a reason for issuing a "reminder to the regulatory community," but it came on the heels of a disastrous event at a Piedmont birthing center that resulted in that center's closure. On the night of Aug. 29, a woman in labor arrived at the Carolina Community Maternity Center in Fort Mill and labored through the night and into the next day, according to a report in the Charlotte Observer. By 12:45 p.m. on Aug. 30, the woman had "experienced a rupture of membranes with light meconium stained fluids," according to state documents released to the Observer, and between 6:05 and 6:53 p.m., the baby's heart rate dropped significantly while in utero.
At 7:30 p.m. on Aug. 30, the two midwives ended up taking the mother to a hospital in their own vehicle without consulting a physician, violating state regulations, according to the report. A doctor at the hospital performed a C-section, but the infant was born without a heartbeat and could not be revived.
DHEC suspended the licenses of the midwives and the birth center on Sept. 2. On Sept. 6, letters went out to birthing centers around the state.
Lindsey Evans, a spokesperson for DHEC, gave the following statement on the status of the investigation today: "As you know, a birthing center in the Fort Mill area recently experienced a death during a delivery and was cited for failing to follow specific practices pursuant to the laws of the State of South Carolina.
"Subsequently, the S.C. Dept. of Health and Environmental Control has performed inspections at the remaining birthing centers across the state to ensure that they are in compliance with the law. If violations are found during the inspection, the center's administrator will receive a letter specifying the violations and seek a plan of correction as required under the law."
Wednesday night at the Charleston Birth Place, Rathbun sat in a rocking chair in the lobby area during an information session with several couples who were considering using the center. The couples sat on couches and chairs around a coffee table as Rathbun spoke in soothing tones about pain management, accreditation, and the biological reason why infants will not drown when born underwater. Wednesday night was also the first night Rathbun had to include a disclaimer about the potential shutdown of the Birth Place.
"I have a very strong belief that out license will not be suspended, but we may need to go to court," Rathbun told them.
After the presentation, Rathbun gave the couples a tour of the facilities, including a dimly lit birthing room called the Palmetto Suite that features a canopy bed, a 300-gallon pool, and an array of flameless candles. Inside the Palmetto Suite, there is a sound system with WiFi for mothers to play their favorite Pandora stations, a beach scene painted on the wall, and a light show like a swirling galaxy projected onto the ceiling. Out in the halls, there's a batik print of a mother giving birth standing up, a bookshelf of maternity books (excluding What to Expect When You're Expecting, which Rathbun deplores), and a small sales area for herbs and supplemental products. The Charleston Birth Place is a lot of things, but a hospital it is not.
When Rathbun started the Birth Place in 2007, she says she was the only midwife and would sometimes sleep overnight in the building. Recently, before the DHEC investigation began, she was considering hiring a fifth midwife and expanding the facilities. But for now, everything is on hold.
Cynthia Lenehan, a licensed midwife and counselor who assists with home births and teaches some classes at the Charleston Birth Place, says she is worried about the future of the center.
"We're really concerned about what's going to happen to the consumers. They do about 30 births a month here, and similar numbers in the other birth centers," Lenehan says. "These people, as you can see, are looking for a really different product than they're going to get in the hospital, and they're not going to be able to get that elsewhere. This is safe, it's cost-effective, and it's what the customers desire. So what's going to happen to all these mothers who are due in three weeks?"