Correction: An earlier version of this article stated that the maternal mortality rate for the U.S. in 2018 was 17.4 percent, when in fact, it was 17.4 deaths for every 100,000 live births.
Correction: Comments by Dr. Richard Taavon, the current supervising physician for Bailey and Paul have been added for context.
Abirth center in Greensboro is facing closure after three years in business, according to the owner and co-founder.
“Technically, our last day, we have to be closed by Aug. 1,” said Tanya Bailey, a certified nurse midwife and the owner of Magnolia Birth Center.
The main reason why the birth center — run by Bailey and co-founder Daniela Paul — is having to close, according to Bailey, is because Bailey and Paul’s relationships with a supervising physician that allows them to practice midwifery is expiring soon and will not be renewed by the physician.
“We’re hoping that someone from the hospital steps forward, but if not, we will be closing out by the end of the summer,” Bailey said.
According to North Carolina law, all individuals who practice midwifery can only do so under the supervision of a licensed physician who actively practices obstetrics.
The main reason why the supervising physician, an OBGYN physician named Dr. Richard Taavon, won’t be able to maintain his partnership with the birthing center is because of competition, Bailey said.
Because Magnolia is a free-standing independent clinic, they are not in-network with other larger corporate medical companies. According to Bailey, Wendover OGBYN, which Taavon works for, may soon be bought by a larger medical network which arguably creates a conflict of interest because the larger networks have their own pregnancy wings and “birth centers.” Even if a physician wants to support the birth clinic, the larger practice they work for and the even larger corporate structure that they work for may not.
On Friday, Taavon and Bailey both clarified that Taavon has been an ardent supporter of the birth clinic for years.
“I support them unequivocally,” Taavon said in a phone call.
From Taavon’s perspective, the reason why the birth center is closing is because it is becoming too busy and it needs community support to expand, which is not happening.
“It was basically a decision to close that the practice because it either needed to expand and get acquired by a larger entity,” Taavon said.
He also stated that Wendover OBGYN being acquired by a larger medical network is just speculative and nothing has been finalized. Still, he understands the decision made by Bailey and Paul because of the uncertainty it poses to the clinic.
“Since Wendover can’t predict the future of what our decision will be and they’re working all the time, I think the decision was made to ‘Let’s just stop now before we have to turn more people away,'” Taavon said. “There’s just no visible plan for the birth center to expand and get the support they need and if Wendover evolves, it further complicates things for them.”
Magnolia is just one of a handful of birth centers, usually run by midwives, in the state that offer prenatal care including natural births, women’s healthcare like annual exams, contraception and STD screening as well as wellness classes like yoga and sleep behavior. Unlike a traditional hospital setting, birth centers like Magnolia take a different approach to pregnancy by typically spending more one-on-one care with mothers starting before birth all the way into early childcare. Most birth centers only take on low-risk clients and prioritize natural births without anesthesia or epidurals.
While births attended by midwives are fairly rare in the United States — attending about 10 percent of all births — in other places like the United Kingdom, about half of births are delivered by midwives, according to data from 2016. Due in part to the number of midwives, the UK has a maternal death rate that is half of the U.S., according to a report by ProPublica.
Several studies, including a 2013 review by the healthcare-research organization Cochrane, found that women whose care was led by a midwife rather than a physician were less likely to receive pain medication in labor, less likely to experience pre-term birth and less likely to experience a miscarriage before 24 weeks gestation.
Obstacles for North Carolina birth centers
Magnolia first posted about its impending closure on Facebook at the beginning of May, stating that it wasn’t just “one reason for this decision, but instead a set of obstacles that [it] just cannot overcome.”
However, the main issue Bailey said, is the fact that no physician is willing to partner with them to allow them to operate the birth clinic.
While both Bailey and Paul are required to practice midwifery under the supervision of a licensed physician, Bailey argues the term “supervising” is misleading.
“The public is meant to believe that midwives are only safe because they are supervised by physicians,” Bailey said in an interview. “When in fact, physicians are not supervising midwives. They are not directly observing or overseeing any care by midwives.”
In an article by the Carolina Public Press from 2014, Alex Miller, a spokesperson for the North Carolina affiliate of the American College of Nurse-Midwives, pointed out that physician supervisors are not required to “literally supervise the practice of nurse-midwives” or even “work in the same setting, in the same county, even in the same part of the state.”
In North Carolina, midwives have additional oversight by the Midwifery Joint Committee at the Board of Nursing, which includes nurses and physicians.
Bailey said that many physicians don’t want to partner with midwives because it creates a conflict of interest.
“That’s really what it comes down to,” she said. “The relationship, the way it’s set up in North Carolina is that nurse practitioners are in direct competition with OBGYNs for the same competition.”
The complicated part, Bailey said, is that both her and Paul, in addition to being licensed to work at Magnolia, are also licensed by Taavon to work out of a private OBGYN practice, Wendover OBGYN.
While Bailey has stated that the clinic is losing Taavon as a supervising physician because Wendover OBGYN is being taken over by a larger medical network, Taavon said on Friday that that’s not yet the case.
Many midwives work for private clinics, according to Suzanne Wertman, a nurse midwife working in Wilmington and the former president of the North Carolina affiliate of the American College of Nurse-Midwives.
“Most midwives work for either a hospital system or work in a physician practice or work for county health departments, family planning clinics,” Wertman said. “But to work, there’s always a sign-ff from a physician.”
For midwives that don’t work as part of a larger health organization, getting licensing can be tough.
“Basically, if you’re not part of that network, you can’t do it,” Bailey said.
The law requiring midwives to have supervision by licensed physicians has been in place since 1983.
Lawmakers have attempted to pass bills to relax regulations on midwives in the past.
The SAVE Act would remove the physician-supervisor requirements for nurse practitioners and midwives. Primary sponsors for the bipartisan bill, filed in February 2019, include Rep. Donny Lambeth, a Forsyth County Republican and former hospital executive, and Rep. Gale Adcock, a Wake County Democrat and practicing nurse practitioner. But the bill stalled in the Health Committee, chaired by Lambeth.
Another bill, House Bill 575, titled the Establish Birth Center Licensure Act, would create a process for birth centers to be licensed and inspected by the state department of health and human services. While the bill, filed in April 2019, appears to be a more restrictive move on birthing centers, Wertman, said that the bill was drafted in consultation with both midwives and OBGYNs to ensure that birth centers are safe.
The bill was drafted in part, after a number of babies died at a birth center in Cary in 2018. Baby + Co., which had locations in Winston-Salem and Charlotte as well, closed all of its North Carolina locations in April 2019 after a state investigation, according to reports by the Winston-Salem Journal. House Bill 575 has also stalled after being referred to the rules and operations committee in the Senate in July 2019.
Midwifery versus traditional hospital care
According to Bailey, midwives in North Carolina typically undergo training to become a registered nurse and then go to graduate school for midwifery, which is an additional two to three years of schooling. Some midwives also go on to get doctorate degrees.
Wertman said there is often a misconception about the practice of midwifery and a disdain for the practice among some physicians.
“I think it’s perception,” she said in an interview. “We have different ways of practicing. We have different ways of approaching births. We approach births as a life event while physicians generally look at pregnancy like a ticking time bomb…. Hospitals are built for taking care of people efficiently, it’s not built to take care of the individual. It’s not anyone’s fault. We need each other, we should be working together.”
According to CDC data, around a third of all births in the United States are Cesarean sections, a number far higher than the World Health Organization-recommended target of 10 to 15 percent. Wertman contends that the fast-paced nature of hospital births contributes to the high number of C-sections, which could be driving up maternal mortality rates in the country.
“Right now, we are facing a crisis in maternity care,” she said. “It’s never been more dangerous to give birth in the United States. Women are more likely to die now than their mothers were.”
According to new data from the CDC from 2018, the maternal mortality rate was 17.4 pregnancy-related deaths for every 100,000 live births, and the rate has increased almost every year for the past decade. A report by ProPublica and NPR from 2017 also found that more American women were dying of pregnancy-related complications than any other developed country and that the United States was the only developed country that had an increasing rate of maternal mortality.
While the reason for this increase has not been pinpointed to one particular problem, maternal health reformers like Eugene Declercq, a professor of community health sciences and a certified childbirth educator at the Boston University School of Public Health, have stated that a more holistic approach to pregnancy and birth could help curb the numbers.
“The only way we’ll reduce maternal mortality is by valuing women’s health for itself, whether or not a woman happens to be pregnant,” Declercq said in a January article by Vox. “That way, women will begin their pregnancies in a healthier state and be well supported after they’ve had their baby.”
According to a five-year study conducted by researchers in Canada and the United States, states that have integrated midwives into their healthcare systems had better outcomes for mothers and babies than those that did not. The 2018 study, which was published in PLOS One, a peer-reviewed open access scientific journal by the Public Library of Science, used a scoring system that rated how well midwives had been integrated in each state. North Carolina, with a score of 17 out of 100, ranked the lowest in the country.
The study analyzed aspects such as where midwives are allowed to work, what kind of care they can provide, how much autonomy they have and whether they can prescribe medication as factors of integration. Then researchers overlaid the data on nine maternal and fetal health indicators like rates of C-sections, premature births, breastfeeding and neonatal deaths. In North Carolina, C-section rates were lower than the U.S. average but the neonatal mortality rate, or the death of a baby during the first 28 days of life, was 5.1 out of 1,000, compared to the 4.0 nationwide average. The rate of breastfeeding at six months was also lower than the national average by 1.8 percent.
Bailey argues that clinics like Magnolia offer the kind of holistic care that Declercq is talking about.
“The birth-center care is not obstetrical care,” Bailey said. “It’s all education and preparation. It’s for going home and taking care of the baby; it’s not just giving birth. The visits are longer, and the focus is to give women and their support network all of the education support they need to be successful parents. It slows down what is typically happening in medical offices where usually prenatal visits are five to 10 minutes with a doctor. Ours are 30 to 60 minutes.”
Birth centers are also significantly cheaper than giving birth in traditional hospital settings. According to data from the American Association of Birth Centers, the cost of giving birth at a birth center is typically 50 percent less than charges for an uncomplicated birth at a hospital.
Bailey also said that Magnolia recently started taking Medicaid to ensure that low-income families could receive the same level of care as others in the community.
“It’s individualized care,” Bailey said. “It’s not templated. It’s very much ‘What do you need?’ and ‘How do we get what you need?’”
What’s next for Magnolia
For the center to remain open, Bailey said that they need to find a physician who will contract with them so they can continue to practice at Magnolia. While they’ve reached out to almost every physician in the city, they haven’t had luck finding one that’s willing to partner with them.
However, Taavon, the current supervising physician, said that he has not pulled out his support of the center.
He said that the closing of the center is more complicated than just one issue. In his eyes, the uncertainty of whether Wendover will eventually be taken over by a network that conflicts with Magnolia, plus the increased amount of patients and hours worked by Bailey and Paul without more support from larger entities like Cone Health has made keeping the birth center open difficult.
“To stay the same is to be overworked,” he said. “It’s just too much, it needs significant help. It needs an expansion plan to stay the same.”
Bailey also said that they wish to partner with Cone Health, the area’s largest healthcare provider.
“Cone Health is the beacon of health in our community,” Bailey said. “They say they support us, but what we need is a physician’s support and backing so we can keep doing what we’re doing. We’ve had many conversations with Cone, but there’s been no movement. They say, yes, they support [Magnolia] and it’s sad that we’re closing but that’s all we’ve gotten.”
Debbie Cunningham, the senior vice president and the president of the Women’s Hospital and Behavioral Health Services for Cone Health, responded to questions from TCB about a potential partnership with Magnolia via email.
“It is unfortunate when any area business is forced to close, even a competitor,” Cunningham wrote. “Cone Health has long understood the importance of birthing options. During normal times, we encourage the use of midwives and doulas.”
A doula, according to a recent New York Times report, is a non-medical professional whose sole priority is to support and provide guidance to birthing mothers, while midwives are trained medical professionals with licenses to practice medicine.
“We support women who want water births or the use of nitrous oxide,” Cunningham continued. “Cone Health is open to the possibility of offering a birthing center and fulfilling this need for our community. We can evaluate this more when our community has recovered from the COVID-19 crisis.”
However, Bailey said patients need a birth center to be open now during the pandemic, not after.
“It’s a way to keep women out of hospitals,” she said. “So, we can save that space for people who need it. It’s just a resource we need in our community.”
Being the only birth center in the area — the next closest one is in Chapel Hill — Bailey said the number of patients the facility has served has doubled each year it’s been open. According to numbers provided by Bailey, Magnolia Birth Center served 111 patients in 2019, up from 66 in 2018, and has already served 171 patients this year. The center also has 97 patients on a waiting list.
“Our consumers want a birth center here,” she said. “They’ve wanted a birth center for a very long time and now that they have one, they don’t want to let it go, either.”
‘A place that’s very homelike’
Psychiatric nurse practitioner Laurie Arena got pregnant at the age of 40 through IVF in 2018. In March 2019, she gave birth to her first child, daughter Dylan, and chose Magnolia Birth Center as her primary form of care during her pregnancy.
“I started with an OBGYN clinic and was turned off after my first couple of visits,” Arena said. “I had asked if they could check my Vitamin D level and they said they don’t do that even after I asked a few times.”
After discovering Magnolia as an alternative, Arena said she fell in love with the intimate care there and decided to try a waterbirth. Later in her pregnancy, she became anemic and had to be referred to Cone Hospital, where she ultimately had a C-section birth, but she says the care she received at Magnolia helped her through her pregnancy.
“I liked that they were small, and I could get to know the two providers there,” Arena said. “I wasn’t having to be shared between eight or 10 doctors who might deliver me.”
Even after her delivery, Arena continued to go to Magnolia for her obstetrics care because of the relationships she’s developed with both Bailey and Paul.
“If you’ve ever been there, you’ll see that they’re very family friendly,” she said. “For me, it was just that I felt listened to. The appointments didn’t feel rushed. They were accessible anytime I had a question. I could call and the person you get on the other end is either Tanya or Daniela, so they know your case…. To me, it’s a complement to care at the hospital. It’s a place that’s very homelike and calming and caring, and they responsibly take on the number of patients they can manage so you get a close working relationship with your care provider. It’s a beautiful thing.”
Now, Arena said she’s worried about the future for other women who want an alternative to a hospital setting for their pregnancies. She’s not sure if she will have more children in the future, but she said she wants Magnolia to be around if she chooses that as an option.
“I just think pregnancy and childbirth is a pivotal time in your life, and it can be a scary time,” she said. “I wanted a supporting, nurturing setting, and I really felt like I got that at Magnolia.”