Hospitals question safety, business model of alternative birthing center

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Certificate of need hearing in Frankfort may last three days

By Marty Finley

FRANKFORT — Legal counsel for the proposed Visitation Birth and Family Wellness Center said the facility would offer needed choice in Hardin County but three hospitals opposing the business cite safety concerns and unneeded duplication of services.


J. Guthrie True, an attorney representing the center during the certificate of need hearing, drew a comparison between pioneer automaker Henry Ford and arguments made by Hardin Memorial Health, Flaget Memorial Hospital in Bardstown and Twin Lakes Regional Medical Center in Leitchfield. In describing his landmark Model T, Ford reportedly said customers could have any color they wanted as long as it was black.

“They can have a baby anywhere they want as long as it’s in a hospital,” True said of expectant mothers.

Wednesday marked the first of what likely will be three days of testimony in the hearing at the Kentucky Bar Association in Frankfort. Mary Carol Akers, a certified nurse midwife who filed the application, seeks to build a facility at 2813 Ring Road in Elizabethtown, which would serve low-risk, expectant mothers who want natural births in a home-like setting.

The first day primarily consisted of testimony from opposition, which painted the center’s business model as unrealistic and haphazard while focusing on perceived safety concerns for the mother and child when emergencies arise.

All the hospitals cite unused capacity in their own facilities as a reason why the center is not needed and should not be approved by the state.

True argued throughout the day that the certificate of need hearing was less about space available in existing facilities and more about offering a choice for mothers in a non-hospital setting. He said the service is available in all but roughly 11 states and most states bordering Kentucky.

Mothers uncomfortable delivering in hospitals have no other choice but to give birth at home, often in unsafe conditions, True argued.

“Women are entitled to have the choice of where to have their child,” he said.

Matt Klein, an attorney representing HMH and Twin Lakes, argued in his opening statement that physicians on staff at the hospitals do not feel comfortable partnering with the center in the transfer of patients, particularly in emergency cases where Caesarean sections must be performed.

He also argued against the need for the services because the center’s application estimates half or more of its patients will come from Jefferson County. Klein contended Louisville is “chock full” of physicians capable of providing high-quality care for expectant mothers and children, nullifying the need for the center.

Safety and quality of care. Dr. Dan Stewart, a Louisville-area physician certified in pediatrics and neonatal-perinatal medicine, has medical privileges at most major Louisville hospitals and consults with Clark Memorial. Stewart spoke of a robust provider network in Louisville that weakens any argument for the center.

He also challenged aspects of the center’s application, including what he described as a lack of collaborative partnerships established by the center with pediatricians, obstetricians, neonatologists and anesthesiologists.

Stewart said a free-standing birth center with no physician or medical oversight could be “risky business” for deliveries, even in low-risk patients, because many infants in need of intensive care cannot be anticipated in advance.

Stewart also questioned the philosophy behind the quick release of patients. The center’s application says it likely would release the mother and child within 12 hours following delivery. Stewart argued 48 hours of observation is the standard practice because symptoms of illness or defects often do not manifest in infants in the first 24 hours.

Stewart also expressed concern about prospective patients at the center not establishing a compassionate and caring relationship with a pediatrician soon enough to make sure the child is properly cared for.

“That’s why I’m here,” he said. “I’m an advocate for the infant. Everyone is about the mother.”

Stewart said he is not opposed to women seeking a comfortable environment to deliver, but such as environment must be safe.

Dr. Stephen Toadvine, vice president and chief medical officer at HMH, said the 10 obstetricians who have privileges at the hospital either verbally oppose center or wrote letters outlining their opposition, primarily because of the safety risks to the mother and child in emergency cases.

HMH delivered about 1,600 babies in 2012 and roughly 122 were performed primarily by one of three nurse midwives on staff, Toadvine said. The hospital acknowledges birthing plans of mothers if they have alternative requests, he said, and willingly performs low-risk, low-intervention deliveries.

Furthermore, Toadvine said all three hospitals have identified their ability to increase capacity and deliver more children. Twin Lakes, for instance, has said it likely could increase its volume by more than 20 percent, Toadvine stated.

Quoting a letter from HMH President and CEO Dennis Johnson, Toadvine said HMH is not motivated by the potential loss of business to the center.

“The impact on our revenue would be negligible,” he said.

Toadvine said the impact on local mothers and children could be risky, particularly when C-sections are needed. While HMH is only five minutes from the center’s site, Toadvine said it would take much longer than five minutes to respond, transport and admit a patient for surgery when the optimal window to start an emergency C-section is 10 to 15 minutes.

True argued that safety concerns for the center in regard to transfers is no different than when HMH or a comparable hospital admits a patient and unforeseen circumstances develop. When True asked Toadvine if HMH would enter an agreement with the center if it receives a certificate of need status, he said it is unlikely but the issue has not been formally discussed.

“We will always care for any (emergency) that comes to our doors,” Toadvine said. “I don’t feel it’s appropriate to speculate on a linkage agreement.”

Flawed methodology?  Klein argued the application’s business model and utilization outlook is “fundamentally flawed to the point of being irrational” even as the center plans to deny assistance to those on Medicaid. HMH officials testified more than half of the hospital’s obstetric patients are Medicaid recipients.

According to Richard Baehr, a healthcare consultant based in Chicago, the center’s business model indicates it will receive more than half of its patients from Jefferson County and only 7 percent from Hardin County.

Baehr detailed his analysis in a series of PowerPoint slides, arguing the center is basing its expected volume on an assumption that nearly all recorded home births in certain counties will move to the center.

But Baehr said those assumptions are faulty. To illustrate his point, Baehr said obstetrics typically is a compact and local industry in which a facility attracts the majority of patients from their home county. For HMH, more than 50 percent of obstetric patients are from Hardin County while more than 60 percent of obstetric patients at Flaget live in Nelson County, he said.

Baehr also questioned a document in the application predicting the number of home births to triple in Jefferson County from 2009 to 2014, which he said there is no evidence to support.

Baehr said the center is banking on an expected growth rate on a surge in home births from 2007 to 2009, which he attributed to the recession. Baehr argued the increase in home births might be tied to the number of people who lost their jobs or felt financial stress while others may choose home births for religious or personal reasons and therefore would never utilize a birth center.

The center may capture a “sprinkling” of patients from Jefferson or Warren counties, he said, but the numbers outlined in the application are not reasonable.

He also said the number of obstetric patients have declined in the Lincoln Trail region in recent years and the population growth for childbearing women is not large enough to close the gap.

Support for Akers. Colleagues, longtime friends and mothers toting small children filled the modest hearing room in support of Akers and the center. During short interludes, the women spoke about the center and their support for natural home births.

Only one of True’s witnesses testified Wednesday, but she expressed a need for an alternative center in Kentucky.

Susan Stone, president and dean of Frontier Nursing University in Hyden, said nurse midwives receive comprehensive and layered education that requires them to complete a rigorous curriculum, log hundreds of hours of training and perform around 40 live birth deliveries before becoming certified.

While emergency cases occur, she said, most women present triggers to indicate something is wrong, which ultimately makes the midwife suspicious.

“Usually you get warning signs,” she said.

Stone said it is very rare for a mother to have major issues if she is healthy and has had a normal pregnancy. Those cases are more often found in heavy smokers or cocaine users, she said.

In cases where health problems do surface, such as gestational diabetes or anemia, the patient will become ineligible for delivery at the birthing center, Stone stated, and be referred for higher care.

“This is not a birthing center for everyone,” she said.

The hearing resumes at 8:30 a.m. today.

Marty Finley can be reached at (270) 505-1762 or mfinley@thenewsenterprise.