REGIONAL REPORT : Regulation of Birth Centers Urged to Ensure Quality

The concept of birthing centers--a less expensive alternative to hospital maternity wards--is catching on in Southern California. But no one knows for sure how rapidly, or how well, the centers take care of mothers and babies.

That is because there is no state licensing or inspection of the centers, and no agency regularly keeps track of them.

“If someone gave you a figure on how many birthing centers there are, don’t believe it because no official records are kept on these centers,” said Janie Cordray, spokeswoman for the Medical Board of California.

Critics say California’s lack of licensing and state inspection are among the flaws and potential dangers of the centers, where babies are delivered with an assist by state-registered nurse-midwives.

The lack of specialists and hospital lifesaving equipment alarms some critics in traditional medicine. “The potential for damage is enormous in obstetrics cases,” Cordray said.

But supporters say that birthing centers--a phenomenon that began to gain in national popularity in the 1970s--are safe, beneficial, low-cost ways of meeting an urgent health care need in the state.

In December, 1989, the Columbia University School of Public Health in New York reported that a two-year study of birthing centers nationwide showed them to be “a safe and acceptable alternative to hospital confinement” for low-risk pregnant women.

“Birthing centers provide low-cost, satisfying care for the consumers,” said Roberta Frank, a nurse-midwife who heads the Best Start Birth Center Inc. in San Diego. “A lot of critics have absolutely no idea of the high quality of care women receive at birthing centers.”

But the critics, which include the American College of Obstetrics and Gynecology, say that consumers do not really know what they are getting when they pick a birthing center, especially if such centers are not licensed.

In California, there not only is no licensing of birthing centers, there also is no legal definition of what constitutes one. Businesses that call themselves “birthing centers” in California range from fly-by-night storefront operations to carefully monitored, multimillion-dollar medical buildings.

One of the smaller birthing centers, operated by a Valencia doctor, resulted in eight deaths of infants and his conviction for second-degree murder in 1990. Supporters of birthing centers say that that case was an aberration and that the doctor did not operate a genuine birthing center.

Although no official tallies are kept, Los Angeles County is believed to have at least six birthing centers. Orange County has three, San Diego and San Bernardino counties two each, and Riverside County one. Ventura County has no birthing centers, according to the county’s Public Health Department. Nationwide, there are an estimated 170 birthing centers.

A birthing center is similar to a clinic. Mothers can give birth at a center, assisted by the nurse-midwife, for considerably less than in a hospital. A 1989 study by the Health Insurance Assn. of America showed that the cost for physicians’ charges and hospital delivery of a baby averaged $4,334, compared to the average cost of $2,111 for a baby born in a birthing center.

For California’s large population of recent immigrants, who statistically have a high birthrate, birthing centers are a much-needed way of getting low-cost maternity care, according to advocates of the system.

Moreover, birthing centers also appeal to some middle-class and upper-income women who fear that the rate of Cesarean-delivery births is too high in hospitals. The advent of birthing centers in the 1970s stemmed from middle-class women’s discontent with high-tech hospital procedures in the eastern United States, according to the National Assn. of Childbearing Centers.

In California, some of the best and largest birthing centers are affiliated with hospitals, officials said. The most notable example is the 8,552-square-foot facility that opened Dec. 5 at UC Irvine Medical Center. The birthing center will handle an estimated 1,500 births a year, greatly easing the hospital’s overload of indigent maternity cases.

But some medical observers say that UC Irvine’s well-supervised birthing center is not typical. Smaller birthing centers sometimes lack adequate supervision by personnel trained in the life-and-death dangers that can accompany childbirth, according to Ken Wagstaff, executive director of the Medical Board of California.

In testimony to a congressional committee last April, Wagstaff said: “There have been repeated instances in ‘birthing clinics’ where little or no physician supervision was available, and births were attended by totally unqualified personnel.”

In a recent interview, Wagstaff said he believes California should require licensing of birthing centers.

“One benefit of licensing would be to help the consumer,” Wagstaff said. “Right now, the consumer knows very little about birthing centers. You can go into one and see people all in white uniforms, and you’d think you’re in a very good clinic. But there is no real medical control in the sense of a hospital or a licensed clinic.”

Wagstaff said birthing centers affiliated with a hospital, such as UC Irvine Medical Center, have good supervision. The ones he worries about, he said, are those that are loosely supervised and not near a hospital.

Similarly, Mort Lebow, spokesman for the American College of Obstetrics and Gynecology, said: “We are concerned about birthing centers for reasons of safety when they are not a part of a health center where, in an emergency, a woman could be quickly given any help she may need.” Lebow said about 20% of low-risk pregnancies unexpectedly turn high-risk during labor and delivery.

Cordray, of the state medical board, said a few birthing centers in California do not make adequate arrangements for rushing women to a hospital in case of a complicated delivery. In one case, she said, there were indications that a birthing center in Los Angeles County put women with complicated birth problems in a taxi and had the driver anonymously deliver them to a hospital.

Under state law, the only rule governing birthing centers is a provision that any place where babies are born should be generally under the supervision of a licensed physician. But the birthing center does not need to be licensed, and there is no regular oversight of the relationship between the physician and center.

“Basically, a birthing center is like a doctor’s office, and state law has no regulations on a doctor’s office,” Cordray said.

In the instances when the state has investigated a birthing center, the focus has been on the licensed physician in charge. Three cases in recent years focused negative attention on birthing centers in Southern California:

* In February, 1990, Dr. Milos Klvana was sentenced to 53 years in prison after being convicted of second-degree murder in the deaths of eight infants born in birthing centers he operated in Valencia and Temple City. The jury found that Klvana proceeded with out-of-hospital deliveries in cases with high-risk prenatal or childbirth complications he knew were beyond his skills.

* Last April, the state medical board revoked the license of Dr. Charles W. Turner Jr. of the Covenant Birthing Center in Anaheim. The board found Turner guilty of “gross negligence” in several births he attended, including a controversial “New Year’s baby” episode. On Dec. 31, 1989, Turner anesthetized a woman in labor and delivered a baby with forceps seconds after midnight. He then rushed the newborn baby to nearby Melodyland Church to display to the congregation and a televised religious program.

* Last June, Dr. Howard E. Marchbanks of La Habra voluntarily relinquished his license after being accused by the medical board of “gross negligence” and “sexual misconduct” in the operation of a birthing center. State officials alleged that Marchbanks was “extremely” negligent in the delivery of two babies and that he sexually mistreated five mothers at his birthing center.

Wagstaff, of the medical board, said a major problem with California’s birthing centers is that the lack of licensing and regulation allows good facilities to be tarred by the reputation of bad ones. He said state licensing would weed out the good from the bad--and help consumers in the process.

There appears to be no organized opposition to state licensing within the birthing center industry. Some center operators said they hope that the state requires licensing.

“I definitely favor licensing. I think it would prevent misinformation and would separate real birthing centers from places that just call themselves ‘birthing centers,’ ” said Frank of the Best Start Birth Center.

There has been no legislative effort to license or inspect California birthing centers, according to Paul Press, chief consultant of the Assembly Health Committee.

Among those strongly in favor of licensing birth centers in California is the Pennsylvania-based National Assn. of Childbearing Centers, an advocacy group. “We support licensing because we believe it is the duty of a state to protect the public. Without regulation, there is no recourse for the public,” said Eunice K. M. Ernst, director of the group.