2/120/07njm

**Q. Are birthing center regulations less restrictive than hospitals?**

A. Birthing centers in Indian Country have the same regulations as Level
I hospitals

**Question**

**Are birthing center regulations less restrictive than hospitals?**

Here is what Wikipedia\* says the definition of a birthing center is:

Birthing Center (noun)

"A medical facility, often associated with a hospital, that is designed
to provide a comfortable, homelike setting during childbirth and that is
generally less restrictive than a hospital in its regulations, as in
permitting midwifery or allowing family members or friends to attend the
delivery."

**Answer**

Though I generally agree with Wikipedia, it also perpetuates a common
misconception for both healthcare providers and the lay public in this
section "**A medical facility ....generally less restrictive than a
hospital in its regulations..."**

In the Indian Health system, a 'birthing center' is subject to the same
regulations as any Level I low risk obstetrical service, whether it is
attached to hospital or offsite. In addition, state and local
regulations apply.

Here are three basic descriptions of levels of perinatal care:

-   Level 1 hospitals provide care to normal and low-risk pregnant women
    and newborns, and they do not operate neonatal intensive care units
    (NICU);

-   Level 2 hospitals provide care to women and newborns at moderate
    risk and do operate NICUs;

-   Level 3 hospitals care for patients requiring increasingly complex
    care and operate NICUs.

To fully understand the implication of a low risk center, regardless of
the terminology, here are two helpful resources:

-The American College of Obstetricians and Gynecologists (ACOG)
Guidelines for Perinatal Care, 5^th^ Edition, Chapter 1: Organization of
Perinatal Health Care, page 7

Table 1-2 - Levels of Perinatal Care
<http://www.acog.org/publications/guidelinesForPerinatalCare/gpc-1.pdf>

-The American Public Health Association has published guidelines for the
writing of state regulations for birthing centers
<http://www.birthcenters.org/pdf/apha_guidelines.pdf>

**Background**

Research strongly supports regionalization as a means of improving
maternal and infant outcomes. Perinatal regionalization represents the
continuum of care that ensures that all pregnant women, fetuses and
newborns have timely access to care.

Here is one example from New York State:

New York State\'s system of regionalized perinatal services includes a
hierarchy of four levels of perinatal care provided by the hospitals
within a region and led by a Regional Perinatal Center (RPC).

The regional system is led by an RPC that is capable of providing all
the services and expertise required by the most acutely sick or at-risk
pregnant women and newborns. The concentration of high-risk patients
makes it possible to enhance and maintain the level of expertise in the
care of high-risk obstetric and neonatal patients, as well as justify
the substantial expense required to establish and maintain neonatal
intensive care units and attending-level subspecialty consultation. RPCs
provide or coordinate maternal-fetal and newborn transfers of high-risk
patients from their affiliate hospitals to the RPC, and are responsible
for support, education, consultation and improvements in the quality of
care in the affiliate hospitals within their region.

The four levels of perinatal care within the regionalization system vary
by the types of patients that are treated, availability of sub-specialty
consultation, qualifications of staff, types of equipment available and
volume of high-risk perinatal patients treated. Besides the RPC, there
are three other levels of care:

-   Level 1 hospitals provide care to normal and low-risk pregnant women
    and newborns, and they do not operate neonatal intensive care units
    (NICU);

-   Level 2 hospitals provide care to women and newborns at moderate
    risk and do operate NICUs;

-   Level 3 hospitals care for patients requiring increasingly complex
    care and operate NICUs.

<http://www.health.state.ny.us/community/pregnancy/health_care/perinatal/hospital_designations.htm>

**Resources**

Robert Wood Johnson, Chapter 8

The Regionalized Perinatal Care Program  * *

To Improve Health and Healthcare, volume IV

<http://www.rwjf.org/files/publications/books/2001/chapter_08.html>

American Public Health Association (APHA) Guidelines for Licensing and
Regulating Birthing Centers

<http://www.birthcenters.org/pdf/apha_guidelines.pdf>

Guidelines for Perinatal Care, 5^th^ Edition, ACOG

<http://www.acog.org/publications/guidelinesForPerinatalCare/>

Level I -- Standards for Perinatal Care

(Illinois General Assembly Section 640.41 )

<http://www.ilga.gov/commission/jcar/admincode/077/077006400000410R.html>

Level II and Level II with Extended Capabilities -Standards for
Perinatal Care

(Illinois General Assembly Section 640.42)

<http://www.ilga.gov/commission/jcar/admincode/077/077006400000420R.html>

Level III -- Standards for Perinatal Care

(Illinois General Assembly Section 640.43)

<http://www.ilga.gov/commission/jcar/admincode/077/077006400000430R.html>

Birthing Center Standards, American Association of Birthing Centers

<http://www.birthcenters.org/open/standards.php>

Birthing Center Regulations, American Association of Birthing Centers

<http://www.birthcenters.org/open/bcregs.php>

Birthing Center Accreditation, American Association of Birthing Centers

<http://www.birthcenters.org/open/bca/index.php>

Utah Rule R432-14. Birthing Center Construction Rule

<http://www.rules.utah.gov/publicat/code/r432/r432-014.htm>

**Articles**

[Yu
VY](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Yu+VY"%5BAuthor%5D),
[Dunn
PM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Dunn+PM"%5BAuthor%5D).
Development of regionalized perinatal care. [Semin
Neonatol.](javascript:AL_get(this, 'jour', 'Semin Neonatol.');) 2004
Apr;9(2):89-97
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16256712&dopt=Abstract>

[Lee
SK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Lee+SK"%5BAuthor%5D),
et al The benefit of preterm birth at tertiary care centers is related
to gestational age.  [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2003
Mar;188(3):617-22

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12634630>

[MacDonald
H](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="MacDonald+H"%5BAuthor%5D);
[American Academy of Pediatrics. Committee on Fetus and
Newborn](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="American+Academy+of+Pediatrics.+Committee+on+Fetus+and+Newborn"%5BCorporate+Author%5D).
Perinatal care at the threshold of viability.
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2002
Nov;110(5):1024-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=12415047>

[Hein
HA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hein+HA"%5BAuthor%5D),
[Lofgren
MA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Lofgren+MA"%5BAuthor%5D).
The changing pattern of neonatal mortality in a regionalized system of
perinatal care.
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 1999
Nov;104(5 Pt 1):1064-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10545548>

Perinatal care at the threshold of viability. American Academy of
Pediatrics Committee on Fetus and Newborn. American College of
Obstetricians and Gynecologists Committee on Obstetric Practice.
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 1995
Nov;96(5 Pt 1):974-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=7478851&dopt=Abstract>

[Cunningham
AS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Cunningham+AS"%5BAuthor%5D).
Level 2 hospitals and regionalized perinatal care. [Am J Dis
Child.](javascript:AL_get(this, 'jour', 'Am J Dis Child.');) 1987
Sep;141(9):938-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=3618564>

**Appendix**

**Example of Levels of Perinatal Care in Indian Health**

**Anesthesia Programs in Indian Health**

**From IHS Part 3, Chapter 13 Maternal Child Health**

  ------ ----------------------------------------------------------------
  1\.    IHS obstetric services which have major obstetric surgical
         programs shall have:\
          

  ------ ----------------------------------------------------------------

  --------- -------------------------------------------------------------
  a\.       An organized anesthesia program under the direction of
            physician member of the medical staff.\
             

  b\.       Anesthesia care provided by anesthesiologists or other
            qualified persons such as certified registered nurse
            anesthetists and physicians with sufficient training a
            experience to be granted specific anesthesia privilege such
            as for subdural and/or epidural techniques.\
             

  c\.       Regulations relative to anesthetic safety.\
             

  d\.       Written policies related to the delivery of obstetric
            anesthesia care.\
             

  e\.       Post-anesthesia recovery should be performed by either
            Certified Registered Nurse Anesthetist (CRNA) or RN.\
             
  --------- -------------------------------------------------------------

  ------ ----------------------------------------------------------------
  2\.    IHS low risk maternity units without major obstetric surgical
         and anesthesia capabilities shall:\
          

  ------ ----------------------------------------------------------------

  --------- -------------------------------------------------------------
  a\.       Provide only analgesia and/or local anesthesia for the
            conduct of labor and delivery utilizing those techniques and
            drugs and approved by the medical staff.\
             

  b\.       Have a physician member of the medical staff as director of
            the maternity analgesia and/or local anesthesia care
            program.\
             

  c\.       Grant privileges for local anesthesia only to those
            physicians and certified nurse midwives who have demonstrated
            ability, training and experience.\
             

  d\.       Have written policies related to the delivery of maternity
            analgesia and/or local anesthesia care.\
             
  --------- -------------------------------------------------------------

Chapter 13, Maternal Child Health IHS Manual Part 3

[http://www.ihs.gov/PublicInfo/Publications/IHSManual/Part3/pt3chapt13/pageone.](http://www.ihs.gov/PublicInfo/Publications/IHSManual/Part3/pt3chapt13/pageone.htm)

\*Wikipedia: Definition of a birthing center

<http://www.answers.com/topic/birthing-center>