The number of births in Missoula is holding steady, but the options for how to give birth are multiplying and evolving to accommodate a growing number of women who want natural births.
Shortly after Community Medical Center announced a pending merger with Billings Clinic and RegionalCare Hospital Partners in March, Providence St. Patrick Hospital said it would begin offering obstetrical care as soon as 2015, placing Missoula’s two hospitals in direct competition.
Efficiencies of scale play a part in decisions to add services, but it’s unclear how many births are required for those services to make sense financially for a hospital in Montana, said Bryce Ward, director of health care research at the University of Montana’s Bureau of Business and Economic Research.
In some communities, hospitals are moving to consolidate services, while in other areas small care centers still provide birth services, Ward said.
In theory, choice provides customers with more leverage and so saves them money, he said.
“As an economist, we tend to like having more choice, so that’s generally a good thing, assuming that both hospitals can provide good-quality service,” Ward said.
Clearly, St. Pat’s leaders feel the move to offer obstetric services is a sound one economically, he said.
Statewide, the number of births between 2010 and 2012 remained nearly level. Missoula’s population, though, has been growing recently, Ward said.
“It will work itself out, particularly as long as Missoula continues to grow,” Ward said of the expanded services. “More babies will be delivered here and whatever capacity St. Pat’s ultimately creates will probably end up getting utilized over the long term.”
According to a report by Larry Swanson at the O’Connor Center for the Rocky Mountain West, the health care industry has grown more then any other sector of Missoula’s economy since 2001.
In 2012, health care generated $545 million of labor earnings in Missoula County, the report shows.
“In line with our long-range regional investment strategy, Providence St. Patrick Hospital is on track to begin delivering babies in June of 2015,” Stacy Rogge, regional director of marketing and communication for Providence Western Montana, said in a written statement about the hospital’s plans to provide comprehensive women’s and children’s services. Rogge added that more details would come soon, as St. Pat’s works to implement its planned expansion.
The number of births affect not only a hospital’s bottom line, but also outcomes for mothers and babies, said Bardett Fausett, a perinatologist at Community Medical Center who handles high-risk pregnancies.
Birth is a natural process, but sometimes things go wrong and larger birth facilities can provide more expertise and have real-world experience in emergency situations, Fausett contends.
Community’s specialized services, including Fausett’s role as a perinatologist and a Level III Neonatal Intensive Care Unit, will continue to draw patients from around the region and state, said Cindy Wolverton, director of obstetrical services at the hospital.
Only two other perinatologists work in the state, Wolverton said.
“That definitely played into our thinking,” she said about Community’s offering of specialized care.
Community also is able to work with women who have previously had a caesarean section to have a vaginal birth after caesarean, or VBAC. The move requires extra staffing and expense to mitigate the potential that the scar from the earlier procedure ruptures, she said.
The overall caesarean section rate is about 30 percent, with the percentage of first-time caesarean sections at 17 percent, in line with national averages that have risen significantly in the past 20 years.
Mothers who want natural births also are served at Community, which in 2012 opened its newly renovated labor and delivery and postpartum facility to accommodate the roughly 1,500 births that occur at the hospital each year. Women in the community provided input that was used in the design process.
“There was a lot of feedback that they wanted it to have a natural feel,” Wolverton said.
High-tech fetal monitors allow laboring mothers to be mobile or in a private jacuzzi tub in their rooms, which were designed to be roomy and comfortable for partners or family members to stay.
A nursery was not part of the overhaul, and babies stay in rooms with their parents instead. Babies also are immediately placed on their mother’s chest post-birth, which helps improve their vitals and helps moms nurse and recover more quickly, too.
“We get to apply holistic care to all women who come to our facility,” Wolverton said.
“We’re not these huge interventionalists either,” Fausett said, adding that as long as there aren’t complications, a mom can birth naturally at the hospital.
But the mom is also literally across the hall from an operating room, he added.
Additionally, he can perform fetal surgeries before babies are born to help ease complications and keep babies in utero as long as possible.
“What this place has is the ability to provide hope even in complicated situations,” Fausett said.
In addition to in-hospital births, Montana law allows for the regulation and licensing of midwives, and the state trend has mirrored a national one that shows more women are opting to give birth at home in recent years.
Of the 12,052 live births in Montana during 2012, about 4 percent didn’t take place in a hospital, according to state statistics. The average is 450 out-of-hospital births a year.
For women who want a natural birth, the Birth Center in Missoula offers two certified nurse midwives and comfortable, home-like birth rooms.
Since the Birth Center reopened in 2009, just over 300 babies have been born at the state-licensed center, with 88 born in 2013 alone, said Jeanne Hebl, certified nurse midwife and owner of the Birth Center.
“We’ve gotten busier throughout the years,” she said. the Birth Center has added staff and birthing rooms to accommodate the demand.
What the Birth Center provides is different from either St. Pat’s or Community’s offerings, Hebl said.
“I think we provide a unique service,” she said.
Most women who choose the Birth Center want a natural birth without intervention measures. Many want the option of a water birth, said Hebl.
Their care begins long before they come to the center during labor, and women receive education, as well as postpartum home visits and newborn wellness screenings as part of their care. A lactation specialist helps women breastfeed as well.
The center provides a more relaxed, homelike atmosphere than the hospital for labor and delivery that fosters empowerment of the woman and her family in the process, Hebl said. “We’re kind of an intermediary between hospital and home.”
Women largely arrive when they’re in active labor, and stay for a few hours after, before departing for their own homes. Some women, due to complications or a wish for pain medications, do transfer to Community Medical Center before fully giving birth. The transfer rate is 16 percent. Of those women, 6 percent receive caesarean sections, Hebl said.
While neither she nor her fellow certified nurse midwife Nichole Loran can make decisions for patients once at Community, they are welcome in support roles, Hebl said.
Longtime Missoula midwife Sandhano Danison, too, said she is welcome at Community in a support role.
Like her Birth Center counterparts, Danison doesn’t accept high-risk patients, mitigating risks of birthing at home.
She spends nine months building a relationship with and educating women about childbirth and helping them prepare their homes for the arrivals. Danison can order labs and send for sonograms and runs prenatal appointments on the same schedule that an obstetrician would.
“We just come to your house for the birth,” she said.
Each year, Danison, working with one of only a handful of Missoula midwives, delivers about 40 babies, a number that has been consistent for several years, she said.
When a woman goes into labor, Danison draws on their relationship to make decisions about the course of the birth.
While it’s rare for a woman to go to the hospital at some point during a home birth, most often the transition is because of exhaustion, Danison said, adding that sometimes women decide they want pain medication after all.
However, when there is a severe complication, a delay of care occurs while women are transported to the hospital, she said.
Just as birth options in Missoula vary, so do prices.
At the Birth Center, the average cost is about $7,000 for the entire regimen of care. Women who give birth at Community Medical Center pay an average of $8,800 for a normal vaginal delivery.
Sometimes, Danison gets paid in barter for her services, which run between $1,800 and $3,000. Unlike the Birth Center and Community, most insurance companies and Medicaid don’t cover the expenses of a home birth.
Both Hebl and Danison said they feel that demand will remain steady for their services regardless of what St. Pat’s adds.
Montana has a longstanding tradition of home birth – in part because of the sheer isolation of the landscape – and Danison said she doesn’t expect that to change.
“I help several women at home who were born at home themselves,” Danison said.
Women make conscious decisions to birth in an alternative setting to a hospital for specific reasons, and the trend of women wanting natural childbirth seems to be on an upward trajectory, she said.
St. Pat’s added services will be a positive for Missoula women, Danison said.
“I really think it will benefit. I really do. I think the more options for women, the better,” she said, with Hebl echoing the same sentiment.