Eliminating the Middlewoman: Elizabeth Seton Closes Its Doors

Wendy Cole arrived on the fifth floor of 32 West 18th Street wearing a grimace and holding the hand of her three-year-old, a boy with closely cut bronze curls who plodded next to his mother with heavy feet. Cole didn’t even glance around the waiting room as she stepped off of the elevator—instead, she went directly to the receptionist’s desk to retrieve her paperwork. She was running late, and had spent nearly twenty minutes walking up and down West 18th Street trying to find the midwifery center of St. Vincent’s Hospital. When she scheduled her appointment, Cole had been told it was on the 18th floor of what turned out to be an unmarked 12-story building between a parking lot and an upscale Chelsea furniture store.

"When I was in my mommy’s tummy we came here," said Orlando of the windowless St. Vincent’s waiting room, the walls of which most patients can never recall the color.

"Well, not here exactly," corrected his mother.

Cole, who lives in Clinton Hill, Brooklyn, is fifteen weeks pregnant with her second child, and Orlando was actually born four blocks south of St. Vincent’s at the Elizabeth Seton Childbearing Center (ESCBC). Cole said she wished she could deliver her second child at the center, too, but its midwives have been relocated to St. Vincent’s as of September.

Last year, midwives and physicians at the ESCBC delivered nearly 300 babies to mothers who, like Cole, sought an alternative to hospital birth. This November, the doors to the center and its three decades of service will close. The center’s insurance policy expired in August and because of the high cost of malpractice coverage—which the center can’t afford—the insurance policy was not renewed. Similar closings throughout the nation mark growing distress that the skyrocketing cost of medical liability insurance is limiting women’s choices in healthcare and childbirth.

"The closing of any birthing center in this city severely impacts women’s choices," says Katherine Abelson, director of the Brooklyn Birthing Center (BBC), a freestanding clinic on Ocean Avenue. Since August, the BBC has welcomed a number of expecting mothers who were turned away at the Seton center. "But not everybody knows we’re here," she says.

This situation is echoed at Long Island College Hospital (LICH) in Brooklyn Heights, just beneath the Brooklyn Bridge. Veteran midwife Joanne Middleton—a Brooklyn-based midwife for more than three decades who today works from LICH—says many women in Brooklyn don’t know about the midwifery services that the 516-bed teaching hospital offers. "It’s hurting everybody," she says of the Seton center’s closing.

Since 1975, the Seton center has served a diverse population of women from the five boroughs, as well as Westchester, Long Island, New Jersey and Connecticut—30 percent of whom require Medicaid. The ESCBC was the first free-standing birth center in the nation and the only free-standing birth center in Manhattan. Affiliated with St. Vincent’s Catholic Medical Center, the Seton center takes its name from Saint Elizabeth Ann Seton. Born in New York City in 1774, Seton became the first native-born North American to be canonized, two centuries later. The Seton center originally opened uptown on East 92nd Street, but in 1996 it moved to 14th Street between Seventh and Eighth Avenues.

The three birthing areas at the center—which Cole describes as "homey"—are equipped with showers and Jacuzzi tubs. Grandmotherly quilts are folded along with medical equipment into cabinets that look like they belong in a suburban kitchen. Colorful oven mitts cover the stirrups of the exam tables under warm, cozy lighting. The Seton center, in other words, is anything but a cold, impersonal hospital.

"I felt sure I could remain calm in such a room and have a positive, spiritual birth experience," says 31-year-old Vijay Owens, who delivered her daughter Charlotte Amelia Owens after a 27-hour labor at the center last May. "It was grueling, but there were no complications and I did it completely without medication of any kind. Thanks to the confidence expressed by the midwife, I never even asked for any," she says.

Midwives attend to low-risk births with minimum intervention and defer to obstetricians only if complications arise. The ESCBC was one of the only facilities in New York City that offered water birth as a delivery option and afforded women an alternative to hospital birth. The center’s record is impressive: it boasts a low C-section rate of 10 percent, compared to the national 26 percent average, and 99 percent of its clients breastfeed upon discharge, exceeding the Surgeon General’s Goal for Healthy People, which says that by 2010, 75 percent of all patients nationwide should be breastfeeding upon discharge.

Despite the attention this notable report card has drawn to the ESCBC, it is not enough to keep the doors to the center open: or, more accurately, to pay its insurance bills. "The center was looking at an increase of 400 percent [in insurance premiums]. They just couldn’t sustain that," says ESCBC media director Michael Fagan.

Obstetricians and gynecologists join neurosurgeons and cardiovascular surgeons as the top three medical fields with the highest insurance premiums because they’re considered high-risk specialists. According to the American College of Obstetricians and Gynecologists (ACOG), obstetricians and gynecologists are sued an average of two and a half times during their career, and one fourth will be sued during their residency. At birthing centers the situation is further complicated by which professional—the midwife or the attending physician—would be held liable in a suit involving both.

In the past three years, birthing centers have been closing across the country—most recently in Nevada and Illinois. In New York City, Soho Midwives closed in December 2002, transferring its patients to the Seton center. A similar midwife shortage took place in the mid-1980s, according to ACOG, whose leadership has vowed to keep medical liability reform high on the nation’s political agenda. In the current medical malpractice climate, large jury verdicts have lead to high insurance rates, forcing midwives out of practice.

Large damage awards are seen as the primary catalyst for the medical malpractice crisis in the United States. "Twenty-seven percent of our fellows have reduced their obstetrical practices, and 12 percent have reduced their surgical practices due to the liability crisis," says Ralph Hale, who serves as executive vice president for ACOG. The organization calls for subsidized insurance rates and caps on non-economic damages for pain and suffering in medical malpractice suits.

The American Trial Lawyers Association (ATLA), however, blames the corporate greed of insurance big wigs for limiting women’s healthcare choices, rather than damage awards in liability lawsuits. The organization calls the medical malpractice crisis "manufactured"; a strategy of the Republican Party aimed at draining the pockets of trial lawyers and courting middle- and working-class voters.

In the October 2002 issue of TRIAL magazine, former ATLA president Mary Alexander, a California-based consumer advocacy attorney, wrote: "It is a myth devised by the insurance industry in the quest for draconian federal restrictions on medical malpractice lawsuits. Lawyers are blamed in order to mask the greed and misdeeds of the insurance industry. They are already gouging doctors. Now they want a government-sponsored bailout in the form of nationwide damages caps so errors that maim or kill will not cost insurers a lot of money."

Trial lawyers are major contributors to the Democratic Party and get paid according to trial awards or settlements: by limiting those awards, those contributions to Democratic candidates would also be limited. This correlation is of particular concern for women since the Republican Party—and the Bush administration specifically—has been a powerful foe of women’s reproductive health, according to organizations such as Planned Parenthood and the National Organization for Women (NOW). "Piece by piece, Bush is tearing down the progress women and other disenfranchised groups have made over the past 35 years," NOW’s website flatly declares.

The current system presents what appears to be a no-win situation for women: while tort reform may keep more birthing centers open, it may also ultimately limit other aspects of women’s health issues by draining Democratic Party resources. But regardless of whether tort reform is ultimately a viable solution, or whether other facets of the insurance industry itself need to change, no strategy will prevent the closing of the ESCBC.

Midwives at the center will proceed with expecting mothers such as Wendy Cole in their new offices on West 18th Street. The Mommy-Baby Yoga classes and other groups that meet at the center held their final sessions there in October and in November the organization will vacate the building for good.

"To see the ESCBC close its doors is devastating. But to have my health care choices stripped from me is humiliating," says Rachael Carnes, who gave birth to her daughter at the center last year.

At the Brooklyn Birthing Center (BBC), Katherine Abelson expects the influx of mothers transferring from the ESCBC to continue into the winter. "Our numbers have quadrupled this year," she says. As of September 2003, the BBC was delivering an average of eight babies per month, up from an average of two births per month in 2002. "It’s word-of-mouth, it’s repeaters, it’s more hits on the website; and Elizabeth Seton has certainly accounted for the recent influx since August," says Abelson of the growing numbers at the BBC.

Cole, meanwhile, says she and her husband, Damon, have decided to remain with the Seton staff at St. Vincent’s. She is due in March, and hopes to have Orlando present at his younger sibling’s birth. Her midwife—who chatted with Orlando about his toy tools while she took Cole’s blood pressure—agreed that Orlando would be old enough to attend the birth (he will be four in November).

As she searched for the baby’s heartbeat—a frenzied pattering amplified for the young family to hear—the midwife assured Cole: "We love to have siblings present."

Contributor

Marjory Garrison

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