Distance: How far is too far? 

The location of a freestanding birth center - that is the allowable distance from the birth center to the acute care obstetric-newborn service - has been the subject of debate since the birth center concept was introduced. When the Maternity Center Association of New York translated the concept into a demonstration model, appropriate distance from the "back-up" hospital was argued back and forth for many months. Those who opposed the concept felt that the birth center belonged inside the hospital and, if not inside, then adjacent to it.

What are the guiding principles for determining the relationship between the primary care birth center site and the acute care hospital service? Is the distance the critical element? Evidence to date would suggest that it is not, for distance is dependent upon a number of other variables.

At Su Clinica Familiar in Raymondsville, Texas, the birth center is 22 miles from the hospital. It is a straight run that takes about 25 minutes. The clinic serves a population where 50 percent are below the poverty level, with limited access to transportation, and the singular option of the traditional birth attendant before the clinic opened. In the first 1,421 births 19 neonates were transferred to the hospital where three died. Three died in the birth center in the first 24 hours after birth. The total neonatal death rate was 5/1000 live births. There were no maternal deaths.

The important factor at Su Clinica was, and is, the birth attendant... not the distance from the hospital. It is quite possible that throughout the maternity care system, the most critical question is, "Who is with the mother?" That person will determine how far away help is when it is needed. Even inside the most sophisticated medical complex, the person with the mother may cause the assistance to be "too far". If the person with the mother does not recognize problems early, communicate the problems so that appropriate response is obtained, and have the trust of the mother to accept the treatment needed, then the distance is "too far."

The location of a freestanding birth center will depend on the community it is established to serve. If the purpose is to serve the poor in a rural area where women have limited access to transportation, placing the birth center next to a hospital will not make much sense. If the purpose is to serve educated middle-class women who are rejecting the illness orientation of the hospital, birth centers in hospitals do not make much sense.

If the purpose is to try to reduce the cost of maternity services, it will be difficult to do

if requirements for hospital construction, regulation and accreditation are imposed upon a preventive health facility.

The response to "how far is too far" cannot be measured in terms of city blocks, miles or even minutes. There are preliminary steps to dealing with all emergencies:

• Prevent emergencies by careful screening, continuous monitoring and comprehensive education of the mother.
• Have a well-rehearsed plan for action spelled out in policies and procedure.
• Be able to initiate treatment while implementing the plan of action for transport.
• Optimize your communication with the mother and the family.
• Understand the capability for the receiving facility to respond to the problem and properly inform them so they can be ready.

If the receiving team is ready for the admission and treatment, the distance can be measured in travel time. If the receiving hospital is not ready, the time (distance) may be greatly extended. Trauma units have worked hard to minimize the time/distance factor and serve as a model for affiliated primary and acute care facilities.

AABC is presently conducting a survey of operating birth centers. The 65 centers reporting to date range from two minutes and a few yards away from the hospital to one hour and twenty minutes away. Thirty percent were less than five minutes; 23 percent were less than 10 minutes; 12 percent less than 15 minutes; 14 percent less than 30 minutes. The remaining centers represent special circumstances relating to population needs. Distance has never been regulated.* Yet reason and precaution seem to have prevailed.

* Subsequently, distance has been regulated (15 minutes) in the New York State Regulations.

by Kitty Ernst, CNM, MPH

(Reprinted from AABC News ~ Summer 1994, edited)