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Though the demand for midwifery services is growing, the options for women who choose planned out-of-hospital deliveries are becoming fewer — especially for those enrolled in the Oregon Health Plan. On the last day of the busiest month in the history of Trillium Waterbirth Center in Medford, midwife-proprietor Augustine Colebrook posted a letter to her clients informing them that the doors will close Nov. 25. All current and future business, she wrote, is being diverted to the newly expanded, but much smaller Trillium Waterbirth Center in Grants Pass. Colebrook, who once had the distinction of operating the only two free-standing birth centers between Eugene and Sacramento, said it’s no longer feasible for her to run both. She cites the Oregon Health Plan’s (OHP) reimbursement process and the Oregon Health Evidence Review Commission’s (HERC) stringent guidelines governing midwifery as primary reasons. “As the OHP medical review board reviews each of our OHP client’s charts they have seen fit to deny payment for almost half of the women in our care,” Colebrook said. Trillium midwives have attended approximately 100 births each year since Colebrook opened Trillium in Medford in 2010 and in Grants Pass in 2013. The staff helped to deliver 17 babies at the Medford center in August — the month she announced the closure. She also will cease operating the five-year-old Wise Women Care Associates, a wellness center assisting mothers prenatal through postnatal. Oregon has one of the highest rates nationwide of mothers giving birth outside of a hospital. The Oregon Section of the American College of Obstetrics and Gynecology reports that about 4 percent of the 42,011 live term births in Oregon in 2012 occurred outside of a hospital setting. And, while OHP’s Medicaid-funded health plan pays for more than half of all Oregon births, the majority are in-hospital births. “The process to be eligible for Medicaid reimbursement for patients birthing out of the hospital is time-consuming for the care provider and, in my opinion, is discriminatory towards women by eliminating many women’s right to choose where and with whom they have their babies,” Colebrook said. Colebrook said that approximately 55 percent of her clients qualified for Medicaid this past year. The Oregon Health Authority requires midwives to submit extensive paperwork before getting compensated, a process that sometimes stretches through the term of the pregnancy. If a woman is declined, or must be transferred to the hospital during delivery, Trillium receives nothing for its prenatal services. Additionally, Colebrook said, the state recently stopped compensating midwives who assist the primary midwife at a delivery. In the first six months of 2015, she said 27 clients were affected. A handful appealed their case and won, but 10 were denied coverage. Since February of this year, she has been unable to collect insurance reimbursement for seven cases. Six mothers opted to pay completely out-of-pocket for care despite qualifying for Medicaid. “It is unfair, confusing, and even traumatizing for mothers to go through their pregnancy and births not knowing if their care will be covered, even when their chosen care provider is working well within the scope of her practice,” said Jessica “Veege” Ruediger, who like Colebrook, is nationally certified and state licensed to practice midwifery. Ruediger, who assists at home births in the southern Rogue Valley, including Ashland, Talent and Medford, added that “some of the low-income mothers I work with are facing the undue threat of altering their medical choices, being asked to accept medical interventions that they don't want and have the right to decline, or pay out-of-pocket for midwifery care even when their midwife is an OHP provider.” Colebrook said OHP reimbursement rates for midwifery care are currently half of the actual costs for services rendered and the amount allotted for facility reimbursements are one-sixth of actual costs of providing care in a birth center. Consequently, The Trillium Waterbirth Center has seen a 52 percent reduction in cash flow since before the Affordable Care Act (ACA) took effect in Oregon in late 2013. Colebrook said that Trillium Waterbirth Center will no longer accept clients covered only by OHP/Medicare insurance. Colebrook is not alone in losing the fight for reimbursement. Home Sweet Home Birth Center in Lincoln City will close in the coming weeks for much the same reason. The closure leaves the Central Coast without a birth center. Like Colebrook, the proprietor of Home Sweet Home said she could no longer absorb the losses. Both birth centers have been unable contract with their respective Coordinated Care Organizations (CCOs), which manage OHP cases. “We constantly have to prove we’re worthy to be in-network,” Colebrook said. Naturopathic doctor Wendy Green, who specializes in obstetrical care at Kalista Birth Sanctuary and Wellness Center in Medford, was accepted in the Jackson Care Connect network, which is managed by Care Oregon. Unlike other birthing centers with a staff of midwives, Green handles the prenatal care and the births herself. Many private insurance companies cover out-of-hospital birth costs. Under ACA, maternity and newborn care is one of the 10 essential health benefits that must be covered in individual and small group plans, according to Dania Palanker, senior counsel at the National Women’s Law Center. Colebrook advises clients to contact their insurance provider and research to see which providers are within that plan’s network. CCOs prefer that midwives carry the same malpractice insurance as obstetricians and hospitals do. Colebrook, however, said that malpractice insurance was cost prohibitive, routinely exceeding a midwife’s annual salary. Private insurance reimbursed her for services without such a requirement. She argued that since nearly all CCOs are owned and controlled by hospitals and physician groups, they have an economic incentive to prevent women from going outside their facilities or choosing direct-entry midwives for childbirth. Malpractice insurance does cover nurse midwives who are nurse practitioners specializing in childbirth and typically deliver at hospitals, including Providence’s BirthPlace — the only accredited “Baby-Friendly” facility in Jackson County — and Asante Rogue Regional Medical Center in Medford, Asante Three Rivers Medical Center in Grants Pass (also designated as Baby-Friendly) and Asante Ashland Community Hospital. The decision by CCOs to deny contracting with free-standing birth centers is not limited to Oregon. Lesley Rathbun, the president of the American Association of Birth Centers, wrote U.S. Health & Human Services Secretary Sylvia Burwell in July, accusing managed care organizations in Oregon and four other states of violating ACA by preventing women from care at birth centers. The scope of Colebrook’s Trillium Waterbirth Centers and Ruediger’s Moonstone Midwifery are defined by their license regulations. Only pregnancies that are deemed to be low-risk are appropriate for out-of-hospital births, but Colebrook said 91 percent of her patients delivered at her birth center. When problems arise such as a breech birth, presence of genital herpes or some other illness that could affect the infant’s health, or in some cases, a history of caesarean deliveries, the woman must deliver her baby in the hospital. However, with new standards likely to be adopted Nov. 12 when HERC convenes in Wilsonville, women planning to give birth outside of a hospital will have to meet stricter risk criteria if they want their care covered by OHP. Dr. Catherine Livingston, associate medical director for HERC, said some women will be unnecessary classified as high risk, but she said, they are the exceptions. “We’re making policy for a population level, so this needs to be the best it can be for the vast majority,” she said. According to the Oregon Midwifery Council, the criteria covers risk conditions that midwives agree are not appropriate for home births, but it also includes conditions that are well within the scope of practice for birthing centers such as Trillium. “Midwives are qualified to assess risk status and offer informed consent,” argued Ruediger. “Look to our recent Midwives Alliance of North America (MANA) statistics, which have a big enough sample size to be fairly compared with medical mainstream research, and you will see that midwives are practicing responsibly, saving huge amounts of money, and producing excellent outcomes.” Cynthia Pellegrini, senior vice president for public policy and government affairs at the March of Dimes, backs that up. “Birth centers and certified nurse-midwives have a good record of safety and patient satisfaction and birth outcomes,” she said. The American Association of Birth Centers also found no evidence of risk in water births. It analyzed data from 3,998 water births that occurred between 2007 and 2010 and were part of a sample of 15,574 obstetrically low-risk women eligible for birth center delivery at the onset of labor. Colebrook who has trained future midwives through her “Pathways to Midwifery” courses, still believes in the practice, but not the policies. "The whole birth experience is really profound," said Colebrook. "A lot of people think of birth as just another hospital procedure, but it's actually a rite of passage in our life cycle. The way we do it here is informed both by the art and by the science."  Reach Grants Pass freelance writer Tammy Asnicar at [email protected].