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Maternal Health Innovation—Colorado Birth Equity Bill Package and The Association of Maternal & Child Health Programs (AMCHP)

Maternal Health Innovation is teaming up with AMCHP's MCH Bridges podcast to bring you this episode on maternal health policy successes, challenges and opportunities while discussing Colorado's recent passing of the Birth Equity Bill Package, featuring George Davis V, Demetra Seriki, and Indra Lusero.

In this special episode, Maternal Health Innovation is teaming up with AMCHP's MCH Bridges podcast to bring you this episode on maternal health policy successes, challenges and opportunities while discussing Colorado's recent passing of the Birth Equity Bill Package. A series of three bills designed to increase access to decrease inequities in and overall improve obstetric care in the state, this comprehensive and community-led response to the maternal health crisis is the first ever state led policy platform for birth equity.

In this episode, host Laura Powis, program manager for Evidence-Based Policy and Practice at AMCHP and member of the Policy Core at MHLIC, is joined by Indra Lusero, Birth at Justice, advocate and founder of the Elephant Circle; Demetra Seriki, midwife at A Mother's Choice Midwifery; and George Davis V, a community member on Elephant Circle's Birth Equity Implementation Steering Committee.

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AMCHP also has information about the Colorado Birth Equity Bill Package available here: https://amchp.org/database_entry/colorado-birth-equity-bill-package/

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Colorado is losing another birth center as midwifery struggles to stay profitable despite rising popularity

A comprehensive article about the closure of midwifery-led services in Colorado.

The Colorado Sun’s comprehensive reporting on the closure of Seasons Midwifery and Birth Center within the larger context of Colorado’s perinatal care landscape. By Jennifer Brown, October 25, 2022.

The closure of Thornton’s Seasons Birth Center leaves the state with just six birth centers, which are reimbursed at lower rates by insurance companies

Colorado is losing another birth center, an alternative for mothers who would rather have their babies in a home-like setting with a midwife than in a hospital labor and delivery ward. 

The closure of Seasons Midwifery & Birth Center in Thornton, which saw a boom during the pandemic when hospitals were filled COVID patients, is the latest in a line of closures of midwifery practices that were not profitable enough for their owners. 

Seasons is owned by a private equity firm, which recently announced that the birth center would see its last patients Nov. 4. The news shocked the practice’s five certified nurse midwives, who immediately began trying to help about 50 patients due to give birth in November and December find new care. 

The closure has sparked protests from reproductive justice groups who advocate for more choice for people giving birth, as well as a petition with 1,200 signatures calling for the opening of a nonprofit birth center as a replacement. 

It comes four years after the closure of two Denver-area midwifery practices that left hundreds of patients scrambling for new care in the middle of their pregnancies. The practices, linked to Rose Medical Center and Aurora Medical Center, were told by their for-profit owner, Hospital Corporation of America, that it didn’t make economic sense to keep them operating. 

With the closure of Seasons, Colorado will have just six birthing centers — in Boulder, Colorado Springs, Grand Junction, Fort Collins and two in Denver.

While 97% of Colorado births happen in hospitals, more pregnant people have been seeking out birthing centers, which offer longer appointments and individualized care so clients can create their own birth plan. The number of people choosing to give birth outside a hospital in Colorado jumped 30% from 2019 to 2020, and the number of babies born at birth centers in this state reached 889 last year, up from 261 a decade ago, according to the nonprofit Elephant Circle. 

More than 550 babies were born in the past three years at Seasons, which has birthing rooms with large, comfortable beds and bathtubs. Women can choose who is with them and incorporate religious or cultural traditions into their labor and delivery. 

And patients who use birth centers report far less trauma surrounding childbirth compared to women who deliver in hospitals. About one in four people who give birth in a hospital in this country reports having symptoms of PTSD, or post-traumatic stress disorder.

But birth centers struggle to make big profits because they are not reimbursed by insurance companies at the same rates as hospitals. “Providers get paid for surgeries, MRIs, procedures,” said Aubre Tompkins, clinical director of Seasons and president of the American Association of Birth Centers. “There is an incentive to always do more things, and that’s not always the best choice. We do not get paid based on outcomes.” 

Health providers are also reimbursed based on appointments, so there is no financial incentive to spend more time talking to patients — which is exactly what midwives do. Prenatal appointments often take more than an hour, depending on what clients want to discuss about their pregnancy, nutrition or their birth plan. “It’s relationship intensive,” Tompkins said. “That takes time and there is not a procedure involved with it.” 

The time, though, shows up in the outcomes, she said. Birth centers nationwide have far lower rates of cesarean section and preterm birth, compared to hospitals. Colorado’s statewide C-section rate is 23%, compared to about 7% of Seasons patients who end up going to a hospital for a C-section. 

The way the country’s private, profit-driven health care system is set up has pushed maternal health care to the point of crisis, said Indra Lusero, director of the birth justice organization Elephant Circle, based in Colorado. The system pays well for surgeries and high-tech care, but not for preventative or holistic approaches. 

“We’re seeing most acutely the limits of that in things like primary care and pediatrics and things that don’t have a dimension that can be the cash cow,” Lusero said. 

The nonprofit has been working for years with Colorado health officials and the Medicaid division to create equity in maternal care. Medicaid, which is government insurance for people with low incomes or disabilities, now reimburses certified nurse midwives for attending a birth. But it does not pay for non-nurse midwives or doulas. 

And Medicaid does not reimburse birthing centers for a specific facilities fee, even though the centers are licensed by the state health department the same as nursing homes or surgical centers. That means that while hospitals charge Medicaid a facilities fee for delivering a baby at a hospital, birth centers recoup lower rates. Advocates are pushing for a Medicaid code that would allow them to get reimbursed as a birth center facility, not just for “maternal services.”

It wasn’t just the pandemic that drove the increase in births outside hospitals, said Lusero, who uses the pronoun they. The protests over the deaths of Black men dying at the hands of police led to an increased awareness of racial injustices in many systems, including health care, they said. America has the highest maternal death rate of any developed country, and it is Black women whose rates are the highest. 

“It was an awareness that hospitals aren’t doing right by us,” Lusero said. 

The World Health Organization says about 15% of births should happen via C-section, yet the rate is 23% in Colorado. “That means 8% of births in Colorado that happen by cesarean section are unnecessary C-sections,” Lusero said. 

Elephant Circle has been in “crisis response mode” helping Seasons and its pregnant patients find new care. Many found new midwives at birthing centers in the Denver area, including Christina Soliz. 

Soliz is seven months pregnant, due just a few days before Christmas. The day Seasons called to tell her it was closing and she would have to find a new clinic, Soliz was crying so hard she couldn’t hear the rest of the message. 

She took it that hard because finding Seasons had been a huge relief. Soliz, who is having her first baby, had been going to an obstetrician/gynecologist and was heading toward a hospital birth. But every appointment felt rushed, and she left feeling bad about herself and worried about her baby. 

“A lot of my appointments centered around my weight,” Soliz said. When she told her doctor she had just had COVID and had lost 10 pounds, she was praised for losing weight. No one in the office eased her concerns about whether her baby was OK, she said. 

“I never heard that I had a healthy pregnancy. It was giving me anxiety.”

At her first appointment at Seasons, there was no mention of her BMI, body mass index. “It was just all this stuff about how you should choose your own birth story,” Soliz said. “They praised my body for what it was doing — growing a human. It was so much different. My first appointment there with the midwives, I cried from relief three times.”

Soliz now is transferring to Colorado Birth and Wellness, in Denver. 

The Thornton center’s owners, Elevate Women’s Health and Shore Capital Partners, did not respond to a request for comment for this story. But employees of Seasons said they were told of the closure during a Sept. 26 meeting in which company officials said the decision was based on money. 

“The private equity group that bought our practice does not feel that we are profitable enough,” Tompkins said. “Birth centers can be sustainable. They can maintain themselves and pay their staff. But they are never going to make the right amount of money for a private equity firm.”

The profitability issue in maternal health care is not unique to birth centers, however. Some hospitals in Colorado have closed their maternity departments, leaving women with fewer choices. Among those is Memorial Regional Health in Craig, which shut down its labor and delivery unit in January 2020. The next closest hospital is 45 miles away in Steamboat Springs. 

Across the country, more than 400 maternity wards closed from 2006 to 2020, creating “maternal deserts” for about 7 million women, according to March of Dimes research. 

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Where's My Midwife Podcast Interview with Indra Lusero

There are lots of ways to access this interview. Click through for more.

If you wish to see the video version of the podcast, you can find it on the YouTube channel here: https://youtu.be/a8fRbmL3_vA. Or you can find it on the a landing page for the audio versions of all of the podcast episodes here: https://anchor.fm/wheresmymidwife/ and all episodes are distributed to multiple listening apps, including Spotify, Apple Podcasts, Breaker, Castbox, Google Podcasts, Overcast, Pocket Casts, and RadioPublic. We anticipate your episode will be fully distributed across all of these apps within a week or so.

This podcast episode is also embedded on the Stories page of the Where’s My Midwife? website.

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How Many Black, Brown, & Indigenous People Have to Die Giving Birth?

Click here to read the open letter, or click through for even more information and links.

Published in the NYT july 25, 2020 - Follow link for the full pdf

This Open Letter was published as a full page ad in the New York Times on July 25, 2020. Elephant Circle signed on and Indra Lusero was one of the writers/contributors.

The letter was part of a broader Birth Justice advocacy effort. Every Mother Counts houses this website where you can find out more, find a social media toolkit and graphics. and sign the petition which has over 12,000 signatures.

There are many links and social media infographics at the above link.

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For People of Color, Could Home Births Be Safer Than Hospitals?

Elephant Circle’s board member Demetra Seriki is quoted in this important article, along with Director, Indra Lusero.

By Kristin Jones

February 13, 2020

Elephant Circle’s board member Demetra Seriki is quoted in this important article from the Colorado Trust, along with Director, Indra Lusero.

Photos by Joe Mahoney/Special to The Colorado TrustDemetra Seriki, left, the only Black home-birth midwife in Colorado, with Lance and Debrisha Flagg and their newborn baby during an office visit. 

Photos by Joe Mahoney/Special to The Colorado Trust

Demetra Seriki, left, the only Black home-birth midwife in Colorado, with Lance and Debrisha Flagg and their newborn baby during an office visit. 

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Good Birth for All Podcast, February 2019

This podcast by Marinah Farrell features interviews with people doing birthwork. Indra Lusero was interviewed for the first podcast, talking about birth issues from human rights to Colorado midwifery integration to the importance of joy and embodiment. Listen here and find links to various things discussed in the interview.

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American Bar Association Journal, January 2019

This article in the American Bar Association Journal highlights the work of Indra Lusero and the Birth Rights Bar Association and introduces the topic of birth justice.

Birth rights: Reproductive justice is a growing practice area

BY DARLENE RICKER

JANUARY 1, 2019, 2:55 AM CST

With women’s rights issues sparking a national dialogue, a niche practice area has emerged that is gaining momentum: reproductive justice. The practice area is broad, encompassing issues including forced sterilization and unwanted medical intervention during childbirth.

Because delivery rights are an evolving concept, few lawyers know how to advise clients or effectively litigate these matters. Legal support groups and networks have formed to fill the void, providing education and assistance to lawyers interested in or already practicing in the field.

“There is a grave need for knowledgeable lawyers, coordinated strategy and resources,” says Indra Lusero, founder and president of the Birth Rights Bar Association and a staff attorney with National Advocates for Pregnant Women. “Currently there is no organization with the capacity to address all of these cases. We aim to fill that void by giving our members the skills, support and education they need to litigate these cases.”

Lusero, who practices in Denver, says the problem is compounded by a “broken maternity care system that spends more and accomplishes less,” while maternal mortality is rising, and evidence-based practices (such as the use of midwives and doulas) are underutilized.

The BRBA has members in 20 states and is expanding nationwide. Its members include litigators in a wide range of practice areas. The organization compiles and tracks data, identifies trends and opportunities for strategic action and helps women in need find attorneys. The organization has filed amicus briefs in reproductive justice cases in California, Delaware, New York, Virginia and Washington.

The body of law on childbirth rights is slim, and the legal issues can be complex. Causes of action include constitutional law, business law, regulatory law, torts, lack of informed consent and public health law.

Michael Bast, a medical malpractice attorney in New York City, has spent four years litigating an ongoing case on behalf of a woman who had a cesarean section against her wishes and suffered a lacerated bladder.

“The time is now,” Bast says. “Women want to control their body in choosing their manner of delivery.”

Bast has received backing from the BRBA and NAPW in the form of funding, finding experts and raising awareness. He says the support is crucial because most plaintiffs attorneys in reproductive justice cases are solo or small-firm practitioners, while the defense is backed by an army of attorneys, many at large firms with tremendous resources.

Reproductive law is about “changing the balance of power” in delivery rights, says professor Ellen Wright Clayton, an attorney and physician who teaches at Vanderbilt University’s law and medical schools. She sees reproductive law as a “pushback against the medicalization of childbirth and the willingness of hospitals to override the wishes of the woman.”

Clayton says disparate treatment of minority and low-income women within the medical system is a significant problem this area of law could address. She points to a history of racism in the health care system that disproportionately affects women of color and non-native English speakers. “If you’re not seen as empowered, you’re not empowered,” she says.

Clayton feels the solution lies in empowering women before they are in active childbirth. “I don’t think you’re going to litigate your way out after the fact,” she says. “The courts have been hostile to these issues.”

Instead, she says, there should be better communication between physicians and patients—and it should take place before you check into the hospital. If you want one mode of delivery and your doctor is opposed, “You’re not going to have that conversation in the middle of delivery.”

Bast recommends that a woman make a birth plan (basically a contract) with her clinician to ensure that her wishes are followed. “Plan ahead. By the time you’re in labor, there is no real weapon,” he says.

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Elle.com, December 2016

Elephant Circle's Indra Lusero contributed background legal information to this article on the challenges to vaginal birth after cesarean that so many face. 

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