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Opening a Birth Center: My Journey From Hospital Midwife to Birth Center Midwife

By Lesley Rathbun

Birth Centers are growing and so are opportunities for midwives to work outside of the hospital setting. The industry has grown 76% since 2010 to 344 total birth centers in the United States and shows no sign of slowing down.

Due to the small numbers of centers, many student midwives do not have the opportunity to experience birth center care during their training and education. A birth center is not a hospital and not a home, but a facility dedicated  to the practice of midwifery. Working in a birth center environment offers a unique opportunity for midwives to practice to the full scope of their education and training.  

My experience with birth centers started in the late 90’s as a Registered Nurse (RN). I had been away from nursing for a few years, enjoying life as a stay-at-home mom, and was looking for a way to get back into Obstetrics (OB) without too much of a time commitment.


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A friend suggested I work at the birth center in our community. Since I had no experience, nor knowledge of birth centers, my first reaction was, “Mothers giving birth outside of a hospital? The moms and babies could die!”  I didn’t know it then, but I had drunk the Kool Aid of medicalized birth.

I decided to give it a chance and quickly realized how off-the-mark my preconceived notions were. I fell in love with the model. Witnessing the power of a woman giving birth without medical intervention was transformative for me. Before working in the birth center, I had never seen a mother give birth outside of a bed. I had never seen the magic of delayed cord clamping or the smooth transition created by skin to skin contact for the baby.

Looking back now, I can’t help but laugh at my biased opinions and narrow experience of birth. The nurses, midwives, and physicians I met in the birth center were some of the most incredible people.

It quickly became apparent that the routine interventions for low-risk mothers and babies that are so common in hospital labor units did not reduce adverse outcomes and in some cases caused harm. This realization fueled my desire to return to grad school to become a nurse- midwife.

My first midwife job after graduation was in an extensive physician-owned, hospital-based practice with five midwives.  One of the main reasons they hired me was because of my previous birth center experience. The plan was that the practice would continue to expand and eventually open a birth center.

However, they lost interest, and I grew frustrated with the restrictions and expectations I was under as an in-hospital midwife. Dissatisfied with the system, I undertook one of the most difficult (and rewarding) endeavors of my life and opened the first freestanding birth center in Charleston, South Carolina.

OB nurses who transition to nurse-midwives know working as a nurse vs. a midwife is a much bigger responsibility and comes with increased stress. While I had some RN experience in a birth center, shouldering the responsibilities that come with being the owner, director, and sole provider was more than a little daunting.

Working in a large practice, I had several physicians and midwives to consult and refer to. As a hospital-based midwife, I had the support of OB, nursery, and postpartum nurses. I also had access to an operating room (OR) and anesthesia, respiratory therapy, pharmacy, and other support services. Services such as laundry, housekeeping and dietary suddenly seemed like luxuries.

As a birth center midwife it is you, a nurse birth assistant, and sometimes a doula or student midwife and that is it. It can be scary jumping from all the hospital support to a birth center, but the job satisfaction can more than make the effort worth it.

Transitioning from in-hospital to birth center has many challenges. Some of the more common include being proficient with intermittent auscultation (IA), trusting physiologic birth, labor support, and newborn care.

IA is a reliable method of fetal surveillance in labor, but many nurses and midwives have little experience with it.  Brushing up on the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) guidelines and practicing doing both IA with electronic fetal monitor (EFM) can help develop trust in your IA skills.

Newborn care can be a big challenge. Although midwives have the training and education to care for babies, they rarely get that opportunity in a hospital. During my transition, I spent extra time in the nursery and actively participated in infant resuscitation. I did lots of homework brushing up on newborn care. I also recruited a friendly pediatrician to be my baby consultant.

One-on-one laboring a mother through unmedicated birth is extremely rewarding but also more mentally, physically, and emotionally draining than laboring a mother with an epidural. Becoming comfortable with the full range of pace of physiologic birth requires developing strong patience. I’ve found knitting helps keep my mind and hands busy when waiting for slow labor and it’s always special when I can give a newly knitted hat to a newborn.

Finally, allow yourself lenience with transfers and consulting. I frequently consulted homebirth midwives as well as my OB and Pediatrics physicians. Asking for another opinion helps build your confidence while also ensuring safe care for your clients. Just as a new grad will consult and refer more often than an experienced midwife, a hospital midwife new to birth center work would be expected to have a higher consult and refer rate than an experienced birth center midwife, and this is not a bad thing. Transferring too early can be a disappointment but transferring too late is a tragedy.

Birth center work isn’t for all midwives. Those who are able to adapt to the unique rigors that come with birth center work often find the job experience much more satisfying than hospital midwifery. If you’re interested in learning more about the birth center model and how you can make the leap yourself, you can watch the webinar we held on Wednesday, March, 7th 2018 at 7:00 p.m. CST, titled “Making the Journey From Hospital Midwife to Birth Center Midwife” where Ginger Breedlove and I will further detail our experience as a birth center entrepreneurs and answer any questions you have.


See the Webinar Here!


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