The Story of Midwives Care: A Birth Center in Cincinnati

When Tricia Branson moved to Cincinnati from Michigan, she had two children, both of whom had been delivered with the help of midwives. She was surprised by how difficult it was to locate a midwife in her new town. She didn't know that Ohio certified nurse-midwives (CNMs) attend only 6 percent of births (compared to a national average of more than 9 percent) or that Ohio was the last state in the nation to allow CNMs, and all other advanced nurse practitioners, to write prescriptions.

Branson's search eventually led her to CNM Jackie Gruer, who opened the state's first and only nationally accredited birth center in Cincinnati in 1997. On a pear-tree-lined street just minutes from the city's major hospitals, the Midwives Care, Inc., birth center is still a largely unknown resource for women's health and wellness, maternity care, and childbirth. Branson selected it for the births of her fifth and sixth children, Samuel and Olivia, and she couldn't be happier about her choice.

"We're lucky to have Jackie here," says Branson. "The staff of the birth center is so wonderful. They all worked in harmony, like a well-oiled machine. I've never been so spoiled in my life. I would travel anywhere to have that experience."

Jackie Gruer is a native of St. Louis and trained to be a midwife in Kentucky, the home of Mary Breckenridge's Frontier Nursing Service, which brought nurse education and professional midwifery to the Appalachian Mountains. An activist by nature, Gruer admired Breckenridge but did not see herself as a modern-day counterpart to the midwife pioneer. Yet that is just what she has turned out to be.

For years after she moved to Cincinnati in 1983, Gruer shuttled between doctors' offices, hospitals, and homebirths, partnering with receptive ob-gyns who would give insured patients access to her care. When her principal doctor lost liability coverage for homebirths in 1986, Gruer and several other midwives formed their own business so they could continue to assist women who wanted to birth at home.

Even though Gruer's practice had been financially independent, in many ways it did not appear that way because of her close collaboration with doctors. "I always felt the physical presence of our business in a doctor's office gave people the idea that we were employees of the physicians," she says. Gruer knew she needed her own space, and she figured that establishing a freestanding birth center might eventually make reimbursement for out-of-hospital births more palatable to insurance companies.

"I've never really liked offices," Gruer says with a smile as she sits in the front room of the circa-1897 Victorian house that is now the birth center and home of Midwives Care. "And I love old houses." However, although Gruer was no stranger to home renovation, she knew that it would take a lot more than new oak floors, drywall, and fresh paint to create a successful birth center.

Keeping a Watchful Eye
"A birth center is a very politically charged operation," says Kate Bauer, executive director of the National Association of Childbearing Centers (NACC), which accredited Gruer's facility in 1997. "You have to be involved in the politics of your state."

"Ohio is not a trailblazer," adds Gruer, who is still continuing a years-long effort to have births in her center reimbursed by Medicaid. In support of her case, she has gathered evidence from 40 other birth centers, representing 20 states, that receive Medicaid funds for their services.

"CNMs in all states encounter difficulty in getting jobs, hospital privileges, prescriptive privileges, and reimbursement," says CNM Joyce Roberts, president of the board of the American College of Nurse Midwives (ACNM). Roberts, who teaches at Ohio State University and the University of Illinois, sees Ohio's laws as representative of outdated legislation that does not provide for widespread use of nurse-midwifery care. "The Northwest, Northeast, and Southwest seem more progressive," she adds. "States in those regions have more CNMs because their laws are less restrictive regarding nurse-midwifery practice, especially about reimbursement and prescriptive privileges."

Gruer knows a lot about Ohio's healthcare policies and laws and the limitations they put on her career. She began attending legislative hearings in Columbus, the state capital, in the early 1990s, when she feared that changes in maternity licensure laws might be aimed at making homebirths illegal. However, what she found in Columbus was a refreshing surprise. CNMs and nurses on staff at the Ohio Department of Health were working with birth centers in mind, in part because two centers in Amish communities were already in operation in the state. One promising aspect of the new policy clarified that "direct supervision" of midwives by physicians meant phone, not physical, contact.