Rita Kearns lies back as her midwife measures her gravid belly. Maria Iorillo presses a fetoscope to Kearns’ side and finds the baby’s heartbeat. “It’s perfect,” she says, passing Kearns the earpieces.
Kearns, 43, is 41 weeks pregnant — one week past her due date. By now, many obstetricians would suggest inducing labor. Iorillo is content to wait. And, when the contractions begin, Kearns will give birth at home, as she’s done twice before.
She is one of a growing number of area women choosing to give birth at home. Local home births have doubled since 2005, even as overall births declined nearly 7 percent from 2007, according to the San Francisco Department of Public Health. Many families choose home birth even though insurance companies frequently leave them holding the bag for some or all of the costs.
Families choose home birth for a variety of reasons, said midwife Michelle Welborn. Some fear hospitals and medical intervention. Others want a natural birth, or control of the birthing environment, Welborn said.
At hospitals, women often face doctors eager to accelerate labor, said Redwood City doula Sandra Caldwell. That can lead to complications, even Caesarean sections.
Others turn away from hospitals because they don’t appreciate rushed prenatal visits attended by a revolving-door cast of nurses and doctors. Gia Schultz, 30, was 22 and 30 weeks pregnant when she hired a midwife to deliver her son at home.
“Instantly knew I wanted her at my birth,” Schultz said. “She had an actual interest in getting to know us ... our wants, needs and unique characteristics. In the hospital you didn’t have enough time for that.”
San Francisco’s midwives and home-birth supporters have worked hard to make The City a home-birth mecca.
They network through the Bay Area Homebirth Collective, offer birth classes and potlucks, and have fought to legalize home birth and encourage hospitals to embrace it.
When Iorillo came to San Francisco in 1985, it was illegal for her to deliver babies at home, despite her license from a renowned midwifery school. She served on the California Board of Midwives for 10 years, during which she saw two bills legalizing non-nurse midwives fail before the third passed in 1994.
Local midwives worked with UC San Francisco’s birth center to overcome the hostility many women faced when they told their obstetricians they were planning a home birth — hostility that often returned if they wound up transferring to a hospital during labor.
“We had doctors who think home birth isn’t safe, and I think the majority of doctors feel that way,” said Judith Bishop, a former home-birth midwife who now delivers babies at UCSF. “We wanted to make sure there isn’t a divisive feeling between hospital and home birth, that people don’t feel they’re treated badly for coming in, or that we treat them with less respect.”
When that happens, she added, women and midwives become reluctant to transfer, risking the health of both mother and child.
Now, the only San Francisco hospital where doctors may decline to accept home-birth transfers is the California Pacific Medical Center.
Spokesman Kevin McCormack said CPMC isn’t opposed to home births, but its obstetricians, who are independent practitioners, can choose not to back up patients planning home births. CPMC delivers nearly half the babies born here each year, and has a 29 percent C-section rate, just slightly lower than the state average of 32.8 percent.
California hospitals charge upward of $15,000 for an uncomplicated vaginal birth, and often $30,000 or more for a C-section. While health-insurance providers cover most or all of those costs, they routinely reimburse 50 percent or less for home birth, which costs just $4,000 to $6,000 — including all prenatal and postnatal care.
“It’s kind of amazing when you think about it,” Bishop said. “It would be so much cheaper for insurance companies not to pay the hospital bill, which is gigantic.”
Coverage for home birth varies depending on the insurance provider and the patient’s plan, noted Schultz, who now handles insurance billing for Rites of Passage Midwifery. Kaiser doesn’t cover anything. Others may pay anywhere from 20 to 50 percent — even 100 percent, if the stars align.
“The key is patience,” Schultz said. “Insurance companies always come back and say they won’t pay you; you have to go through the process of denial over and over.”
Susan Pisano, spokeswoman for America’s Health Insurance Plans, a collective of 1,300 insurers, said the coverage issues relate to patient safety. “The bottom line,” she said, “is the evidence has been pretty sparse on the safety of home births.”
But according to a 2005 British Medical Journal study of 5,000 American births, home birth has similarly low rates of infant and maternal mortality as low-risk hospital births. Other studies have echoed these findings.
The American College of Obstetricians and Gynecologists is beginning to soften. In October, it met with midwives for the first Home Birth Summit in Virginia. “Instead of all the backstabbing and trying to squelch us out of existence, they had an open conversation about where we can find consensus,” Iorillo said.
Home births are increasingly popular, but the sagging economy has hit natural-birth advocates hard, leaving pregnant parents with fewer choices.
St. Luke’s Hospital closed its “Homestyle” program — which offered in-house midwives and a more natural birthing model — in 2007 to help keep the financially strapped hospital from closing. Earlier this year, Sage Femme, The City’s only independent birthing center, shuttered its Capp Street facility after reimbursements from Medi-Cal and other insurance providers shrank.
Natural Resources, the 24-year-old shop that provides classes, birth-tub rentals and supplies for natural-birth families, narrowly escaped the same fate in November when it raised $48,000 through crowd-sourcing.
“It started with the economy,” said Natural Resources owner Cara Vidano. “Over time, our revenue has decreased.
Even with cutting costs, we haven’t been able to pay all our bills.” After failing to find a buyer for the struggling store, Vidano faced two choices: raise donations or close.
Sage Femme and its head midwife, Judy Tinkelenberg, delivered hundreds of babies in their 12 years in the Mission district. Tinkelenberg was the only midwife in San Francisco to accept Medi-Cal. The average client paid $3,820 to $4,500 for a birth at Sage Femme, including all prenatal and post-natal care. Until recently, Medi-Cal would cover almost $2,000 of that, but in recent years, their reimbursement dropped to less than $1,200 per birth.
“And, if the patient transfers to a hospital” — which 5 to 40 percent of home-birth moms do, depending on the midwife — “I don’t get paid at all,” Tinkelenberg said. “If I had cut Medi-Cal I don’t know if it would have been made up for with paying patients.”
For both businesses, the community — not the health care industry — is what may keep birth options alive.
Tinkelenberg is now attending home births and working with the Alameda-based Birth Options Foundation to raise money for a new birth center somewhere in the Bay Area.
For Natural Resources, the influx of donations “means we will be able to function again,” Vidano said. “If everything goes as planned, we will be in business for a while. This isn’t just a short-term solution."