WINTER GARDEN — This Central Florida office feels more like a home than a maternity ward, with portraits of glowing mothers-to-be proudly displayed on the walls leading to the "suites." The Van Gogh room has a nighttime feel, with a dark blue couch near a star-designed quilted bed and the Starry Night painting hanging above.
And then there is the birthing stool oddly found in the mix, looking more like a misplaced item in a bedroom.
It is the vision of Jennie Joseph, an energetic midwife originally from England who has run this birthing center since 1994.
Her waiting room is filled with expectant parents, but times are still tough for her and many of Florida's approximately 110 midwives.
Insurance is expensive — when policies are available. The number of new mothers choosing midwives seems to have peaked. Some colleges have closed their midwifery programs citing a lack of enrollment. And some still question the safety of having a child outside of a hospital.
"We have this complete myth we created around birth. Subsequently that has prevented midwives from becoming a staple in this country," Joseph said.
There are about 20,000 midwives in the United States, performing about 320,000 reported deliveries per year, according to the North American Registry of Midwives and federal government statistics. That's about 1 in 12 nationally. Because of under-reporting, the actual number is probably higher.
Many handle deliveries solo at the mother's home or at a birthing center, while others work at hospitals under the direction of a doctor. And for low-risk births, midwives are just as safe as doctors, with 1.7 infant deaths per 1,000 planned home births, according to a study by the British Medication Journal, which collected statistics of all certified professional midwives in 2000 in North America. That's similar to risks in other studies of low-risk home and hospital births.
No mothers in the study died. Also, the rate of medical intervention — including the use of epidural, episiotomy, forceps, vacuum extraction, and caesarean section — were substantially lower than for low-risk women having hospital births.
Still, the American College of Obstetricians and Gynecologists opposes home births while supporting licensed and accredited birth centers. ACOG's policy reads: Studies comparing the safety and outcome of births in the hospital with those occurring in other settings are limited and have not been scientifically rigorous.
The Birth Place tries hard not to be seen as a doctor's office, said Sandra Chandra Johnson, a childbirth educator there. She greets patients behind a makeshift desk in the waiting room stacked with educational pamphlets and posters. "We want patients to call" with every and any question they may have.
The rooms — or suites — have a large bed with throw pillows, a comfortable couch and a birth stool that helps the delivering woman support herself in a position that's more comfortable and less strenuous than squatting.
Women experiencing healthy pregnancies are encouraged to use the center's birthing options such as birthing balls (or a medicine ball), the birthing stool, squatting and other positions and, of course, water birth. Joseph offers a kiddie pool because they are softer than a bathtub for the mother, who is constantly moving around the water.
If complications are anticipated for the mom or the baby, it is recommended that the birth happen at a hospital because there is easier access to obstetricians, perinatologists and other experts.
Rachell Hill had her son, Joshua, at Joseph's birth center in September. She hadn't always planned to use a midwife.
"We started researching and started considering the option," said Hill, 34, of Orlando. "We were able to bond with our baby right away after he was born and there was not as much interference and concern medically" as you would find at a hospital.
Many patients discover midwifery because they can't afford regular care. Charges for childbirth vary considerably depending on the type and place of birth. A study done by the Milbank Memorial Fund, a health research foundation, showed that the average hospital charge in 2005 for an uncomplicated birth was $7,000. Out-of-hospital birth centers charged only about a quarter of that.
The median salary for full-time nurse midwives in 2007 was between $79,000 and $90,000 and about 20 percent less for a licensed midwife, according to Israel Teitelbaum with Contemporary Insurance Services.
Insurance requirements vary from state to state. Florida requires midwives to carry malpractice insurance, but most states don't. The cost can be high — a fifth-year midwife working in Miami could pay $30,000 a year for $250,000 in coverage.
Health insurance companies and Medicaid and Medicare are also cutting their reimbursements and are demanding discounts.
"If you have to discount your fees, how do you cover your expenses and why would you expand your practice? That's not just a midwife problem. That's a health care problem," said Ann Geisler, who sells insurance policies to midwives and birthing centers.
Still, Joseph gets a lot of satisfaction from her job.
As she rubs mounds of gel on a patient's stomach, Joseph uses a heart monitor to check a developing baby's progress, counting down the beats that can be heard from a few feet away.
When the heartbeat is heard, she practically yells, "You have a wonderful baby!" It's an excitement she can't contain despite assisting in hundreds of births.
"I can't help it," she said with a smile.