Boston — DANA and Tom Ericson's first three children were born in a hospital. But when Dana became pregnant for the fourth time, the Ericsons decided to make a change - a surprising decision. She's a registered nurse. He's a physician. ``Labor had been induced with my second child for the convenience of the obstetrician, and after my third child was born I was significantly debilitated because of a drug I'd been given,'' Dana recalls.
``So I began to do some reading and some real soul-searching.
``I'd been conditioned to think that pregnancy was an illness and childbirth was a medical event - I had really bought into that orientation.
``But then I began to think, `What if I'd asked questions?' Couldn't all the children's births have been a much more meaningful experience for me and Tom and the whole family?''
Like some couples today, the Ericsons wanted to have a larger say in key questions about the kind of care mother and baby would receive. After considering the options, they decided to have their fourth child delivered by a certified nurse-midwife.
``We wanted to be partners in the decisionmaking process, and the philosophy of midwifery clicked with us immediately,'' Dana explains.
She followed up reading on the subject with action.
With a group of similarly concerned women from her hometown, Des Moines, she made the rounds of local businesses asking for donations and pledges to establish a birth center. Several hundred thousand dollars later, renovation started on the Des Moines Birthplace.
When it opened its doors in January 1984 - in time for Dana's daughter, Ainslee, to be born there - it was a fully funded, grass-roots project that had the support of the corporate community and that began attracting families looking for birthing alternatives.
Today, the Des Moines Birthplace is one of an estimated 130 birth centers in 38 states - up from 14 centers nationwide a decade ago.
Like all birth centers, it is designed to look and feel like home away from home. The d'ecor in the birth rooms runs to antique quilts and calico curtains - with teddy bears stenciled on bassinets and cradles.
Some families arrive with casseroles to heat up in the kitchen. Others order out for pizza. They can stay anywhere from two to 24 hours, with most choosing an average stay of 12 hours after a birth.
``Free-standing'' by definition, the Birthplace is physically separate from, but situated close to, a hospital. By law, all nurse-midwives maintain backup relationships with physicians, who see their clients occasionally and can have them admitted to a hospital if complications develop.
Although some physicians have historically tended to oppose midwifery on medical grounds - and possibly because some may see midwives as a financial threat to their practices - midwives interviewed for this article say it's relatively easy today to find doctors who understand and support their work.
``We're in the heart of downtown Des Moines, 100 yards south of a major hospital,'' says Dana, who is now on the board of directors of the Birthplace.
``But I should add that in the four years we've been open, we've never had any emergency transfers. Complications are identified before they become emergencies.''
About half of the free-standing birth centers in the United States are members of the National Association of Childbearing Centers (NACC), a nonprofit organization that aims to promote standards of quality for families in settings staffed by qualified nurse-midwives.
The association is headed by Eunice (Kitty) Ernst, a nurse-midwife who's been delivering babies for about as long as she can remember. Ms. Ernst trained with the legendary Frontier Nursing Service in Kentucky, where she ``roamed from hollow to hollow'' on horseback attending women in labor.
Ernst later worked with a home-birth service in Harlem. She also directed graduate studies in nurse midwifery at Columbia University.
Over the years, Ernst has watched the tide turn in women's - and society's - attitudes toward birth.
``When I was a student nurse in obstetrics, we went through a period when women were heavily drugged,'' she explains.
``Then, in the late 1940s, there was a gradual awakening that we were not doing this the right way - that we might be hurting the mothers, and we were certainly hurting the babies.
``What we want today is to restore to women the notion that they can give birth. We want to say to them, `You can take responsibility, and you can take control.'
``And that essentially is what birthing centers are doing.''
The NACC has also led the way in educating state and local regulatory agencies about the quality of care provided by accredited birthing centers, and in demonstrating how cost effective these centers can be.
According to a recent study published by the nonprofit Alan Guttmacher Institute - based on figures compiled in a 1985-86 survey of the Health Insurance Association of America - the average bill for a normal hospital delivery in the US is $4,300.
By contrast, the charges for normal-birth care in birth centers nationwide has consistently averaged 50 percent less than regular hospital stays, including physicians' fees.
At the Des Moines Birthplace, for example, a package fee for prenatal care, delivery, postpartum care, education classes, and lab fees is $1,975 - or a saving of between $1,100 and $1,500 per birth in the Des Moines area, according to Dana Ericson.
The NACC's Kitty Ernst is quick to point out, however, that not all birth centers operate on the same bottom line.
``I'm beginning to separate them into `missionary' and `mercenary' centers,'' she explains.
``For example, there's Sister Angela, taking care of poor women in Texas, who charges $500 for a whole year of care.
``And there are obstetricians who want to do the same thing and also make money at it - like those at the $1.5 million Boulder Birth Center [in Boulder, Colo.] and the Birth Center of Santa Fe [N.M.].''
Although escalating medical costs are one of the driving forces behind the birth-center movement, studies show that financial considerations are not the prime reason most families seek out midwives and birth centers.
Rather, they're looking for the kind of personalized care that nurse-midwives offer. By tradition, nurse-midwives work to facilitate natural childbirth. No drugs are used to stimulate labor or speed up delivery.
Because of current medical malpractice concerns, however, some obstetricians tend to be wary of being sued. Some tend to depend on technology rather than let a woman's labor end normally. As a result, the proportion of babies delivered by Caesarean section is rising dramatically, up from 4.5 percent in 1965 to more than 24 percent in 1986 - the highest rate in the world today.
``This is the system we're challenging, and it's an uphill struggle,'' says Ericson.