The state's first birthing center - where women could deliver their children standing up, under water or even after a long African dance - has shut its doors after more than two decades because of the pressure of rising malpractice insurance rates and other costs.
The Baltimore Birth Center, which opened on Park Heights Avenue in 1981, delivered its last baby - a girl whose brother was born at the center about a year ago - May 23 and closed for good last week.
"It just has become increasingly difficult to maintain our practice. Everything has gone up," said Ann Sober, a registered nurse and one of the birth center's founders. "It's very similar to physicians who are in private practice. It's very difficult to be in private practice today."
Maryland has four remaining birthing centers, in Arnold, Annapolis, Bethesda and Huntingtown in Calvert County.
The birth center's closure comes at a time when malpractice insurance rates have skyrocketed. Sober said the Baltimore center's premium doubled in the past year. She declined to give specific costs.
Other birthing centers have also found themselves unable to make ends meet. The largest birthing center in Manhattan, N.Y., Elizabeth Seton, closed last year, reportedly after it faced a 400 percent premium increase.
At the Baltimore center, even the rising cost of gas to heat the 6,000-square-foot building - which provides women a home-like atmosphere in which to deliver - became a burden.
"The reasons are almost all financial," said Sober of the decision to close. "They have nothing to do with our mission or our patients' desire for us to be here."
Sober said she tried unsuccessfully to find a new owner, then gave patients two months' notice of the closure. One of the center's midwives opened a midwifery practice in Hagerstown, and some women plan to have her deliver their babies - albeit in a hospital.
"We opened the birth center not because we were opposed to hospital births in any way, but because we wanted there to be more options for families in terms of health care provider and site for giving birth," said Eileen Ehudin Pagano, another center founder who has been a nurse-midwife since 1977.
"When you give birth in a hospital, you are restricted to the rules of that particular institution," she said. "We really offered families the opportunity to be themselves in labor, with great respect for what their needs were."
Nationwide, 99 percent of births in 2002 took place in hospitals, according to the National Center for Health Statistics. Nearly two-thirds of the 1 percent of babies delivered outside of hospitals were born in a residence; the rest were born in freestanding centers.
The Baltimore Birth Center handled 68 deliveries its first year - the number peaked in the 1990s at 175. Last year, Sober said, the center had 126 deliveries.
She said it became increasingly difficult in recent years to retain registered nurses, who attend the births along with midwives, in part because the nursing shortage has left them in high demand. Nurses working in a hospital might be paid up to 50 percent more than she paid, Sober said.
Pagano remembers women who gave birth to the accompaniment of country Western or gospel music, women who brought their children to watch and even one who danced through the house before her baby emerged. Others have chosen to have their children in birthing tubs.
"It was their thing. It was their celebration," said Pagano. "My view was, I was there as the overseer of the process, to kind of guide them, to make sure that things went along safely. Having a baby is a rite of passage. It's a monumental life experience.
"Birth in this country has become a medical event - which it really is not," she said. "In most cases, there's no reason why you need to intervene."