Making the alternative the mainstream. Maintaining a family-centered focus in a large freestanding birth center for low-income women.

The BirthPlace program in San Diego, California, is an example of a successfully "mainstreamed" alternative maternity care program. It was developed to address an access to prenatal care problem in the county, and it has successfully integrated four systems of care: 1) a private practice of nurse-midwives and obstetricians, 2) the public community clinic system, 3) the tertiary university hospital, and 4) a freestanding birth center. It provides a model of care that, if replicated, could be an answer for ensuring universal access to maternity care in the United States. The BirthPlace program primarily serves a public-funded, Hispanic population, with certified nurse-midwives as the primary providers. The program's greatest challenge has been to maintain a personalized, family-centered focus, which has been the hallmark of freestanding birth centers to date, in the face of large numbers of clients and low reimbursement for care. The program has addressed the challenge of increasing access and cost-effectiveness while ensuring family-centered care through decentralized clinic management, informed consent, culturally sensitive care, and appropriate use of technology. However, in the face of an ever-changing health care system, balancing these issues will remain a constant challenge as we reshape our maternity care services.

Human fetal hypothalamic GnRH neurosecretion: dopaminergic regulation in vitro.

An in-vitro perifusion system was used to investigate GnRH release from fetal (21-23 weeks gestation) human hypothalami in response to dopamine (DA) and the DA receptor antagonist haloperidol. Administration of 1 mumol/l DA during five perifusions in which 1 mumol/l haloperidol was added to the medium failed to alter basal GnRH release. In contrast DA evoked a rapid and sustained 95.8 +/- 20.3% increase (P less than 0.01) in GnRH release during five matching perifusions with medium containing the alpha-adrenergic antagonist phentolamine. While exposure to 0.01 mumol/l DA failed to alter basal GnRH release during three perifusions, 0.1 mumol/l DA elicited a 145.7 +/- 65.2% increase (P less than 0.05) in GnRH release in three matching perifusions, indicating a dose-dependent effect. These studies demonstrate that DA can stimulate in-vitro release of GnRH from the mid-gestation fetal human hypothalamus by a DA receptor mediated mechanism.