The Holistic Hole
Local hospitals battle for the earthy birth market.
Thursday, April 26, 2012
The eight women circled at Pacific Grove Adult School’s Parents’ Place, who have requested anonymity in this story, are familiar with the DONA International definition of doulas: trained professionals who provide “continuous physical, emotional and informational support to the mother before, during and just after birth.” It’s a strictly non-medical role, and one that suggests ultimate deference to doctors.
But these local doulas have strong opinions about the mainstream approach to modern birth. They lament what they view as a cascade effect leading from artificial labor induction to pain-blocking epidurals to cesarean sections.
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One believes mothers acquiesce to such medical interventions because they’re scared. “How do you argue against [doctors] when you’re told your baby is going to die?” she asks.
This crowd dearly values a woman’s freedom to choose a natural birth, but doesn’t have much patience for moms who choose pain medications. “I wouldn’t be comfortable working with a mother who starts off saying she wants an epidural,” one doula says. “I would send her to someone else.”
These women are part of an organized community that encourages a natural approach to pregnancy, childbirth and parenting in Monterey County. It includes doulas, midwives, alty OB-GYNs, lactation specialists, yoga teachers, hypnobirthing instructors and hundreds of crunchy moms.
With some variation from one woman to the next, they share the ideal that birth is at its healthiest when it’s without medical interventions, like Pitocin to induce labor or an epidural to block the pain. They do everything in their power to prevent cesarean sections, which they view as riskier and more traumatic than vaginal births for both moms and babies.
They work to create a labor experience that’s more primal and less medical, navigated by the mother and supported by birth professionals – many of them listed in The Birth Network of Monterey County’s directory. Their clients swap notes through the Monterey County Birth Group, mingle at La Leche League meetings, stretch at Seaside Yoga Sanctuary and share birth stories at P.G. baby-and-mom hub Babymoon.
Karen Shihadeh, co-leader of the Holistic Moms Network’s Monterey Bay chapter, says the group empowers women to make their own decisions about birth. “Sometimes when you go down a particular path, you feel like there isn’t a lot of choice, when in reality there is,” she says.
Still, not many local expectant mothers – “holistic” or otherwise – opt for home or out-of-county deliveries. In 2011, almost 92 percent of Monterey County’s 6,436 births happened at one of three hospitals: Community Hospital of the Monterey Peninsula, Salinas Valley Memorial Hospital and Natividad Medical Center.
CHOMP and SVMH are among the nation’s 140 designated “Baby Friendly” birth facilities – a fairly rigorous accreditation process recognizing hospital policies that encourage breast feeding. Natividad is in the process of joining them. That commitment alone is a testament to the mainstreaming of the holistic approach, which shuns nurseries and pacifiers in favor of mom-baby bonding.
All three hospitals offer other fundamentals for moms who want comfortable natural births: private labor-and-delivery rooms, adjustable beds and squatting bars for laboring in different positions, in-house lactation consultants and rooming-in policies to keep moms and babies as close as possible.
Each hospital is eager to market itself as a welcoming place for a holistic mom to drive up a five-figure bill: The average maternity hospital stay in Monterey County is almost $23,000 for a vaginal birth and $39,000 for a C-section.
But only one local hospital is making bold institutional changes in an effort to become that standout choice. And for the sort of pregnant women who make organic coconut-and-kale smoothies and practice baddha konasanas, it might be a surprise.
Community Hospital of the Monterey Peninsula
Jill Ellis hadn’t gotten more than a few long blinks of sleep all weekend. She’d been having contractions on and off since Friday, and on Monday her obstetrician suggested an induction. Scared by the potential risks of a prolonged labor to her baby, she agreed.
Ellis lived closer to both SVMH and Natividad, but she headed to CHOMP for the delivery. She was born there, her mother’s a nurse there, and after touring the Family Birth Center (where thousands of expectant parents have rubbed the toe of a Dennis the Menace statue for good luck), she knew she wanted to have her babies there.
Labor induction usually means the administration of Pitocin, a synthetic form of the hormone oxytocin that creates stronger, longer contractions. The sudden onslaught of labor pain provoked Ellis, who had planned on a natural birth, to request an epidural. “I figured I would be able to handle it, but it was just a little too much for me,” she says. “The pain was really kind of crazy.”
Her daughter Grace, now three and a half, was born around midnight after less than a half hour of pushing.
Eighteen months later, Ellis was back at CHOMP for her second delivery. But this time she had plans for a medication-free birth: “I really wanted to have this experience all these other women before me had had.”
Equipped with mantras, visualizations and breathing techniques from a local hypnobirthing class, Ellis approached labor more calmly the second time around. She spent much of it in the private shower of her CHOMP delivery room, coming out only for periodic fetal monitoring and cervical checks.
When contractions came on, she imagined a giant birthday candle flaming up in front of her and breathed to blow it out. “I know it sounds New Agey, but it works,” she says.
After blowing out a particularly bright candle, she got out of the shower and felt an intense pressure on her pelvic floor. The nurse recognized that nervous look on her face. Three pushes, and Benjamin was out.
Catherine Powers, R.N. and director of CHOMP’s Family Birth Center, says medication-free births like Ellis’s only represent about 1 percent of the hospital’s deliveries. Doulas, though rare, are allowed to attend to laboring moms.
“They can be very helpful,” Powers says. “We make sure they stay within their role as a support person; they are not supposed to interfere with the OB’s orders.”
Powers drew some fire by shifting the hospital’s childbirth classes from in-house to online over two years ago. CHOMP still offers tours of its birthing center along with breast feeding, prenatal and post-delivery classes.
Mothers who want holistic births will find CHOMP staff accommodating within the limits of standard protocol, like getting prepped for IV access upon arrival and fetal monitoring for 20 minutes of every hour.
Those are the sorts of medical elements that differentiate mainstream hospital births from holistic ones involving midwives and birthing tubs. “We’re all moms here at the Family Birth Center. We believe birth is a choice,” Powers says. “[But] we are a medical model, so that’s what we provide.”
Salinas Valley Memorial Hospital
Erin Maude was determined to deliver her first baby naturally, so she started prepping early: She and her husband took classes in the Bradley Method of childbirth. She practiced yoga, worked out almost every day, hired a doula and made a birth plan.
“The more we read about C-sections and epidurals and Pitocin inductions, we were getting cold feet about [a hospital birth],” she says. “Ideally we wanted a birthing center, but didn’t want to go to Santa Cruz. We wanted a midwife in a hospital, but nobody allowed that.”
So just five weeks before her due date, she decided to switch from an OB-GYN to a midwife and a home birth.
Not too long after her water broke, Maude was staring into her doula’s eyes and breathing the way she’d practiced. Her husband and midwife cheered her on while she pushed. But the baby just wasn’t moving down. “Everything was in place the way I wanted it, but it wasn’t working,” she says. “I felt like a failure.”
At her midwife’s suggestion, Maude transferred to SVMH. Within minutes of checking in, she was in the care of an OB-GYN she’d never met.
“The doctor walked in and I said, ‘Is this guy old enough?’” she remembers. “He looked me in the eyes and said, ‘We are going to get this baby out. Don’t worry.’ I felt immediately safe.”
He showed her where and how hard to push, and with the help of a gentle vacuum, baby Liam was out within 15 minutes.
Two years later Maude was pregnant with her second baby. Again she practiced yoga, did Zumba workouts and hired a doula. She enlisted a network of birthing professionals she describes as “holistic and also just badass. They’re like warrior women; they’re in the swamp with the moms.”
This time, Maude planned to have her baby at SVMH with the same OB-GYN who delivered her first. At the hospital she meditated on the computerized graphs of her contractions, guided by the nurses and doula while her husband and 2-year-old slept. “I cannot say how much support I got at the hospital – and this is coming from someone who did not want to give birth in the hospital,” she says.
Within three hours of her check-in, and without the use of pain meds, she delivered her second son, Finn.
SVMH has the county’s only Perinatal Diagnostic Center for high-risk pregnancies, and a Level-III Neonatal Intensive Care Unit. Both are joint ventures with Stanford University Medical Center.
The labor, delivery and mother-baby areas of the second floor are undergoing an aesthetic remodel, but there are few visible signs of upheaval. Like the rest of the hospital, this wing has carpet and heavy wooden accents in the style of a colonial estate.
Maria Yesenia reclines in one of the postpartum rooms, a dreamy look of bliss on her face and newborn Adalynn Marie asleep on her chest. Yesenia says her labor was longer than she’d expected, but aside from some IV pain medication – most likely Fentanyl, a narcotic analgesic that dulls the edge of labor pains but doesn’t block sensation – it was all natural, like she’d wanted.
In the NICU, doctors tap quietly at their keyboards while behind a privacy curtain, new mom Nicole Bulich rocks her new baby girl. Shayla is the smaller in a set of twins; her brother has already gone home.
An empty labor-and-delivery room feels like a Southern bedroom, with hardwood floors, wooden shutters and a framed watercolor of a country garden. Medical equipment is hidden behind a wall panel. “We try to give it a look that’s not that sterile,” says Pat Valenzano, M.S.N., R.N., the hospital’s director of women and children’s services.
The room contains a mix of holistic-friendly and more conventional birthing features. SVMH is the only local hospital with soaking tubs in the private bathrooms, but for safety reasons moms can only use them before their water breaks.
Fetal monitors are hard-wired, but laboring mothers are encouraged to walk around between hourly check-ins. Around 4 centimeters dilation, the mothers are hooked into an IV. Doctors usually order an antibiotic drip within 12 hours of the water breaking, Valenzano says, and aim for delivery within 24 hours (though some will stretch it if both mom and baby are doing well). When that timer runs out, the stalled labor usually heads to C-section.
At both SVMH and CHOMP, that first incision represents a point of no return. Hospital policies require every subsequent birth to be repeat cesareans, to the horror of holistic-minded moms.
Natividad alone offers an alternative.
Natividad Medical Center
Sara Phelps felt robbed by an unplanned C-section in 2009. “I hated the whole experience,” she says.
So she resolved to try a vaginal birth after cesarean, or VBAC, for her second pregnancy.
She looked into three out-of-county hospitals that perform VBACs. But because of Phelps’ gestational diabetes, all of them wanted to induce before the baby reached full term – a deal-breaker for her. Only Natividad was willing to let her go the full 40 weeks.
Phelps had strong feelings against male doctors, but she was running out of options. When she met Natividad OB-GYN Dr. Caleb Liem, she made a leap of faith.
Then she turned to the Monterey County Birthing Network, hired a doula, attended Mothers To Be classes, received acupuncture and prenatal massages, and took a hypnobirthing class.
Liem reported for Phelps’ delivery on his day off and stayed with her through 38 hours of labor. He massaged her perineum with mineral oil to reduce the risk of tearing, while Phelps’ doula rubbed her back and legs, bringing a sense of heat toward her feet.
About 30 hours in, with Phelps’ labor stalling, staff administered Pitocin; at that point she also got an epidural.
“If I had been at any other place they probably would have done a C-section,” she says. “They were just so patient. They met my every need, emotionally and physically.”
When it came time to push, Phelps used the unconventional “breathing-down-the-baby method” she’d learned in her hypnobirthing class: long, slow breaths and a gentle bearing-down, rather than the hard, tense pushing typical in hospital births. The nurses were surprised, but it worked: Phelps’ second son, Hudson, came out healthy and calm.
Peter Chandler, M.D., Natividad’s Obstetrics and Gynecology Services director, started Natividad’s VBAC program with Liem in May 2009.
“We really felt the women of Monterey County needed to have that option,” Chandler says. “We’re tired of doing these repeat C-sections. It can get dangerous after a while.”
But it’s not an easy change for a hospital to make. In order to permit VBACs, guidelines from the American Congress of Obstetricians and Gynecologists require in-house OB-GYN, operating-room and anesthesia personnel ready for a C-section 24/7. Natividad had to invest about $1 million in a dedicated anesthesia unit to make that happen.
The reason for the precaution, Chandler explains, is the small but very serious risk that the uterine C-section scar will rupture during a vaginal delivery. In the 0.5-to-1 percent chance that happens, the baby can die or suffer permanent brain injury.
Studies show that if doctors perform a C-section within 18 minutes of rupture, “nothing bad happens,” Chandler says. Natividad has seen three ruptures since its VBAC program was started, and all the babies turned out fine, he says. Natividad’s team is set up to do emergency C-sections in 15 minutes or less.
Attempted VBACs can lead to unplanned C-sections for the same reasons a first-time mom’s labor can, including failure to dilate, babies in uncooperative positions and signs of fetal distress. Among the 129 attempted VBACs at Natividad last year, about 40 percent ended up as C-sections, Chandler says.
That’s higher than the 28 percent cesarean rate for non-VBAC births, but it’s a fair shot compared to the 100-percent likelihood of a repeat C-section at SVMH or CHOMP.
The VBAC program has made Natividad the unlikely destination for hundreds of moms from the Whole Foods set. “Because we’re the only game in town, people travel to have us deliver their baby,” Chandler says, “and they’re pleasantly surprised.”
After decades delivering babies exclusively to mothers on Medi-Cal – California’s Medicaid program, which provides state-sponsored healthcare to low-income families – Natividad opened a specialty clinic for patients with private insurance in 2008.
Last year, about 90 percent of mothers who gave birth at Natividad were Medi-Cal patients, compared with 43 percent at CHOMP and 45 percent at SVMH.
Chandler’s proud of Natividad’s increasingly holistic birthing approach. “Starting a VBAC program? Nobody does that. They’re shutting them down,” he says. “We’re watching our C-section rates fall while the rest of the country’s trending up.”
April Ritchie, supervising R.N. of labor and delivery, says she’s seen dramatic changes at Natividad’s labor center in her seven years there.
“When Dr. Chandler and Dr. Liem came here, it just felt like everything clicked into place,” she says. “It’s progressive; it’s evidence-based.”
Natividad’s labor-and-delivery rooms include a few special perks for the holistic patient. In addition to the standard-issue monitoring station, which tracks mother and baby’s vitals during labor, Natividad offers wireless fetal monitoring that allows laboring moms to walk around. IVs aren’t required at check-in, Ritchie says, but most doctors order them close to delivery.
While all three local hospitals allow doulas to attend to their patients during labor, delivery and postpartum, only Natividad makes it standard practice to allow the doula in the operating room during a C-section.
It’s part of a hospital policy that goes beyond tolerating doulas to actively welcoming them, in the belief they help women achieve more relaxed labors with fewer complications.
For women who can’t afford $500-plus to hire their own doulas but want the emotional support during labor, Natividad Medical Foundation is working to create a team of six DONA-certified, on-call doulas. If the foundation can raise the $25,000 needed for that first phase, the doula service will expand to include special support staff for patients from Mexican indigenous communities struggling with language and cultural barriers.
The hospital’s position on midwives, however, is only welcoming in theory; OBs and family medicine doctors currently perform all of the hospital’s deliveries. Chandler says that’s because only certified nurse midwives can get hospital privileges, and the county’s two licensed midwives don’t qualify. “We would love to have midwifery here,” he says. “It would be a very friendly place for midwives to come.” (4.30.12 UPDATE: The Birth Network of Monterey County's Resource Guide lists four licensed midwives and one certified nurse midwife.)
None of the Above
Amy Tulley’s first home birth took about 15 hours from the time her Carmel Valley midwife arrived at her Monterey home. She walked around, dipped in a hot tub, tried different labor positions and pushed for a little over two hours before delivering her daughter, Claire.
The same midwife delivered Tulley’s second baby, Patrick, in a home birth two and a half years later. The themes were the same: all natural, no meds and no complications.
The pain, in Tulley’s view, helped her feel present throughout the labor experience. “I’m sure if I was in a hospital with the ability to take drugs, I would have,” she says. “There were moments I felt I couldn’t go on.”
Home births tend to cost a fraction of hospital births. Tulley’s family paid over $4,000 in midwife’s fees per baby, plus a few hundred dollars in home-birth supplies, compared with local hospital bills ranging from about $19,000 to $29,000, pre-insurance, for vaginal births (see table, this page).
Tulley says her insurance only picked up $500 of her first home birth, and none of the second. Her total out-of-pocket, ironically, could have been lower in the hospital.
During their meeting at Parents’ Place, the doulas dream about having a birth center like Sutter Maternity and Surgery Center of Santa Cruz here in Monterey County.
Sutter’s plush accommodations and reputation for holistic-friendly birthing convinced Monterey mom Kaira Kilpatrick to travel there for the VBAC birth of her second child.
“They were probably more hands-off than my birth plan wrote up,” she says. “I had my doula there, and they let me do my thing. I hardly ever saw the nurse.”
The doulas at Parents’ Place are a bit wistful about that haven of holistic birth so close, yet so far, from Monterey County. “It’s like a different world up there,” one says. “The difference of 30 miles is remarkable.”
“We need more competition here,” another adds.
“There is competition here,” retorts a third, citing Natividad’s VBAC program and planned doula service.
In the absence of concrete plans for a new birth center in Monterey County, that might be their best lead yet. The doulas talk about the potential for getting some licensed midwives on staff at Natividad.
One doula wonders if Natividad can ever really win over the moderate-to-affluent patients who might view it as a hospital for poor women. “It’s a pretty high-class problem to have, whether you have to share a room [postpartum], or have a window,” she says. “It’s a luxury to think about this stuff.”
Still, Shihadeh of the Holistic Moms Network feels Monterey County has a wider range of birthing choices than it gets credit for.
“My impression is that we’re better off than other parts of the country,” she says by phone. “We’re not Santa Cruz, but we’re certainly not Mississippi.”
Her own daughter, now 3, was born at CHOMP. Now four months pregnant with her second, Shihadeh is planning a home birth with a midwife.
“I don’t need any [medical] intervention,” she says. “I didn’t really need it for the first one.”