Editor's Note: A version of this article was originally published in our January 2013 issue.
Courtney Jarecki was as prepared for childbirth as a woman could be. She teaches childbirth classes at her business Full Moon’s Daughter, and served as an apprentice midwife. She estimates she’s attended more than 30 births. With that experience, she firmly believed most women don’t need a hospital or a doctor to give birth.
“I didn’t pack a bag for the hospital just in case,” she says, “because I was someone who was not going to go to the hospital.”
When she went into labor in March 2011 at the age of 35, her husband, Dave, filled a birthing tub with warm water in the living room of their Northeast Portland home. When Jarecki began to have back labor—a particularly painful ordeal—she used every technique she knew to cope, including a mantra: just this one, just this one.
After 54 hours, she saw thick meconium—an infant’s first stool, sometimes a sign of fetal distress in a long labor. Completely exhausted, Jarecki climbed into her minivan and headed for the one place she never thought she would: the hospital.
A long history of hostility has left people who favor home birth—a position that is nationally controversial, but popular in Portland—very wary of hospitals. But the doctors and nurses at Legacy Emanuel, where Jarecki transferred, did not criticize her choice to try to deliver at home, or her decisions that directly contradicted standard hospital procedure, like allowing her labor to continue for two days after her water broke.
Jarecki’s certified nurse midwife—a nurse pratictioner with additional training in midwifery—sat down to talk to her so she could be at eye level. When a C-section proved necessary to deliver the baby, who was breech, the staff let Jarecki walk to the OR on her own two feet. Emanuel also granted her every wish: no vitamin K shot, no vaccines.
“It was like being at a spa,” she says. “I made a lot of demands, and they honored every one. To be honest, I was not ready for their kindness.”
Two hours after arriving at the hospital, Jarecki gave birth to a healthy baby girl.
Jarecki’s experience reflects Legacy Emanuel’s efforts to appeal to women who begin a home delivery but end up needing hospital care, and to the midwives who assist them. In a city and state with a marked affinity for alternative health care, potential demand for a last-resort option for home births is strong. The vast majority of home births go smoothly (though some stats suggest that infant mortality rates might be worse than among hospital births). But when things go wrong, some mothers and midwives fail to seek hospital care, for reasons ranging from fear of criticism from staff to some midwives’ inexperience in recognizing the need for a hospital’s assistance.
Emanuel is trying to change that, and meanwhile make its labor and delivery unit friendlier to a growing number of women who want a no- or low-intervention birth, even in a hospital setting. The reforms involve a massive shift in hospital culture, and started with a highly unlikely changemaker: a by-the-book, male obstetrician in his fifth decade of doctoring.
“Home birth is going to happen whether we like it or not,” says Duncan Neilson, chief of Women’s Health Services at all five of Legacy’s hospitals. “Getting mad about it is like getting mad at the rain.”
Neilson, a self-described introvert, speaks so softly that to record his voice, an iPhone’s microphone must be placed directly in front of him. His father was an obstetrician. So was his dad’s identical twin. Later, the two went into practice together in Portland.
On the other hand Neilson, who grew up in Northeast Portland and attended Reed College, imagined a career in neurophysiology. And then neuroanatomy. Or human pathology. Delivering babies? Not even a consideration. And then, just as he was starting his residency at Johns Hopkins, his wife had their first child. It was 1969, a time when fathers were not allowed in the labor room, but Neilson’s medical credentials earned him an invitation. (He remembers having witnessed only one previous birth—a C-section, which almost caused him to pass out.)
The baby, a boy, was turned the wrong way, so the doctor pulled out a pair of metal forceps, opened them up, and placed them around the baby’s head. “I thought if this goes well, my life will proceed according to plan,” Neilson says. “If not, everything will change.” It was the first time he understood the magnitude of helping a baby enter the world.
Everything did go well: his son, Duncan Neilson III, is now the composer-in-residence at the Portland Chamber Orchestra. But the course of Neilson’s life still changed. He became an ob-gyn, and over the next four decades helped literally thousands of women give birth—every one of the babies delivered in a hospital. During his career, however, Neilson has seen many changes in how hospitals manage birth.
“We have this environment that looks like a high-tech intensive-care unit,” Neilson says. “That has caused some people to rebel from the modern obstetrics and seek a return-to-nature kind of approach.”
Depending on the stats you look at, 2 to 3 percent of Oregon’s newborns take their first breaths in their own homes or at an independent birth center, making Oregon no. 2 in the nation for out-of-hospital births. (Montana is no. 1.) Alternative-minded Portland, Eugene, Bend, Corvallis, and Ashland are home-birth hotbeds. “Midwifery culture goes along with our food culture, our bike culture, and sustainability,” says Holly Scholles, founder of Portland’s Birthingway College of Midwifery, which each year graduates up to nine midwives. “It fits in with that particular Oregonian spirit that combines frontier independence with liberal outlook.”
As more women choose to give birth at home, more women, like Jarecki, will—at some point—need services that only a hospital can provide. A woman might seek a labor-inducing drug like Pitocin to move a stalled birth along, or an epidural that allows her to rest. Yet in many cases, when hospitals and home-birthers meet, the result can be a savage clash of cultures.
Many obstetricians consider home birth risky at best and reckless at worst. Contributing to physicians’ distrust is the fact that there’s no national standard for midwife licensing; it varies greatly from state to state. (Oregon has voluntary licensure for midwives who want to be eligible for Medicaid reimbursements.) For their part, many midwives and women who choose out-of-hospital birth see hospitals as part of a medical system run technologically amok. In 2010, the United States had a C-section rate of some 33 percent, while the World Health Organization recommends that the rate should not be higher than 10 to 15 percent.
Neilson encountered the tension firsthand in his first months running Legacy Women’s Health Services. Shortly after accepting the post in 2005, Neilson received a call from a nurse midwife who had overseen a home birth. The mother, who also happened to be a nurse, had had a long and difficult labor. She wanted to come to Legacy Emanuel for an epidural to help her rest, so she could continue pushing.
The attending midwife contacted Neilson to let him know that when she’d called to let hospital staff know they were coming, the obstetrician on the phone—a staunch anti-home-birther—aired his opinions in no uncertain terms. “This midwife said, ‘What’s wrong with you guys?’ I had to agree that that did not seem like a professional response,” Neilson recalls.
The experience revealed to Neilson the need for an environment where midwives could safely transfer home-birth patients.
“By safe, I mean safe from ridicule, and safe from the judgment they were encountering everywhere,” Neilson says.
Neilson, it should be noted, is not an advocate of out-of-hospital birth. He is a fellow of the American College of Obstetricians and Gynecologists and agrees with its most recent statement, issued in February 2011, “that hospitals and [hospital-affiliated] birthing centers are the safest setting for birth.” But he possesses an uncommon willingness to look at the midwife-obstetrician divide and arrive at his own, dispassionate conclusions. So he began to ask a question that few other ob-gyns would dare: Does a hospital’s unwelcoming environment prevent women from seeking care when they need it? In short, were the hospitals contributing to poor home-birth outcomes?
“We take care of all kinds of people in hospitals who do things that we think aren’t smart. They drink too much, they smoke,” notes Terri Cohen, Legacy’s midwifery service program director. “But we don’t just tell them they can’t come to our hospital.”
Neilson decided to turn Legacy Emanuel into a place where home-birthing women would feel supported, welcomed, and understood.
The doctor’s first move was to change how Legacy staffed its labor and delivery floor. Previously, ob-gyns in private practice signed up to work the floor as the on-call delivery doctor one or more times a month—a system that meant the hospital had little control over the attitudes doctors brought with them.
Instead, Neilson wanted Legacy Emanuel to hire its own obstetricians. “If I said they had to take transfers from community midwives and be nice about it, then they had to do it,” he says. The difficult part was getting Legacy Emanuel to pay for the five doctors’ salaries. But after he argued that in-house obstetricians (called hospitalists) would provide better safety, Legacy Emanuel agreed to lose money on the program.
Up next: changing the protocol for how the hospital handled home-birth transfer patients. Before Neilson’s new regime, all women who transferred to the hospital from home or a birth center were labeled “high risk”—even if a mother only wanted pain medication. That meant home-birth transfers were automatically placed under the care of an obstetrician-gynecologist, rather than, say, one of the hospital’s nurse midwives.
Now, home-birth transfers are assessed individually—often on the phone before a patient even arrives. Obvious emergencies, as when a mother is bleeding heavily, receive immediate care from the staff ob-gyn. Those considered low-risk—about half of the transfers—go to Legacy Emanuel’s nurse midwives, skilled at supporting natural birth. (Several, like Cohen, have themselves given birth at home). Before the protocol shift, very few women who transferred to Emanuel from an out-of-hospital birth situation delivered vaginally. Today, about half of them do.
Neilson also wanted to make the hospital more appealing to women who desired a low-intervention birth. He realized water births—common at birth centers and at home—were one of the easiest ways to address concerns about hospitals being “overly medicalized.” When a woman deliveries in a tub of warm water, she can’t have continuous IV infusions and doctors can’t perform continuous fetal monitoring. So in 2008 Legacy Emanuel became one of the first hospitals in Oregon to offer underwater birth. (OHSU has had a water-birth program since 1997, though obstrecians there rarely make use of it. It’s typically used by nurse midwives.) Since the program at the Legacy hospitals began, some 700 women have delivered babies there using the technique.
Legacy Emanuel is now the go-to place for local midwives whose clients need hospital care. In 2013, 90 women made that move. The total number of transfers is even greater, when the more emergent cases transferred directly to an OB are taken into account.
“If you make a more inviting environment, word will spread,” Cohen says. “We want midwives and women to know that if you are out of hospital and need hospital care, this is good place to bring your patients.”
More important, Neilson says, are what the hospital no longer sees: “We used to have these horrible [home-birth] disasters show up at the ER. And we do not see those disasters now. They have just about gone away.”
Alma Midwifery looks nothing like a hospital. In its 1904 Victorian, there is tea in the waiting room, and a candle burns in the foyer when someone is in labor. A great big bathtub anchors each of the four birth rooms, which are decorated with tiled murals, plants, and cute bedsheets. About the only thing that cues a visitor that she is standing in a birthing room and not a bed-and-breakfast is a baby scale.
About 10 percent of the births attended by Alma’s midwives, at the birth center or in mothers’ homes, result in transfer to a hospital—most of them, if insurance allows, go to Legacy Emanuel. The hospital’s willingness to work directly with community midwives has improved care protocols here, says Alma midwife Stephanie Sherman.
As a result of conversations with Legacy Emanuel, Alma changed its charting protocol. Now, in addition to “story charting”—chronicling births with notes about a woman’s family, or even the weather—midwives fill out a checklist of information on a form prepared by Emanuel’s Cohen to make it easy for doctors accepting transfers to find essential data.
“What doctors want to know is What are vital signs for mom? What are vital signs for baby? Is she drinking? When did she last drink?” Alma’s owner and director, Laura Erickson, says.
Alma also prepares its clients better for the possibility of hospital transfer—and even for the possibility of a C-section. “Here it’s not ‘We’re going to the big bad doctor, the enemy.’ It’s ‘We’re going to give you more resources,’” Erickson says. “Hopefully the clients don’t go in with their boxing gloves on and get defensive.”
Alma’s midwives, too, have developed strong relationships with Emanuel’s nurses and the hospitalists—most of whom have visited the birth center. Under these kinds of partnerships, women still choose how and with whom they give birth, but now the people in charge of their care collaborate instead of fighting over whose point of view is right.
“The only way we’re going to get to a middle place is by talking about all birth stories and sharing all of the knowledge that both sides have to offer,” says Jarecki, who is coauthoring a book about home birth. The result, both Alma’s midwives and Emanuel’s nurses and doctors agree, is a vastly improved experience for the people who count most in the equation: mothers and babies.