“The new unit is essentially a home birth that happens to be in a hospital,” Dr Jollow said.

With the Health Department and midwives’ groups angrily denying the changes would jeopardie the health of women and their babies, The Manly Daily yesterday spoke to the most important people in the debate – new and expecting mums.

Amee Harland said she would wait for the Mona Vale maternity ward to reopen in full before having a second child there.

“I had a 24-hour labour and then they had to call the doctor because the baby’s heart rate was falling and he was there in five minutes and had to use a surgical vacuum,” she said.

… “You wouldn’t want to drive to Manly (or St Leonards) in the middle of labour …

“I would prefer to go to Mona Vale – it is my home town. Why would I want to go anywhere else? They were so good there.”

Mother-of-three Kellie Finney said low-risk births could also require immediate action.

Midwives say doctors and nurses at OHSU have filed baseless complaints to the licensing agency meant to thwart competition … The threatened lawsuit spurred a passionate online debate among supporters and critics of home birth.

Conflicts between midwives and doctors run deep. One of the biggest problems: Many physicians deal with midwives only when a laboring mother experiences difficulties during a home birth and requires transport to a hospital, sometime urgently.

“It’s an extremely tension-fraught encounter,” according to Melissa Cheyney, an Oregon State University assistant professor and practicing midwife who studied the interactions of midwives and doctors in Jackson County last year. Nearly every physician interviewed by Cheyney and her graduate student expressed the view that births must take place in a hospital to be “safe.”

Studies including higher-risk pregnancies have found that fetal deaths are more likely in home births. But in low-risk pregnancies, most research shows no significant difference in risk to the baby, while home-birth mothers experience fewer complications. In a study in British Columbia last year, women giving birth at home suffered fewer than half as many serious perineal tears, and about a third less postpartum bleeding.

By choosing a hospital birth, women substantially increase the risk of having a surgical delivery. More than 29 percent of hospital births in Oregon resulted in a cesarean during the years 2006-2008. Less than 4 percent of home births ended with a cesarean in a 2005 study of 5,400 births attended by midwives in the U.S. and Canada.

Women who choose home birth often cite the desire to keep birth free of medical intervention. Heather Hermans … transferred to the care of a midwife because she wanted to try a vaginal delivery rather than schedule a cesarean section, as her obstetrician-gynecologist recommended.

Conflicts aren’t inevitable. Cheyney is working with midwives in Lane County and a Eugene obstetrician, Dr. Paul Qualtere-Burcher, on guidelines for smoother, more collaborative relations. Qualtere-Burcher and his colleagues have agreed to help midwives get access to laboratory testing and ultrasound screening for their clients. Midwives are referring higher-risk home birth clients to the physicians for assessment and another perspective.

“We’d like them to come in and see us before it becomes a big issue during labor,” Qualtere-Burcher said. “I think it’s been very successful.”

Home birth by the numbers

Planned home births in Oregon last year: 877 out of 47,675 total births, or 1.8 percent.

Chances of giving birth without medical intervention: 78 percent with a home-birth midwife versus 54 percent in hospitals, according to the 2009 British study.

A women’s chances of having cesarean section when giving birth in an Oregon hospital, 2006-2008: 29 percent.

Fetal deaths in births attended by licensed midwives in Oregon, 2001-2007: 4 in 2,906 births, about 0.1 percent.

Complaints lodged against licensed midwives, 1999-2007: 40.

Disciplinary actions imposed by the Board of Direct Entry Midwifery, 2000-2004: 12

Midwife guide

…

Direct Entry Midwife – A general term for practitioners who train directly into midwifery without a nursing or medical background, and attend births outside of hospitals. Oregon law allows direct entry midwives to practice with no licensure.

Certified Professional Midwife — Direct entry midwives certified by the North American Registry of Midwives, which requires written and practical examinations and practical experience attending 40 births.

Licensed Direct Entry Midwife — Direct entry midwives who obtain a license in Oregon are authorized to use some prescription drugs and medical devices. They must pass a national examination, demonstrate experience in attending births, and complete continuing education every three years. They are licensed by the Oregon Board Direct Entry Midwifery and subject to disciplinary actions if they violate professional standards.

Although home birth seems to be safe for low-risk mothers and, when compared with hospital delivery, is associated with a shorter recovery time and fewer lacerations, post-partum haemorrhages, retained placentae and infections, the evidence is contradictory for outcomes of newborn babies delivered at home … The problem arises when planned home births become hospital births when complications arise, and this can then lead to an underestimation of the risk and overestimation of the benefit of home births. Data from the Netherlands, for example, suggest that up to 40% of nulliparous women who start labour at home are transferred to the hospital. Most studies also rely on different midwifery models for home delivery, which are not generalisable.

Professional organisations … have issued contradictory policy statements regarding home deliveries. The Department of Health of South Australia has a detailed policy for home birth among women with low-risk, singleton term pregnancies, while the UK’s Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives jointly support home birth in women with uncomplicated pregnancies. By contrast, ACOG does not support home birth, citing safety concerns and the lack of rigorous scientific evidence. Choosing to deliver a baby at home, states ACOG, is to show preference for the process of giving birth over the goal of having a healthy baby.

Last year Ms Roxon announced that from November this year midwives would for the first time be able to use the Pharmaceutical Benefits Scheme and Medicare rebates for their clients.

At the time, Ms Roxon said the historic move would boost a midwife’s ability to work independently and increase options for pregnant women …

Doctors’ groups who say home birth is unsafe are believed to have lobbied the government for the changes.

Yesterday, midwives and home-birth advocates accused Ms Roxon of trying to hide what will be an unpopular decision with midwives and mothers.

Australian College of Midwives president Hannah Dahlen said the change would effectively give doctors the ability to veto their access to Medicare and the PBS.

AMA President, Dr Andrew Pesce, said today that the new arrangements would provide a safer higher standard of care for patients.

The new scheme will see the majority of northern beaches births take place at Manly Hospital, where a combined obstetric maternity service will operate, with about 200 births a year scheduled for Mona Vale, where midwives will now manage them all.

… the new “midwifery group practice model” was unanimously endorsed …

But Mona Vale obstetrician Dr Chester Kent said the hospital had no representatives on the council and that none of its maternity staff supported the decision.

“It seems there is nobody being included in the decision-making process who really represents the interest of local women,” he said.

Another hospital worker, who did not want to be named, said they were only told about the changes at a meeting on Tuesday and that neither Manly or Mona Vale staff supported the decision, which they found “very distressing”.

Pittwater State Liberal MP Rob Stokes said operating a midwifery group practice model at Mona Vale was not a bad idea, but it should not be used as a replacement for obstetric services.

… “It’s not good enough to put a delivering mother into an ambulance and take them down to Manly, or the North Shore.”

What happened is this: In my 39th week, I am induced because of high blood pressure. At the hospital, I am given Pitocin, a synthetic form of the labor-inducing hormone oxytocin, and Cervidil, a vaginal insert used to dilate the cervix. Within two hours, my contractions are one minute apart. I had lasted as long as I could without an epidural because I had read that they sometimes slow dilation. That’s the last thing I need: I’m at a pathetic 2 centimeters. My doctor comes up with a solution for the pain: a syringe full of a narcotic called Stadol.

“I have a history of anxiety,” I tell the nurse who has brought in the syringe, as I always warn any medical professional who wants to give me drugs. “Is this drug OK for me?” “It sure is,” she says.

It is not. Within 10 seconds, I begin hallucinating. For five hours, I hallucinate that I’m on a swing that’s soaring too high, that houses are flying at my face. My husband has fallen asleep on the cot next to me, and I’m convinced that if awakened, he will turn into a monster — literally. I’m aware this notion is irrational, that these images are hallucinations. But they are terrifying. I buzz the nurse. “Sometimes that happens,” she says …

By noon the next day, 24 hours after I had arrived, I am only 3 centimeters dilated. The new nurse, a nice lady, tells me the induction isn’t working. “Your blood pressure isn’t even high anymore,” she says. “Tell the doctor you want to go home.”

When my OB comes in, I say, “I’d like to stop this induction, if that’s possible. I’m worn out. I hallucinated all night … I just don’t think this is working out.”

“OK,” he says. “Let me examine you. If you’re still not dilating, we’ll talk about going home.”

My previous dilation exams had been quick and painless, if not entirely pleasant. This one takes a long time. Suddenly, it hurts. “What are you doing?” I scream. “Why does it hurt?”

No answer.

“He’s not examining me,” I scream at my husband. “He’s doing something!” My husband grips my hand, frozen, unsure.

I scream to the nurse, the nice one who had suggested I go home. “What is he doing?” She doesn’t answer me, either. I writhe under the doctor’s grasp. The pain is excruciating.

The first sound I hear is the doctor’s directive to the nurse, in a low voice: “Get me the hook.”

I know the hook is for breaking my water, to speed my delivery by force. I scream, “Get off of me!” He looks up at me, as if annoyed that the specimen is talking. I imagine him thinking of the cadavers he worked on in medical school, how they didn’t scream, how they let him do whatever he wanted.

“You’re not going anywhere,” he says. He breaks my water and leaves. The nurse never looks me in the eye again.

Eleven more futile hours of labor later, I am exhausted and terrified when the doctor comes in and claps his hands together. “Time for a C-section,” he says. I consider not signing the consent form, ripping off these tubes and monitors, and running. But the epidural I’d finally gotten won’t allow me to stand up.

It’s nearly midnight when I hear a cry. My first emotion is surprise; I had almost forgotten I was there to have a baby.

I was desperate to find someone who could tell me what had happened to me was normal. To say, “You hallucinated? Oh, me, too.” Or “My doctor broke my water when I wasn’t looking. Isn’t that the worst?” Nothing …

Now, I’d never loved my doctor … I’d found him patronizing — “Normal!” he’d shout at me, when I asked a question — I thought his assuredness might be a good antidote to my anxiousness. It seemed to work, until it didn’t.

… I also didn’t have a birth plan … Sure, I had a plan for the birth: Have a baby using whatever breathing method I’d learned in the hospital’s birth-preparedness class, maybe get an epidural. But I didn’t have the piece of paper that so many of my friends have brought to the hospital with them … in my opinion, the very act of creating such a contract was to ignore what labor is: something unpredictable that you are in no way qualified to dictate.

… people who hear my story ask … Did I consider a home birth? A midwife instead of an obstetrician? … The answer is no. I am not holistically minded. My philosophy was simple: Everyone I know has been born. It can’t be that complicated.

The women who ask me about my preparations for my first son’s birth — who imply with these questions that I could have prevented what happened to me if I’d been more diligent — are part of an informal movement of women who are trying to “take back” their birth — take it back from the hospital, the insurers and anyone else who thinks he can call the shots.

But hospitals aren’t so interested in giving women back their birth … stipulations dealing with labor and delivery (“I want only one medical professional in the room at a time”) garner barely a glance. University OB/GYN in Provo, Utah, even has a sign that reads, “…we will not participate in: a ‘Birth Contract’, a Doulah [sic] Assisted, or a Bradley Method delivery. For those patients who are interested in such methods, please notify the nurse so we may arrange transfer of your care.”

… This question of whether I could have prevented my trauma has lingered in my mind since that day; now that I am pregnant again, it has become deafening. I have a chance to do it all over. Would I benefit from thinking more holistically? Should I bother taking back my birth?

During my pregnancies, friends gave me two books; their spines are still barely cracked. The first is called “Ina May’s Guide to Childbirth.” … The other book is “Your Best Birth” by Ricki Lake and Abby Epstein; it’s an offshoot of their 2008 documentary, “The Business of Being Born.” Their urgent message is that women who want to deliver vaginally can do so if no one intervenes. Instead, doctors and hospitals are doing all they can to “help” the laboring woman along … and failing. Inductions like mine, epidurals given early in labor, continuous fetal-heart monitoring — all of them have been associated with a higher risk for cesarean section. The result is an epidemic — 32 percent of U.S. births were C-sections at last count, the highest rate in our history. Individual surgeries may be medically necessary, but as a matter of public health, the best outcomes for mothers and babies come with a rate of no more than 15 percent, according to the World Health Organization.

Sam … was five months pregnant when watching “The Business of Being Born” convinced her that hospitals could be dangerous and a home birth would be more meaningful. She and her husband found a midwife … and spent the rest of the pregnancy preparing.

After 24 hours of labor, Sam’s contractions were two or three minutes apart, yet when her midwife examined her, she was only 3 centimeters dilated. The midwife gently told her that she was nowhere close to delivering, despite her contractions, exhaustion and pain. Sam asked to be taken to the hospital.

The change of scenery did her good. “At that point, I had been in labor for 40 hours,” she says. “I entered the relaxed zone. The epidural took the edge off … It was a sacred space.”

After her son’s delivery, Sam passed out, having lost 50 percent of her blood volume in a postpartum hemorrhage. Needless to say, she was relieved that she was in a place where blood transfusions were readily available … she believes she will want midwife care at a hospital next time.

… Bialik’s first birth didn’t go the way she wanted. After three days of labor at home, she stalled at 9 centimeters, one short of the goal. Her midwife suggested they go to the hospital, where after a natural childbirth, Bialik’s son spent four days in the neonatal intensive-care unit. “My son was born with a low temperature and low blood sugar, which isn’t unusual in light of the fact that I had gestational diabetes,” she explains. “I understand doctors need to err on the side of caution, but there was nothing wrong with my child. All of our plans for bed sharing, nursing on demand, bathing him — gone.”

The experience was scarring. “I felt a sense of failure that I had to call my parents from the hospital,” Bialik continues. “Yes, I know vaginal birth in the hospital is the next best thing to a home birth.” …

I point out that natural childbirth in the hospital — her “failure” — was my best-case scenario. But I also understand when she says, “Everyone is allowed her own sense of loss.” She realized her vision when her second son was born at home.

The second time around
I don’t consider myself a candidate for a home birth. The risk of uterine rupture from an attempt at vaginal birth after cesarean (VBAC) makes it unthinkable … I’m also not really interested in a home birth … But I’m also not interested in another C-section …

So I’d like to attempt a VBAC, but I know that it doesn’t always succeed. I have a new doctor — the 10th I interviewed following my son’s birth — at a new hospital, and he has agreed to help me try. But my primary goal is more modest: not to be retraumatized. Even now, my heart pounds at the sight of hospital receiving blankets, the antiseptic smell of the maternity ward.

The common thread in Bialik’s and Sam’s stories that impressed me was how supported and safe they felt with their midwife …

In an e-mail Bialik sends after our meeting, she goes back to my idea that some women weren’t meant to have babies the holistic way. “There are those among us who believe that if the baby can’t survive a home labor, it is OK for it to pass peacefully,” she writes. “I do not subscribe to this, but I know that some feel that … if a baby cannot make it through birth, it is not favored evolutionarily.”

I think about my appendectomy, back in 2003. Had I not made it to the hospital in time, I would be dead. What would it be like to refuse medical intervention? I’d call my family, say my good-byes. “I’m sorry,” I’d say. “But I’m not evolutionarily favored. It’s time for me to go.”

This attitude, that everything was better back when there were no doctors, seems strange to me. C-sections, although certainly done too often, can save lives. Orthodox Jews still say the same prayer after childbirth that those who have been in near-death experiences say — and with good reason. A birth that leaves mother and child healthy may be commonplace, but it’s also a miracle every time.

As the weeks pass and my belly grows, I can’t stop thinking about Sam. Her pregnancy was a sacred time, and she had truly looked forward to labor. Is that what I should try for — a meaningful birth, as well as an untraumatic one? At what point had people like Sam and me learned to feel entitled to a meaningful birth?

“I think that birth should be a beautiful experience,” says obstetrician Kimberly D. Gregory, M.D. She’s the vice chair of women’s health care quality and performance improvement at Cedars-Sinai Medical Center in L.A. “It should be exactly the way you want it, and doctors should intervene only to preserve the health or life of you or your baby.”

Naturally, one would assume that Dr. Gregory advocates birth plans. When I ask her this, she laughs. “We always say, ‘If you show up with a birth plan, just get the C-section room ready,’” she says. “You get everything on that list that you don’t want. It’s like a self-fulfilling prophecy.” Dr. Gregory led an unpublished study that compared women who took traditional hospital birth classes with those who employed Bradley-like training and a birth plan. The birth-plan group trended toward a higher C-section rate and more interventions. “There’s a certain personality type that tends to be more anxious. Maybe the anxiety hormones themselves put them at risk,” Dr. Gregory theorizes. “It seems that being open and honest and choosing the right doctor is probably a better option than writing everything down. Walking in with this list appears to set up an antagonistic relationship.” …

… In the past three weeks, I’ve had the same dream. I’m in a field (I believe at Ina May Gaskin’s Farm), and women in braids are dancing around me as my baby is born, painlessly, joyously. As I reach down, I notice my C-section scar is gone.

I wake up upset. Am I truly under the impression, subconscious though it may be, that taking back this birth will undo the damage of the last one?

“I don’t understand this phrase ‘take back your birth,’” nurse-midwife Pam England, creator of “Birthing From Within,” … tells me. “Who took it? What would a woman tell herself it meant about her if she failed to meet the criteria she made up for ‘taking back’ her birth? I am concerned that this phrase, meant to generate action and a feeling of empowerment, may actually be generated by or feeding the victim part of her.”

England is right: Having a childbirth that I deem successful this time will not change what I haven’t overcome from the first. I try to find a way to make what my doctor and nurses did to me OK, but my mind rebels. I feel loss — no, theft — of an opportunity for me to have a baby the way so many other women do: a carefree pregnancy, a labor that could still go any way.

Maybe I’m not so different from the women I spoke with, after all. Bialik had a successful natural childbirth but felt like a failure because it was in the hospital. Women who had a C-section also used words like failure. Perhaps part of the problem is that our generation of women is so ambitious, so driven, that we don’t know how to do anything without quantifying it as a success or failure.

According to Dr. Gregory, women are now requesting a C-section for their first birth, even without indication. “A lot of people are uncomfortable with the unknown,” she says. Plenty of people are wary of C-sections by choice, from holistic moms to obstetricians. But isn’t this, too, taking back your birth? Refusing to be out of control seems to me the epitome of taking it back. You don’t have to have an unattended birth in the woods to be considered a real woman.

Deciding that you can’t control the uncontrollable — and committing to that decision when you are, in fact, out of control — is also taking back your birth. It’s what your grandmothers did. It’s what their grandmothers did.

With this, I realize that I have already taken back my birth, but not as part of any movement. I have stopped judging women who take extra precautions as defensive and started to understand that everyone has to find her way.

I don’t know how this story ends. I’m still not convinced my body was made to deliver vaginally. But here’s what I do know: I will insist on kindness. I will insist on care. And I hope I will be open to being treated kindly. It’s harder than it seems.

The proportion of surgical births should be reduced to 20 per cent by 2015, from 30 per cent now, and first-time mothers would be attended by the same midwife throughout labour.

The Minister for Health, Carmel Tebbutt, said the directive was ”designed to support women to have a birth that is as free as possible from invasive medical intervention, while also recognising that labour occurs across a wide spectrum … The safety of mother and child are, of course, paramount.”

The president of the Australian College of Midwives, Hannah Dahlen, said: ”For the last 15 to 20 years [birth interventions] have just gone up and up and up. At some point we have to start coming down again. The policy says, ‘Let’s stop, let’s regroup and try to get a balance.’ ”

She emphasised it would remain ”the safest option for some women to have a caesarean section, and women should not feel lesser because they had to have an intervention”.

Only about 13 per cent of women now achieved a vaginal birth after a caesarean, while up to 80 per cent could do so if properly supported. The NSW targets specify a 30 per cent rate by 2012 and 50 per cent by 2015.

Dr Weaver said the appropriate caesarean rate was about 25 per cent of all births, because the current generation of women represented ”an older population, a fatter population, and a lot of first-time mothers”, Factors which raised their risk.