By On the occasion of our 20th anniversary
By Gustavo Arellano
By R. Scott Moxley
By Alfonso Delgado
By Courtney Hamilton
By Joel Beers
By Peter Maguire
By Charles Lam
I Want my Midwife!
The list of OC hospitals that allow midwife-assisted births just got shorter—but moms-to-be and midwives aren't taking it lying down
About a month from now—possibly during some still-black predawn hour, as it was with her first two children—Robin Parker's water will break. Parker, her belly taut and engorged, will grab her bags, pack her two young sons into the car, and depart Mission Viejo with her husband to begin the hour-long ride north. Before she leaves, she will phone the person who's been with her since the beginning of her pregnancy.
During her 50-mile trek, she'll cross the Los Angeles County line; she'll end at a birth center in Whittier.
When Parker arrives, B.J. Snell will likely be waiting for her. Snell is Parker's primary prenatal-care provider and a certified nurse midwife. She will spend as many hours as it takes with Parker until the baby is born.
This wasn't the Parker family's original plan. They were going to drive about 10 miles west to Laguna Beach's South Coast Medical Center, where Parker would give birth under Snell's care. But since the June closure of that hospital's maternity ward, the only facility in South County that granted midwives the privilege of delivering their patients' babies, Parker and dozens of other women have had to either give up their midwives, change doctors or find places, like the birth center in Whittier, where midwives can deliver their babies.
While midwives have long been a topic of debate and controversy among medical professionals in the United States—especially when it comes to home births—midwife-assisted deliveries are increasingly seen as a mainstream choice for healthy women with low-risk pregnancies. Midwives have been proven, in research study after study, to have as good or better outcomes (for example, lower C-section rates, lower infant-mortality rates) than physicians working with the same patient population. Midwife-assisted hospital births are widely available in both Los Angeles and San Diego counties.
But the closing of South Coast's maternity ward has left Orange County women with precious few places to get what some see as the best of both worlds: The hands-on, supportive care of a midwife, with the medical expertise of an obstetrician/gynecologist (OB/GYN) and full hospital facilities standing by in case of emergency.
In response to the closure, a group of former South Coast patients has banded together to educate women about their various birth options, dispel some of the myths around midwifery care and push for midwifery as a delivery option at all county hospitals. "The Community Alliance for Birth Options [CABO] was developed in response to the fact that so many of our patients were left disenfranchised and without recourse," says Lisa Sherwood, a certified nurse midwife who shares her practice with Snell. "They came to B.J. and me and said, 'What can we do? How do we try to make the community aware and make hospitals aware and also look at alternatives?'"
Angelique Boynton, a Costa Mesa mother who has had two children under Snell's care and is active in CABO, stresses that they're not trying to tell any woman the right or wrong way to have a baby. "We're not saying don't see an OB/GYN or don't have an epidural or a C-section," she says. "I had an epidural during my second birth with B.J. We just want women and families to know what their options are. And we believe natural birth with a midwife should be an option that's offered in a hospital setting along with everything else."
For mothers-to-be like Parker, giving up Snell and transferring her care to only an OB/GYN was a compromise she says she couldn't make.
Her first son was born at Mission Hospital, where Parker was under the care of an obstetrician. Parker arrived at the hospital with a doula, a specialized birth attendant who advocates for and supports women in labor. "I was really determined to have a natural birth," she says. "But it was a disaster."
Parker says she couldn't get any doctor to come in and see her for five or six hours. When the doctor did arrive, Parker was in heavy labor; she was told to wait on her pushes until he changed and came to her room, she says. "But the body does what it does when it's in labor. I'm pushing, and they were saying, 'Don't push!'"
The delivery itself was difficult, Parker recalls. She experienced a third-degree tear, losing a lot of blood and needing stitches.
"My husband unfortunately overheard the staff talking, and they said, 'Well, that's what you get when you decide to have a birth that way [natural childbirth].'" She later fainted in her room.
Three months later, she returned to the hospital with a severe infection from her stitches. She asked for help with her wound, since by now she was having trouble sitting and standing up. She was told she would be responsible for the coverage since the stitches were considered "elective surgery."
Two years later, when she considered having another child, Parker says she wanted to try a different approach. She wanted something more personalized and friendlier toward natural birth, she says, but she still wanted to deliver at a hospital in case anything went wrong.
Even though she'd known she wanted to have a natural birth during her first and now second pregnancy, she wasn't familiar with midwives. Parker's doula introduced her to the idea, but Parker was hesitant. "I was pretty naive about the whole thing," she says. "When she brought it up, there was a concern. The whole idea of midwives to me at that point was, well, what does that mean? Are they some hick from the backroads? Are they educated?"
At the beginning of the 20th century, midwives were delivering about half of all babies born in the United States. A majority of these midwives were immigrants or African-Americans and had been apprentice-trained; no formal schooling for midwives existed. During the same period, the burgeoning, male-dominated medical-obstetrics specialization was having difficulty establishing itself among the elite medical sciences; it was viewed as not much different from midwifery. This concern, along with a spike in infant-mortality rates in the U.S., led to a well-documented public and legislative campaign waged over two decades by doctors and nurses on what was then referred to as "the midwife problem."
Midwives were blamed for the country's high infant-mortality rates despite evidence to the contrary. Britain and Germany had lower mortality rates than the United States; in those countries at the time, midwifery had been formalized, and midwives were delivering 75 percent to 80 percent of all babies. By 1935, traditional midwives were only delivering about 12 percent of U.S. babies. During the same decades, nurses who had an interest in formalizing midwifery began establishing the country's first midwifery schools and training programs. Although midwifery gradually regained ground and exists today as a nationally certified profession with thousands of practicing nurse midwives, the stigma of the early campaign created barriers that persist today.
Midwifery is not nearly as widely accepted in Orange County as in other parts of California. In San Diego County, half of all hospitals grant delivery privileges to nurse midwives. In Los Angeles, about a third do, including UCLA; USC did before it closed its nursing division. The closure of South Coast's ward left only two county hospitals—Orange Coast Memorial Medical Center in Fountain Valley and Kaiser Permanente in Anaheim—where patients can deliver with a midwife. Kaiser employs 23 full-time nurse midwives who handle 90 percent of all vaginal births there.
The reasons for the county's limited offerings are varied. Some point to the ongoing misconception that midwives operate as unlicensed, backroom doctors who only do home births.
In reality, certified nurse midwives—who become nurses before they begin specialized midwifery training and are one of four midwifery designations in the U.S.—deliver primarily in hospitals or birth centers affiliated with hospitals. Midwives deliver about 10 percent of the babies born vaginally in this country annually; almost 97 percent of those deliveries are attended by nurse midwives in hospitals. Home births account for fewer than 1 percent of total births. Certified midwives, certified professional midwives and direct-entry midwives are the other midwifery designations; all involve varying degrees of professional training. Certified nurse midwives are the only group that can practice legally in every state.
Although the recent film The Business of Being Born has done much to debunk the backroom-midwifery myth, the documentary's focus is not hospital-based midwifery. The account of Ricki Lake's and other women's blissful midwife-attended home births also offers a biting critique of the current industry surrounding traditional hospital births. The film prompted the American College of Obstetricians and Gynecologists (ACOG) to reiterate its opposition to home births. Just two weeks ago, the American Medical Association joined ACOG, stating that it would support legislation banning home births in the U.S., a move that prompted an outcry from women's-rights supporters nationally and reignited the century-old debate over midwifery.
Another reason for Orange County's limited midwifery offerings, some say, may be tied to the county's obstetricians, who are steadily growing in number and who could be viewed as having an interest in keeping midwives at bay and out of hospitals, since they're often seen as direct competitors. When midwives seek privileges at hospitals, that hospital's physicians, not its administrators, must vote on whether to write the midwifery category into their bylaws and approve the applications.
By all accounts, delivering at South Coast Medical Center, a community hospital perched on the lip of the shimmering Pacific Ocean, was a kind of idyll. When patients chose to deliver with midwives Snell or Sherwood, the event was a seamless blending of multiple disciplines. Nurses worked with midwives who worked with doctors in a collaboration of streamlined care driven by what mothers wanted—and an overall trust in the labor supervision done by midwives. "We were like one big family there," Dr. Ken James says. "Really."
James was Snell's and Sherwood's "supporting physician" at South Coast, meaning he would intervene if any complications arose with their deliveries. He also shares an office with Snell next door to the hospital.
When a woman chose to deliver with one of the two midwives who had privileges at South Coast, she knew she was signing up for a particular kind of care. Prenatal visits would last no less than half an hour. Phone calls would be answered and returned promptly by Sherwood or Snell. On the day of delivery, a patient could wear her favorite pair of pajamas or nothing at all. She could sit, squat, shower, eat, drink, laugh, roll around on a giant yoga ball, get on all fours, pace down the hall—whatever her body craved, she could do, so long as her baby was progressing normally. Snell and Sherwood would spend the bulk of their patients' tumultuous labor with them.
Like all midwives, Snell and Sherwood treated labor as a vigorous, lively, normal experience; the midwife, who knows her patient's body and the baby well, is there to examine, coax, support and ultimately help her patient deliver with as little medical and physical intervention as possible. If there were no complications, the physician was never called into the room. If there were, Snell and Sherwood worked collaboratively with James to deliver the baby.
"We can get as medical as we need to be. If a baby is in trouble or mom is, we say, 'We can't do this,'" Sherwood says. "Then they're delivered into the hands of the OB/GYN."
"It was a wonderful experience," says Parker of her second birth, which was at South Coast. She saw Snell throughout her entire pregnancy; Snell was out of town when Parker went into labor, so Sherwood delivered the baby. "I was actually happy and excited this time around," she says. "I just have full confidence in Lisa and B.J. to take care of the baby and to take care of me."
All this came to an abrupt end when the small maternity ward closed in June because of a drop in deliveries there and high overhead costs, according to hospital administrators. Doctors, nurses and midwives who were delivering babies at the hospital were given six weeks to relocate themselves and their patients. For nurses, it meant scattering throughout the county for new jobs at various maternity wards. For doctors such as Ken James, it would mean transferring patients to the other hospital where he had privileges.
But Parker and the 50 or so other patients who were going to Snell and Sherwood weren't sure what would happen. Some assumed they would just transfer to another hospital like James' patients.
"The difference, of course, is I have privileges somewhere else, so I say to my patients, 'We can't go to South Coast; we'll go to Saddleback,'" James says. "The problem is, for the midwives, they don't have any other hospitals to go through, so their business kind of dissolved or is dissolving. It's really sad and disappointing."
Snell and Sherwood are familiar with the ins and outs of hospital privileging. Sherwood worked at local hospitals for most of her 24-year career as a labor-and-delivery nurse before earning her master's degree at USC, becoming a nurse midwife and working at Kaiser. Snell has been a nurse since 1977, has a Ph.D. in public health, directed the midwifery program at USC, worked at Daniel Freeman Medical Center in Los Angeles, and served as director of the birthing center at UC Irvine Medical Center in Orange (the county's second; the other is in Irvine) in the mid-1990s. They both knew that gaining hospital privileges following South Coast's maternity-ward closure might be tricky, but they were hopeful.
The first option was to go to Saddleback Memorial Medical Center in Laguna Hills, where James already had privileges and where he offered to again serve as their supporting physician (a role that, in his case, led to the doubling of his malpractice insurance, despite the fact that both Snell and Sherwood are required to carry $2 million to $3 million in malpractice coverage of their own). Snell and Sherwood approached administrators, who, they say, expressed interest. But the decision ultimately would be up to the doctors.
In April, Saddleback's OB/GYN committee met to discuss the possibilities of granting the midwives hospital credentials. Dr. Elizabeth Lyster, an OB/GYN who worked with Snell and Sherwood at South Coast for three years and who first worked with Snell at USC, was at the meeting. Lyster says her fellow physicians didn't have safety concerns about midwives. "[Midwives] practice excellent obstetrics," she says. Dealing with serious complications is up to the doctors, and the midwives know this, Lyster says. This collaborative model, she says, worked well at USC.
And yet the doctors at Saddleback balked. "No one wanted the [midwives]. They saw them as a threat," says James, who was also at the meeting. James says doctors expressed fear that opening the door to Snell and Sherwood would invite in too many other midwives who could potentially undermine the business of the physicians. "That whole competition thing is not real," James says. "Patients who want natural childbirth will seek it out."
The Weekly's requests to speak with Dr. David Lagrew, medical director of the Women's Hospital at Saddleback, about the meeting and the hospital's decision were declined. The hospital released only this statement: "The decision to offer a midwifery program is an issue facing many hospitals in our region. At this time, Saddleback Memorial Medical Center does not have a midwifery category in our allied health staff."
Snell and Sherwood also approached physicians with privileges at the next-nearest stop, Mission Hospital in Mission Viejo, but the physicians they spoke to said they could not act as supporting physicians for the midwives, Sherwood says.
A spokesperson for Mission Hospital says the hospital had not been approached by any midwives and said Dr. Marvin Posner, director of maternal and fetal medicine at the hospital, was not available for an interview.
The midwives faced different challenges at other hospitals. At Orange Coast Memorial Medical Center, where a physicians' group has four midwives on staff, Snell and Sherwood were told the hospital did not need any more. Orange Coast administrators did not return calls seeking comment for this story.
Irvine Regional Medical Center momentarily held some promise. Director of Medical Staff Katie Love says the hospital had moved forward with drafting bylaws to create a midwifery category and that the position of the physicians there was neutral. But the midwives could not find a doctor who could act as their supporting physician, Snell says. "The physician we were working with had agreed, but when he called to check in with his malpractice insurance, they said they would drop him if he took us on."
The result has been a frustrating transition for many of Snell's and Sherwood's patients, who have looked for any way to keep them or midwifery as part of their care. "We were told a month before we were supposed to deliver, 'You're basically screwed over,'" Denise Highshaw, who lives in Anaheim Hills and recently delivered her first baby, says of the South Coast closure. "Once we found out no hospitals were letting B.J. come on, I was pretty adamant that I wasn't going to go to an OB. I didn't want that," she says. Her urologist husband, she says, felt the same.
After weeks of sorting through different possibilities, Highshaw found a loophole that let her switch over to her husband's Kaiser insurance; Snell works at Kaiser's Anaheim hospital, but only occasionally.
"We're probably the only ones who get to have her deliver our baby at a hospital," she says. "Others have to do a home birth or have her as a doula."
Whatever they call themselves when they sign in, whether doula or midwife or visitor, both Snell and Sherwood now have their hands tied when it comes time for their patients to deliver at the hospital. One of the temporary solutions has been to have their patients deliver at Saddleback with Dr. James while they attend as visitors.
"When we go into hospital settings now, they make us sign waivers that we're not going to get in the way," Sherwood says. "It's about subtly setting the tone of who's in charge."
James says he's tried to be as hands-off as possible when he's delivering the midwives' patients. "It's worked out nicely," he says. "But the problem is that patients go to midwives because they want midwives to care for them; they don't necessarily want me there."
"It's been really hard," Snell says. "We can't do what we're trained to do."
Little stirs along the road of color-coded custom homes in this scrupulously planned Ladera Ranch community. A snippy gate attendant yaps out directions; a lone jogger climbs the paved hills. But on this warm, midweek July night, there's a break in the silence farther down the road, as voices spill out from the clubhouse on the hill. Inside, rows of women—their hands cradling their bulging bellies—and a handful of men quiet down and turn their attention to the doctor, the midwives, the doula and the moderator.
Tonight is the first of a series of town-hall meetings hosted by CABO, the network of mostly young parents, nurses, doulas and midwives who came together after the South Coast maternity ward closed and they learned there was virtually no place where midwives could deliver their babies.
On tonight's panel are Snell, Sherwood, James, doula Sherry Alden and Sue Morrison, the former head of nursing at South Coast and now head of nursing at Hoag Hospital in Newport Beach.
The meeting is boisterous. Questions abound: What exactly does a midwife do? Where can I find a midwife in Orange County? What is a birth center? How can we convince our hospital to allow midwives to deliver there? How can we get physician staff to respond to what we want?
"We're doing these meetings to let women know they have options for childbirth," says Boynton, who had Snell as her midwife twice. "We're not going to stop until we get this out there to people like me, who didn't know any better."
Boynton says her first pregnancy experience, for which she saw an OB/GYN, was cold and impersonal. She remembers being redirected to a nurse practitioner during one of her first appointments with her doctor. Several friends who went to the same doctor said he had not made it to their births. That pregnancy unfortunately resulted in a miscarriage; by the time she was pregnant the second time, she began asking around about other options. A friend referred her to Snell.
"B.J. had my husband help pull the head out," she says of her delivery at South Coast. "Then she said, 'Bend over and pull the baby out with your own hands,' so I bent over and pulled my baby out. It's such a different experience. People don't know that they can do this."
"What you want is to feel safe, to feel like you have choices for your birth," Morrison says to the group. "The big issue, the big elephant in the room, is: How quickly do we jump to a C-section?"
Dozens of studies examining nurse midwifery care have proven that for healthy, low-risk women, cesarean rates tend to be lower (around 8 percent to 10 percent) when they deliver with midwives. Cesarean rates nationally and statewide jumped 46 percent between 1996 and 2005. In 2006, nearly 1 in 3 women in California had C-section births. Rates in Orange County are similar to the rest of the state, with some hospitals—including Kaiser, Saddleback and St. Jude Medical Center in Fullerton—having a rate closer to 1 in 5.
These national and local rates for C-sections, which are considered major surgery and do have a higher risk of complications than vaginal delivery, are not broken down by the degree of risk in a given pregnancy—or whether the C-sections were chosen by the mother-to-be or her doctor or done in an emergency. Still, they are far higher than the World Health Organization's recommended rate of 10 percent to 15 percent. Once that rate is exceeded, the WHO concluded in 2005, "the maternal injury and death consequent to major abdominal surgery begins to eclipse the lives and health saved." Despite spending nearly twice as much on births, the U.S. still has poor infant-mortality rates when compared to the rest of the developed world, ranking below Cuba, South Korea and the European Union.
"I think people view a C-section as easier," Morrison says after the meeting. "I think it's convenience, consumer-driven . . . but your complication rate is going to go up."
For his part, Dr. James says he's learned to be more patient working with Snell and Sherwood. "Just the other night, we were delivering a baby at Saddleback, and the mother had been in labor all day," he says. "I was thinking, C-section, C-section, C-section, but B.J. said, 'Hold on, now,' and a couple of hours later, she did it, she delivered. I don't doubt what my decision would have been, but I think the patient got what she wanted."
At the meeting, Lauren Mitchell, a former South Coast labor-and-delivery nurse who now works at Irvine Regional, wants to know what can be done to educate labor-and-delivery nurses, who are there during most of the labor process and who, she says, are often less familiar with what full natural childbirth with a midwife looks like.
"There's no emphasis whatsoever on natural births. It's just inductions and planned C-sections. That's kind of our daily routine," Mitchell says. "If it weren't for me having worked at South Coast with B.J. and Lisa, I don't think I would have known how beautiful and wonderful [natural birth] could be."
When the question comes up of what will now happen to the group who once labored and delivered together, the panelists exchange glances. Snell says she is exploring the option of opening up a birth center; she ran the first free-standing one at UC Irvine Medical Center in the mid-1990s while she was the head of maternal child nursing there. But she still would also like to be able to work in a hospital collaboratively with physicians and nurses even if she opens the birth center, she says. "We don't want to replace physicians because we are a team."
"The midwives did an outstanding job and the outcomes were great," Dr. Manuel Porto, professor and chairman of the Department of Obstetrics and Gynecology at UC Irvine Medical Center, says in an interview about the birth center. But the center, which was just two miles from the hospital and where physician residents practiced natural birthing with Snell, eventually closed because it was not financially viable, Porto says. This had to do with a loss in patient load for insurance reasons not related to the center, he says.
For Sherwood, the question is difficult. She hesitates, then tells the group that she will be closing down her half of the practice and taking a position with a physicians' group in Phoenix, where she'll be able to deliver in a hospital. Some in the audience wipe away tears.
"We want to jump up and down. What can we do?" someone implores from the back.
The panel offers some suggestions: Call the hospital CEOs. Talk to the hospital medical staff since they make decisions about who gets privileges. Call the chairpersons of OB departments. Ask that they write midwives into their bylaws. Educate nurses. Educate women in your own communities.
There is talk of petitions, letters, phone calls and future meetings to be held in every city in the county, including one in Costa Mesa in late August. "We're not going away," she declares. "We are definitely not giving up on the hospitals."
B.J. Snell jumps up from her desk and peeks out over her small round glasses at Robin Parker. "How're you feelin'?" she says with the slightest southern inflection, a vestige of her Alabama roots. She crinkles her nose, and there's a flicker: her hallmark, mid-sentence smile.
It's there again when she's talking to Parker about her baby's fetal position or explaining newborn blood draws and screenings. She measures Parker's 34-week belly, applies a little jelly, and then places a Doppler listening device not far from her navel. A thumping echo, like something submerged in deep water, fills the room. Even though she's heard similar baby heart pounds thousands of times over the past 30 years, Snell smiles proudly, this time holding it longer as she looks into Parker's eyes. "He sounds great," she says.
Parker says being under the care of Snell and Sherwood has taught her to trust her instincts. "In the end, it's about the whole picture," she says. "It's like you're trying to push a giant egg out of you; your body knows what to do. You get in your position, and you do it.
"I didn't know my options when I was first pregnant," Parker says. "I wish someone would have just said, 'Girl, you need to go get a midwife.'"
In a few weeks, she'll be pushing her third giant egg out, miles away from her home but with Snell by her side. "What we're asking for is to allow women to have their choices incorporated into the health-care system," Snell says. "It shouldn't be an either/or.
"The Robin Parkers shouldn't have to go to Whittier . . . to get the kind of care she was able to get in her own back yard. That's the issue. It's a women's-rights issue."