Traveling through Waianae and into Makaha, Hawaii’s natural rawness settles on the skin, combining Leeward air, ocean salt and primal electricity. It makes sense that Hale Kealaula, the first birth home on Oahu, has taken root here.
“We should be coming away from birth feeling like we did this, we can do anything,” says Selena Green, Hale Kealaula’s founder.
“Instead,” conventional hospital birth procedures make women “feel like we can’t trust ourselves, can’t trust our bodies to do what they were designed to do,” says Green, a certified professional midwife (CPM), who opened Hale Kealaula in September 2012. “Hale Kealaula arose from an invitation from a local kupuna,” says Green, who’s also CEO of Sacred Birth Angels Foundation (SBAF). The kupuna had travelled from Oahu to Oakland, Calif., for the births of two great-grandchildren, delivered by Green at SBAF’s original birth home, Sacred Birth Place. The third was delivered at Hale Kealaula.
Representative of a global movement that’s gaining momentum in Hawaii, the birth home’s goal is to increase women’s access to certified midwifery services. In other developed nations, midwives usually preside over low-risk, normal births, but in the U.S., birth is largely overseen by OBGYNs.
Midwife-led care, which emphasizes prenatal care and a natural, medication-free birth, is becoming a popular option among low-risk pregnant women–those without hypertension, diabetes or other medical disorders that could cause complications. After 14 years of decline, the percentage of home births with midwives rose by 29 percent from 2004 to 2009, the highest level since data collection began on this in 1989, according to the U.S. Centers for Disease Control and Prevention (CDC).
What’s been taken from women, and what midwives bring back, Green says, is the ability to birth with dignity, respect and informed decision-making. Currently in the U.S., one in three babies is born by major abdominal surgery, and one in two women receive drugs to artificially force labor progression.
Despite our spending more than any other country on health care, and more on maternal health than any other type of hospital care, a woman’s chance of dying in childbirth is higher in the U.S. than in 49 other developed countries, according to Amnesty International’s 2010–11 publication Deadly Delivery: The Maternal Health Care Crisis in the USA. More than two women die every day in the U.S. from complications of pregnancy and childbirth. More than half of maternal deaths occur between one and 42 days following birth. The report asserts that postpartum care in the U.S. is inadequate, generally consisting of a single visit to a physician weeks after birth. Many women’s participation is restricted in hospital settings: They are not given a say in decisions about their care and do not get enough information about signs of complications and risks of interventions such as induced labor or cesarean delivery (C-sections). The risk of death following C-sections is more than three times higher than for vaginal births. The U.S. C-section rate is twice as high as recommended by the World Health Organization, which maintains that a 15 percent cesarean rate is optimal for mother and baby health.
Hawaii mirrors the national average with a 30 percent cesarean rate. C-section rates continue to climb because for most of the 20th century, once a woman had undergone a C-section, doctors believed her future pregnancies required surgery due to risk of uterine rupture.
Despite this trend, the medical evidence, as referenced in the June 2010 issue of Obstetrics & Gynecology, reveals that women who try for vaginal birth after cesarean (VBAC) are at decreased risk of maternal mortality compared to elective repeat C-section. The article concludes that standards of care should be based on medical evidence, not the patterns of litigation that have been the norm, and that attempts to increase the VBAC rate make little sense without addressing the root of the problem: reducing the number of primary cesareans.
Beginning in January 2014, The Joint Commission, which accredits and certifies more than 20,000 health care organizations in the U.S., will require reductions in cesarean rates for first-time mothers in U.S. hospitals with more than 1,100 births a year.
“One of the great benefits of this requirement is that, since some hospitals actually ban VBACs, to avoid the first cesarean is logical,” says Summer Faria, co-leader for the Hapai Hawaii Birth Network, a local chapter of the national nonprofit BirthNetwork National.
Cost of birth
Half of all births in the U.S. are covered by private insurance, while Medicaid covers some 42 percent. “The Healthcare Costs of Having a Baby,” a study commissioned by the March of Dimes Foundation, found that approximately one-third of 45,450 deliveries were C-sections, which were almost 50 percent higher in cost than vaginal deliveries. For women insured through large employer private plans, the average cost of having a baby vaginally in the U.S. was more than $8,000. Hospital payments accounted for more than half the total costs and one-third of patient out-of-pocket costs.
Unlike well-child care or mammography, prenatal care was generally not considered a preventive service. Therefore, these health plans impose cost sharing and high deductibles on prenatal care services, according to a study by the Henry J. Kaiser Family Foundation.
In juxtaposition, birth centers saved the health-care system $30 million in facility fees alone for the 15,574 births tracked in a study by the American Association of Birth Centers. The study concluded that if more pregnant women delivered their babies at midwife-led birth centers, the nation’s C-section rate would go down and cost savings would go up, reversing the current twin trend of rising health care expenditures and numbers of cesarean surgeries. And be alert to the “estimated total increase in cost of about $2,000 when you have an epidural,” which “the hospital and its staff have financial presure to encourage,” according to Suzanne M. Smith, CPM and owner of Better Birth LLC.
While private insurance and Medicaid do not cover services at a midwife-led birth home like Hale Kealaula, the out-of-pocket payment can be lower: Hale Kealaula’s prenatal, labor and birth and postpartum services are less than $3,000 total.
“Having a midwife or healthcare provider that supports your vision of birth can prevent unnecessary interventions, even in the hospital,” states Dr. Heather Schlessman, associate professor at Chaminade University’s School of Nursing. “A hospital, by nature, is where sick people go to get better. Birthing isn’t an illness. A birth center or home has an entire wellness focus.”
“I recommend that a woman see an OB to get her initial labs and physical to rule out [high risk] situations, [and that also she] go to the 28- and 36-week appointments,” Green says, pointing out that, should problems arise in labor, the woman will be “in the system already, so transfer of care would be smoother,” and, if in a hospital, covered by insurance. Comprehensive care at Hale Kealaula includes prenatal care, labor, birth and postpartum services. Prenatal appointments are every two weeks until 36 weeks, and then every week thereafter. A pregnant woman learns self-care at prenatal visits, checking her own blood pressure, urine sample and pulse at the beginning of each visit. “She learns to do this in order to know what’s normal for her body and be an active participant in her care,” Green explains.
Prenatal appointments are an hour long, which allows time for midwife and mother to discuss nutritional, emotional, physical and social factors in the process of growing a baby and preparing for birth. Women are referred to ultrasounds when and if necessary. Otherwise, the midwife feels the stomach for size, the position of the baby and amniotic fluid levels and listens to the heartbeat with a Doppler.
However long labor lasts, Green sends new mothers and their babies home four hours after birth if both are doing well. “I want my moms comfortable in their bed in their home for a week after, bonding strong, breastfeeding well,” she says. She goes to their home 24 hours after birth for a checkup, then visits the home again after three days, five days, two weeks and six weeks. By contrast, postpartum care for a woman who delivers vaginally in a hospital in Hawaii usually consists of a two-week and eight-week checkup. “Birth is an ordinary miracle,” says Piper Lovemore, childbirth educator, doula, and owner of Baby Awearness. “If everything goes as it should–and it does in an overwhelming majority of births–you really just don’t need a whole lot of intervention.”
Barbara Ehrenreich, in Witches, Midwives and Nurses: A History of Women Healers (Feminist Press: 2010) describes how in the early 20th century, conflict between surgeons and midwives arose as medical men pushed for a legal monopoly on obstetrics. As a result, midwifery became heavily regulated or outlawed throughout the U.S.
In Hawaii, while midwives licensed as independent primary care providers can work collaboratively with other health care providers located in hospitals, there are no licensed birth centers. By law, an OBGYN with admitting privileges must serve as the medical director of the birth center.
“This has proved to be a problem, as OBGYNs have been unwilling or unable to support a birth center due to malpractice issues or distinct philosophical differences,” says Roxanne Estes, president of the Hawaii affiliate of the American College of Nurse Midwives. In the absence of centers, birth homes like Hale Kealaula offer a much-needed alternative as “a safe place to deliver out of the hospital in a more controlled setting, decrease cesarean rates, decrease preterm labor rates, decrease intervention rates and increase maternal satisfaction,” Estes says.
There are some hospitals that allow midwives to work within an OBGYN’s practice, and some that have midwives on staff. Kaiser Moanalua Medical Center, which sees up to 1,600 deliveries annually, started a midwifery service in 2009, currently has eight CNMs [edited to correct error in original article] and plans to add one more in 2013. The primary C-section rate for first-time moms there is 10.9 percent. It also allows VBACs.
Also on Oahu, Tripler, Castle and Kapiolani also offer midwifery services. On Hawaii Island, North Hawaii Community Hospital offers midwifery services, but has a limited capacity and serves only women who live in the immediate area. Molokai General has a midwifery program. Hospitals on Maui, Kauai or Lanai do not offer midwifery care.
“As far as hospital births go, I see much fewer complications with unmedicated or natural births,” maintains Estes, who has attended almost 1,200 births in and out of hospitals in her career. “Complications tend to arise with each medical intervention added. Widely used interventions like continuous fetal monitoring and IVs limit a mother’s movement, which assists optimal fetal positioning as the baby transitions down the birth canal.” Interventions that limit movement, she adds, “can lead to other interventions like Pitocin, a medication used to speed up labor [and whose] routine use contributes to poor or less-than-desirable outcomes. Epidural use, which is widespread these days, can increase length of labor and can lead to more interventions like cesarean section,” she warns.
Estes adds she believes that increasing access to midwives has the potential to drive down costs in Hawaii’s overburdened health-care system while also ensuring safe, quality care in pregnancy and childbirth.
Then there are the unquantifiable, but very real, benefits. Green smiles as she stands in the breezy backyard of her Makaha birth home. “The woman you see going into labor is different than the one that comes out after birth. When she participates in this sacred journey, she knows she can do anything,” she says.