Neilson’s first move was to change the way 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, which would give him more say over not just the way they practiced but also their attitudes. “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, improve residents’ education, and improve relationships and satisfaction among staff and patients, Legacy Emanuel agreed to lose money on the program. (It costs more to maintain hospitalists rather than rely on on-call docs.)

Up next: changing the protocol for how the hospital handled home-birth transfer patients. Before Neilson’s arrival, all women who transferred to the hospital from home or a birth center were labeled “high risk”—even if a laboring mother only wanted some pain medication. That label meant that 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—are placed under the care of Legacy Emanuel’s nurse midwives, who are skilled at supporting natural birth (and empathetic: 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, in part so more women wouldn’t feel that home birth was their only option for a natural delivery in the first place. 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.  

As a direct result of the changes Neilson has implemented, Legacy Emanuel is now the go-to place for local midwives whose clients need hospital care. In the first year of these changes, some 30 women transferred to Legacy Emanuel’s nurse midwife practice at some point during their home births; in 2011, that number was 79. 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 the opening, if you make a more inviting environment, then 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. Its birth center is housed in a 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 local hospital—most of them, if insurance allows, transfer 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 the way it did its charting. Now, in addition to traditional “story charting”—chronicling the birth with notes about a woman’s family support system, or even the weather—midwives fill out a checklist of vital information on a form prepared by Emanuel’s Cohen to make it easy for doctors accepting transfers to find essential information. “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 Alma. Under these kinds of partnerships, women still get to choose how and with whom they give birth, but now the people in charge of their care are working with each other 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 women’s experiences with 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.