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.