Depending on the stats you look at, 2 to 3 percent of Oregon’s newborns take their first breaths in their own homes or at an independent birth center, making Oregon no. 2 in the nation for its rate of out-of-hospital births. (Montana is no. 1.) While such births account for less than 1 percent of babies born in the US, according to the Centers for Disease Control and Prevention they increased 29 percent between 2004 and 2009.
Portland, along with Eugene, Corvallis, Ashland, and Bend, are loci for women who opt to give birth at home. “Midwifery culture goes along with our food culture, our bike culture, and sustainability,” says Holly Scholles, founder of Portland’s Birthingway College of Midwifery, which each year graduates up to nine midwives. “It fits in with that particular Oregonian spirit that combines frontier independence with liberal outlook.”
As more women choose to give birth at home, more women, like Jarecki, will—at some point—need the kinds of services that only a hospital can provide. It isn’t always an emergency that sends them there. Often a woman might be seeking only a labor-inducing drug like Pitocin to move a stalled birth along or an epidural that allows her to rest. Yet in many cases, when hospitals and home-birthers meet, the result can be a savage clash of cultures.
Most obstetricians consider home birth risky at best and reckless at worst. Support for that view: the American College of Obstetricians and Gynecologists reports that out-of-hospital births are associated with a two- to three-times increase in neonatal death, a statistic that is hotly debated. Contributing to physicians’ distrust is the fact that there’s no national standard for midwife licensing; it varies greatly from state to state (except in the case of nurse midwives, who are nurse practicitioners with master’s degrees in nursing plus additional training in midwifery). Oregon has voluntary licensure for midwives who want to be eligible for Medicaid reimbursements.
Some staff have been so hostile toward midwives that, fearing retribution, some midwives have dropped their patients off at the emergency room and fled.
Most midwives and the women who choose out-of-hospital birth see hospitals as part of a medical system run technologically amok. Support for that view: in 2010, the United States had a C-section rate of some 33 percent, while the World Health Organization recommends that the rates should not be higher than 10 to 15 percent.
And at times, both sides have behaved poorly. “We’ve had midwives who wouldn’t hand over the medical records, because they were so suspicious of us,” says Terri Cohen, the midwifery service program director at Legacy Emanuel.
On the flip side, some hospital staff have been so hostile toward them that some midwives, fearing retribution, have dropped their patients off at the emergency room and fled.
Neilson encountered firsthand the fallout that can occur when home-birth and hospital cultures meet in his first months as chief of Legacy Women’s Health Services. Shortly after accepting the post in 2005, Neilson received a call from a nurse midwife who had overseen a home birth. The mother, who also happened to be a nurse, had had a long and difficult labor. She wanted to come to Legacy Emanuel for an epidural—just to help her rest so that she could continue pushing.
When the attending midwife called the hospital to let staff know they were coming, the obstetrician on the phone—a staunch anti-home-birther—let fly how he felt. “This midwife called me and basically said, ‘What’s wrong with you guys?’ I had to agree that that did not seem like a professional response,” Neilson says.
The experience revealed to Neilson the need for an environment where midwives could safely transfer home-birth patients. “By safe I mean safe from ridicule, and safe from the judgment they were encountering everywhere,” Neilson says.
Neilson, it should be noted, is not an advocate of out-of-hospital birth. He is a fellow of the American College of Obstetricians and Gynecologists and agrees with its most recent statement, issued in February 2011, “that hospitals and [hospital-affiliated] birthing centers are the safest setting for birth ....”
But Neilson possesses an uncommon willingness to look at all of the factors that might be contributing to the midwife-obstetrician divide and arrive at his own, dispassionate conclusions. So he began to ask a question that few other ob-gyns would dare: Does a hospital’s unwelcoming environment to midwives and women who need to transfer prevent them from seeking care when they need it? In short, were the hospitals contributing to poor home-birth outcomes?
“We take care of all kinds of people in hospital who do things that we think aren’t smart. They drink too much, they smoke,” Cohen notes. “But we just don’t tell them they can’t come to our hospital.”
Neilson decided that the right solution was not to condemn the practice, but to turn Legacy Emanuel into a place where women would feel supported, welcomed, and understood. “We wondered, if we create that opening, will they come?”
He was in a position to find out.