Sunday, April 11, 2010

Kid Planning and Mountain Midwifery

Jennifer and I have been married for over a decade, and we've been talking about having a kid since before we were married. We've finally decided to go through with it. Further, we've decided to share our experiences, not only as a record for ourselves, but perhaps as a useful point of reference for others. Perhaps experienced parents will also be motivated to write in and offer us guidance when we seem to need it.

Today we went a long way toward resolving one of our big decisions: where to have the baby. We visited Exempla Good Samaritan in Lafayette yesterday. Very nice, but not especially welcoming or reassuring. We visited Mountain Midwifery Center (MMC) today, and we both fell in love with the place, so much so that we didn't make it to our third appointment at Avista in Louisville. (We may tour other facilities in the coming weeks.)

To back up a bit, Jennifer is not yet pregnant. Thus, there are a lot of things that could go wrong between now and birth. We could fail to get pregnant. We could miscarry. We could suffer a seriously deformed fetus -- personally my biggest fear -- in which case we would obtain an abortion, as we've discussed at some length. We could suffer problems during the delivery that could endanger the life of Jennifer or the baby. But we expect a normal, healthy birth, and of course that's what every parent-to-be hopes for. As with much of life, then, the goal is to expect the best but plan for the worst.

MMC, we learned this afternoon, is the largest midwifery center in the nation, with five registered nurse midwives and eight nurses. The center has facilitated 592 births in its four-year history. (I'm not sure if this included a birth today prior to our visit.)

The visits to Exempla and MMC were completely different. I'll begin by highlighting some of the major differences.

Detail of information -- At MMC, Tracy Ryan, the owner, addressed a room full of about 20 prospective parents for over an hour. She told us what to expect, answered in detail questions about medical contingencies, and talked about general birthing facts. At Exempla, frankly I learned more about the in-hospital store than I did about the medical aspects of birthing.

Ritz -- Exempla is beautiful. The building is beautiful and the rooms are beautiful, with beautiful views and hardwood (or faux wood) floors. I began my notes at MMC, "Looks like an old Spanish-style Super 8." There were toys on the floor of the main room. Something was covered by a colorful sheet. It had a definite urban-hippie feel. I wondered in my notes whether this meant that MMC didn't waste money on frivolities or if it meant that the clinic was unserious. I soon became at ease at MMC, finding its less-formal environment to be "lived in" and meant for real people.

Pricing information -- Before we went to Exempla, I spent twenty minutes or so on the phone with a representative of the hospital. After getting a range of prices, the representative noted that she was giving me only the insurance rates. "What are the self-pay rates?" I asked. "I can't tell you that," the representative replied; I'd have to call another business office. I got no additional information from our visit to the hospital in terms of pricing. Moreover, Exempla offers a "complimentary welcome home" dinner as well as diapers for the baby. Complimentary, my ass. Somebody's paying for that nonsense at jacked up rates, and that somebody obviously would be me. At MMC, Tracy made a special point to discuss pricing. And MMC's prices are much lower, "around" $4,000 plus fees for outside tests. (Of course this is the cost of a normal delivery, not an emergency one.)

Water delivery -- Exempla will let the mother sit in the tub during labor, but it offers no water delivery. That's a facade of "natural childbirth," not the real thing. At Exempla, you end up on a hospital bed, and that point is pretty much non-negotiable. MMC features water delivery tubs as well as birthing stools. Tracy explained that mothers often have to try different approaches and positions. The point at MMC is to let the woman's body do what it does naturally, work with the baby's body, and use gravity to natural advantage.

Expected recovery -- I thought it was odd that Exempla offers a room for delivery, then moves the mother into another room for recovery. Obviously this would add to the cost, I thought. I asked, "Can a mother just leave straight from the delivery room?" Oh no! Heaven forbid! Absolutely not! That sort of thing just isn't done, apparently. Tracy said the normal delivery at her facility is quite different. Often a mother has her child and goes home to bed after a few hours (provided all the health markers are normal, of course).

Crowd engagement -- The general attitude at Exempla was "fill out this form and figure out how we do things around here." The general attitude at MMC was that the mother and her partner are in charge, and it is the job of the midwives to educate the mother and facilitate her decisions. This attitude was reflected among the prospective parents, who chatted before and after the class and peppered Tracy with difficult questions. (One of the prospective fathers there was a doctor, and he asked some great technical questions.)

I felt like Exempla was a good hospital and we'd be in good hands, but we hardly felt like we had found our birthing home. I don't have much else to say about Exempla, though I thought I'd share my photos of the building and the two rooms:

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I have a lot more to say about Mountain Midwifery Center. I'll start with pictures, which capture the tubs, a stool, the building, and Tracy standing by photos of her birthday babies:

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I'll start at the beginning of my notes. Tracy entered the room looking confident, nice, and down-to-business. She was wearing jeans, but in a way that conveyed a let's-get-busy attitude rather than a casual one. After finding everybody chairs (a few sat comfortably on the floor), Tracy sat in a folding chair facing everyone and began her spiel. MMC is the only licensed birthing center in Colorado, though there are 200 in the country. Tracy is hoping to expand to other locations in Colorado. As noted, her facility has helped with nearly six hundred births in four years.

MMC accepts thirty-six families per month. Five midwives work there. The facility has three birthing rooms. I asked what happens if more than three women go into labor at the same time; Tracy assured me that's practically impossible.

Tracy said that a typical delivery might happen at noon with the woman walking out by her own power by four.

"Pregnant women aren't sick. That's just something our bodies do," Tracy said. Usually there aren't big medical complications. She urged us to see the film The Business of Being Born -- which we own but haven't yet watched (perhaps tonight!), and said the "best maternity care is not in hospitals." MMC is "more like a home-birth center," Tracy said.

However, she quickly added, "We are not anti-hospital." In fact, Swedish is literally just up the street, and MMC has a good relationship with that hospital and has sent several mothers and babies there who needed extra help.

I learned some new terms today. An "episiotomy" is when the medical assistant basically makes an incision to enlarge the vaginal opening. (Sounds unpleasant.) MMC can do an episiotomy, but it rarely does one, Tracy said. Half the women who deliver there walk out without a stitch.

"We use intervention appropriately," Tracy assured us. It is definitely not true, she emphasized, that all babies come out naturally and easily. If one looks at a developing region (she mentioned Ethiopia), one finds that more babies die there and women sometimes suffer severe physical trauma.

Eleven percent of the women who have gone to MMC have ended up at Swedish. This drops to a single percent for the second baby, which often more or less "falls out." (That's not how the mother would describe it, Tracy clarified.) While most babies do come out naturally, "some babies need help."

Few "certified nurse midwives" -- nurses with additional graduate training -- work in Colorado, Tracy said (find more through the midwives association), and five work at her facility (including her). They can do all sorts of things from sew up tears to order lab work.

Tracy said that typically there's a blood test of the mother-to-be between eight and ten weeks into the pregnancy. While sometimes a nurse at a hospital will draw a woman's blood without so much as an explanation of the purpose, at MMC the goal is the inform the woman, educate her on the pros and cons, and then enact her decisions. That's exactly the attitude we're looking for.

MMC offers all sorts of classes, covering nutrition, birthing, feeding, and so on. She repeated the refrain, "diet, exercise, and three liters of water a day." (Later she guessed that Colorado's high premature birth rate is linked to dehydration.)

The staff of MMC will discuss money, family, work, and the "fear of doing labor." "Everybody has fears of doing labor, but you can do it... Labor is tough. But at the birth center, you get support."

The attitude at MMC, Tracy continued, is that as a pregnant woman "you are normal and healthy." Birth is an active event. MMC facilities mostly "hands and knees water birth by candlelight." (She said it rapidly but thankfully repeated it a few times so I could write it down.)

Tracy said that actually about forty percent of births there take place in the water. Another common position is on the bench. She said laying-down births are more common for subsequent babies, which often come out easier. Practically all the women at MMC get in the tub at some point. Women often need to try different things out and shift around, Tracy said. Moreover, babies can prefer different positions.

Tracy said that at many hospitals -- and our friends' experiences confirm this -- the spouse needs to act as the advocate for the woman to enact her birthing plan. But at MMC "we are your birth plan. We are your low-intervention place," so it's not all up to the spouse to keep things flowing according to the woman's intentions.

While MMC allows outside guests, Tracy cautioned prospective mothers to invite in only people they're comfortable with. "You can fake an orgasm, but you can't fake your birth," she said. In other words, the birthing process is an extremely emotional process, and "you need that ability to have intimacy" with everyone present.

The staff at MMC tends to cut the umbilical cord a bit later in order to allow the child to get all the available red blood cells. Then, the staff lets a child adjust before breast feeding. "Give that baby time, give that mamma time," is the usual advice.

Every mother meets every midwife. That way, whoever is on call can handle the birth. Tracy said she used to serve as a midwife in homes, but she was on call all the time. After missing her own kids' birthdays one year (and she has five kids of her own), plus her anniversary and Christmas morning, she and her husband decided it was time for a change. Her husband quit his job with Ball Aerospace to become the business manager at MMC. Working from a center allows the midwives to spend time with their own families, too. And pregnant women have the assurance that somebody will be available to help handle the birth.

After the birth the clinic follows up with in-home and in-clinic care.

Tracy believes that inducing pregnancy with drugs, while sometimes necessary, can interfere with the natural, hormonal communication between a woman and child. While such drugs can be "a really great tool," Tracy said, often they are used when women are "under the gun" to deliver.

Tracy said that the national C-section rate is 33 percent. She said the rate should be much lower than that, and the rate at her clinic is six percent. Of course, the MMC figures look good in part because women with problematic pregnancies go elsewhere to deliver, but I'm convinced that a big part of the reason is the fact that MMC works hard to work with the woman's body.

"We've only called an ambulance four times," Tracy said, once for a vaginal breech birth (which means the kid comes bottom first, I learned).

MMC features two consulting doctors, and "the best thing about the birth center is our relationship with them... they're helpful and they're not adversarial... and it's the part that you most likely won't need to see."

When needed, "then we ask for tools and drugs, because you've tried the natural thing here, and it's not working."

There are some cases that MMC can't handle, such as gestational diabetes and high blood pressure. What I like about Tracy's approach is that she is not irrationally wed either to a "natural birth" or to an interventionist birth, but she instead treats natural birth as the reasonable default and calls upon more intervention when it is objectively needed.

Tracy's passion is to facilitate a woman's choices: "I'm a convincing person and I love what I do, but this is not for everyone," she said.

Tracy said that she could be making more money elsewhere, but "we're all very idealistic here... We believe this will change your life."

Jennifer and I also talked with Nancy, another midwife. We had a question about whether Jennifer needed to switch from fish oil (for Omega 3) to algae-based oil. Nancy recommended Kirkland brand fish oil, which happens to be the kind we use. She also recommended pro-biotics. We discussed screening tests with her as well.

Tracy gave us some great advice on birth control (she likes the IUD over the pill). And she encouraged me to make sure our high-deductible insurance covers maternal care. (I have no idea whether it does or not.) Reviewing our insurance is our next major step before getting ourselves into this. I would hate to leave my high-deductible plan, but, as I've long argued, the insurance market has been totally screwed up since long before the Democratic health bill. At this point I don't even know whether or how long my high-deductible plan will remain in existence. So that's the big variable at this point. But, even if we switch insurance, we'll use MMC regardless of the plan. (We already have ample funds in our Health Savings Account to pay for a non-emergency delivery.)

At one point Tracy discussed the barriers she's faced in starting the clinic. Sure, she has faced challenges, but, she noted, "I've pushed five babies out," so she can face anything else.

UPDATE: Here's a video of a water birth at Mountain Midwifery:



And here's another water birth that Jennifer and I watched on video:

5 comments:

  1. Congratulations on your exciting decision, and I hope you enjoy the whole process! My entire pregnancy and water birth experience with midwives at a birth center was wonderful.

    You've found what sounds like an excellent birth center. This approach is not easy to find:

    "What I like about Tracy's approach is that she is not irrationally wed either to a "natural birth" or to an interventionist birth, but she instead treats natural birth as the reasonable default and calls upon more intervention when it is objectively needed."

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  2. One thing you may want to look into, if your wife intends to breastfeed, is if they have lactation consultants available on-site. I will say, however, that at the facility where my wife delivered (eight years ago), they insisted on getting the baby to feed within the first 24 hours, and if the baby did not feed successfully in that time, they urged formula feeding. That policy caused us some unnecessary angst, as we later read that most babies will do just fine without feeding within the first 24 hours.

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  3. They definitely have "lactation specialists" available, and they seem very supportive of breast feeding, which I am convinced is important for good health of the baby. (A delay of 24 hours seems like quite a long delay to me, but I haven't researched the particulars.)

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  4. Ari, this birth center sounds fantastic. I wanted to comment that the rate of 11% hospital transfer is pretty good. The homebirth midwife that I used (and worked for) had a 10% transfer rate for first time moms, and it was one of the lowest I found. Good for you and your wife for researching so carefully and finding a place you feel comfortable in! And I labored in water and loved it!!

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  5. Congrats on your decision! I love being a parent, I wish the same amazing experience for you two! Two thoughts: I have read that nursing within the first hour is a good way to launch breastfeeding, that's what I was able to do with my full-term birth, and close to it for the preemie birth (pumping). Went to a couple LaLeche meetings before birth that proved very helpful. 2nd thought: Since you are already visiting birth centers, I would recommend reading up on parenting a little bit over time as well. I recommend the Nursing Mother's Companion, Your Self-Confident Baby, Healthy Sleep Habits Happy Child. Will reserve my conception advice!! All the best!

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