When it came to choosing between an obstetrician and a midwife, Leila Bouhedda knew what she wanted. The 32-year-old Berkeley resident liked that midwives had more time to spend with her, and considered midwifery a reassuring alternative to a male doctor who didn't know her very well. "It's woman thing," she says. "You're more friendly with the midwives. And because they are women, they understand you better than men do." For Bouhedda, who emigrated from Algeria ten years ago, it was also a cultural choice. "Because I'm a Muslim, I'm more comfortable with a woman," she says.
All three of Bouhedda's children were born into the hands of midwives at Alta Bates Medical Center in Berkeley, which is striving to become the East Bay's premier baby mill. Since Sacramento-based Sutter Health acquired the hospital in 1996, the nonprofit HMO has aggressively expanded Alta Bates' maternity ward, proclaiming it as one of the plan's "Centers of Excellence." The hospital boasts that it handles nearly two-thirds of the East Bay's births and has the Bay Area's most prolific nursery, delivering nearly 7,500 babies last year.
While midwives are delivering an increasing number of these babies, not all women can afford them. But Bouhedda, who was uninsured at the time of her pregnancies, had access to a midwife through Alta Bates' contract with a small team of certified nurse-midwives. So did hundreds like her: Last year, members of the Alta Bates Nurse-Midwife Delivery Panel helped more than six hundred women in similar situations give birth.
Soon, however, low-income women may have to take whatever they can get at Alta Bates. The panel, which for six years has given women from around the East Bay the option of giving birth with a midwife, has had to cut back its 24/7 services in recent months, citing low pay and a lack of support from hospital administrators.
Indeed, the panel's future and the future of full-time midwifery for poor women at the hospital may be in jeopardy. As part of its merger with Oakland's Summit Hospital, Alta Bates plans to phase out the midwifery panel and replace it with midwives who only would be on hand during business hours. Panel members worry that this change will limit choices for many women who, for personal, cultural, or religious reasons, prefer a midwife to a physician. "With the new merger, Alta Bates wants to bill itself as the maternity center," says Gina Catena, a midwife on the panel. "In my mind, if you're going to have a 'Center of Excellence,' you have to have options."
Alta Bates first enlisted the panel in 1996 to provide midwifery services for women coming from regional health clinics. It was a great success, says Lindy Johnson, a fifteen-year midwife who helped found the panel. At its height, she says, the panel delivered 75 to 100 babies every month and was achieving the kind of stats that midwives like to cite as evidence of their advantages over traditional obstetrics: more personalized attention, higher birth weights, and lower rates of cesarean section for both first-time mothers and those with prior C-sections.
The panel's cesarean rate, its midwives say, was around ten percent. By contrast, a study from the federal Centers for Disease Control released earlier this month showed that nearly one in four births nationally last year was a C-section. Perhaps the biggest point of pride for panel's members was that, no matter when a patient arrived at the hospital in labor, one of them could always be found on duty or on call.
Alta Bates paid the panel a flat fee for each birth, while the panel, in turn, paid its midwives an hourly wage. Originally, they made $35 to $40 an hour, which Johnson describes as a "decent salary." The hospital based its payments on Medi-Cal reimbursement rates for vaginal deliveries. In 1996, this was around $480, of which the panel received $400. But while Medi-Cal's rates now approach $600 a birth, there has been no increase in compensation for the midwives.
With no benefits, and wages about half of what Bay Area midwives typically earn, the panel members have grown increasingly demoralized. "The midwives who have remained are doing it on top of other full-time work," says Laurie Galaty, another panel member. "They're doing it out of commitment and belief that the women deserve and need the service."
The midwives say they've become stuck in a vicious cycle: Because their wages on the panel are lower than the going rate, they are losing staff and covering fewer deliveries, which means less money, and so on.
The midwives also complain that Alta Bates has rebuffed their efforts to renegotiate the contract. Katie Tobin, director of the Women and Infant Services at Alta Bates, says the panel's demands have been unrealistic. "I think the reimbursement per delivery is very good," she says, noting that some insurers won't reimburse Alta Bates for midwife deliveries. And given the hospital's hemorrhaging of nearly $50 million annually, she says, it's in no position to increase payments to outside contractors.
As a result, the panel had to renege on one of its earliest promises: 24/7 service. During the past few months, it has been unable to fully staff its after-hours shifts. That means clinic patients who show up at Alta Bates may find themselves delivering with a doctor, often one they have never met. This has been a problem for the low-income clients at Berkeley Primary Care and West Berkeley Primary Care clinics, who get prenatal care from midwives and are coached to expect a midwife in the delivery room. Toby Furash, lead clinician at Berkeley Primary Care, says she has been getting messages from upset women who are unable to find an on-call midwife as they go into labor.
In April, panel member Catena met with Berkeley Mayor Shirley Dean, who fired off a letter to Alta Bates president and CEO Warren Kirk. The Berkeley City Council and Community Health Commission joined her in supporting the panel, as did more than seventy Alta Bates labor and delivery nurses. Kirk didn't officially respond until June, when he issued a one-page memo describing some of the changes the hospital planned for its maternity program -- although representatives from Dean's office, the Community Health Commission, and the midwifery panel say they never got copies of the memo.
Kirk wrote that the new program would eliminate the panel while protecting nurse-midwife services. On July 1, Dr. Stuart Lovett, who has run Summit Hospital's perinatal program since 1995, is slated to take over its sister program at Alta Bates. Following the same model he put in place at Summit, Lovett won't hire midwives as contractors; instead he will add them to his private practice, East Bay Perinatal Medical Associates. He says he hopes to hire members of the midwifery panel to staff his operation at Alta Bates. As of the writing of this article, however, neither Lovett nor Alta Bates management had met with panel members to discuss the upcoming changes.
Hospital spokeswoman Carolyn Kemp says Alta Bates has no immediate changes in store for the panel or its patients. "In all likelihood, the panel will change, but when it does, they will have a long notice," she says.
Lovett says Alta Bates will remain committed to serving low-income women and supporting their decision to use midwives. "I think it's important to stress that we're very pro-midwife and very midwife-friendly," he says. "If you look around, I don't think there is any other hospital system that is as supportive of midwives."
But the 24/7 availability of midwives could be history. Lovett plans to have just one midwife on duty at the hospital eight hours a day. If there's enough demand or volume of births, it is possible that coverage and staffing would expand, he says.
Yet even if coverage were doubled, midwives would not always be available. Off hours, the primary obstetrician on duty would juggle all vaginal births. "During the day is when most of the action happens," says Lovett. "After three or four o'clock, everything kind of slows down. And it's been our experience that one doctor can handle it."
The midwives are not so confident. The new plan, they say, doesn't provide enough doctors or midwives to cover Alta Bates' 22 busy birthing rooms -- which are also expected to absorb Summit's maternity traffic within two years. Babies, the midwives point out, don't stick to a nine-to-five schedule, so it doesn't seem unreasonable that a woman might expect a midwife to be on call at, say, 3 a.m. on a Sunday. Under Alta Bates' new system, low-income moms who want a midwife will have to deliver between dawn and dusk.
News of the new program is trickling out slowly, and has elicited mixed reactions among the midwife panel's supporters. State Assemblywoman Dion Aroner says the Summit model might work at Alta Bates. "We've had this model before and it works well," she says, adding that better communication between the hospital, doctors, and midwives is needed to ease such a transition. "The question is, who's involved in the decision-making? And will there be such upheaval that we lose continuity of midwife care?"
Marty Lynch, CEO of Lifelong Medical Care, which runs the Berkeley Primary Care clinic, says that 24/7 midwife care is still necessary and expected by his clients. "We're worried about not having that service any longer," he says. "If women want that service, it should be available to them."
Clinic patients will just have to be prepared to deliver with whoever's on duty, Lovett says. "When they're in the clinic, you'll just say to them, 'Look, this is the way the clinic works. If you really want a midwife, you should go out and get a midwife.'" He insists women don't mind if they get a doctor rather than a midwife, particularly if it's a female doctor. "The patients really seem to like the system the way it is," he says. "I've never had anybody come up and say, 'Gee, I wish I had a midwife instead of doctors.'"
Of course, hiring a private midwife isn't always a viable financial option for women who are uninsured or simply can't afford it. And for women like Leila Bouhedda, it goes beyond personal preference. The members of the Alta Bates midwifery panel say that choosing a midwife is an especially important medical decision for poor or immigrant women who already feel intimidated by the complexities of managed care. For them, being denied access to a midwife isn't merely an inconvenience; it's a complication.
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