Kaiser members have been flocking to Walnut Creek in search of less medicalized births, and Kaiser Oakland has finally taken notice. In an attempt to draw back birthing women to Oakland, and to improve the hospital’s poor maternity care rankings, they have brought in six midwives, and with them, some big changes.
Head midwife Anne Galko sat down with a roomful of doulas last week to give them the skinny on the new structure. As a home birth midwife, I attended the meeting with my colleague Firen Jones, glad for a chance to scope out the hospital. Although we mostly attend planned home births, we accompany the occasional transport or monitrice client to the hospital, so we like to know what to expect. There is much to be glad about, although the structural integration of the midwifery team is unusual. And there are certainly some areas that still need improvement.
First, the fact that meeting took place at all and that Anne was willing to meet is encouraging. While many hospitals around the country are still openly or passively hostile to doulas, birthing women are better served when hospitals recognize that doulas have become important members of the care team. Anne’s commitments to welcoming doulas and maintaining dialogue and transparency are commendable.
The new midwife team is atypical in that they are there to teach the residents about normal birth, not to give direct midwifery care to patients. Midwives will not be providing any prenatal or outpatient postpartum care. The six staff midwives supervise all first- and second-year residents for births, and will be available around the clock except for Saturday and Sunday from 8am to 8pm. Anne hopes that eventually they will be able to add those shifts. Any women designated as low-risk will be managed by the resident/midwife team — including vaginal births after cesareans (VBACs). Higher risk laboring women will be managed by third- and fourth-year residents and a supervising obstetrician.
Anne was clear that residents are supposed to check in with the supervising midwife before they intervene in any way, such as breaking a bag of waters or performing a vaginal exam. You cannot request a midwife without the resident — they come as a package deal. Although this will frustrate many women who would prefer to have just a midwife, the silver lining is that the residents will get plenty of experience with midwifery care.
There are lots of positives about the new hospital and team:
- There is routine delayed cord clamping of one minute for cesareans.
- They are trying hard to increase skin to skin between mother and newborn.
- They are getting a TENS unit and nitrous oxide for pain relief.
- Every room has more bells and whistles than in the old building, such as showers, fridges, rocking chairs, mirrors, and screens that can play calming music and meditation videos.
- Every room has portable monitoring units (telemetry), meaning that women don’t have to compete for one or two telemetry units.
- Low risk women can have intermittent monitoring. The protocol is to listen through two contractions every 30 minutes, and then to have continuous monitoring for 20 minutes every two hours.
- Out-of-hospital midwives will be happy to know that clients who choose not to screen for Group B Step prenatally, and transport in labor to Kaiser Oakland, will be treated with antibiotics only with risk factors (greater than 18 hours of ruptured membranes, less than 37 weeks gestation, fever).
- The hospital will not terminate care with people who refuse postdates inductions — although I imagine the pressure to induce from the staff will be extreme at 42 weeks.
Unfortunately, there are some major areas in which the built environment and protocols are far from the midwifery model of care. A huge drawback of the new facility is that it does not have a single water birth tub. Every room has a shower, but I am shocked — perhaps naively — that a new hospital could be built in this day and age without even a single tub in which to labor, let alone birth. With ample evidence of safety and benefits, I just don’t understand the deep-rooted fear the obstetric profession has of water birth.
Also defying current research, birthing women are not allowed to eat anything in active labor, although they may continue to drink fluids. Active labor is defined by Kaiser as six centimeters, instead of the more common four, but still, many women need some energy in the form of food to keep going through a long labor.
The ability for women to freely eat and drink in labor is part of the Ten Steps of the Mother-Friendly Childbirth Initiative, endorsed by the American College of Nurse Midwives and the Midwives Alliance of North America. A Cochrane review from 2013 concludes that “there is no justification for the restriction of fluids and food in labour for women at low risk of complications”. Kaiser has no evidence base to support this punishing policy.
There are some other questionable protocols:
- Heavy use of Misoprostol inductions, despite a controversial risk profile.
- Routine Pitocin shots after the birth of the baby.
- Only three support people are allowed in the birth room. I’ve personally been to lots of births where the mother wanted more than three support people with her at some point. There’s definitely a place for clearing the room in certain circumstances, but having a blanket policy about something so personal and subjective is ridiculous.
- The protocols around spontaneous rupture of membranes (SROM) don’t make much sense. Women are supposed to go to the hospital immediately upon SROM for evaluation. If they refuse induction, they are told to remain in the hospital, and can only go home to wait for labor Against Medical Advice, even though the risk of infection is higher in the hospital.
- All women receive a routine ultrasound to check for breech at 36 weeks. We’re not sure if this means that there is no palpation being done prenatally or if the obstetricians don’t trust their palpation skills. Either way, it’s strange.
The doulas also raised a number of issues that their clients have experienced at the old and new Oakland hospital, which Anne promised to investigate. The list includes availability of hot postpartum meals, mandatory ultrasounds in triage, doulas not being allowed in the operating room, and nurses placing towels between newborns and mothers immediately after birth instead of facilitating skin to skin.
A Kaiser member myself, I will definitely switch to a different insurance company if I ever plan a pregnancy, because they are one of few companies that offer zero coverage for out-of-hospital birth. But all in all, the introduction of midwives at Kaiser Oakland can only benefit families planning a hospital birth. I believe Anne Galko and her team have every intent of bringing better care to the new Kaiser Oakland, despite some institutional barriers. I hope they succeed.