Organized Labor : High Rate of Cesareans and Impersonal Care Prompt More Pregnant Women to Turn to Birthing Assistants

SPECIAL TO THE TIMES

As the contraction swept over her body, Lisa Maloney closed her eyes, put her arms around Sherri Alden and clung to her for dear life.

"You're doing great, sweetie," Alden whispered, holding Maloney tightly. The two women rhythmically swayed back and forth, breathing together, riding out the wave of pain.

It was about one o'clock in the afternoon, March 15. Maloney, had been in labor for 19 hours. Exhausted, but still able to smile between contractions, she asked, "So how long is it going to be till we have this baby?"

Little did she know, she had 11 more grueling hours to go.

But she wouldn't be going it alone. On one side was her husband, Patrick. On her other side was Alden, a registered nurse hired independently by the San Clemente couple to guide them through the birth of their first child.

When Maloney was weary and in pain, it was Alden she most often turned to for comfort.

"I can trust her," explained Maloney. "And when the contractions come, I can fall into her arms and welcome them."

Alden, who calls herself a labor support professional, is part of an emerging trend in the childbirth arena. Concern over the high rate of Cesarean births and frustration over doctors and hospital staff whose care is often perceived as impersonal or insensitive, are leading some pregnant women to turn to labor companions like Alden.

For flat fees ranging from $250 to $600, these labor room companions may do everything from massage your back to stand up to your doctor.

Some doctors see labor assistants playing a positive role, particularly as coaches to expectant mothers; others believe they can end up creating problems if they interfere with the patient-doctor relationship. Women such as Maloney, who are determined to avoid a Cesarean section and give birth "naturally" with the help of little or no medication, see these labor assistants as their guardians against so-called intrusive medical care during childbirth.

In fact, many of the clients of labor assistants include women who believe they had unnecessary C-sections or had a previous unpleasant birthing experience. Some want an advocate in the labor room to help them feel they have control over how they give birth.

Most doctors have had limited experience working with private labor assistants. Although their presence in the labor room is growing, the overall number of women employing them is small.

Maloney's obstetrician, Henry Pollak, had worked with Alden before and was comfortable with having her help coach Maloney through labor. Pollak is chief of obstetrics and gynecology at Samaritan Medical Center in San Clemente as well as medical director of its family birthing center.

Alden, a strong backer of limited medical intervention in the birthing process, had worked as a labor and delivery nurse before becoming a private labor assistant. She has assisted with about 60 births in that role.

Maloney got in touch with Alden after hearing her speak on the radio about the benefits of having a labor assistant. Their association began in mid-pregnancy and, by the time the delivery date was at hand, they felt they knew each other well. Alden explained to Maloney the kinds of choices that might be open to her--from refusing medication to opting to use a Jacuzzi in the labor room. Maloney drew up a written birth plan that detailed how she wanted her baby to be born. Among other things, she wanted to be able to reach down and touch the baby's head just before delivery and her husband wanted to cut the umbilical cord.

A primary goal, though, was to avoid a Cesarean delivery.

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The rate of Cesarean births in Southern California is between 15% and 25%, according to Pollak.

In the late 1980s the Cesarean birth rate at Samaritan was as high as 37%, he said. The hospital made a conscious decision to lower that rate, which is now at 24%--close to the national average. Much of the decline has been achieved because women who have had one delivery by Cesarean are not automatically considered candidates for another. Each Cesarean at the hospital undergoes a peer review process to determine if it was medically necessary.

Some labor assistants, such as Anne Sommers of Corona, state in their literature that they can actually prevent or reduce the chance of Cesareans. While doctors may be skeptical of those claims, Sommers and others contend they can achieve a lower Cesarean rate by assisting their clients in coping with labor, suggesting alternative labor techniques and by negotiating with doctors in an attempt to dissuade them from administering drugs to the women or performing hasty C-sections.

Even if having a labor assistant lessens the odds of having a C-section, it certainly doesn't guarantee a woman won't have one.

Maloney and her husband discovered that the hard way. After 30 hours of labor, Maloney delivered her baby--an 8-pound, 6-ounce girl--by Cesarean. The position and size of the baby prevented Maloney from delivering vaginally.

Although the Maloneys' goal had been a natural childbirth, and despite all the pressure she put on herself not to have drugs or a Cesarean, Maloney said she felt comfortable with the outcome.

"What makes it OK to me is that I went the distance. I did everything I could to try to deliver the baby (naturally)." She says she would have felt "cheated and angry" if she would have given up early. But because she kept laboring until the doctor finally said there was no other alternative but surgery, "I don't feel like I'm a (Cesarean) statistic."

Alden and the Maloneys are deeply religious and even though the chance of a vaginal delivery looked remote as her labor dragged on, they still talked about how if they kept on trying, a "miracle" could happen.

Pollak kept close watch over the baby's health during labor via a fetal monitor. He said he allowed labor to continue as long as it did because there was no evidence of fetal distress.

Finally, Pollak set a deadline for medical intervention of midnight--29 hours after labor had begun. Maloney was exhausted. It was clear surgery was necessary.

Alden and the Maloneys were finally resigned to the need for the Cesarean. "We've pushed that envelope for even the most liberal doctors. Most would have cut hours ago," Alden told them.

Maloney was given an epidural in preparation for the Cesarean, and the baby was delivered about 1 a.m. March 16.

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Maloney and Pollak both praised Alden's role in the birth.

"Sherri was wonderful," said Maloney. "Not only did she keep encouraging me to keep trying, she was a trusted friend. I just hope she's still around when I'm ready to have my second child. We would use her again."

Pollak said that while medically much has been gained over the years in the area of childbirth, "we've overlooked the emotional well-being of the patients. The birthing experience has become more like a factory."

Because of other demands on their time, doctors and nurses often end up being in and out of the room, sometimes very briefly, during the labor. A labor companion, on the other hand, "is totally focused on the mom and the labor process," Pollak said.

The presence of a labor support professional has been such a positive experience that Samaritan hospital is considering creating a staff position so the service would be available to anyone who wanted it, Pollak said.

During Maloney's labor, Alden was cheerleader and companion. She massaged Maloney's back, sang to her during tough contractions, explained medical procedures and calmed her when she became weepy and overwhelmed and didn't think she could go on.

Although Maloney's husband also assisted in the labor room, he said he was relieved to have someone like Alden on hand who is a nurse and knows what is going on.

Later, when Alden asked him if he felt at all left out because of her presence, he said, no. "I saw an unspoken language between you two," he told her.

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There are no licensing agencies that regulate labor assistants. Some, like Alden, are nurses, others may be midwives or have simply received training in prepared childbirth techniques. Most are committed to vaginal births with little or no medication.

Sommers, who is not a medical professional but has been a labor assistant for six years and assisted in more than 100 births, said that some women employ labor companions because they want the gentle help and understanding of a woman who can empathize with the birthing experience. "They respect me because I am a woman and I've been through it," says Sommers of her clients. "They feel safer. Labor can be a very scary thing."

Sommers notes that laboring women sometimes change their minds and decide the pain is too much and want an epidural after all.

To those women, Sommers said, "I would say, 'Be brave. Remember what we learned? Whatever goes into you goes to the baby.' "

"Some women will say, 'Forget it, get me the drugs,' " said Sommers. "It's not my purpose to make her feel guilty. I have to support them (in their decision)."

There have been times when labor assistants may have been too strident in their opposition to what doctors were recommending in the labor room and were asked to leave, acknowledges Claudia Lowe, founder and president of the National Assn. of Childbirth Assistants in San Jose.

When that happens, "labor support gets a bad name," she said. As a result, there's been an emphasis on establishing positive relations with doctors.

If labor assistants get too pushy and try to argue with the doctor over what medical procedures are appropriate, "they can be a real pain in the neck," said Dr. Ralph Steiger, assistant professor of obstetrics and gynecology at UCI. "Their interference could result in a bad outcome."

Dr. Vivian Dickerson, vice chairman of the American College of Obstetrics and Gynecology and assistant clinical professor at UCLA, stresses that the primary goal should be a healthy mom and baby.

If labor assistants help women feel more comfortable and knowledgeable about the birthing process, that's good, she said. But they are not qualified to make medical decisions. And she doesn't feel they should be in the labor room "pushing a philosophy."

She recalled one patient whose labor coach kept insisting that the woman should deliver the baby while in a squatting position. The patient, however, didn't want to and was so exhausted she couldn't even balance.

Dickerson finally told the coach, " 'I'm the person in charge of this patient. I have to make the medical decisions." Dickerson said it was clear at that point that the decision needed to be made by her and the patient without the coach's input.

It is important, she said, for the mother and coach to be flexible in dealing with whatever develops. "Catastrophes can happen very rapidly and without warning even in a very healthy patient," Dickerson said.

Doctors do not perform Cesareans on a whim, she said. They do so when they believe they are necessary to the health of the mother and baby.

Although Alden agrees that a healthy baby is the primary objective, she sees women's choices in the birthing process as black and white.

Women who opt for pain medication and easily accept their doctor's recommendation for a Cesarean, "don't place any value on the birthing process. Their attitude is 'Knock me out. Hand me a kid. That's all I care about.' "

On the other hand, those who value the birth experience, said Alden, forgo the medication, accept the pain and do all they can to deliver vaginally.

Not all mothers agree with Alden's philosophy.

"With that attitude, she is putting the birthing process on a higher plane than the health of the baby or the mother," said Elizabeth Hopkinson, who recently gave birth to her third child in Long Beach.

"It's not all black and white. Some women are just not equipped to physically handle a long period of intense pain. Just because a woman may require medication to complete labor or has to have a Cesarean, does not mean she doesn't value the birthing experience."

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