With birth rates above the national average, Arizona offers parents-to-be more options than ever.
...in the Beginning there was an egg and a sperm. Whether their union was divinely ordained, scientifically schemed or accidentally arranged is for their owners to say, but their triumph over the obstacle course of the reproductive system – from fertilization to implantation to gestation – is by turns miraculous, monumental and downright messy. Every human has the same basic biological building blocks for his or her origin story. What happens next is where the plots diverge, and in Arizona there are more possibilities than ever before.
According to the Arizona Department of Health Services, 87,274 babies were born in Arizona in 2012 – about one every six minutes. That’s roughly 15,000 more babies than there are seats at University of Phoenix Stadium. Though birth rates have dropped locally and nationally since the recession, we’re still above-average breeders in Arizona, with a 2012 birth rate of 13.2 live births per thousand of population per year, compared with the U.S. rate of 12.6.
Those babies were born at glossy, high-tech medical centers, run-of-the-mill suburban hospitals, bare-bones inner-city clinics, hardscrabble rural hospitals, naturopathic birth centers and even in their homes, on mom and dad’s bed or in an inflatable tub in the living room. Today, Arizona mamas – and papas, if they’re involved, though 38,770 of those babies were born to unwed mothers – face a much different birthing landscape than their mothers and grandmothers did, with birth plans and Bradley classes and fierce mom competition on every topic imaginable. Hospital or home birth? Epidural or no? Breastfeed or formula? They have plenty of options, and, with the accessibility and ubiquity of information in the technological era, they’re also more educated and empowered to make their own decisions.
The conflict between home and hospital births has been particularly divisive, with each side painted with broad strokes by opponents. Midwives and home birthers have been vilified as careless hippies or backwoods zealots willfully ignoring medical advances and jeopardizing mothers’ and babies’ safety in service of their progressive vanity. Doctors and nurses, meanwhile, have been demonized as calculating, number-crunching Napoleons drugging women and interfering with the natural birth process to jack up their paydays and make their 10 o’clock tee times. The truth, of course, is in neither extreme, and both sides have grown more respectful of each other over the years.
The options can be overwhelming, but at least they’re there.
About 99 percent of Arizona women give birth in hospitals, according to the Arizona Department of Health Services, like Amy Clark did for her first pregnancy with daughter Layla, now 2.
“When I initially got pregnant, I thought, ‘Oh, I’ll just get a doctor and they’ll tell me what I’m supposed to do and it’ll be fine,’” Clark says. “Then, the further along I got, I thought, ‘I don’t want any interventions, I don’t want them to give me any drugs of any sort, I don’t want an IV.’”
She and husband Steve Walmsley gradually became disillusioned with their OB-GYN’s impatience and terse answers to their questions. The last straw was when the doctor balked at Clark's rejection of a later-term vaginal exam. Clark says her doctor refused to explain why it was necessary and their disagreement devolved into the doctor shouting at Clark and storming out of the appointment. The couple then started researching birthing centers and midwifery, but because she was 37 weeks pregnant, they decided the stress of changing course would be worse than sticking it out. They hired a doula, a birthing aide trained to comfort and support laboring mothers, and had Layla in a hospital sans “interventions,” i.e. a pain-relieving epidural and labor-inducing Pitocin.
“I always knew if we had a second one it would be a home birth for sure,” Clark says as she rests her hand on her swelling belly on a balmy January afternoon at her home in Anthem. She’s 37 weeks pregnant again – another girl – but this time she’s Zen about her impending delivery. She even looks a little like a meditative Buddha meets fertility goddess, sitting cross-legged on her couch in a flowing maxi skirt and tank top draped over her bump, her long dark hair falling past her shoulders.
Clark and Walmsley “prefer to go natural whenever possible. I appreciate the medical side of things when we need it, but I definitely want to try to go natural,” Clark says. She also prefers the closer relationship she has with her midwife, Pamela Qualls. Since midwives have far fewer clients than the average OB-GYN, they have the luxury of longer appointments and more time to get to know their clients. Clark says she appreciated having the time to discuss her questions and concerns in greater depth with Qualls, who never pressured her to go through with a test or practice she was uncomfortable with.
Midwifery and home births have been practiced for thousands of years, and for many of those years, they were the norm. They fell out of popularity during the expansion and professionalization of the health care system and are currently illegal in 10 states because of safety concerns. The counterculture-driven natural birth resurgence of the 1970s and 1980s brought the practice to the surface of the American birthing landscape, and according to the Centers for Disease Control, home births increased 29 percent from 2004 to 2009. They enjoyed a bump in exposure to the mainstream after the release of actress Ricki Lake’s 2008 documentary The Business of Being Born, which examined the birthing culture in America, albeit through a pro-midwifery lens.
Proponents of midwifery and home birth maintain that birth is a natural life process that women are inherently equipped to experience without medical intervention. Women instinctively know what is best for their bodies, they say. They encourage women to emote during labor and get in whatever birthing position feels most comfortable – for most, that's a frog-like squatting position, floating in a birthing tub, or bent over on all fours. The medical model has its place, they say, for complicated or high-risk pregnancies and deliveries that warrant emergency intervention. Arizona midwives cannot deliver multiples or work with pregnant women with increased risk factors like heart conditions or advanced age, for example. For the average birth, though, they say no doctors are needed.
“There’s an ownership [with home birth],” says Wendi Cleckner, licensed midwife and president of the Arizona Association of Midwives. “[As opposed to] ‘Oh, the doctor saved me. I’m so grateful I got the epidural and was cut off from everything.’ It is this whole ownership of ‘I did it,’ and that can’t be replaced. And that’s not me, that has nothing to do with me or even a home birth, necessarily. This women’s empowerment – ‘I did something so amazing that’s so not in our culture anymore’ – is beyond.”
Arizona midwives gained licensure in 1978. In 2012, 730 babies were born at home and 272 were born at birth centers, a sort of home-hospital hybrid that could be staffed by any combination of OB-GYNs, nurses, certified nurse midwives, licensed midwives and doulas. Certified nurse midwives are licensed nurses in addition to being trained midwives and have often functioned as a bridge between the medical and midwifery communities. Licensed midwives are trained and certified by the North American Registry of Midwives, a process which includes a didactic or apprenticeship model as well as practical, written and state law tests. They are then licensed by the state. As of 2013, there were 209 practicing certified nurse midwives and more than 75 licensed midwives in Arizona. Cleckner says things have come a long way since she got licensed 15 years ago.
“When I first got licensed, I got two responses: ‘That exists still? Isn’t that a witch?’” Cleckner says. “Or: ‘You mean you carry the baby? You’re constantly pregnant?’ They thought I was a surrogate.”
Even Clark, who is happily resolute in her decision to birth at home, and whose own mother gave birth to her and her four siblings at home, skates around the topic to avoid people’s reactions, which she says range from the rare encouraging support to the more pervasive alarm for her and her baby’s safety and disgust at the concomitant mess of birth.
“I’m so excited and so set on this decision. I didn’t want those negative vibes coming my way from people,” Clark says. “The few people I’ve told, I start out with, ‘I’m so excited we’re going to do a home birth.’ Kind of like, ‘Don’t rain on my parade. Just go with it, as weirded out as you are.’”
The most enduringly popular and accepted way to have a baby in Arizona is still the traditional hospital route, but even that has room for individualization. Hospitals aren’t one-size-fits-all human factories churning out babies like iPhones. Most OB-GYNs today are willing to work with patients to develop a birth plan accommodating their wishes for their birth experience. They can specify the amount and type of medication they want to receive, bring in a doula, use a birthing stool or bar, pack a peanut ball (a peanut-shaped ball that spreads the legs and opens the pelvis to make it easier for the baby to descend), hold the baby before it’s cleaned up and weighed and measured, and choose from myriad other pre-, during- and post-labor options.
“I encourage my patients to make a birth plan. I just tell them not to hold so fast to everything that’s on that birth plan. Understand that labor can deviate from the course that we have outlined, and if you remain so fixated on everything on that birth plan and it doesn’t go that way, you’ll be extremely disappointed,” says Dr. Teresa Malcolm, an OB-GYN at Banner Del E. Webb Medical Center in Sun City. “My goal is to give you a healthy child and for you to also have a healthy outcome. If it means that you don’t get the aromatherapy candles, it’s OK.”
The OB program at Banner Del E. Webb represents another birth trend in the Valley: the baby boom on the west side. In 2012, 32 percent of babies born in the Valley were born in West Valley hospitals, second only to the 34 percent born in the East Valley. The fact that it’s happening in Sun City, the retirement capital of the Southwest, of all places, shouldn’t be such a revelation to the rest of the Valley, Malcolm says.
“A few years ago the West Valley was growing almost exponentially. Surprise was a very low-priced but hot commodity,” Malcolm says. “So we saw a huge implant of families coming in here because it was affordable. It’s a myth that the babies are only coming out of Scottsdale or central Phoenix.”
The hospital’s educational offerings reflect other trends in Arizona’s baby climate. Gina Herrera, manager of prenatal education and outreach, recommends new parents take the CPR and car seat safety classes to keep in line with the Arizona Governor’s Office of Highway Safety’s booster seat law. She and the rest of the Banner staff also strongly encourage breastfeeding, in adherence to the Joint Commission’s 2014 breastfeeding initiative that aims for 100 percent of mothers breastfeeding at the time of discharge – part of a national shift in breastfeeding philosophy, informed by many studies indicating that babies who breastfeed are healthier in both the short- and long-term. Banner Del E. Webb has a boutique in the maternity wing with nursing bras, breast pumps and certified lactation consultants to help meet their goal.
“Nurses are getting more lactation-friendly than before,” Herrera says. “I’m from California and pretty much everyone in California is lactation-friendly. You’re a minority if you’re not. Over here, the recent trend is that we’ve just caught on to that. All of a sudden they’re all pouring into lactation workshops and classes.”
The hospital birthing culture reflects a broad socioeconomic swath. Dr. Nicholas Bujak, an OB-GYN who practices at Valle del Sol Family Practice in Phoenix and delivers babies at Maryvale Hospital, works in an underserved area with predominantly lower-income women. He encourages his patients to breastfeed, too, but also to make crucial lifestyle changes, such as to stop smoking, drinking and using drugs. His patients have included methamphetamine and cocaine addicts, gunshot survivors and a woman who was murdered by her husband only days after her initial consult.
“These people have hard lives and being able to impact their health is important to me,” Bujak, a Polish-Canadian transplant, says in animated, accented English. “I love this population. They are so much more colorful, my patients, than a population who’s entitled. They are grateful, they are happy, they have stories behind them. The stuff that I see is pretty insane.”
Bujak’s practice struggles to compete with nearby practices and federally funded clinics; consequently, he offers unorthodox goodwill perks to his patients to encourage them to start and maintain care with him. First visits and first ultrasounds are free; after that, he charges $25 per visit. The majority of his patients are insured, with the bulk receiving assistance from the Arizona Health Care Cost Containment System (AHCCCS). He delivers roughly 180 babies a year.
“I’ve tried to provide the same care to everybody, whether they’re paying me or not paying me,” Bujak says. “The good thing about Arizona is almost anybody can get insurance.” When moms fail to secure insurance before their babies are born, he doesn’t get paid. Birth costs vary across the board, with a range of $1,500-$5,500 for a home birth; OB-GYN and hospital fees vary with insurance coverage, so a mother on AHCCCS could have a nearly free hospital birth while others could pay up to $50,000 or more, according to Truven Health Analytics.
Bujak is also favored by midwives – including Amy Clark’s midwife, Pamela Qualls – for his tolerance and respect during “transfers” – when home births go awry and moms must be transported to hospitals for care. Not all doctors are as friendly in such stressful situations, though Cleckner and Qualls say there has been improvement in the last 10 years in OB-midwife relations.
“People have choices in life. If my girlfriend was having a baby, I would not have that baby delivered at home, because I’ve been brought up in a medical model,” Bujak says. “Occasionally bad things happen, so when they happen in the hospital we have many more options of how we can deal with them. But I feel that the patient should have the right to receive care how they want to.”
Malcolm says they don’t get a lot of transfers at Banner Del E. Webb, but they do get some. In most cases, she says that by the time transfers get to the hospital, it’s not too late to save the mother and baby, but it’s much later than they would prefer.
“We feel, ‘This should’ve been recognized a long time ago; why did it take this long for you to finally come in and see us?’” Malcolm says. “It’s a little frustrating for us, because what you’re really getting is a drop-in. You’re getting somebody who you’re completely unfamiliar with who you’re now trying to quickly establish a relationship with and provide them with good clinical care in a very stressful situation.”
Qualls agrees. “There’s always a place for a hospital. There’s always a place for doctors. Things happen,” she says. “We never have that mindset of, ‘We’re not going to a hospital unless there’s a bad problem.’ We’re better off safer than sorry. It’s much easier to transition the mother in early labor before there’s an emergency situation.”
Home births and midwifery have had increased media coverage in the last year as archaic state regulations regarding midwives were updated. Home birthers secured key victories – vaginal births after cesarean (VBAC) sections are now permitted at midwife-attended home births – but discovered that state law forbids them from carrying and administering potentially life-saving medications in the event of a home birth gone bad. Midwives unsuccessfully lobbied the state legislature last fall for permission to carry medications such as antibiotic eye ointment to prevent newborn eye infections, vitamin K to aid newborn blood clotting, Pitocin to prevent mothers from hemorrhaging, Lidocaine to numb sites for stitches and oxygen for mothers and babies. Despite opposition from many in the mainstream medical community and reticence from legislators concerned about the safety of home births, midwives and home birth advocates plan to rally their efforts again this fall.
Ten days after reflecting on her first labor and birth at a hospital, Amy Clark is in labor in an inflatable green tub at the foot of her bed. Her belly bobs up above the surface of the warm water as her husband Steve Walmsley leans over the side of the tub to support her back and rub her shoulders. Her low moans and hums between contractions escalate to guttural exhalations and shouts during them. Her daughter Layla peeks over the top of the tub, chattering and trying to get in the water to play with mommy, unfazed by the impending birth of her baby sister. Midwife Pamela Qualls monitors the baby’s progress at the foot of the tub and guides Clark with her sweet, soothing voice. Clark’s mother, a birth photographer, and Qualls’ student midwife Zabrina Pell hover around the tub. Clark’s labor pains are punctuated by the click of the camera and Layla’s babble.
“The baby’s right there, she’s ready,” Qualls announces. Walmsley hurriedly moves to the foot of the tub and reaches down. After a final agonizing push, Walmsley and Qualls pull the baby out and up, and with a rush of water and a piercing cry, another baby is born – another story to unfold.
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