(Editor’s note: A shorter version of this commentary appears in the Wednesday, Aug. 4, 2010 edition of the Big Island Weekly.)
By Tiffany Edwards Hunt
I am hapai (pregnant) with my second child. I had my first child at the Waimea Women’s Center. I was hopeful that, with this pregnancy, I could avoid the hour-and-a-half commute to Waimea, by getting the midwifery care that I desire at Pahoa Women’s Center, which is operated by the Bay Clinic Family Health Center.Â All too soon I learned that the prenatal care in Pahoa is limited and ultimately results in a hand-off to an ob-gyn at the Hilo office of the Bay Clinic.Â Let me give you the run-down of my interaction with Dr. Eric Helms, who is fresh off the jet from Florida.
After my initial visit with certified nurse midwife Roxanne Estes at Pahoa Women’s Center,Â I was scheduled to meet with Helms on July 14, 2010. A week before that scheduled visit, pain in my lower left pelvis area led me into the Pahoa Women’s Center again.
I hoped for an ultrasound to relieve anxiety that I could possibly have a tubal pregnancy. Â As it turns out, a $25,000 ultrasound machine I understand is supposed to be at the Pahoa Women’s Center is not there. Â It is located in Helms’ office in Hilo.Â ButÂ Helms’s schedule was too full to see me before July 14. Â I drove myself to the Hilo Medical Center emergency room (ER) and, five and a half hours and an ultrasound later, was assured my fetus is safe and sound in the womb, but I have an ovarian cyst. Â Pressed for details, the ER doctor said I would have to consult with my ob-gyn.Â Enter Helms.
The day of my scheduled appointment with Helms, driving from rural Puna into Hilo, I had trouble finding the new office of the Bay Clinic and ended up being 10 minutes late for my appointment. Â The nurse tried to reschedule, but I was determined to see Helms and discuss the results of my ER visit.Â I waited for nearly two hours and, thanks to my persistence, I ultimately saw Helms.
When conversing with him, Â I shared that I am a “cheerleader for midwives.” Â Â I told him my plans to meet the new Hilo Medical Center medical director, Dr. Ted Peskin, later in the week to see about incorporating some of the successes in Waimea in Hilo.Â Helms prefaced with, he didn’t want to be discouraging, before speculating that it would be “five to 10 years” before midwives are allowed access to the Hilo Medical Center. He then shared with me that if he is to be my ob-gyn for labor and delivery at the Hilo Medical Center, I would not be permitted to have a midwife present. Â He also told me that, for him to be the doctor at my delivery, I needed to have my baby during business hours Monday through Friday.Â If not, there would be an 80 percent chance he would be the one on call at night or on the weekends, since he shares on-call duties with the handful of private-practice ob-gyns in Hilo.
After my visit with Helms, he called meÂ a few hours later to tell me he was referring me to the Waimea Women’s Center. IÂ contested, saying I had not decided I wanted to make the trek to Waimea. He stressed that if he was to be my ob-gyn I would not be permitted to have a midwife at my birth in Hilo. I noted “there is a disconnect” with Bay Clinic, offering midwifery services for prenatal care and then not allowing a midwife to be present for labor and delivery in Hilo. Â He noted his ob-gyn practice is very different from midwifery. Â IÂ told Helms I wanted a chance to meet with the Hilo Medical Center medical director a couple days later and to confer with my husband, before being referred to Waimea.
The very next morning, Helms called to tell me he was going to refer me to Waimea.Â I reiterated that I had not decided I wanted to give birth in Waimea.Â He let me know that it was not my decision to make.Â I said, “What are you trying to tell me? You’re going to deny me care?” Â “Yes, I am” he responded. Â I told him I would be contacting the chief executive officer of Bay Clinic, Paul Strauss.
I had hoped Strauss would be the voice of reason.Â Alas! With Bay Clinic management having a notorious reputation for overworking staff, burning them out, and firing people on a whim without apparent cause or explanation, I was too optimistic.Â After two unreturned phone messages, I emailed Strauss details of my interaction with Helms and the forced referral to Waimea.Â Strauss replied within a few days with what I view as a paternalistic response that does not bother to genuinely address my questions or concerns:
“Dear Ms. Edwards Hunt,
Thank you for your correspondence concerning your experience as a patient at Bay Clinic Family Health Centers. Â We appreciate the opportunity to answer your concerns regarding midwifery services and value your perspective for continued quality care and service.
As you may know, certified nurse midwives are an integral part of our Women’s Health Care Team. Â Certified Nurse Midwives at Bay Clinic provide a spectrum of primary women’s health and preventive services and support OB/GYN services including prenatal care up until delivery. Â Unfortunately, at this time Certified Nurse Midwives are not able to be credentialed to provide delivery services for our hospital patients in the hospital setting.
We recognize and respect your preference for a delivery performed by a Certified Nurse Midwife, and in that spirit have provided a referral to a healthcare organization that can best accommodate your favored choice. Â We wish to continue to be your provider of choice for all other aspects of your general primary and women’s health needs at both our Pahoa and Hilo-Komohana locations.
We hope that this letter expresses our sincere appreciation to you for sharing your views as a patient of our health centers and member of the community we serve.
Chief Executive OfficerÂ “
Notice, while he doesn’t offer me a cookie, he does provide me crumbs.Â Bay Clinic won’t offer me prenatal care, but is willing to assist me in “primary and women’s health needs.” Talk about fragmented care. Strauss doesn’t say why the $25,000 ultrasound machine is in Hilo and not at the Pahoa Women’s Center; he doesn’t say why Bay Clinic failed to address my emergency health needs; He doesn’t say why Helms, a doctor for a community health center that receives county, state and federal funding, can deny me prenatal care.
StraussÂ gives no regard to the fact that the Waimea Women’s Center that Bay Clinic wants to refer me away to is located an hour and a half away from the community in which I live and work. He offers no explanation for why certified nurse midwives are not able to be credentialed to provide delivery services in the hospital.
See, Bay Clinic was on the precipice of something great by opening the Pahoa Women’s Center and staffing it with a certified nurse midwife.
When applying for the Hawaii County Council’s 2009-2010 Human Services and Economic Development Committee grant, Bay Clinic claimed the women’s center would provide for the “whole health of mother and child.” Noting the need for providers and support staff for women’s health services, the grant application, stated, “This will include one obstetrician/gynecologist to compliment our certified nurse midwives and nurses” who were hired in December 2009.Â It all sounds so great on paper. The reality has proven to me to be quite different.
Bay Clinic, if it would utilize certified nurse midwives to the full extent that they are able, could become known as one of the most progressive health care organizations in the state. As it stands now, Waimea Women’s Center at the North Hawaii Community Hospital is the one shining example of a health care organization leading the way here on this island, allowing certified nurse midwives to attend all deliveries.Â Kalihi Pulama Health Center and Kaiser Permanente on Oahu are also allowing certified nurse midwives to attend deliveries.
So many women who wish to have midwives attend their births, who cannot afford the commute to Waimea or Oahu, are resorting to home births.Â They pay up to $2,600 for a lay midwife.Â Those of us who have given birth know what fragile ecosystems we are, and that technology exists for a reason.Â There have been bad outcomes from women giving birth in the boondocks.Â I’m sure that the staff and ob-gyns at all the island’s hospitals can all talk about those bad home-birth outcomes. They don’t talk so much about the successful home births, because they are only seeing the ones that went wrong.
Peskin, of the Hilo Medical Center, when I finally met with him, noted he is supportive of midwives, but he does have a concern with home births.
“I have a strong life long interest in making pregnancy and childbirth as safe as possible, while making the experience a warm, positive experience, which encourages the strong family bonds, which are so important to the psychological and physical health of our infants and children,” Peskin told me.Â “I have worked with certified nurse-midwives and ‘doulas’ (labor support individuals) Â in the past and am very supportive of them. Â However, I have a major concern with home births. Â The majority of home births are uncomplicated and can provide a very warm and comforting environment and I understand their appeal,” he said. Â “However, I have seen cases of infants who died or have life-long disabilities because of complications of home birth, either because the problems were not recognized in time or because the home was too far from a medical facility. Â I have also seen many cases in the hospital where rapid actions saved the lives of mothers and infants.”
I understand and share Peskin’s concern.Â In my mind, the success of Waimea Women’s Center is that it has been able to bridge both the home birth and hospital birth for an experience that acknowledges the need for “a very warm and comforting environment” and the latest technology for that dreadful occasion when nature does not take its course.
Peskin listened intently and showed a keen interest in knowing why my natural child birth experience in Waimea was so positive, and after just a few minutes of visiting with him, transformed a bad week into a good one.
A resident of Kapoho Vacationland subdivision, Peskin understands the commute we Puna residents have to make to Hilo, let alone Waimea. He helped start two midwifery programs at hospitals on the mainland.Â Hailing from Massachusetts, his resume reflects an impressive amount of experience and expertise in obstetrics and gynecology.Â HeÂ has been the medical director for acute care, including obstetrics, at Hilo Medical Center since April 2010. He has a voluntary position as clinical professor of obstetrics and gynecology at the University of Hawaii Medical School.Â He also plans to soon have a small gynecology practice at the Family Practice Residency Program in Hilo.
Peskin and I toured the obstetrics unit of the Hilo Medical Center with head nurse Christina Ranan.Â There are an average of three to four births per day at the Hilo Medical Center.Â The unit is comprised of eight private labor rooms, and three rooms are used and equipped as birthing rooms for labor, delivery, and recovery. Â Two of the birthing rooms have a shared shower, while the third has its own shower, which laboring patients are free to use as long as they and their baby are doing well. Knowing how much I relied on a hot shower for relief during most of my labor,Â I cannot imagine having to share the bathroom with another laboring woman.
I did not like hearing that, after the baby is born in Hilo, he or she is taken from the mother to the nursery for cleanup and a pediatrician’s examination.Â In Waimea, the baby never leaves the mother’s side.Â The cleanup and pediatrician’s exam occurs in the birthing room.
As we toured, I looked out the windows of the rooms, trying to find a space outside that could be transformed into a garden for laboring women to walk around â€” like the garden that lies outside all of the Waimea Women’s Center birthing rooms. I spotted a triangular-shaped atrium through the window of one of the rooms.Â My mind raced, envisioning how this existing green space could easily be manicured and have a trail cut for laboring women to traverse.Â Peskin later responded later with, “Unfortunately, that area is not safe for walking or sitting because of building code issues.”
I told Peskin about the birthing tub available to laboring women in Waimea.Â He said he would inquire about installing bathtubs or whirlpool baths in Hilo. Later, he responded with, “There are construction issues that prevent this from occurring.”
While news of inaccessible atrium and construction issues blocking the installation of birthing tubs was discouraging, Peskin did offer some hope for the obstetrics unit in Hilo.Â “We will be embarking on a painting and renovation of the obstetrical unit shortly, which we think patients will appreciate,” he said. Generally, Peskin emphasized that Hilo Medical Center is “very open to suggestions from current and potential patients about what they would like to see in Obstetrics” there. He asks that comments and suggestions be relayed to the hospital’s community relations director, Elena Cabatu, who can be reached via email at email@example.com.
Did you have a successful natural child birth at the Hilo Medical Center?Â Did you opt for Waimea Women’s Center instead?Â Did you receive your prenatal care at the Pahoa Women’s Center, and then get handed off to an ob-gyn in Hilo or referred to the Waimea Women’s Center?Â I would love to know your birth story as well.Â Email me your comments, concerns, even your suggestions, at firstname.lastname@example.org.
Maybe the time has come for Hilo to pursue a birth center.Â Do you realize how far Waimea is from rural Puna, even Ka’u?Â Imagine being in labor trying to make that drive?Â Â What that drive requires is an insured and reliable vehicle, the gas money to get there, and the money for a hotel room in the event that the laboring woman is not dilated enough to be admitted into the hospital. Imagine being in the car laboring, and how nerve-racking the thought of giving birth on the side or the road could be?! It’s truly a psychological journey that commute to Waimea.
In my view, despite the funding, backing and the necessary tort insurance, Bay Clinic has dropped the ball on progressiveness. I am no longer looking to that organization to be making positive headlines on anything progressive.Â Maybe Hilo Medical Center will lead the charge in maternal health care by accepting certified nurse midwives into the fold â€” either Hilo Medical Center or Kaiser Permanente up the street.Â Or, maybe just maybe, the University of Hawaii John A. Burns School Of Medicine Hilo Residency Program will be the one?!Â Women should not be forced to commute an hour, even two hours, to a medical facility while in labor, bypassing another hospital and staff that refuse to get with the times and offer midwifery care.
As our nation looks to 2014, when health care reform is to take effect, we must look long and hard at maternal health care.Â Think about it: How women give birth changes their entire perspective on life.Â How children are birthed into this world will have a lifelong effect on them, their parents, and their family unit as a whole.Â Indeed, when looking at maternal care, and at health care in general, we must see and conceptualize the continuum. This is not about practicing defensive medicine, offering fragmented care, warehousing people, treating clients as a statistic, referring customers away, or neglecting people altogether â€” leaving women to give birth in the middle of nowhere or, God forbid, on the side of the road.
This is â€” about exactly what the mayor is calling his upcoming health care conference â€” building a healthier future together.Â This is about being inclusive, incorporating varied philosophies, building consensus, and seeking quality care to maximize health and well-being.Â Let’s change the politics of birth here. I guarantee, we have nothing to lose and plenty to gain.