Delivery Dilemma - the birthing debate

Bay of Plenty Times

Bay of Plenty Times

A new luxury primary birthing facility has opened its doors to Bay women. While some rush to book their births at the centre, others question the risks of birthing away from hospital. Annemarie Quill reports.

"It's not mumbo jumbo. I'm not going to be hypnotised into dancing the funky chicken."

Karen Clarkson laughs off cynicism over her planned HypnoBirth. The 33-year-old communications manager for chef Nadia Lim is 34 weeks pregnant.

At home in her 1950s Mount beach bungalow, she is carefree in a floral Neon Gypsy dress, a pop of colour amid the Scandinavian-inspired simplicity of her living room. A single white orchid adorns the room.

Her first baby is due in January.

"We don't talk about due dates so there is no hysteria if that day comes and goes."

After previous miscarriages, Clarkson is adamant her birth will not only be drug free but pain free. Under HypnoBirth practitioner, Vicki Bullick, Clarkson plans to use relaxation techniques. The theory is that a state of deep calm increases natural endorphins that block out pain.

"I will use visual affirmations such as imagining layers of the uterus opening like a rose bud."

"Good luck with that," has been the reaction of friends with children. It has not deterred Clarkson and husband Kyle from seeking out the perfect place for the flowering.

Their baby boy is to be born in Bethlehem.

A NEW BIRTHING CENTRE FOR TAURANGA

Bethlehem Birthing Centre, Tauranga's first private primary birthing unit, opened late last month. The multi-million-dollar site, opened by Prime Minister John Key, occupies the first floor of a new building that also houses midwives, chiropractor, acupuncturist and physiotherapist. Next year, a Pilates studio is planned.

At the bottom of the stairs leading up to the new birthing unit, a yoga teacher advertises her services.

Upstairs, the centre oozes urban opulence, its wide corridors illuminated by soft LED lighting. A colourful painting of children adorns the wall. Peeling off from the corridors are 12 large rooms, each with muted clays and soft blues.

The centre has a boutique hotel feel. Rooms have a queen bed, tiled bathroom, flat-screen television with breastfeeding videos on demand, and fitted wardrobes. Soft curtain patterns of falling leaves hide the state highway below. There are no delivery rooms - women deliver in and stay in the bedrooms.

They can upgrade to a deluxe room with a tilted bed, fridge, Skype and tea- and coffee-making facilities for an extra $240 per night, for three nights. An on-site chef provides meals.

The design has been a hands-on affair for the two directors, Nicky Campbell and Chloe Wright.

Wright says: "One morning I was walking on the beach with the dogs, and the sky and sea were just this amazing blue and I wanted to call our designer to say, come down here now as this is the colour."

That blue now colours the soft cushions and chair in each room. Breastfeeding comfort for mum or slumber for an anxious dad. A hook on the ceiling allows labouring women to drape a rope to cling to.

Wright and Campbell even tested the baths. "We both hopped in them to see if they were right for mums ... the person in the store thought us mad."

Clarkson was won over at a recent open evening.

"Who wouldn't be impressed? The luxury was something I definitely noticed. It seemed a calming space ... perfect to fulfil my dream. I wouldn't be able to HypnoBirth in hospital with the buzz. Being my first baby, I didn't want to be at home either. The birthing centre seems the perfect compromise."

As a primary care facility, there are no specialists, obstetricians or GPs on site. Women enter the facility under the care of their midwife. There are no drugs or medical intervention available during labour apart from Entonox (gas).

Across the bridge in central Tauranga, copywriter Talia Kilmore-Waldegrave is converting a room in her character bungalow. The antique tea trolley with spirits where husband James mixes cocktails is making way for a Phil and Ted pram and Miniwilla bunny wall art in chic monochrome. Kilmore-Waldegrave, 32, is also expecting her first baby in January. Like Clarkson, she wants a natural, drug-free birth.

But unlike Clarkson, Kilmore-Waldegrave has chosen a hospital birth.

"Our midwife said she didn't know much about the set-up and was more comfortable with hospital ... in the centre the lack of people concern me ... at the hospital it has everything you need ... the medical staff with all their knowledge."

Husband James is more comfortable with a medical setting.

"He didn't want me to do anything 'hippy dippy', like giving birth at home or on a bouncing ball. He is a Kiwi bloke. Even the idea of a pool freaks him out. I was discussing positions for birth like standing or crouching, and he seemed surprised, saying, 'oh I thought you just lay on your back with legs in the air'."

The couple is not ruling out a transfer to Bethlehem after a hospital birth. The centre offers free postnatal care, although priority is given to birthing mothers.

A NEW BEGINNING

On the roundabout at the edge of the affluent suburb of Bethlehem, two circles of light on the exterior of the birthing centre's building have been beaming intermittently pink and blue for the past two weeks.

A switch inside lights up the outside to herald a birth. The building glowed pink for the first time on November 19 for the centre's first baby, Maungatapu bub Millie Fryer, born in the en suite bathroom in room 8, one of the centre's luxury rooms.

Since then, rooms have been filling up with mums and new babies.

A few days after Millie, Violet arrived, born to 36-year-old marketing manager Laynie Perrett and her husband, George.

Perrett considered a home birth but had been worried that her Papamoa home was too far from hospital. Like Clarkson, Perett viewed the centre as a home away from home, with "warm towels" and "beautiful rooms".

George stayed the night in the queen bed and shared breakfast the next morning.

"In hospital, after the adrenalin of giving birth everyone leaves and you are alone. Here it was a family experience."

Perrett's experience is close to the vision that Bethlehem Birthing Centre directors Wright and Campbell had for the unit to provide "a sanctuary" for birthing mothers.

A mother-of-five, Wright wants to offer mothers a natural alternative to hospital births.
"I wish in a way it wasn't necessary ... that hospitals could provide everything, but it has changed."

Changed from when Wright had her last child in hospital some 30 years prior.

"I stayed six days ... I learned everything. How to feed, bathe and wrap the baby. They would take the baby away to let the mothers rest. Having had five children, my experience tells me a mother needs this time to heal, not just physically but emotionally, and psychologically."

WHO PAYS?

The Bethlehem Birthing Centre is free for all expectant women eligible for publicly funded maternity services in New Zealand to give birth and stay three nights post-natally at the centre.

The Bay of Plenty District Health Board funds labour and delivery and 44 hours' post-natal care, but Campbell and Wright decided to offer an extra day.

Women who wish to stay longer can do so at a charge of $450 per night for a standard room or $550 per night for a deluxe room.

The scheme of private entity offering services under government contract is not a new business model to either woman.

Wright's husband Wayne is the director of New Zealand's largest childcare provider, Kidicorp. Campbell's background is residential care for the elderly. Negotiations with the health board have been on-going for the past 18 months, says Campbell.

"Yes, it is the same model as rest homes and early childhood centres where there is government funding ... like rest-home care it is about fee for service ... but the emphasis is helping our mums."

And Wright says a service that is much needed, with some women not having an "optimum experience" in hospital.

"It upsets me to hear about women having babies in Tauranga hospital and going home in hours. Or it being full and asked to leave. "

Wright insists it is a desire to offer Tauranga women birthing options that drives them.
"I don't view it as a business. It's a philosophy.

"If mums are healthy and happy and leave here feeling prepared, it trickles down to baby, to the whole family, to the community."

BOOMING BUSINESS

Yet the business of birthing is booming.

Roy Younge, managing director of Birthcare in Auckland and Huntly, has been in the field for 20 years and says birthing centres with adequate volume of women provide good revenue.

The fee for labour and delivery and postnatal stay is a negotiated fee and will vary from DHB to DHB, but Younge says the fees he discussed with the Bay of Plenty DHB were around $600 for delivery and $1000 for post-natal stay. Another industry player, Clare Hutchinson, owner of one of Hamilton's private birthing centres River Ridge confirmed that these fees were typical.

Bethlehem Birthing Centre says this figure is "incorrect" but would not reveal the amount of public money it has received, seeing it as commercially sensitive.

The health board also refused to reveal the amount, citing commercial confidentiality.
Private business providing primary birth facilities is a win for women in the community, and the Government, says Younge.

"DHBs actually save money by contracting to a private provider on a fee per service basis because they don't contribute to the capital cost. Primary facilities don't have significant overheads so can provide services at a lower cost than the DHBs. It frees up the DHB to focus on other healthcare."

Younge said it could potentially be a booming sector like residential care and childcare.

Would Wright - with the experience of her husband's Kidicorp chain - be planning more birthing centres for the future? She is not ruling it out.

"It is like asking me am I going to have another child when I have only just had one ... I am not saying no but will settle down this one first."

Whether there is enough demand for more centres in Tauranga remains to be seen.

Younge says that too many facilities potentially makes the sites - including the hospital - run less efficiently from a business model, even factoring in Tauranga's population growth.

MOVING ON

Health Minister Jonathan Coleman says that while individual boards can determine the number of primary maternity facilities required, a move toward more private maternity care is not planned.

Wright's concern about women being turfed out of Tauranga Hospital hours after birth is disputed by the Government.

Coleman pointed out last month that strengthening maternity services has been a priority for the Government with more than $100 million extra invested across health boards with improved maternity services, including longer stays for mothers in hospitals.

The Health Ministry refutes that women are asked to leave hospital early, telling the Bay of Plenty Times Weekend: "Women and their babies are entitled to stay in a hospital or birthing unit as long as is clinically necessary."

Latest figures show the average post-natal length of stay for January to June 2012 was 2.46 days for the whole of New Zealand, and 2.09 days for Bay of Plenty. Auckland women are staying on average a day longer at 3.09 days. This does not include the time a woman spent in hospital during labour as this varies significantly between women.

PERSONAL CHOICE

Tauranga Hospital midwifery manager Esther Mackay dismisses any notion that the Tauranga maternity unit has been under pressure. Mackay says that the unit runs to 100 per cent capacity as little as once or twice a year. If this happens, other beds are opened.

Nor is a stay in the maternity unit a rough ride, according to Papamoa mother Katherine Doherty, who is resting in one of the hospital's single rooms with en suite, her third day after giving birth to her second child, Imogen.

The 36-year-old lawyer says she has had a relaxing stay. Noise is not an issue.

"I can shut the door", and having experienced the birth of her first baby in London, she said the service in Tauranga had been excellent.

"If I needed a midwife, I pressed a button and they come running ... compared with when I had my son in a London hospital three years ago you literally had to hunt someone down in the corridor."

Doherty is glad to have delivered Imogen in a medical facility as while the delivery "went well, pretty quick and easy" in the unit's delivery room, she had to be whisked into theatre post birth because she had retained the placenta.

The DHB unit boasts features that give the birthing centre a run for its money in the luxury stakes. The seven delivery rooms are well appointed with private en suite and two with birthing pools. Medical equipment is concealed in cupboards to give a more natural environment. Even the delivery beds can be described as tilting, something that mothers are charged more for at the Birthing Centre, given they can be just straight beds or function as electric obstetric beds suitable for more complex care.

There are 17 post-natal beds, nine single rooms with en suite and four double rooms with external showers and toilets, three antenatal rooms and three assessment beds, plus a TV lounge and whanau room.

"We can dim the lights, alter the temperature, and accommodate support people," she adds.

While there may be no Pilates or yoga classes, Mackay says the notion of mothercraft has been offered in hospital for years.

"Breastfeeding support and education is a priority ... baby bathing, wrapping safely or not wrapping, temperature regulation and mothercraft is routine."

Despite Mackay's obvious pride in the hospital facility, she believes a certain group of women can have safe births in the community, and is supportive of women having choices.

"We have had people here today that needed pain relief, others unwell, high blood pressure, or being induced ... but some healthy women can birth naturally away from hospital."

NOT SO BLACK AND WHITE

Bay of Plenty District Health Board's obstetrics and gynaecology department chief Michael John agrees.

"The opening of a birthing centre in Tauranga is an interesting and exciting event which will provide another choice for birthing mothers to that of the hospital or home birth."

The official response from the obstetric community is a muted nod to primary facilities.

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists says "it accepts that women assessed at low-risk of pregnancy complications may choose to labour in relatively low-technology standalone primary childbirth units".

However this is qualified by a note about location, "wherever possible, such units should be sited within or immediately adjacent to a 24-hour hospital facility ... the RANZCOG believes that it is less desirable for metropolitan standalone primary childbirth units to be located remotely from such a hospital facility".

Dr John says it is simplistic to compare locations:

"A simple answer of whether one option is better than another is inappropriate. Mothers will choose to birth in different locations for complex reasons.

"For many mothers, childbirth is a normal uncomplicated event and they do not need hospital facilities. However, other mothers have conditions which make delivery in hospital safer."

The international Cochrane group has reviewed the research on home-like birth environments compared with a conventional labour ward. It concludes that primary care facilities can offer "modest benefits, including decreased medical intervention and higher rates of spontaneous vaginal birth, breastfeeding and maternal satisfaction".

But this thumbs up comes with a damning qualifier. The report also states that in home-like birth environments "there may be an added risk of perinatal mortality".

WHAT'S THE RISK?

New Zealand's Perinatal and Maternal Mortality Review Committee details and analyses maternal and perinatal deaths (deaths from 20 weeks gestation to 28 completed days after birth).

In the latest report from January 1 to December 31, 2012, New Zealand recorded 669 infant deaths.

Committee chairwoman Sue Belgrave says the perinatal mortality rate has remained stable at 10.7 per 1000 births. This is equivalent to one baby dying in pregnancy or during the first month of life for every 100 babies born.

The perinatal mortality rate in the Bay of Plenty health board is slightly less than the national average. New Zealand's perinatal mortality rates are comparable with rates in Australia and the United Kingdom.

However, Dr Belgrave points out that 19 per cent of these deaths have been determined as "potentially avoidable" and Health Quality and Safety Commission chairman Alan Merry commented on the report that "there is clearly still work to be done to improve safety of our maternity services".

The latest report records one death where transfer from a birthing unit was a contributory factor.

Earlier this year, a Hamilton inquest investigated the death of 20-year-old mother Casey Nathan who died in May 2012 just hours after giving birth in Huntly Birthcare. Her son, Kymani, died two days later.

The February inquest heard how hospital staff may have been able to diagnose her condition - had they received her earlier.

The inquest also heard how midwives at the Huntly Birthcare Centre had difficulty securing an intravenous line into Ms Nathan but did not seek further help from staff at Waikato Hospital. It heard evidence from St John Ambulance that staff were concerned about the young midwife's apparent lack of experience, with one saying "she had no idea what was going on".

Jenn Hooper, of parent support and lobby group Action to Improve Maternity, represented Ms Nathan's family at the hearing. The group supports families where a "birth tragedy" has occurred.

Hooper says that out of the 650 families it has represented, 95 per cent of the cases are mothers who gave birth away from hospital.

Hooper, 43, is now pregnant with her third child. Hamilton-based, she will be birthing in Waikato Hospital.

Her first child, daughter Charley, 9, was born in a Morrinsville birthing unit, a birth that left Charley "brain damaged, blind, tetraplegic, not knowing who I am".

The families' stories of "botched" births and "near misses" [Hooper's words] on the group's website make emotive and frightening reading.

CONCERN

But Hooper is unapologetic. She worries about outcomes in primary birthing units and it is her opinion that they sell birth as an experience with the emphasis on the beauty of the room and the food.

She said that in her opinion these centres are, "no different to home with someone else changing the sheets."

Hooper says women need to make an informed choice, but it should not be left up to women to ask the questions about such aspects as rate of transfer, time to transfer, will the ambulance have the right equipment, how much training the midwives have had, or record keeping.

"Currently, birth centres do not publicise their transfer rates or give realistic transfer times for emergency situations."

Before opening, Tauranga Hospital took part in a practice transfer scenario with the Bethlehem Birthing Centre, which took 40 minutes.

Bay of Plenty health board midwifery leader Margret Norris told the Bay of Plenty Times Weekend: "Whilst the first practice transfer took 40 minutes, the processes around them are continuously streamlined and the estimate of 30 minutes is a more reasonable expectation of transfer times going forward."

The Bay of Plenty Times Weekend asked Bethlehem Birthing Centre about the number of births and transfers since the centre opened in November. There have been nine births as at midday Wednesday but the centre refused to reveal transfer numbers - or if any transfers occurred, saying it is "subject to patient privacy".

When the Bay of Plenty Times Weekend put the same question to the health board, Norris replied: "There have been three transfers from the birthing centre since it opened without any problems or safety risks to the women or their babies."

Birthing centre director Campbell says transfers from a birthing centre to hospital should not be viewed as negative, and are the sign of a service that does not want to put mothers and babies at risk.

"A transfer is not a bad thing. We expect to have transfers. As soon as there is any cause for concern we will transfer, so we have reassurance from the specialist teams at the hospital that mum's okay and everything is alright. We welcome that."

Dr Belgrave says there needs to be understanding about exactly what a primary birthing facility offers and Bay obstetrician Dr Johns agrees it is vital that mothers are fully aware.

Hooper's advice to Tauranga women is to carefully weigh up these risks. Her opinion: "There is a saying that life is not about the destination it's about the journey. In birth it's the opposite. Birth is about the destination and the destination is your child. From someone who knows about what happens when that destination goes wrong, what I say to Tauranga women is - don't base your birth choices on an experience ... birth is just one day in your child's hopefully long life. If you have to share a bathroom in Tauranga hospital, isn't that a small price to pay for a healthy baby?"

Back at the Mount, first-time mum Karen Clarkson is resolute on her choice to give birth in the new birthing centre.

Her two-page birthing plan does not consider a transfer to hospital.

"My body will do what it is meant to do. I don't think about what ifs, because I don't want to bring those doubts into the birth. I am not naive."