Special delivery

His duality extends into the way he came into the world as well, an experimental mix of the sterile, technology-driven health care system and the personal, hands-on world of midwifery. Our birth system was nontraditional even by nontraditional standards — officially, it doesn’t even exist. It’s called tandem care childbirth, and it was developed by Lansing-area obstetrician Dr. Nancy Herta. It’s a little-known alternative for local mothers who want to attempt a homebirth with a midwife but still want to have access to the latest medical developments.

“I invented the term tandem care, but it’s not a new idea,” Herta said. “It takes the place of the European model, (which is) no-intervention midwife-driven birth centers attached to hospitals. I don’t know of anyone else doing this in the area, but it may be going on behind the scenes in (other) communities.”

Gaëlle (pronounced “Gah-ell”) calls it the best of both worlds, but we chose it because it felt like the ideal arrangement stemming from what we perceived as a lack of local options.

‘HOMEBIRTH IS GOING TO HAPPEN’

Herta is an assistant professor at MSU Women’s HealthCare, inside the Michigan State University College of Human Medicine. She’s also associate residency director at Sparrow Hospital’s OB/GYN residency program, where she’s been for 12 years. And she’s worked with local midwives to provide tandem care assistance since 2003, filling what she sees as a vital niche.

“Homebirth is going to happen,” she said. “My goal in my work with midwives is to make it safe and produce outcomes everyone wants. But my system is still not the best. I can’t go into homes. I can’t even give direct advice to midwives — I have to phrase it as hypothetical situations.”

Herta, 50, oversees about 25 tandem care patients annually, which this year included us. She performs regular check-ups on women in her office in accordance with their insurance plans — running all tests, taking all ultrasounds, doing all screenings — but in preparation for homebirth that will be overseen by either a certified nurse midwife (CNM, a certification awarded by the state and requires a nursing degree) or a certified professional midwife (CPM, a designation earned from a midwife association and doesn´t have state sanction). Herta maintains recommendation-free communication with the midwife; each keeps the other apprised of any issues or possible complications that may mark a woman as high-risk.

“But a high-risk pregnancy does not necessarily equal a high-risk delivery — that’s where we get lost,” Herta said. “Every situation is different. I’m an obstetrician so I can say this: Obstetricians think they need to be there — they don’t understand that women are made to give birth. I think mothers care more about their own babies than (doctors) do, and I think homebirthers tend to educate themselves even more, so they’re more aware of potential problems.”

Two years after an “accidental homebirth” in 2001 (her ride didn’t show up in time, so she delivered her baby in her own bathroom), Herta had her next child at the Greenhouse Birth Center, a freestanding, midwife-run clinic in Okemos that has since closed. This was her introduction to the local midwifery scene, and the start of an uneasy alliance that’s put her in the middle of what she calls “bad blood.”

“It’s a hard road to walk,” Herta said. “I’ve heard colleagues say very negative things (about midwifery). The medical system looks down on it, and then midwives feel they can’t trust physicians. It’s a vicious cycle.”

CALL THE MIDWIFE

Childbirth is far from an exact science. Last month, the Centers for Disease Control reported that the U.S. ranks 27th out of the 34 major developed countries in infant mortality, with 6.1 infant deaths for every 1,000 live births. That’s down from the previous year, but still nearly double the numbers for France, Italy and Spain. Meanwhile, homebirths in the U.S. rose slightly: In 2012, the most recent year for which numbers are available, 1.4 percent of American births took place outside the hospital, up from 1.3 percent the year before.

McLaren Greater Lansing Hospital has a CNM on staff and rooms with whirlpools, but the full European model doesn’t exist in Lansing. Providence Hospital in Southfield has an Alternative Birth Care Unit that comes close, as does St. Joseph Mercy Ann Arbor’s Family Birth Center. In Grand Rapids, the Cedar Tree Birth and Wellness is a freestanding alternative birth center. But in Lansing we have no such alternatives.

Gaëlle and I were fully covered to have a hospital birth through her insurance, but our first visit with her network obstetrician was strangely impersonal — it felt as if we were taking out a mortgage. We sat in a tiny office across the desk from a nurse practitioner who gave us a glossy information packet. She proceeded to read aloud every single word and we followed along. When we asked who our doctor would be, she directed us to the page with 10 thumbnail-sized headshots and said it would be one of these. There would be no way to know who would be on call come delivery day, and it was highly unlikely we’d have time to talk to all of them before the birth.

But we had a birth plan — unless it was an absolute emergency, she wanted no drugs, no C-section and no episiotomy, a surgical procedure to widen the birth canal. If we didn’t know what doctor we were going to get, how could we know where each doctor drew the line at “absolute emergency”?

So that night we called our friend Audra Post to ask some questions. She’s a former Greenhouse CPM who is the sole proprietor of Harmonious World Midwifery, a private midwifery practice. She was also one of the midwives named in the 2012 lawsuit against Greenhouse filed by Sara and Jarad Snyder following the death of their son, Magnus, in a breech delivery attempt.

When Gaëlle and I said we were concerned about doing a homebirth completely outside the hospital system — insurance was, after all, paying for it, so why not utilize it for everything we could — Post told us about tandem care and put us in contact with Herta.

“I think homebirth is the safest option for low-risk women,” Post said. “But what is best for family is the safest way to go, and a medically supported (birth) might be the safest way. There is no one answer for everybody.”

Fortunately Herta was in our network, so we switched to her office. Post’s services are not covered, however — we had to pay about $3,000 for her part of the tandem care. Gaëlle started having monthly meetings with Post for two- to three-hour chat sessions in our living room. She didn’t just feel at home — she was at home

“This was my favorite part of tandem care — the time I got to spend with Audra,” Gaëlle says. “She put me in touch with a prenatal yoga studio, she loaned me books, she answered all my questions. It was very touching. Back in France, my sister didn’t even have this level of intimacy with her midwife.”

But Sara Snyder said it was exactly that intimacy that led her to put a high level of trust in the Greenhouse midwives that she feels was betrayed.

MAGNUS’ STORY

Snyder found a similar distaste for the impersonal nature of the hospital system (“We felt like cattle”) that we did when she was preparing for her first birth. She sought out the Greenhouse midwives for birth classes in preparation for a hospital childbirth.

“We developed friendships, built a trust with the birth center,” Snyder said. “I was all about the natural experience. We spent an hour together at each (prenatal) visit. We had maybe 10 minutes at the hospital.” After her son, Jonah, was born in a hospital with the help of a Greenhouse doula (mother assistant), Snyder wanted to try for a delivery at the birth center for her second child. Late in her pregnancy, Snyder found out her son was in the breech position, but she and her husband made the decision to proceed with a nonintervention vaginal delivery. Snyder said the midwives convinced her it would be safe, and she did not seek a second opinion.

However, the birth was a disaster: Her son, Magnus, suffered complications that caused brain damage and other injuries. He died 13 days later.

“I felt like I was as prepared as I could be,” she said. “Looking back, though, I feel ignorant. I didn’t realize how high risk I was.”

The Snyders sued their midwife for wrongful death, and Greenhouse closed in the wake of the lawsuit. In May, the couple was awarded a $5 million judgment, but Snyder said she doesn´t expect to receive payment; the midwife filed for bankruptcy after the suit was filed. Snyder has since started a group called Safer Midwifery for Michigan that urges hospitals to hire CNMs and develop natural birth centers in their maternity departments.

“You really have to know how midwifery is different here than in Europe,” Snyder said. “The education is vastly different. They’re not attached to a hospital. It’s not an integrated model of care. I think there’s a solution that allows you to incorporate the best of all the pieces in place so that it wouldn’t be any different than having a homebirth and going to a hospital.”

In our case, Herta detected that Gaëlle had a placenta previa in the early part of her pregnancy, which meant her placenta was partially obstructing her cervix. If it didn’t move, this created a very real possibility for a hemorrhage in the event of a vaginal birth. Herta monitored the placenta as it moved throughout Sagan’s development, and at 30 weeks it was sufficiently out of the way to not cause alarm. By week 37, he was in the right position and we were cleared for homebirth.

FULL CONTROL

We expected some blowback from our friends and family, several of whom already dismiss us as being hippy-dippy. What I wasn’t prepared for was open hostility.

“What’s wrong with you, don’t you want your baby to live?” snapped one of my relatives last spring after we told him our plan. His reaction felt like a slap in the face, but I recognized similar sentiments in the raised eyebrows and sudden silences of others. Eventually, I stopped telling people.

But Gaëlle and I hadn’t made this decision lightly, and we weren’t doing it to live dangerously or to be contrarian, as some of our family had suggested. Parenthood, to us, starts with pregnancy. We had done our research — we knew what we were getting into. Having a baby was the single most important thing that either of us had ever planned for and we wanted to be able to call all the shots.

“I knew that anything could still happen, but I wanted full control to decide the fate of my son,” Gaëlle says. “Because of hospitals, people forget they’re an active part of the process. I didn’t want to get lost in that process.”

Dr. Maude “Molly” Guerin is a Lansing obstetrician who says she’s delivered over 5,000 babies.

“It’s dumb luck (that I’ve never lost a baby), but it happens to even good doctors,” Guerin said. “I see how fast bad things can happen. When it does, it can be brutally awful.”

She said CNMs are “strongly supported” by the medical community — she used them for two of her own three birth experiences — but she thinks hospitals are the best place for childbirth.

“I’d say that about one or two deliveries out of 100 require urgent medical intervention,” she said. “We do 100 deliveries a month, so for us it’s (a regular) occurrence. We love to stand back and let (childbirth) happen naturally, but if you’re that one or two in 100, you want to be in a place where you have everything you need at your fingertips.

“I’m very supportive of women giving birth where they’re most comfortable as long as they’ve educated themselves. But saying birth in a (freestanding) birth clinic or at home is as safe or safer than in a hospital? That’s not true.”

She did agree with Herta, however, that the European model of birth centers attached to hospitals is the ideal system. However, neither sees it happening within the decade.

“The Greenhouse closing had a huge (chilling) effect on the issue,” Herta said. “I think we’re a long way from that.”

WHAT TO EXPECT

Gaëlle started having contractions on a Tuesday afternoon, and after 30 hours of squatting on a yoga ball, stretching in the inflatable hot tub and walking around the block, the contractions weren’t getting any closer or more intense. Audra noticed the baby wasn’t coming down straight, and after trying a few things, nothing helped. Gaëlle’s body was getting weak and she wasn’t even to the pushing stage yet. Around 3 a.m. Thursday, Audra suggested we should start considering going to the hospital.

Because she had gone to all her checkups, Gaëlle was already in the Sparrow computer system. And because Audra had spent the last two days with us monitoring every contraction, taking regular heartbeats, keeping track of every change, the doctors who took over had a full record of the labor. We consented to an epidural that allowed the doctor to go in and line him up properly, and once Gaëlle was recharged she started pushing.

But hang in there, dear reader, things are about to get a little unavoidably grody. When the water broke, the doctors saw there was meconium in the fluid: Basically, our son had pooped while he was still inside, which could lead to a whole set of respiratory problems if it was aspirated. Twice during the pushing process our son’s heart rate began to dip dangerously low, but it quickly recovered. When he came out he was whisked over to an open-air incubator where a pediatrician roughly sucked out all the meconium from his nose and mouth and blew oxygen into his little face. He wasn’t breathing, and time stretched out; it felt like an hour, but it was probably only about 30 seconds before he started to cry.

At first, what had felt like weakness — going to the hospital, getting drugs, using high-tech equipment — was everything that contributed to Sagan surviving. Tandem care had saved my son.

“Sparrow has worked very well with me over the last few years for midwifery transfers,” Post said. “The ideal system would be a team of doctors who wanted to work together to support midwifery. I have sent out requests, but besides Dr. Herta, I’ve never heard any response.”

´IN A HUNDRED BILLION GALAXIES’

Our story has a happy ending. Sagan was born on time and healthy, and his physical and intellectual developments have been right on track. But I accept that his successful birth amounts to a series of lucky accidents. Which isn’t to disparage the team of knowledgeable, skilled people who helped us at every point along the way. Quite the opposite — they were part of that good fortune.

As I held my son for the first time, I thought about all of the improbabilities that led to him being there in my arms. Not just the last nine months, but all of history. My wife’s ancestors, all of mine, meeting each other over the millennia and creating our two lineages, all of which would culminate in a random meeting at a house party in downtown Lansing three years ago. And now, after a scary 36-hour labor that put our experimental plan to its full test, here was this perfect little boy.

“Every one of us is, in the cosmic perspective, precious,” said Carl Sagan, my son’s namesake. “In a hundred billion galaxies, you will not find another.”

And in a hundred billion realities, things could have gone as many different ways. I’m happy with the way this one went, but it would have been better if we’d had more choices. Until then, tandem care is the way for us.

This story is dedicated to the memory of Magnus and to the memory of Arya, our friend’s daughter who died last month after what should have been a routine hospital birth. You will always be loved and you will always be missed.