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As APD, D-H Merger Nears, Expecting Families Are Left to Consider Their Options for Birth Sites

  • Midwife Katherine Bramhall examines Maeghan Finnigan, of Lebanon, N.H. in Bramhall's office in Lebanon on June 27, 2018. Finnigan plans to deliver her baby at home. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • At her home in Lebanon, N.H. Kayla Harvey reads to her children Grayson, 4, and Gavin, 2, on June 27, 2018. Harvey is due to have a home birth for her third child in August. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Midwife Katherine Bramhall listens to Maeghan Finnigan's baby's heartbeat during an office visit in Lebanon, N.H. on June 27, 2018. Finnigan plans to deliver her baby at home with Bramhall attending her. Lauren Godfrey, Bramhall's summer intern records the heart beat for Finnigan. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Grantham, N.H. resident Katrina Gleich, left speaks with DHMC midwife Karen Schelling while her partner Emmanuel Hudon helps to settle their son, Ludwig “Ludo” Pierre Hudon, while pediatrics resident Emily McCarty examines the newborn in Lebanon, N.H., on June 27, 2018. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Kayla Harvey starts dinner at her home in Lebanon, N.H. on June 27, 2018. Her son Gavin, 2, often helps her in the kitchen. Harvey is due to have her third child in August with the help of a midwife at her home. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Maeghan Finnigan, of Lebanon, N.H., discusses her pregnancy with midwife Katherine Bramhall, center, and Bramhall's summer intern Lauren Godfrey during an office visit in Lebanon, N.H., on June 27, 2018. Finnigan plans to deliver her baby at home. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • During an interview in Lebanon, N.H. at APD midwife Laurie Foster, left, listens to colleague Suzanne Shipman an obstetrician on June 22, 2018. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Kayla Harvey sits down for dinner with her sons Grayson, 4, Gavin,2, and her husband Garret at their home in Lebanon, N.H., on June 27, 2018. Harvey is due to have her third child in August. The family is planning a home birth. (Valley News - Jennifer Hauck) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.



Valley News Staff Writer
Saturday, July 07, 2018

Lebanon — Katherine Bramhall didn’t know Alice Peck Day Memorial Hospital was closing its birthing center and merging obstetrical services with the nearby Dartmouth-Hitchcock Medical Center later this month “until my phone started blowing up,” the Barre, Vt.-based home birth midwife said in a recent phone interview.

The closing of APD’s birthing center is of particular concern to Bramhall, 58, not just because she’s a midwife but also because of why she decided to become a midwife back in the 1990s: She wanted women to “have choices about their (lives) and their bodies.”

The narrowing of choices for pregnant women of the Upper Valley that comes with the closing of APD’s birthing center is actually the continuation of a well-established trend among smaller hospitals in the region. In recent years, Valley Regional Hospital in Claremont, New London Hospital and Cottage Hospital in Woodsville also have closed their birthing units. As of mid-July, Springfield (Vt.) Hospital and Gifford Medical Center in Randolph, both federally qualified medical centers, will be the only Upper Valley hospitals other than DHMC that still have birthing units.

“There’s a huge radius now where there is now one choice,” Bramhall said.

But Bramhall hopes to help Upper Valley women who are seeking alternatives in anticipation of the closing of APD’s birthing center. Demand is such that she opened a new office on Bank Street on May 1 in Lebanon.

Under the merger the hospitals announced in February — which comes following APD’s formal affiliation with D-H in 2016 — midwives and obstetricians will continue to offer prenatal and postnatal care on APD’s campus. But, beginning on July 16, patients who receive prenatal care at APD will give birth at DHMC. Hospital officials attribute the decision to close APD’s birthing center to difficulties in recruiting providers and maintaining consistent staffing in the face of low birth numbers

As part of the merger, three APD midwives and one obstetrician-gynecologist will become D-H employees. In that role, they will provide outpatient care at both APD and DHMC and attend deliveries at DHMC. Three nurses also are making the move from APD’s six-bed birthing unit — where 248 babies were born last year — to DHMC, which has a 24-bed birthing unit where nearly 1,200 babies were born last fiscal year.

DHMC will have 13 midwives after the integration, which makes it less certain that a woman in labor will know the person attending the birth.

Though the options have narrowed, some parents such as Lebanon resident Maeghan Finnigan, a former APD patient, have still sought them out in reaction to APD’s birthing center closing. They aim to find a comfortable place and a homelike atmosphere, as well as to guarantee that they will recognize the face of the person attending the delivery.

“I had my first two children at APD with the midwives in the birthing center and had wonderful experiences,” Finnigan said in a phone interview. Her daughter, Frankie Webster, is now 3½ years old, and her son, Finnigan Webster, is 2.

Finnigan, who is expecting her third child in August, said “even though we could continue care at APD, there was no guarantee that we would know anyone at our delivery. ... It felt really (bad) not having a choice.”

Finnigan and her husband, Luke Webster, decided — a couple of weeks after the February merger announcement — not to deliver at DHMC. Instead, Finnigan contacted Bramhall, who had attended a delivery of one of Finnigan’s friends. Though Finnigan said she thinks she would receive good care at DHMC, it’s not the experience she’s looking for and, based on her previous births, hers is not a high-risk pregnancy and shouldn’t require a lot of medical intervention.

Still, it wasn’t an easy choice to make.

“I had such a great relationship with the midwives at APD that leaving them was hard,” Finnigan said. “They know me. They know my babies. ... That was a hard decision. ... Ultimately it just came to remembering what it felt like to be in labor.”

It’s a time when it’s important to be “surrounded by familiar faces,” Finnigan said.

Though Finnigan’s insurance will cover only a small portion of the cost of the home birth, Finnigan said, “I think ultimately having a good birthing experience sort of outweighed the cost.”

‘Every Parent WantsA Healthy Baby’

Like the women she’s cared for, APD midwife Laurie Foster will miss the relationships she’s been able to develop through the smaller APD practice. She’ll also miss some of the nurses who will not be making the move to DHMC, she said in an interview at APD’s new Multi-Specialty Clinic. Of the 12 nurses employed at APD’s birthing center, three will go to DHMC, six have found positions at other health facilities in the Upper Valley and three will be leaving the area, APD spokesman Peter Glenshaw said in an email last week.

But there are things Foster is looking forward to about the change, including having more colleagues to work with, bounce ideas off of and share the work. She also seems to be excited about the prospect of teaching residents, who attend births at DHMC along with midwives and two nurses — one for mom and one for baby.

The “fun thing” about teaching the residents is that they will attend the entire birth, not arrive just in time to catch the baby. She’ll have the chance to show them “what you can learn by just being present — which is a lot.”

Foster and her APD colleagues, who have felt welcomed by their soon-to-be new D-H colleagues, plan to bring their understanding of the different needs and wants of each mother and family with them to DHMC.

“I think it’s important to really remember that maternity care is not one-size-fits-all,” Foster said. “Every parent wants a healthy baby. That’s everyone’s bottom line. They differ in how they feel that they’re going to achieve that.”

Now that the decision has been made to merge the services, Miriam (Mickey) Cordell, who directs D-H’s Division of Nurse Midwives and Nurse Practitioners, said she and other providers are focused on easing the transition for women and their families. To that end, there have been two tours of the newly renovated birthing unit at DHMC specifically for APD patients and families.

Cordell and her team are “really trying to make sure that we are doing right by the women of the Upper Valley,” she said in a June phone interview. They “know that this integration is a difficult step.”

She acknowledged that some differences between APD and DHMC are undeniable.

“It is a different feel,” she said. “It’s a longer walk from the parking lot.”

However, she said, the birthing experience is not affected by such differences.

And while Cordell understands that one of the reasons some women chose APD was for its small group of midwives, she said that all of the midwives at DHMC share the same philosophy.

“We work really hard to make sure that women are comfortable with their care,” Cordell said in a recent phone interview. The “goal is to provide them with the choices they want.”

Cordell said DHMC midwives, like APD midwives, provide women in labor with a range of pain-management techniques, including spa therapy and encouraging women to walk around. There is a tub that women can use to ease labor pains.

In part because they don’t know who will be working at the time of a birth, Cordell said, DHMC midwives and patients spend a great deal of time developing a birth plan and writing down what type of care a patient wants in terms of pain medication and other interventions.

Though some women caught up in this transition may fear that being a patient at DHMC might make medical interventions — such as C-sections — more likely, Cordell said that is not the case.

“Because it’s available doesn’t mean we jump to a more medical birth,” Cordell said.

‘Our Decision’

First-time parents Katrina Gleich and Emmanuel Hudon, of Grantham, chose to work with DHMC’s midwife group because they wanted a birth that was as low-intervention as possible.

“We wanted this to be treated like a natural process,” Gleich said in a late June interview in a room at the birthing pavilion. “I didn’t want to be treated like a patient going through a medical procedure. Women have literally done this since the dawn of time.”

Though their son Ludwig “Ludo” Pierre Hudon was born via C-section on the evening of June 25, Gleich and Hudon felt that their wishes were respected throughout the process, and they did recognize at least some of the faces at the delivery.

Ludo was a week late by the time Gleich went into labor on the morning of June 24. After her water broke at about 9 p.m., things began to speed up, she said.

“Everything seemed to be going the way that we wanted it to,” she said.

But when, 12 hours later, Ludo hadn’t moved, “we had to start talking about other alternatives,” Gleich said, tearfully.

The choices Cordell presented included an epidural and a C-section, but she also said Gleich could keep trying to move the baby on her own. Then, she left and gave Gleich, Hudon and their doula, Tia Parr, about four hours. A doula provides non-medical support to a mother and her partner during and sometimes after delivery.

When Cordell returned, she saw Gleich working through a contraction and stepped right up to help.

“That was the moment I understood that she was truly on my team,” Gleich said.

But by 2:30 p.m. on June 25, Ludo’s heart rate started to drop.

“He was starting to go into distress,” Gleich said. “We did have to start pursuing options to make sure that we were keeping him safe.”

Gleich tried an epidural, but Ludo still wasn’t moving to the exit. She and Hudon looked at each other and within seconds had made the decision to move forward with a C-section.

“The team here made sure I left nothing on the table,” she said. “It was so clear that was the only path left. I couldn’t be more grateful that they let me take that journey.”

The C-section wasn’t scary, Hudon said, because “it was our decision.”

Choosing Home

So far, demand is strong for Bramhall’s home-based midwifery services, which include prenatal and postpartum care, as well as assistance with the delivery.

With eight new Upper Valley patients since May, she said, “I’m busier in Lebanon right now than I am in Barre.”

Bramhall, with an assistant, can reasonably attend three to four births per month, she said. So taking on eight new patients is “a little bit insane,” even though they’re not all due at the same time, she said.

Fortunately for Lebanon resident Kayla Harvey, 29, she already had developed a relationship with Bramhall, who served as a doula during the birth of her second son. She has two boys: Grayson, 4, and Gavin, 2.

“We’ve got history,” Harvey said.

That history helped Harvey to make plans in the wake of APD’s February announcement, which came when she was well into her third pregnancy. She is due in August.

“It was a pretty big shock to have to kind of change my mind frame and figure out what I was going to do from there,” Harvey said in a phone interview. “ ... For those of us that were farther along ... it felt really abrupt.”

Like Finnigan, Harvey’s biggest reason for opting not to go to DHMC was that she might not know the midwife attending the delivery.

“I wanted to know who would be there when I would be there,” she said.

Though Harvey has had to adjust her expectations, she is now feeling almost prepared for the home birth.

“She has to be one of the — if not the — nicest, most amazing women that I’ve ever met,” Harvey said of Bramhall. “Her voice is very soothing. She’s very kind and loving.”

There are some circumstances in which a woman in labor trying for a home birth might need to be transferred to DHMC, Bramhall said. For example, if a woman is tired and needs some pain medication or, in more dire circumstances, starts to hemorrhage.

DHMC makes such transitions happen “seamlessly,” Bramhall said.

“The important thing, probably the most important thing about my care for me, is that I have unbelievable relationships with providers in facilities when I need help,” she said. “ ... It means I can relax and know that I’m not alone.”

Concord Birthing Center

Home birth isn’t the only other option for former APD patients seeking a birthing experience outside of a tertiary care medical center in the Upper Valley. At least one woman is choosing to deliver at Concord Birthing Center.

New London resident Cara Leone, 31, is due to deliver her second child in January. Her son, Connor Leone-Butler, who was born at APD in 2014, will be 4 years old in September.

“It was fabulous,” she said of her experience at APD. “I kind of envisioned that we would go back there.”

Though she said she knows many people who love DHMC, she finds it “very impersonal” and worries that because it is equipped to handle complicated medical problems, that will make it more likely that such a problem will develop.

“I just feel like that’s inviting more stress that I don’t need,” she said.

She also pointed to the possibility that if she delivered at DHMC, she might not know the midwife who would attend the birth.

“Going in and not knowing what you’re going to get, that in and of itself causes me anxiety,” she said. “ ... That makes it more likely I’m going to have some complication or some kind of negative experience.”

The Concord Birthing Center, which she said she found through the recommendation of an APD midwife, is “very homey,” she said. It has two midwives and another in training, two birthing rooms and is a seven-minute trip from Concord Hospital, in case of emergency.

It takes about 10 more minutes for her to get from New London to Concord than to Lebanon, she said.

The birthing center can’t do everything. For example, if she goes into labor before 37 weeks, she will need to deliver elsewhere, she said. But it won’t be New London Hospital because that obstetrics department closed several years ago.

“There’s just not that many options,” she said.

Federally QualifiedHealth Centers

At least one former APD patient is choosing to deliver her second child at Gifford Medical Center in Randolph. The 34-year-old Sharon resident has a 20-month-old son and is pregnant with her second child. She asked not be identified because she does not want her decisions about birth to affect her work.

She choose Gifford, which has five beds and a sixth rollover bed in its birthing center, because of its similarities to APD. She said she likes that it’s a smaller hospital and that the midwives and obstetricians “cater very well to low intervention births.”

She also noted that Gifford remodeled its birthing center in 2016. New features include a large tub room for those choosing hydrotherapy to manage pain during labor or for water births, and a fully equipped modern nursery for infants needing extra care, according to Gifford’s website.

Gifford, which had 180 births in 2017, has seen only a few cases of patients transferring there because of the impending closing of APD’s birthing center, Gifford spokeswoman Maryellen Apelquist said in an email.

Springfield (Vt.) Medical Care Systems, which operates a childbirth center at Springfield Hospital that had about 120 births last year, has seen an increase of 12 to 20 families seeking more information regarding obstetrical and gynecological services since APD announced it would close its birthing center, CEO Tim Ford said in a June email.

Hoping for an Early Baby

Enfield resident Ashley Cole-Henry, 29, was into the second trimester of her pregnancy when APD announced it would close its birthing center.

“It was really frustrating that I was about four months pregnant and they weren’t keeping it open for their current patients,” Cole-Henry said in an exchange of messages in June.

Now, as both the date of the birthing center’s closing and Cole-Henry’s due date near, it is a bit of a race. Cole-Henry is due on July 26, less than two weeks after APD’s birthing center will close its doors.

“Honestly, I’m hoping my baby is two weeks early so I can deliver at APD and have the same experience that I had with my first child,” Cole-Henry said.

She gave birth to her daughter, Alexandra, at APD nearly two years ago.

“I loved that it was the same midwife I’d met with several times and there wasn’t a lot of people going in and out,” she said. “... It’s nice to have the birthing center at APD be so close to the outside so you can feel like it’s not a hospital.”

She has gone on a tour of DHMC.

“Although the facility is mostly the same (as APD), it is still different,” she said, citing parking and the number of people who attend the birth.

If the baby doesn’t come early, Cole-Henry is resigned to delivering her baby at DHMC.

“We don’t have anything huge against D-H,” she said. “We go there when we need to, but we’d prefer the quieter environment and easier parking situation.”

Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.

Correction

Alice Peck Day Memorial Hospital handled 248 births in 2017. An earlier version of this story and stories in February reported a lower number that had been provided by hospital officials when they announced their decision to close the birthing center.