The three dozen parents-to-be at the George Washington University Medical Faculty Associates building on a recent Tuesday night fill the lobby’s waiting room seats and overflow onto office chairs that have been dragged into the room for the occasion. By all appearances, it’s a high-end D.C. crowd: Suits and spectacles, ages that range from the middle years of childbearing to the late ones. There’s copious note-taking about birth outcomes, labor options, and this particular practice’s set of rules—No sugar! No processed foods! Daily exercise!—for natural childbirth.
Welcome to “Meet the Midwives” night at one of Washington’s newest, most talked-about labor-and-delivery operations, a place where the admissions process can be as coveted as that of the most pedagogically up-to-date preschool.
Midwifery once evoked images of giving birth at an organic farm, but GW’s Wisdom Midwifery works in a hospital setting—low-tech and high-touch, sure, but just steps away from cutting-edge medical expertise. In an age that fetishizes slow food and iPhones, it’s a potent combination.
In its 16 months at GW, the practice has grown from one nurse-midwife delivering 10 babies a month to four of them delivering 30, the maximum their time-intensive model can handle. There are plans to hire a fifth midwife. Meanwhile, there’s a waiting list out to July, and most months already have the maximum of 10 people on the list. Some women say they call Wisdom the day they find out they’re pregnant.
Tonight, the pitch is simple: Instead of being hooked to an IV in a hospital bed, Wisdom’s moms can labor in an aqua tub, take warm showers, receive massages, and move around into different birth-facilitating positions (one of the midwives pops into a squat to demonstrate). Rather than discussing epidurals, there’s talk of raising natural oxytocin levels through yogic heart-opening. And there’s a promise that the midwife—“birth provider,” in 2011 terminology—will be on hand through it all, rather than simply arriving for the big finale.
“We’re in the business of giving women what they want,” says Whitney Pinger, GW’s director of midwifery services. “They don’t want to fight to get what they want. We are their birth plan.”
Among a network of holistic-minded mamas who chat in Washington’s yoga studios and childbirth education classes, Pinger doesn’t even need to use her last name. In online maternal message boards, her work gets described in capital letters. “I absolutely LOVE her. Whitney is amazing in every way,” gushed a member of DC Urban Moms in a recent comment. The 51-year-old certified nurse midwife is a veteran of the local scene. After running programs at Washington Hospital Center and Georgetown University Hospital, she came to GW last year, arriving like the LeBron of the up-market natural childbirth community.
You’d imagine Pinger’s practice appeals to those expecting mothers who admire her collaboration of crunchy and clinical. But at the Foggy Bottom medical center, she’s also demonstrated her standing among hospital administrators. They’ve come to see her as a practitioner who brings the sort of devoted following that allows a new practice to grow with little formal advertising.
Pinger is thus a pretty good example of how midwifery has become a significant business. She sensed the demand after she started Wisdom as a pilot project at Washington Hospital Center. It grew beyond what the facility could handle, so she looked for another home. GW bought in. (Since the move, the practice has officially been known as Midwifery Services at George Washington University Hospital.) In addition to the medical and teaching benefits, the logic went, a practice like Pinger’s also promised to bring new patients into the GW system—patients that are educated, privately insured, and likely to be making their family’s medical decisions for the next 18 or so years. That’s the sort of stuff that can make a calculator-wielding hospital administrator go all touchy-feely.
Pinger’s argument at the open house is simpler: “We have amazing outcomes,” she tells the expecting couples. “Among the best in the country.” About 95 percent of her clients deliver vaginally, 80 percent without any intervention. Wisdom’s cesarean section rate is approximately 5 percent, vastly lower than the nation’s rate of 33 percent.
It’s not just Pinger. Midwives across the area say they’re having a moment. Though the percentage of births they handle remains small—nationally, they do just 8 percent of the country’s annual 4 million births—midwives beyond Pinger’s cadre report a new interest in their service. Pinger’s former employer, Washington Hospital Center, didn’t have room to accommodate Wisdom last year, but has brought on two full-time and three part-time midwives since Pinger left; its new service can accommodate 30 women a month. “Midwifery has gone mainstream,” says Ursula Sabia Sukinik, a local doula, midwife assistant, and childbirth educator. (Full disclosure: I took a childbirth class with Sukinik earlier this year.)
In fact, demand right now seems to outpace supply. At the “Meet the Midwives” session, a woman asks about her chances of getting off the wait list. Her due date is March 30. But March, a popular time for births, has been full for months. “I’ll call myself April,” she says. It’s hard to tell if she’s joking.
Earlier in her career, Pinger used to wear a pin that read “Just Say No” and depicted a doctor standing over a supine woman in labor. It was her protest against the increasing technologization of birth. If that history makes her an unlikely choice for a chain-owned hospital, embracing her typical patients is a no-brainer.
In addition to promising to adhere to a set of diet and exercise guidelines that would please the most traditionalist doctor, the women in Pinger’s practice must be in excellent health and agree to hire a doula, a birth assistant whose services can run from $800 to $1,200 dollars in the Washington area.
It’s no surprise, then, that the group is largely composed of the highly educated and the professionally employed. Pinger says she sees lawyers, doctors, and even OB-GYNs. They are athletic women who have pushed their bodies before and will apply the same strength and endurance to preparing for labor.
To the women drawn to Wisdom, power is important. “They know what they want and know what their body can do,” Pinger says. “They want to be empowered, to be powerful.”
Tracey Mills, communications manager for George Washington Hospital, offers an identical characterization. “They know what they want and know how to find it,” she says. “They seem to want to embrace the whole experience.”
Cameron Rupprecht, a holistic health coach, is delivering with Wisdom in March. A dedicated CrossFit athlete, she liked Pinger’s emphasis on exercising during pregnancy. She also liked the idea of letting her body do what it was designed to do. “We’ve done this forever. We can do it. Why not try?” Rupprecht says. She says some people don’t understand why she’d want to experience pain. “I want to be present for the birth, fully feeling,” she says.
But for all the emphasis on natural, Rupprecht says she knew home birth wasn’t for her after seeing the Jennifer Lopez movie The Back Up Plan, which included a scene mocking home-birthers with a water tub and someone playing bongos in the background. Rupprecht also liked the idea of being at a hospital. “I can do the natural thing, but if something goes wrong, you’re right there,” she says.
Scholars who study birth say it’s hard to tell if more women are going the natural route. The overwhelming majority of births happen in hospitals, where epidurals and interventions are the norm. But Eugene Declercq, the assistant dean of doctoral education of Boston University’s School of Public Health, says anecdotal evidence indicates pockets of women interested in low-intervention births.
One pocket appears to be in the D.C. area. Pinger’s patients, who are typically over 30, represent the fact that educated women typically bear children later. This population, she says, has given more thought to the kind of birth experience they want.
Dr. John Larsen Jr., chairman of the obstetrics and gynecology department at GW, brought Pinger into his hospital. He says her hiring was partially a response to a demand he’d seen in the market. “Many women in Washington, D.C. are very interested in having a completely normal birth without medication, and vaginal delivery,” Larsen says.
Susanna Montezemolo, a vice president of legislative affairs for a non-profit organization, says she became interested in natural childbirth several years ago via prenatal yoga training (she’s also a yoga teacher). As a 36-year-old first time mother, she wanted the access to immediate medical backup that a home birth would not provide. Montezemolo did her homework. “Wisdom gave the best probability of having a natural childbirth,” she says. The day she found out she was pregnant, she emailed Pinger. “I got the positive test at 6 a.m.. At 6:20, I emailed her to get a spot.”
Montezemolo’s labor this fall was not an easy affair. She arrived at the hospital almost ready to deliver her baby, and describes it the most painful thing she had experienced. But, she has no regrets. “It was really such an amazing, empowering experience.”
Our definitions of “amazing” and “empowering,” of course, change with the times. And from diets to drugs, ours is a moment of a certain suspicion of the expert in the white coat. In the maternity industry, that means a backlash against practices that aren’t medically necessary and don’t benefit both mom and baby. The number of home births, while still tiny, has been rising. That’s true especially among educated white women, according to a 2011 Centers for Disease Control report. Talk show host Ricki Lake has become a front person for this trend with her documentary The Business of Being Born and her new book Your Best Birth. A glance at the latter’s cover is telling: Rather than depicting the kind of shaggy 1970s types whose images adorned prior natural-birth guides, the tome is illustrated with a cover shot of stylish, beautiful, and expensively made-up expectant mothers. In August, a prominent doctor published an editorial in the Obstetrics and Gynecology medical journal about how to stop the “relentless rise” in cesarean deliveries.
That’s not just a concern for the natural-process obsessive. The prospect that cesareans could reach 50 percent of births also sparks cost concerns by public-health types. Wisdom Midwifery boasts a cesarean rate of approximately 5 percent—and takes women who’ve previously had c-sections and want a vaginal birth, a group some practitioners deem too risky.
Regan Nelson, who delivered her son at GW last week, believes her birth would have gone much differently if she hadn’t delivered with the midwives. After her water broke without going into labor, they gave her time to try delivering her son naturally. She went to the hospital 24 hours later, where she spent the night before receiving an oral medication to kickstart labor. Twelve hours after that, she gave birth to her son—a “very primal, sacred moment.”
“I knew I was at the beginning of what in a traditional hospital setting could very easily lead me down the slope to a cesarean section,” says Nelson, so pleased with her experience that she offered to be interviewed the next day. “For ten months you work so hard toward a natural birth. It’s so great it was able to happen to me.”
Besides health trends, one less quantifiable factor also helps explain Pinger’s lengthy waiting lists: It’s human nature to want something not everyone can have. With a small number of slots, Wisdom has “exclusivity cachet,” Larsen says. He’s seen patients who wouldn’t be candidates try to re-describe their health history, making themselves sound healthier than they are. He’s seen influence peddling, women calling the executive offices of the university to ask if there are ways they can jump the waiting list—and never knows what he’ll hear when the phone rings.
“Tell a lawyer, lobbyist, or top-level bureaucrat she can’t have something and suddenly she’s hungry for it,” he said.
GW wasn’t looking to add midwives when Pinger first approached Larsen. Her goal at the time was to simply deliver to doctors and residents a presentation called “Pearls of Midwifery,” highlighting best practices and outcomes. GW hadn’t had midwives in 20 years.
“If she hadn’t walked through the door, it wouldn’t have happened,” Larsen says. “Whitney can sell.”
Pinger does so well beyond the confines of medical establishments. On July 4 of this year, she and other midwives marched in the Palisades parade wearing signs that said “Where’s Your Midwife?” She carried a placard of those same clinical “pearls,” which she says maximize the chance that women will have a natural, normal labor: eating and drinking during labor, allowing labor to start on its own rather than inducing it, and changing positions rather than lying on a bed.
Pinger’s presentation to the GW doctors was postponed by the early 2010 blizzard. As Pinger and Larsen tried to find another date, they began talking. At the time, she was working at Washington Hospital Center. The practice had grown rapidly, and it didn’t have a neat place on the center’s organizational chart. Might GW have the capacity to give it a better home? “Your patients are leaving you to come to me,” she recalls telling him. “Why don’t you bring me there?”
The decision, Pinger wrote in a paper this year, helped “attract an educated insured population of women to [GW] for maternity care and delivery.” This was good for the hospital. Pinger, for her part, loved the idea of training residents, physicians, medical students, and nurses who once looked at her peers with suspicion.
What makes Pinger so dynamic, Larsen says, is a combination of competence, character, and chemistry. Pinger is an expert in natural, normal birth; she continually works to improve her patient outcomes; and she’s got a innate quality that draws people to her. Her expansive personality is the extra element that has made her so attractive to so many pregnant women, he says.
Pinger was born in San Francisco, a fourth-generation Californian; you can still see her West Coast proclivities, even after two decades in Washington. She wears her blonde hair long and sports flowy skirts and silver jewelry. At the open house, she was chewing gum and swiveling her hips, looking younger than her 51 years. She says her energy comes from following the same exercise and diet Wisdom asks of its patients. (That gum, incidentally, was sugar-free.)
Pinger says she was first exposed to the idea of natural birth in a high-school biology class and apprenticed with local midwives. At the University of California-Berkeley, she wavered between medical school and midwifery school until visiting the Frontier Nursing Service in rural Kentucky, one of the country’s first midwifery practices. “I really didn’t like the operating room,” Pinger says. “My tribe was the midwives.”
Pinger got a nursing degree at Yale University, where she also studied midwifery, and practiced in Connecticut while her husband finished his law and business degrees. In 1990, when his parents offered to help them buy a home, they moved to D.C. with their first child. They settled in Cleveland Park and had three more children, all natural births with midwives.
Pinger worked as a midwife at Prince George’s Hospital, then spent ten years at the Washington Free Clinic providing prenatal care for low-income women. In 2000, she went to Georgetown University Hospital to become their director of midwifery. When that practice closed (the hospital says it wanted to focus on high-risk births instead), she went to the Washington Hospital Center.
Nowadays, Pinger says, her vision for maternity care is bigger than GW: She wants to see what has happened there go national. “The model is definitely replicable,” she says. “Doctors, nurses, midwives—we can do it all, high-risk and low-risk women, all together.”
This may be the moment to go forth. Concern of a workforce crisis in obstetrics, combined with a new swell of activism around birth issues, spurred by The Business of Being Born and the book Pushed, present a political climate ripe for collaboration. Those involved in promoting this kind of maternity care say they see an awakening among consumers about what kind of birth they want to have.
“There is more excitement about working on birth issues than there has been in 20 years,” says Declercq.
This excitement spreads for free, which is no mean feat in an age when hospitals must advertise their cardiac-care centers on bus stops. Typically, GW would roll out a marketing campaign with a new division, says Lisa McDonald, head of marketing and business strategy for the hospital. In the case of the midwives, the hospital is holding back because the practice already fills quickly. Besides, the informal advertising makes the formal kind—like a recent cover story in the hospital’s magazine—seem redundant. (GW would prefer we use the hospital-branded “Midwifery at George Washington Medical Faculty,” but the Wisdom name, which came with Pinger from Washington Hospital Center, is how the practice is best known.)
Pleasance Lowengard Siliki says Pinger was “literally the first person I called” upon learning she was pregnant with her second child. Siliki, a yoga studio owner who had a traditional hospital birth with her first child, wanted something different for her second. Even before her son was born in July, she became another voice in Wisdom’s word-of-mouth network. She’s talked up the practice to her yoga students and blogged about it on her studio’s website.
“It’s pretty amazing to be in the hands of such a birthing powerhouse in D.C., and to learn from her,” Siliki wrote. It’s a good bet that sort of devotion and publicity doesn’t attach itself to all of of Washington’s more traditional providers.
High-profile hires notwithstanding, midwifery practices are not a great economic model for hospitals out to maximize short-term profits. All the same, having someone like Pinger on board can help a hospital differentiate itself from competitors and develop long-term loyal customers, says Declercq.
In 2009, the average charge by a hospital for a vaginal delivery without complications (not including anesthesia services, newborn care charge and provider charge) was $9,617, according to information from Childbirth Connection’s “Transforming Maternity Care” project. A vaginal delivery with complications averaged $12,532. A hospital c-section with no complications was $15,799 and with complications, $21,495.
But for GW, the addition of Pinger and the other midwives have brought in additional patients for prenatal care and delivery: Women who may have gone to other practices and delivered at one of the city’s other hospitals.
Wisdom enrolled 200 women for prenatal or gynecological care in its first six months at GW. The hospital’s total number of births has gone up from 1,465 last year to an expected 1,800 this year. In pure numbers, Washington Hospital Center and Sibley Hospital dominate the D.C. birth market, with more than 4,000 and 3,456 births last year, respectively. Pinger’s practice, though, helps win her hospital a very attractive niche.
Pinger, meanwhile, says showing off GW’s status as the home of evidence-based midwifery could yield more benefits to come.
That, of course, could mean fighting more battles. Robbie Davis-Floyd, a medical anthropologist who studies birth, says a midwife would have to be a strong leader and an astute politician to overcome traditional resistance in hospitals, where her research shows midwives tend to get kicked out when doctors feel their business is threatened.
Pinger, though, is able to articulate the scientific and financial benefits of working together. For example, the women coming to GW to have their babies with midwives are increasing patient volume for nurses, the nursery, and other medical departments such as genetics. “The downstream effects are enormous,” she says, using a term associated more with business suites than birthing rooms.
Larsen says the decision not to compete was a deliberate one. “Each of us has lived enough years, seen enough in our years. We’ve seen doctors and midwives compete against each other.” He calls working with Pinger “just one of the happiest developments in my life,” while Pinger tells potential patients that Larsen as a wizard with forceps, an expert hand who can manipulate the tool so skillfully that a woman can have a vaginal birth and the baby can emerge without a mark.
“Everyone at the hospital is on our team,” Pinger tells people at the “Meet the Midwives” event. Without Larsen, GW’s anesthesiologists, and other doctors and nurses, the midwifery practice wouldn’t have the kind of outcomes they do, she says.
Extraordinary effort is needed to make collaborative birthing practices sustainable after the people who have established collaborative relationships move on. “The challenge is to be able to institutionalize it,” Declercq says.
At any rate, it makes sense for a hospital to make sure women’s maternity experience is emotionally positive as well as medically sound. Maternity care is one of the few services in a hospital that is typically joyful. Women make many of a family’s health care decisions, and providing great maternity care is a wise move if a hospital wants to provide them future medical care, says Trish MacEnroe, head of Baby-Friendly USA, an organization that promotes breastfeeding best practices in hospitals. “They have the business of the family for the long haul,” she says.
In the America that worships scientists but suspects science, we are of two minds about childbirth.
One places all importance on the end result. As long as the baby comes out with no complications, how mom experienced the birth is not that important. When I was pregnant, one doctor at the large practice I used compared childbirth to a wedding. That single day is insignificant compared to the marriage, which comprises all the days that come after.
Others see the experience of childbirth itself as transformative. “The process affects the product,” is how Davis-Floyd, the medical anthropologist, puts it. In this view, how a child is born affects the physical and mental health of baby and mother.
For every Ricki Lake who is selling an argument (and book, and film) advising women to demand the kind of birth they want, there is someone like Élisabeth Badinter, the French philosopher, selling a different argument (and book) that slams our fascination with “natural” motherhood—with its drug-free births, long breast-feeding periods, and cloth diapers—as setbacks for equality.
Pinger and other midwives believe the tide is starting to turn in their favor, and that the culture is changing as evidence builds that the their model is the best approach for low-risk women. The D.C. market, which gives women dozens of choices for their maternity care, is full of examples of institutions appealing to desires. Sibley Hospital, a much bigger player than GW, offers a combination spa/childbirth education weekend for parents-to-be: just $1,200 for two nights at the Ritz Carlton in Tysons Corner and four sessions of childbirth education (plus facial or prenatal massage!). Shady Grove Adventist Hospital now offers the area’s first “birth advisor,” who gives personal consultations to mother’s-to-be about what they want. (The hospital’s tagline sums it up well: “Everything Mom Wants, Everything Baby Needs.”)
Pinger’s October “Meet the Midwives” event wound up drawing 100 people and was relocated to the hospital auditorium. That’s quite a feat for a practice that just delivered its 200th baby. “We’re not doing hoochie choochie midwifery craziness,” she says.
That’s what you’d expect Pinger to say, of course. Even as she’s moved into a prominent institutional setting, she remains an advocate. What’s more interesting about our current midwife moment is how her line is echoed by hospital administrators, whose jobs typically involve balancing a professional obligation to focus on healthy outcomes with a fiduciary obligation to cater to the customer. In Pinger’s Washington, losing out on the business of empowered maternity consumers is a bad call on both counts.
“Seeing a midwife is a revolutionary decision for a woman,” says Lorel Patchen, head of midwifery at Washington Hospital Center. “It’s also a revolutionary decision for a hospital.”
And, for that matter, it may also be a non-negotiable choice: “If we don’t create this model, the chance of natural birth moving out of the hospital are very possible,” Pinger says.