My introduction to Elizabeth Cooper-Schultz comes by way of a text message in which she refers to Mary Birch as “that hospital that claims to be mother and baby friendly.”

When I arrive at the apartment she shares with her husband and two children in the UTC area, Cooper-Schultz welcomes me into her home with a hug, a cup of coffee, and a plate of strawberries and coffee cake. Once we’re seated, Cooper-Schultz begins. She’s eager to tell the story of her son’s birth.

“Usually I start off by telling people my C-section started even before I got to the hospital. I had a C-section because my doctor didn’t care if I had a C-section.”

According to statistics compiled by the Office of Statewide Health Planning and Development, Sharp Mary Birch Hospital for Women and Newborns had the highest rate of cesarean section deliveries in San Diego County in 2009. The California average was 29.8 per 100 births; at Sharp Mary Birch, the rate was 37.7. The World Health Organization suggests that C-section rates should be between 10 and 15 per 100 births.

“I had a C-section because my doctor didn’t care if I had a C-section.” — Elizabeth Cooper-Schultz

Photo by Howie Rosen

At 40 weeks, two days prior to her due date, Cooper-Schultz’s water broke, though she was not in labor. In a birthing class she’d taken at Mary Birch, she’d been told that this happens to 25 percent of women. She says she’d never recommend the class “because it’s focused on the assumption that your birth will be intervened on in some way.” If your water breaks, they told her, we have to get the baby out within 24 hours. So she and her husband went to the hospital right away.

“They pretty much wanted to put me on Pitocin the minute I walked in the door because I wasn’t having regular contractions,” she says.

Pitocin is a synthetic form of a natural hormone called oxytocin that stimulates uterine contractions. The drug is controversial not for what it can do — help induce labor — but for its overuse as a tool of convenience, for managing or controlling labor, despite the risks it presents, including, in rare cases, uterine rupture and fetal distress.

Dawn Thompson, a private doula, or birth coach, based in Encinitas, calls Pitocin the first in the “snowball effect” of interventions that ultimately lead to a C-section. The contractions induced by Pitocin come strong and fast, unaccompanied by the endorphins present with natural contractions, and the use of Pitocin requires constant fetal monitoring, which limits mobility for the mother. Most women find the pain intolerable and end up needing an epidural. An epidural is an injection into the bony spinal canal of a local anesthetic that blocks nerve impulses in the lower half of the body. While epidurals eliminate pain, they come with their own set of risks, potentially slowing down the process of labor, causing a drop in blood pressure for the mother, and causing a lower heart rate for the baby. Ultimately, these interventions set the stage for the C-section.

Mary Birch administrators do not deny that their C-section rate is high. John Cihomsky, Sharp’s vice president of communications, wrote to me in an email, “Sharp Mary Birch Hospital for Women & Newborns is the busiest high-risk, Level III delivery center in the state. Sharp Mary Birch not only delivers the most babies in the state, but we also deliver the most babies weighing less than 1500 grams. These very low birth weight babies are almost always delivered by cesarean section. In addition, we also care for many mothers with high-risk perinatal conditions, such as placenta accreta, and medical conditions that often require delivery via cesarean.”

Hospital administration declined to give me a tour of the hospital or a face-to-face interview.

To be fair, Mary Birch is but one hospital among thousands across the country whose C-section rates are two to four times higher than they should be. And it’s likely that the “too posh to push” crowd and the “I want my kid born on Valentine’s Day” moms do their fair share to raise these rates with their elective C-sections.

But a significant number of women believe their C-section deliveries at Mary Birch were the result of convenience for the doctors, fear of litigation, and/or lack of staff training in nonmedicated childbirth options.

A study done in Portland, Oregon, in the late 1990s found a correlation between the use of Pitocin and C-section rates. The January 1, 2003, issue of Ob.Gyn.News outlines the study, in which 4635 women who went into labor spontaneously had an 11.5 percent C-section rate, while 2647 who were induced had a rate of 23.7 percent.

On the Drugs.com website, an “Important Notice” accompanies the indications and usage information about Pitocin.

“Elective induction of labor is defined as the initiation of labor in a pregnant individual who has no medical indications for induction,” the notice reads. “Since the available data are inadequate to evaluate the benefits-to-risks considerations, Pitocin is not indicated for elective induction of labor.”

It is common for hospitals to use Pitocin if a woman has not gone into active labor within 24 hours after her water has broken to avoid the risk of infection. But the staff at Mary Birch wanted to give Cooper-Schultz Pitocin within the first two hours.

Cooper-Schultz refused the Pitocin at first. She wanted to get things going naturally, and for the next several hours, she and her doula walked and used the birth ball, a large physiotherapy ball on which the mom can sit to relieve pain during labor and which is believed to assist in positioning the baby. At the 12-hour mark, her cervix had dilated to four centimeters. She says she now understands that this “is a good natural labor progression for a first-time mom.”

But it wasn’t fast enough for the staff at Mary Birch. Cooper-Schultz, who describes herself as the kind of person who will “try not to be a problem because you might be mean to me if I am,” allowed them to give her the Pitocin that she says they’d been pushing since she’d arrived.

“No human should have to withstand Pitocin contractions on their own. It’s awful,” Cooper-Schultz says. “They weren’t honest with me. They didn’t say, ‘If you get the Pitocin, you’re probably going to need an epidural.’”

Thompson, the doula, says that the lack of informed consent is a big problem when it comes to the medical interventions doctors use to manage labor and delivery. When women ask for her services as a doula, the most common statement she hears from moms who have had previous births is, “If I would have known this, I would’ve never done that.”

Care Messer and Dawn Thompson

Photo by Howie Rosen

Many doulas, including Thompson and Care Messer, who is also a hypnobirthing instructor, believe that a large part of their job is to help inform the patient about the effects of Pitocin and other interventions. They see themselves as advocates, helping to remind the mothers that in a hospital setting they are the customers and they have the right to say no. But Cooper-Schultz didn’t know any of this before her experience at Mary Birch, and she chose her doula for her nurturing characteristics rather than her strength of advocacy.

“I needed somebody to be like a mom for me because my mom wasn’t going to be there. And that’s what she was,” Cooper-Schultz says. “I didn’t go into this situation thinking I have to be an advocate for myself. I didn’t know I had to do that.”

Cooper-Schultz withstood the pain of Pitocin contractions for eight hours before she finally gave in and got an epidural. “I was in so much excruciating pain I couldn’t move. All I could do was just sit in the chair. Every time I would get up, I would have one contraction on top of another on top of another.”

The epidural worked on only her left half.

At one point, the doctor came in to check on her and alerted the nurses that she was going home to take her kids to school. Sometime later, she returned with wet hair, checked Cooper-Schultz, found her at nine centimeters, and told her to try pushing.

“I pushed, and [the baby’s] heart rate went down, which I now know can be in a normal range of labor. But she said she’s worried about it. She said, ‘He’s not in distress, but he’s a little bit stressed.’”

The doctor told Cooper-Schultz it would go one of three ways. In the first scenario, Cooper-Schultz would push for 20 or so minutes and the baby would come out. In the second, she could push for 20 or so minutes, the baby would not come out, and they’d have to do an emergency cesarean section. Or, the doctor said, they could do a cesarean section right now.

Cooper-Schultz chose the cesarean.

“I was really afraid [of the emergency C-section] because my husband wouldn’t have been able to be there with me,” she says. With the nonemergency C-section, her husband was allowed in the operating room.

Cooper-Schultz had never been hospitalized or had surgery before. She recalls the anesthesiologist as a kind and concerned man who offered her a shot of Demerol, but that’s all she remembers.

“I kind of passed out, and basically, I missed my son’s birth,” she says. “The next thing I remember was them holding up a baby on the other side of the room that could’ve been mine, could’ve not been mine, who the hell knows.”

∗ ∗ ∗

Dawn Thompson, who has been a doula for eight years, no longer provides her services to women who plan to deliver at Mary Birch because, she says, the environment is particularly unsupportive of the natural birth process. A doula can only provide information and support to a mom; she can’t make decisions for her. And to deliver naturally at Mary Birch, a mom has to be prepared to fight.

“I couldn’t handle the emotional ride,” she says. “As a doula, if I don’t invest with these moms, I’m not doing a good job. So, to feel their disappointment and their devastation and knowing that I had all the information and could have offered them something different is just huge.”

In eight years, Thompson has overseen 134 births. Of those, 17 took place at Mary Birch, 12 of which resulted in a C-section. That’s 71 percent. Of the remaining 117 births, only 9 resulted in a C-section. That’s just under 8 percent.

“When the guidelines are so stringent, you know that you’re working uphill,” she says. “The moms shouldn’t have to battle to have a normal childbirth.”

∗ ∗ ∗

Helen Dover (not her real name) welcomes me into her North Park apartment shortly after the dinner hour on a Tuesday evening in mid-September. She tells me she’s an unlikely candidate for natural childbirth.

“I’m like Woody Allen,” she says. “I am a New Yorker who likes living in the city, who likes creature comforts. And for somebody like me to be embracing [natural childbirth] is humongous.”

We sit together on her couch, she with one foot tucked beneath her. Her two-year-old daughter hacks away at purple construction paper with a pair of plastic scissors on the floor near the coffee table.

Dover’s story is similar to Cooper-Schultz’s in that it begins with a desire to give birth naturally at Mary Birch and ends in what she considers an unnecessary C-section. One difference is that when Dover started out, she did know she might have to fight for what she wanted. When she began to labor, she called her doula first, not the hospital. She stayed home and labored for 10 to 12 hours before she went to the hospital, avoiding “the clock” for as long as she could.

When she arrived, armed with her research and her hopes for a natural birth, she found that the environment at Mary Birch had a greater impact on her than she’d imagined it would.

“There’s so much fear on their part when you walk in the door that something’s going to go wrong, and it’s overwhelming,” she says. “It was never, ‘We’re so excited. You’re going to have a great birth.’”

The progression she’d experienced at home, from two centimeters to four, slowed drastically when she arrived at the hospital. A doctor told her that it might help if he broke her water. So she allowed it. But nothing happened. Her daughter’s position, she says, acted like a stopper, and Dover’s labor continued to advance slowly.

“I should’ve stayed as cool as possible,” she says. “I’d read the books where they say once you get to the hospital, you’re a little bit more tense because you know there’s a clock running. They kept coming in and nothing was happening, and I was getting a little bit more stressed. The only person coaching me along was my doula. Everybody else was, like, ‘Are you there yet? Are you there yet?’”

Dover’s husband, Henry (not his real name), pipes up from the nearby kitchen table, where he’s been listening in.

“As things were not progressing, there was never any inflection or tone of ‘You’ll be all right,’” he says. “It was just more and more concern, more and more concern, like, ‘Things are not going the way we have our script to play out.’”

Dover lists her regrets: Not waiting and laboring longer at home. Allowing the Pitocin at 12 hours. Giving in to the epidural after 8 more hours. But the regrets go as far back as her pregnancy, when she chose to stay with Sharp.

“I should’ve just switched, but it’s so hard with an HMO,” she says. “In order for me to switch to Scripps and go to one of the birth rooms at Scripps, which has a much better record, would have meant changing everything: changing my primary care physician, changing my OBG. I would’ve had to totally change my insurance policy. And at the time, I already had a pediatrician picked out for her and everything. We’d interviewed, and just the idea of doing all of that was overwhelming. I thought I didn’t have the strength to do it.”

Dover’s daughter, who has finished cutting all the purple construction paper available, piles her blanket, stuffed horsie, and stuffed giraffe into her mother’s lap. Then she climbs up on the couch and joins us.

Dover tells me that around the 40-hour mark, she began to cry.

“[The doctor] said, ‘You need a C-section,’” she says. “I said, ‘I don’t understand why I need a C-section. Everything seems to be fine. Her heart rate’s not dropping.’ And he said, ‘Well, she’s stuck.’”

Dover reaches out and runs a hand over her daughter’s hair.

“I’d read all these books where the midwives use their hands and try to help gently,” she says. “But he said, ‘No, I’m not going to do that.’”

When she asked why not, the doctor said he didn’t know what position the baby was in and didn’t want to cause a broken shoulder.

“He wasn’t even willing to use his hands and help,” she says. “And I was totally against using the suction, but anything besides the total hands-off. He said, ‘I don’t want to hurt your baby, and you don’t want to hurt your baby.’ I started crying. And I just finally said, ‘Fine. Cut me open.’”

∗ ∗ ∗

“Moms are easily led at the very end because they want to get the baby out. They’re tired,” Messer tells me.

Elizabeth Cooper-Schultz confirms that this was true in her case.

“Go without eating for 27 hours — on Pitocin and with an epidural that’s only working on half of you — and try to make a rational decision,” she says.

Wait.

Without eating for 27 hours?

The staff at Mary Birch emphasizes the no-food-in-the-labor-and-delivery-unit policy during the hospital tour that most moms take earlier in their pregnancies, Messer tells me. “The first thing they say is, ‘What can’t you do when you get here?’” And the answer she says is, “No eating or drinking.”

“At Kaiser, you can eat and drink,” Messer says. “UCSD, you can eat and drink. Pomerado, you can eat and drink. Palomar, you can eat and drink. But at Sharp, their reason is if you need a C-section, you can throw up, you can aspirate, and you can get really sick.”

When I email Cihomsky, the communications vice president at Sharp, to ask about the no-food-or-drink policy, he responds, “It serves as a precaution in case of an emergency that requires a mother to undergo general anesthesia during labor. Anesthesia is always safest on an empty stomach because of the risk of aspiration. Other factors come into play, such as how long the labor lasts, the mother’s particular condition, etc., so the ultimate guidance on whether or not a mother eats during labor rests with her physician.”

Messer scoffs at this policy.

“How do you expect a woman to run a marathon with no fuel? It’s dumb,” she says.

∗ ∗ ∗

The obstetrician a woman chooses plays as large a role in her birth experience as the place she chooses to deliver her baby. Some doctors have a reputation for being more inclined to help with a natural birth, and others for being less inclined. Childbirth books suggest that a woman question potential candidates to get a feel for their practices. Messer and Thompson agree that’s not always enough.

Thompson cites the “bait and switch,” where a doctor claims to support a woman’s birth choices up until the final weeks, when it’s too late to change doctors. Messer says she’s seen doctors who’ve initially said they’d support the hypnobirthing process but later changed their minds.

“All of a sudden it’s, ‘That’s not going to work. No, you can’t be on your hands and knees. That’s not safe, and this isn’t,’” Messer says. “And that’s at 40 weeks. So now, where can I switch?”

“I think at 2:30 in the morning, a C-section at Mary Birch is, ‘We can manage this and then we can all go home.’” — Christine Stewart

Photo by Howie Rosen

Christine Stewart, a petite redhead and mother of twin girls born at Mary Birch in September 2009, says she experienced something similar with her doctor.

We’re sitting in the dining room of her home at the end of a cul-de-sac in Carlsbad. The girls, who will turn two tomorrow, are just up from their naps. Their Austrian nanny ushers them past us and into the kitchen for their snacks. One runs back for a quick kiss from Mom.

“My husband and I, we took a Bradley Method childbirth class,” Stewart says, “which is a 12-week class, pretty in-depth, and we decided we wanted to do natural, unmedicated labor.”

When she first mentioned this to her doctor, Stewart says the doctor told her to “keep an open mind” and not to “fixate on any particular way of labor and delivery.” At the time, Stewart thought the doctor didn’t want her to be disappointed if natural birth didn’t work out, but now she speculates that the doctor was always leaning toward a C-section.

At 36 weeks, the doctor suggested they induce her at 38 weeks. Stewart refused.

“From what I can tell,” she says, “it’s just common that it’s more manageable to have twins at 38 weeks because of size. Sometimes they’re concerned about size. But [my girls] were normal-sized.”

The doctor suggested 39 weeks, then 40. Finally, Stewart agreed to induce at 41 weeks if she hadn’t gone into labor by then. But it was unnecessary. At 40 weeks, three days short of her original due date, Stewart went into labor.

Stewart chose Mary Birch because it had everything she was looking for. Originally, she’d wanted to deliver at Best Start Birth Center in Hillcrest, but they don’t accept women who are pregnant with twins. Mary Birch, she says, seemed like the next best thing.

“It had the facilities, doctors on hand, and all these different classes — prenatal yoga — and since I was diagnosed high-risk because I had the twins and since I was over 35,” she says, “I just thought their whole entire focus is for women and newborns, so I’ll probably get the best care because they’ve got all the resources for that.”

Stewart had heard about other women going into the hospital prematurely and getting “strapped down” immediately. But in her natural childbirth class she’d learned that mobility helps with labor. So she and her husband didn’t go in right away.

Once they did arrive at the hospital, Stewart was four centimeters dilated. She gave the nursing staff her birth plan, which stated that she did not want any mention of pain medication.

“Thankfully, they did not offer medication. They were respectful of that. The contractions were intense,” she says, pulling her feet up onto the chair and hugging her knees. I was slowly dilating in a normal time frame. They were telling me that was normal. My doctor still was not present. She did not actually arrive until about 10:00 p.m. So up until that time, it was the labor nurse who was in communication with my doctor over the phone.”

The nurse who’d been assigned to her provided juice, watched the fetal monitors, and kept the doctor informed about any changes. But otherwise, Stewart received no help from her.

“She was there, I guess, as a resource, but she wasn’t active or in any way involved in the labor process itself,” Stewart says. “Everyone knew we were doing nonmedicated birth, but I think we just felt like if that’s the decision we made, we were just on our own. There was just no assistance getting through it.”

While it may be true that doctors call the shots, doula Dawn Thompson believes that the nurses’ lack of training in unmedicated births plays a large role as well in whether a woman gets a C-section.

“Nurses have a lot of power, and the reason they have a lot of power is because the doctors aren’t present,” Thompson says. “The nurse is the one calling the doctor to give them an update. So if the nurse is inexperienced, she might say, ‘She hasn’t changed dilation in two hours.’ She might constantly be giving the doctor a negative report. Or she might say, ‘She’s doing great. Just a little bit of change.’ In that case, then the doctor might say, ‘Okay, call me when she’s ready to push.’ The nurse absolutely has a lot of control.”

Christine Stewart believes that the main reason she ended up having a C-section was that her nurses had no training in natural childbirth.

“Ultimately, the outcome was because there was no one in the labor room who had the experience to help get the babies in position to be delivered,” she says.

By the time the doctor arrived, Stewart was fully dilated. She knew her babies were healthy, that they were both head down, in a good position, face forward. Her blood pressure was not elevated, she had no fever, and she’d been in labor for less than 24 hours. Everything was normal except that the babies were wedged in, each trying to get out first.

“There were a couple of things they asked me to try,” Stewart says, “but I never really felt like there was any truly proactive measures to say, ‘Okay, can we move the babies around? Let’s see if we can move this one up so the other one can move down.’ There was nothing hands-on.”

At 2:00 a.m., the doctor came in and said, “It’s time to meet your girls.”

“There was kind of an emotional appeal going on. I just said, ‘Okay, fine.’ It was a disappointing moment. I kind of resigned myself, like, ‘If this is what we have to do, this is what we have to do.’ I felt like crying because it just went against everything I had hoped for, everything I had planned and practiced for.”

The twins run past us now and into the room behind us, where an air mattress sits in the middle of the floor. They leap onto it and begin to jump. Stewart watches them for a moment and then turns back to me.

“I think the hospital has some standard protocols, and I think that if you don’t follow their standard protocols, they just don’t know what to do with you,” she says. “And a C-section is manageable. They know exactly how to do it, and I think at 2:30 in the morning it’s, ‘We can manage this, and then we can all go home.’”

∗ ∗ ∗

In mid-October, Care Messer lectured student nurses at San Diego State University who were doing their obstetrics rotation at Mary Birch.

“They were floored by what natural birth is like and what all the hospital procedures do to the natural process,” she wrote to me in an email. “It happens every time I teach there.”

She adds, “I’d love to teach it to a whole hospital staff so they’d see where we’re coming from. The problem is that they’re just never trained about natural birth in their system. And our doctors aren’t either. It’s really not their fault. We don’t train them in it. And OBs are trained surgeons. Their specialty is surgery.”

Alexis Martin (not her real name), a former labor and delivery nurse at Mary Birch, says that her training lacked exposure to any nonmedical methods of helping women through labor.

“The training that I got there was mostly about the medicalized [procedures]: how to run Pitocin and what fetal-monitor-strip reading is all about, interpreting the data,” she says. “That’s what the majority of our training was all about.”

Today, Martin works as a doula and private monitrice, a labor-support person who may perform some clinical tasks, such as monitoring the fetal heart rate or taking the mom’s blood pressure, tasks a certified doula is not allowed to perform. Some of the moms that Martin helps do give birth at Mary Birch, and from what she can see, “Not much has changed,” she says, in the ten years since she worked there as a nurse.

“You can have a natural birth at Mary Birch, too. It’s not impossible,” she says, “but the nurses are not that helpful with it, other than maybe bringing you a squat bar,” a device that fits on a hospital bed and supports the mom in squatting. “I often say I wish the labor and delivery nurses would have a doula training so that they’re familiar with how to facilitate that process. It would have been maybe two days extra in your nine-week orientation and education to give you that information: how to help a mom have a natural birth.”

∗ ∗ ∗

Last March, when her first son was two and a half years old, Elizabeth Cooper-Schultz had her second child in the back bedroom of her UTC apartment, in the company of her husband, her midwife, two apprentice midwives, and a doula.

Today, Helen Dover is pregnant again. When I ask if she plans to give birth at Mary Birch, she and Henry simultaneously answer, “No.”

“What I’ve learned is that at Mary Birch, everybody’s going to try to get you to do the birth that they want you to do,” Dover explains.

For their next baby, the Dovers will stay with Sharp in order to take advantage of the tests, which would cost them thousands of dollars out-of-pocket. They will also register at Mary Birch so that they are prepared in the event of an emergency. But they have hired a midwife to help them birth at home.

“We’re going just to get what doctors are good for,” Henry says, “and then to use the midwives for what they’re good for.”

∗ ∗ ∗

Over the summer, Care Messer heard an ad on the radio saying that Sharp Mary Birch honors women’s birth options. Her first thought?

“Bullcrap,” she says.

Messer was so incensed by what she considers false advertising that she looked into purchasing space on a vacant billboard over the 163, where it would be seen by hospital patients. The message she wanted to share echoed her original thought. The billboard would read, “Bullcrap.” But at $1000 for the initial vinyl and $6000 for a 30-day rental, the price was too high.

“If I had that kind of cash, it would have been up that week,” she says.

∗ ∗ ∗

In early November, John Cihomsky confirms a rumor that Sharp Mary Birch is developing a doula program. “It’s in response to our patients’ desire for more options during their birthing experience,” he says in an email. “The Doulas will be independent contractors, and our target date to start offering this service is at the beginning of 2012.”