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A Room of One’s Own

Nirit Artzi-Shapira flitted about the swanky Tel Aviv parent-child center Diada, clad in loose khakis and an orange top, her infant daughter snug against her chest in a blue sling.

Children bring an easy smile to the face of Artzi-Shapira, a program director at Diada, who dedicates most days to their well-being. The state of childbirth in Israel, however, leaves a bitter taste in her mouth. In rapid-fire Hebrew she told the Forward about the goals and successes of the grassroots movement she founded, Nashim Korot LaLedet: L’Ma’an Leida Hofsheet (Women crying out to give birth: Freedom of choice in childbirth), which advocates individualized midwifery care within the context of a state-funded system. Currently, there are no birthing centers, and women who choose homebirth pay out of pocket. But Artzi-Shapira remains hopeful.

“Since we’ve begun our work, things have gotten much better,” she said. Daida is housed a few blocks away from the Dizengoff Center at 75 Shderot Ben-Gurion, once home to the fashionable café Apropos, which was struck by a suicide bombing in 1997. Nashim Korot LaLedet’s advocates want women to be able to choose their birthing options — home, hospital or a birthing center — and want all of these choices to be paid for by the Israeli government’s National Insurance Institute.

Nashim Korot LaLedet was founded in 2001 after Misgav Ledach hospital in Jerusalem — then the only hospital in the country to offer natural childbirth options — shut its doors.

Many turned to home-birthing guru Ilana Shemesh, 51, who oversaw thousands of deliveries as a midwife at Misgav Ledach. Shemesh, author of the recent Hebrew-language book “Homebirth: A Guide to Homebirth in Israel,” described the “dark ages” of birthing conditions in Israel when she began midwifery 22 years ago. She said standard operating procedure back then was for women to be “drugged and heavily sedated, flat on their back, immobilized by an infusion drip and a monitor and many given labor-accelerating drugs, and their babies were isolated from them in nurseries…. I was fighting against this from the beginning.”

Though things have changed a good deal over the years — for one thing, since the 1980s women have been able to choose which hospital they give birth in — Shemesh and other natural birth advocates think Israeli hospitals have a long way to go.

“Many interventions in the hospital serve the best interests of the doctor — and not the woman or the baby,” Shemesh said. “The atmosphere is very high-tech and institutional with most women getting epidurals.”

Dr. Michael Shenhav, director of labor and delivery rooms at Lis Maternity Hospital in Tel Aviv, denies such charges. “We only intervene when there is a medical indication that compels us to do so, and even then only after we have explained the situation to the birthing woman and she agrees to the procedure. The birthing woman is at the center of it all.”

The Lis hospital has for the past few years offered the option of a midwife delivery in a natural birthing room — with a comfortable bed, curtains, a couch and even a Jacuzzi. This, Shenhav said, is the safest option; advanced medical care is a few feet away.

He added, “We are changing our thinking about birth to seeing it as a natural process, rather than treating it as an illness.”

Although Nashim Korot LaLedet has played a large part in this evolution, the movement still has its work cut out for itself, according to its proponents.

Shemesh said that for low-risk pregnancies, home births are the healthiest option and the best way to prevent “unnecessary medical interventions.” But Shenhav disputes this, saying that the time it takes to get to sophisticated medical treatment, should an emergency arise, can make the difference between life and death. Shemesh said she now conducts homebirths in her clients’ homes or in the backyard of her moshav home in special cabins she’s had built for this purpose.

When Shemesh started doing homebirths in 1983, she was the only homebirth midwife in the country and oversaw a homebirth once every few years. Now there are 10 homebirth midwives in Israel, each overseeing between one and eight homebirths a month, according to Shemesh.

There are no laws against homebirths, yet Israeli policy provides its own disincentive. Women who do not give birth in a hospital are required to have a hospital medical examination in a hospital within 24 hours if they do not want to relinquish their birth stipend. For first children, the stipend is about $300, but for children later on in the line up, the sum goes down to about $90.

The Israeli Ministry of Health maintains that it is “medically preferable that birth take place in the hospital,” and that their stipend policy is meant to encourage hospital births, according to a statement faxed to the Forward. The reasoning is that the newborn needs to be examined and tested and receive inoculations; the mother also needs to be examined to ensure that there is no infection, bleeding, tearing of the womb or cervix, or other complications.

“It’s ridiculous,” Artzi-Shapira said. “Their money is like a noose around our neck.” Artzi-Shapira birthed her first two children at home and dutifully went to the hospital for medical examination and to receive her stipend. “The next time,” she said defiantly, “I’m not going.”

She conceded that “there’s been a lot of change,” but said “it’s not enough.”

Over the past few years, the movement has helped bring childbirth issues into the public eye. More pregnant women are expressing interest in home or natural births, and doctors and midwives are far more familiar now with natural birthing techniques.

Today, according to Shemesh, Artzi-Shapira and Debby Gedal-Beer, a certified nurse midwife, there are fewer episiotomies (the cutting of perineum — the tissue and muscle between the vagina and anus). Now Israeli hospitals regularly stock massage oil for use in perineal massage, which can reduce the need for episiotomy, said Gedal-Beer, who is based at the Tel HaShomer hospital in Tel Aviv and is the Coordinator of Women’s Health and Midwifery Studies in Israel.

“Hospitals want women’s business, and here you have a grassroots movement saying, ‘Hey! Women, you should have the choices you deserve,’” said Gedal-Beer, 42. “The hospitals wake up and say, ‘Uh-oh. We have to wake up and get these women’s business.’”

The public awareness created by the grassroots movement has motivated hospitals to offer women more choices in birth — although Gedal-Beer, who is also part of Nashim Korot Laledet, concedes the motivation may by financially driven. The National Insurance Institute pays hospitals a flat fee of about $1,750 per birth.

Artzi-Shapira and her colleagues even met with representatives from the Ministry of Health recently to establish protocols for home births and to create state-recognized birthing centers.

“It was pretty positive,” said Gedal-Beer. “They heard us out.”

In general, she said that while there is definitely room for improvement in Israeli hospitals, “I think that for the most part, women feel they are getting very good care.”

Today there is no continuity between prenatal care and delivery; in Israel all births are attended by midwives under supervision of an OB-GYN, however, women cannot choose their own midwife and instead are assigned one when they arrive at the hospital, in labor. Artzi-Shapira and her cohorts think that women should be able to choose one midwife to oversee her care from pre-natal through post-partum.

Shemesh still thinks homebirth is the best option for women with low-risk pregnancies, and for society. She says that “since homebirth is so much more cost effective, the government will actually save money in an economy plagued by financial burden” and points to countries like Holland and Great Britain where this is the case.

But the movement’s impact is likely to be felt mainly in Israel’s hospitals, said Gedal-Beer, where most Israeli women will continue to give birth.

“Women who want natural childbirth are a very small minority,” she said. “Most women want an epidural.”

Jill Suzanne Jacobs, author of “Hebrew for Dummies” (Wiley, 2003) is a writer and Jewish educator in the Boston area who travels frequently to Israel.

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