Kristen Eson said it was hard to find the words to describe what went through her mind after a strong contraction caused her to give birth to a son while she was being helped from her birthing tub to a bed at Brookwood Women’s Health Center.
If not for the doula Eson had hired — who had the presence of mind to lay a towel on the floor beneath Eson when her contraction started — her son would’ve fallen into the world and onto a wet tile floor.
A doula is a woman trained to assist other women during the process of childbirth, a legal birthing coach. Unlike a midwife, a doula is not considered a health care provider.
“The umbilical cord snapped and there was blood everywhere,” Eson said, noting that she did not immediately know what had happened amid the imbroglio. “I felt terrified for my son and confused as to how this could have possibly happened.” Eson recalled she was ordered out of the tub by the doctor who was on call — even though she had planned with her own doctor to have a water birth — “for [her] and [her] child’s safety.”
That happened in March 2012. By her own account, Eson was one of the first women to use the then-newly marketed birthing tubs at Brookwood. After having her first child, she had decided to make the switch from her doctor at St. Vincent’s after seeing the advertisements lauding the “beautiful new Women’s Center” and natural birthing plans offered at Brookwood.
However, as she explained in vivid detail, her experience was far from what was advertised.
“I was laboring in the tub. I sort of knew I was close to pushing and I told the nurse. She didn’t seem to believe me,” Eson said. “I didn’t have an epidural and I was fully aware of what was going on with my body. Finally, she conceded and she got the doctor who was on call. It wasn’t my doctor I had been working with.
“She checked me and said, ‘Oh yeah, you’re ready to go.’ She then told me to get out of the tub. If I remember correctly she said, ‘I’m ready for you to get out now.’”
Eson likened her labor experience to, “being in another world,” and said she was in no condition to protest the doctor’s orders. “It’s kind of like when you’re really sick and someone tells you to go lay down in bed. You don’t really know what you’re doing; you just obey. I got out of the tub and was dripping water everywhere. I was going really slow and was trying to be very careful.”
According to Eson, neither the doctor nor the nurses helped her from the tub, just her doula. Eson considers herself extremely lucky to have a healthy son that did not suffer any complications after his fall from utero.
Eson is not alone in complaints about Brookwood’s labor and delivery practices, which several women have said fail to live up to their advertising. A lawsuit has been filed against Brookwood by a former patient who outlines a similar situation. Unlike Eson, that plaintiff was left with severe nerve damage which she blames on the medical staff. She alleges they “[held] the baby’s head in prior to delivery,” and forced her into a position she was not comfortable with.
Representatives of Brookwood Women’s Health Center did not answer questions regarding the lawsuit or the complaints that have been leveled against the hospital in this story. Brookwood Marketing Strategist Laura Bright did, however, offer this statement: “In regards to your questions, due to pending litigation, we are unable to discuss this matter outside of the legal process at this time. Further, HIPAA regulations and other statutory requirements prevent us from discussing confidential patient information.”
Seated at the kitchen table in her Mountain Brook home, Caroline Malatesta scanned over several documents pertaining to her lawsuit; the footsteps of excited children echoed down the staircase at the end of the hall.
Malatesta, a 36-year-old mother of four, is currently suing Brookwood for fraud and medical negligence after her experience at the hospital left her with Pudendal Neuralgia, a debilitating nerve condition that she said was a result of “the nurses physically holding baby Jack in my body.” She also has been diagnosed with PTSD since the ordeal.
Pudendal Neuralgia, a rare problem caused by trauma to the pudendal nerve, has left Malatesta unable to have children and in “pain on a near daily basis — pain much worse than labor.” Malatesta said her obstetrician labeled it “the worst injury he has seen in all his decades of practice.”
The impact of her injury, which she said is almost certainly permanent, has been both physically excruciating and psychologically demoralizing. And because it is an invisible injury it’s often challenging for friends and family to comprehend her plight.
“The pain plus the effects of medications is exhausting,” Malatesta said. “ I can only do a fraction of what I used to do. My children have a hard time understanding why I need to spend so much time resting. I’ve lost the ability to have sex because of the nerve damage. I’m unable to have children because of that, and because simply being pregnant would exacerbate the pain. We did want more children, but at this point I can barely take care of the ones I already have.”
The lawsuit, which was filed in Jefferson County Circuit court, alleges, among other things, that the staff at Brookwood “[forced] Caroline out of her chosen labor and delivery position; [forced] Caroline to continuous fetal monitoring when she was anticipating an unmedicated delivery; [held] the baby’s head prior to delivery; [marketed] natural birth services without sufficient coordination to ensure that the medical staff and other caregivers were aware of, trained in and committed to providing the services advertised.”
What happened to Caroline?
In 2012 Malatesta decided to make the switch from her doctor at St. Vincent’s, who had delivered her previous three babies, to Brookwood. Malatesta recalled being, “bombarded with advertisements that appealed to exactly what [she] was seeking, which was to let a normal physiological process play out.” As it happened, it would be her last child because of the nerve trauma she suffered.
“Around this time Brookwood came out with their advertising which obviously their marketing team was capitalizing on the fact women were starting to educate themselves and the internet has all the information out there,” Malatesta said. “Instead of just blindly doing what they’ve been told to do, they are questioning it.”
As laid out in Brookwood’s marketing strategy on their website in 2015, “We hit on an idea that healthcare providers often forget: before you’re a mother, you’re a woman, Instead of cute babies, the Brookwood campaign featured beautiful pregnant women and moms.”
She made the switch about halfway through her pregnancy.
When she arrived at the hospital to deliver her child, Malatesta was told the natural birth plan she had discussed with her Brookwood doctor, which included a water birth, would not be available to her because “your doctor is not on call.”
After being told she could not be mobile during the labor, Malatesta said, she was ordered to get into the bed. She said it became evident to her that the water birth was never meant to be available to her. Instead of the plan she had in place, “It became very clear that this wasn’t about health or safety. It was a power struggle,” Malatesta said.
Once in bed Malatesta maneuvered herself onto her hands and knees just as her water broke.
Instead of rehashing the troubling details with a reporter, Malatesta provided a statement she had written for the blog birthmonopoly.com. The following is her recollection of what happened:
[After her water broke] That’s when the nurse said, “Let’s get you on your back!” and everything went haywire. She grabbed my left wrist and forced it out from under me. I pulled back, but couldn’t escape her grip. She pulled my arm and rolled me over to my back. That is the moment I lost control over my birth. Forcing me to stay on my back was like forcing a person to hold their hand steady over an open flame — it was impossible for me to comply. The instinct to get off my back was overwhelming. I desperately tried to flip back to my hands and knees, struggling against the nurses to do so. The nurses held me down and pressed my baby’s head into my vagina to delay delivery as he was trying to come out.
By her estimate, this struggle went on for roughly six minutes. When the doctor arrived, the baby was delivered immediately, despite Malatesta still being held in a painful position by a nurse, she said.
Depositions of the doctor and nurse
In an April 27, 2015 deposition, Beth Murphee, a nurse who has been at Brookwood since 1992 and who allegedly forced Malatesta into the uncomfortable position to give birth, said that she remembered Mr. Malatesta — Caroline’s husband — and the room the mother was taken to. But she said she had no recollection of Mrs. Malatesta or if the hospital offered natural birth classes for the staff. Murphee also said Brookwood no longer offers water births, even though advertisements still pointed to the contrary when she was being deposed.
Asked by an attorney if anyone with Brookwood communicated the message of the commercials about natural births to the nursing staff, Murphee said, “No.”
After looking at the Malatestas’ charts, Murphee said she recalled “vague things” and could not remember specifics. She did recall, “I did not know that the patient had requested natural delivery prior to going to the room to help Melissa [another nurse]. I see that that was documented here. But I do remember that it was a natural delivery after reviewing the chart.”
The chart also shows, according to the deposition, that at 2:55 a.m. Malatesta was encouraged not to push. The attorney asked Murphee her interpretation of that statement. She responded, “Well, a patient that is — doesn’t have an epidural with no medication on board, you usually have to coach them through that last part of the delivery. And when delivery is close, as it seems to have been here, because she was crowning when she arrived, you have to encourage them not to push. Because their natural urge is to want to push.”
Malatesta contends that even though she arrived shortly before she gave birth, the hospital made no effort to accommodate her request for a natural water birth and that there is no system in place to inform staff of a patient’s birth plans.
During a separate deposition, Dr. John Morgan, the obstetrician who delivered Malatesta’s baby, was asked if Brookwood had ever implemented a system that notified on-call doctors as to whether or not a patient had requested a natural birth. “No, I don’t think it matters to them,” he responded.
Morgan, who is not a defendant in the lawsuit, said the first thing he remembers about Malatesta is making eye contact with her upon entering the room. But he admitted the minute details of the situation eluded him because that was “hundreds of deliveries ago.”
He did recall that the nurses were “scattered” around the room. But Morgan did not recall any specific instance where a nurse was physically restraining Malatesta. “To my recollection, nobody was fussing,” Morgan said.
Morgan did not have any memory of Malatesta or the baby being in any danger while she was postured on her hands and knees, even upon a review of her records. But he had delivered babies that way and said there is nothing wrong with that posture “if it comes out safely.”
“Bait and switch”
“Brookwood was saying they welcomed natural childbirth and this is where you should come. They put out all this literature. It was in the newspapers, it was all over Facebook,” Jennifer Dunbar, a 40-year-old mother of three, explained over the phone June 26. “But when I got there, they wouldn’t even set it up for me. It was a bait and switch from the moment we got there.”
According to Dunbar, her doctor was aware of these inconsistencies with advertising and the services offered and instructed her to “labor at home as long as you can and come in late, that way you won’t have to deal with the nursing staff.”
She took her doctor’s instructions to heart and labored at home with her doula until she couldn’t wait any longer. Unfortunately when she arrived, Dunbar’s doctor was not there. In fact there weren’t any doctors at all, she said.
“We were like, ‘Why are there no doctors here? You say this is where you come when you want to have a natural childbirth, but there isn’t anyone here,’” Dunbar said.
Even though she arrived at Brookwood at 3 a.m. “ready to push,” Dunbar said she was instructed not to push. She was also told there was no time for them to set up the water birth even though he had planned for exactly that. She was told “we don’t have time to set up a pool for you,” she said.
She didn’t have her baby until 6:30 a.m. Dunbar said the circumstances revolving around the birth process left her with an uneasy feeling. She had expected to have freedom of movement and that she would not have to get on her back in the bed.
“They gave me a rickety pole to grab onto and actually made me stand on the bed, which was scary in itself,” she said. “It’s three feet off the ground and I’m about to have a baby. The doctor came in and said, ‘We’re going to push now, you need to get on your back and assume the position. It turned into an argument and she said if I didn’t get on my back she would walk out of the room.”
After giving birth, the argument with the doctor continued as Dunbar was told it was “time for Pitocin” because she needed to “get the afterbirth out.” But Dunbar insisted nature would take care of that once she started nursing her baby.
“The doctor takes my chart and throws it across the room and said, ‘Fine. You’re going to bleed out. Your doctor comes in 30 minutes. Good luck,’” Dunbar said. “It was crazy. All we did was fight that doctor the whole time. My husband and my doula were just looking at me like, ‘Did that just happen?’”
The reality of advertisements
The hospital officially banned water births in January 2013 according to the deposition of Kelly Taylor, Brookwood’s marketing director. However, Brookwood continued to advertise them as late as July 15, 2015.
As late as May 25, 2015, Brookwood’s website read, “If your birthing plan involves a natural, unmedicated delivery, we have a variety of birthing equipment, including water birth tubs.”
In a December 11, 2014 deposition, Brookwood’s marketing director, Kelly Taylor, was asked by an attorney representing the plaintiff: “If a doctor who delivers babies at Brookwood makes a statement about the services that the hospital provides, should the patient be able to trust that that statement is true and accurate?” Taylor responded, “Yes.”
Taylor was asked, “Would you believe that because of your effort and Brookwood’s efforts in promoting natural birth as an option at Brookwood, that those efforts have led to labor and delivery patients choosing Brookwood as their delivery hospital?”
Taylor replied, “I believe it could have been a factor to influence choice.”
As late as October 21, 2014, over a year after the hospital banned water births, Lynn Jeter, a women’s supportive services educator at Brookwood was quoted on the hospital’s website saying, “Natural birthing is growing in popularity because people are more and more internet savvy — they are able to see all the options involved with childbirth… Our nursing staff is very supportive of water births.
“We want to support the options for our patients. In doing so, we’ve pulled in many supplies — birthing bars and birthing balls for support — as well as birthing tubs,” Jeter said on the site.
According to the website, “The new facility’s water birthing suite offers a birthing tub with LED lights and warmers for a very pleasant experience.”
Lack of choices
Even as more women educate themselves on alternative options, Alabama provides very few legal options for natural childbirth. The practice of midwifery, for instance, is illegal in the state. Jennifer Crook is a midwife who lives in Birmingham. Her advice for expectant mothers in Alabama: Move or drive to Tennessee.
“There are some hospitals in town that are approaching a 50 percent cesarean rate. [The World Health Organization] recommends a rate of 10 to 15 percent,” Crook explained. “I would encourage women to avoid those hospitals at all costs. More than anything, I would suggest that women read, learn, ask questions, hire a doula, and, above all else, that she know and understand her rights.”
According to the Alabama Department of Public Health, the cesarean rate at Brookwood is 43.8 percent, compared with their closest competitor, St. Vincent’s, whose rate is 36.8 percent. Another telling statistic is the low-risk first time mom cesarean rate, which there are only two area hospitals to report this number: Brookwood (31.9 percent) and the University of Alabama at Birmingham Women and Infants Center (15.3 percent).
The World Health Organization considers the ideal rate cesareans to be between 10 to 15 percent.
Bess English, 22, was a first-time mother who said she was “bullied into a C-section” when she arrived at Brookwood. She had decided to make the hourlong commute from Prattville after having a bad experience with her original obstetrician in Montgomery and was enticed by the commercials touting natural birth plans at Brookwood.
English’s doctor also was not at the hospital when she arrived, she said. “My stats were fine, my baby’s stats were fine,” English said. “But the doctor who was there was getting toward the end of his shift. All of a sudden it was like a flip switched. I got yelled at, screamed at, because he wanted me to have a C-section. But there was no immediate threat to me or immediate threat to my child.”
Knowing she was about to consent to major abdominal surgery, English said she felt overwhelming pressure to agree with the doctor who was accusing her of not knowing what was best for her or the baby because she was young and it was her first child.
“I finally consented. But I begged for another doctor to do it because I did not want this man who just spent the last half hour screaming at me to cut me open,” English said. “I was told there was no other doctor and he was going to have to do it.”
Because of complications with her surgery, English spent five days in the hospital afterward. Asked if she planned on having any more children, English said, “I’m terrified to have another baby. Doctors treat this like a business. I live smack dab in the middle of Alabama and I’ve had bad experiences with doctors in Montgomery and Birmingham. If nothing else, I could just break the law and have a natural birth at home.”
The slow pendulum
Around the turn of the 20th century in the United States, doctors started professionalizing and began competing with one another. By about the 1950s the majority of women were giving birth in hospitals, explained Cristen Pascucci, vice president of the national advocacy organization Improving Birth.
“This was obviously a new idea in the history of mankind. In order to affect that shift, doctors convinced women that doctors were safer than midwives who had been the birth attendants,” Pascucci said. Midwifery, she noted, has been around since Biblical times. “This was a result of lobbying and calculated marketing campaigns that were not based on any actual evidence.”
This led to a paradigm shift of doctors treating birth more like a medically induced extraction as opposed to having mothers participate and being engaged in the birthing process, Pascucci explained.
“It’s a very slow pendulum and it seems we’re just now getting away from that practice again,” Pascucci said. “If you look at the research and the numbers it’s very clear that doctors drive C-section rates. It’s not a medical circumstance-led situation.”
Another practice that has become normalized in hospitals is women being positioned on their backs and not allowing freedom of movement. “This is also tied to C-section rates,” Pascucci said.
Crook agreed. “The issue is that doctors aren’t trained to care for women who are active and mobile in labor,” she said. “They are comfortable with one position: women on their backs. And to women who are laboring and birthing without an epidural, that’s the last place they want to be. It just doesn’t make any sense. The bottom line is that a woman’s choice of position in birth needs to be both honored and respected. Women know what they’re doing.”
While at Brookwood, Laurel Bassett saw firsthand how often what she described as careless practices are harming new mothers. Her case highlights some of the inherent risks associated with hospital births.
Bassett’s doctor was not on call when she arrived. “I too almost died at the hands of an uncaring doctor at Brookwood,” she said in an email. “My regular doctor was out of town, so I got stuck with a condescending doctor who told me that ‘pain is just a part of childbirth’ and sent me home, despite intense pain, fever and uncontrollable shaking a week after delivery. They ignored my husband’s calls of concern.”
When she returned home, Bassett learned that she had contracted a MRSA infection during childbirth. Her husband called 911 and she was rushed to the hospital. “ I was in septic shock with failed kidneys, liver and lungs, and a 50/50 chance to live,” Bassett recalled. She was placed into a medically induced coma.
While she considers herself lucky to have a healthy baby and to still be alive, Bassett, who wants to have another child, said that she will do more research about alternative options. “I lost the first month of my child’s life, the chance to breastfeed — which Brookwood pretends to pride themselves on valuing — but thankfully not my life,” Bassett said. “I want to have another baby, but I will certainly be better informed about where I do.”
Dr. Jesanna Cooper prides herself on one number: 12 percent. That’s the rate of her primary C-section rate (first time C-section) at Princeton Baptist Medical Center. She’s seen the number steadily drop since she began working there in May 2013.
The overall number of C-sections has dropped from 32 percent in 2014 to 23 percent in 2016 since Cooper’s time there. As she described it, the rate of C-sections are a “huge problem” nationwide.
“C-sections are not the answer to all bad obstetric outcomes. In the legal world they are. I think that is a big driver,” Cooper said. “I also think it has to do with economics and how we get paid. Depending on your practice you may get paid more if you actually catch the baby – practices divide this up in different ways. So a lot of the time there is nothing to be had if you sit with a mom for 24 hours and not catch a baby.”
That is something that Cooper attributes to the success of her practice. “We don’t tie our own personal [payment] into the delivery. With our call partners we share time rather than the number of deliveries.”
Back to the lawsuit
“[Malatesta’s] case is so important because Alabama is in a crisis around maternity care,” Pascucci said. “From a national standpoint we have not been able to identify more than two or three doctors in the entire state that are moving forward with modern, evidence-based practices. The challenge for women in the state is very real.”
It’s something a lot of women don’t feel comfortable fighting back against.
Before Malatesta filed the lawsuit she had to think about the implications; reliving the trauma over and over, being subjected to very personal questions. She filed the lawsuit in February 2014, nearly two years after she had given birth to her son. She said she had not planned to do so, but the staff at Brookwood did not give her any other option.
“A few months after my birth I went and talked to the director of labor and delivery and the vice president of the women’s center and expressed my concerns. I was assured that they would deal with these but indeed they did not,” Malatesta said. “As my injury unfolded — it’s a nerve injury and developed over months; I didn’t realize the severity until several months later — I wanted more real answers to my questions. I felt like they had just given me a corporate runaround answer. They never answered straight up why I was forced to my back.”
When she tried to get answers to that, they cut off communication with her, she said. “They said the people with risk management and other key individuals have declined your request and eventually just hung up,” Malatesta said. That was the moment she started thinking about the lawsuit.
“Even though I knew that was a tough road I had to put one foot in front of the other. They didn’t really give me another option,” Malatesta said. “You can’t have somebody shut you out like that. For my own healing, I needed an answer.”
Her trial date is set for the week of July 25, 2016.
“Shoving it under the rug was not an option for me,” Malatesta said, appearing to shoulder a burden that was bigger than herself. “It’s not going to go away by ignoring it. The legal process is almost a trauma in and of itself. They’re asking very, very personal questions and long depositions and in some cases implying blame on me for what happened and implying I was being irresponsible in ways. And that is really hard to hear. But I have to do it as part of the healing process.”