Sitting with Ella Tehorlev and her husband, Harel, in the spring sunshine on the terrace of her parents’ home in Haifa while she breastfed her newborn, Shaya, the atmosphere was calm and tranquil.Two days earlier, Ella had given birth in a water-pool there, assisted by one of the few obstetricians who are prepared to attend home births.Giving birth: Ella and Harel Tehorlev, Metulla“The choice of home birth was obvious. But my father is a physician, and he was very concerned about the distance from our home to the nearest hospital, so a compromise was made and I gave birth in my parents’ home, which is a five-minute drive to Carmel [Government] Hospital,” Ella tells Metro.“We did visit hospitals while I was pregnant, but I was concerned about unnecessary intervention and separation from the baby after birth,” she says.“I shared my wife’s concern about hospital births and supported her choice,” adds a euphoric Harel.The obstetrician who attended Shaya’s birth consented to be interviewed on condition of anonymity. “I have too many problems with the health establishment,” he comments, having worked for 14 years in a hospital labor ward and choosing to attend home births in northern Israel. Asked for his criterion in agreeing to attend a home birth, he says that according to Health Ministry protocols, the pregnancy needs to be low-risk. “But the most important thing is that the woman feels confident,” he stresses. “In such a small country, there are few locations that are really remote from a hospital.”Health Ministry spokeswoman Maggie Ben-Mordehai comments, “The Health Ministry respects the right of every woman to choose how and where she wants to give birth. Nevertheless, the ministry feels it has a responsibility to declare that birth in a registered and licensed hospital maternity ward is safest for the mother and newborn infant.“With awareness that there is a demand for home births in Israel, protocols have been set down to balance the freedom of choice with the safety of the mother and newborn.” (The full text of these protocols from 2012 can be found in Hebrew at: www.health.gov.il/hozer/mr17_2012.pdf). Some health professionals find this statement incomplete, as they note that the Health Ministry does not acknowledge studies from countries where home birth has been established and organized within health services for decades.As for Dassie Elad, the certified doula who also attended the birth, she enthuses, “Ella gave birth like she lives; she flows with it. I knew she would have a good birth; there was so much love between her and Harel. And spending another week in her parents’ home, she is receiving the best of ‘mothering the mother.’” Elad attends births in hospitals and homes in the North. Noting the increasing demand, she says it is not always a question of money. “Sometimes I go into a really poor home, but the parents have made home birth a priority.”METRO COULD not help comparing this with the environment in most hospital postnatal wards – crowded conditions and medical routines that disturb the bonding between mother and baby. And all this after a birth where the progress of labor is strictly timed, often induced or accelerated, requiring continuous monitoring and keeping the mother confined to bed. So begins the cycle of interventions, slowing down the descent of the baby in the pelvis and causing more pain, resulting in a much higher demand for medicated pain relief, which in itself can slow down labor or cause fetal distress. In this way, today the percentage of births in Israel by cesarean section is 20 to 25, whereas the World Health Organization recommends an average of 12 percent, including elective C-sections.During labor and delivery, “love hormones” build up in the woman’s body – the oxytocin and prostaglandins that induce and accelerate the stages of labor, and the surge of endorphins that provide the unmedicated woman with strength, optimism and the resulting euphoria when it is all over.The optimum environment for giving birth is a quiet, safe, dark private room, attended by familiar people. Humans, like animals, are territorial and, in times of stress, need familiar surroundings, quiet and privacy.And what about the baby born in this hi-tech environment? American philosopher and psychologist William James described the reaction of the newborn as a “buzzing, booming confusion.”It is true that during the past few years there has a been a vast improvement in hospital births in terms of tending to the family’s emotional and physical needs, and acceptance of the rights of the family on the basis of informed consent. Midwives have better training on how to support mother with natural remedies such as massage, oils, baths and showers, more flexible positions, relaxation and breathing, and use of herbs.However, licensed home midwives, who in Israel must have extensive hospital experience, have chosen to work mainly with home births because they are frustrated with the high rate of hospital interventions, the disturbed environment after the birth and their influence on breastfeeding and postpartum health.Midwife: Ilana Shemesh, Yashresh Immigrating from New Jersey in 1973, Ilana Shemesh has 35 years of experience in midwifery, having worked at Ichilov, Assuta and Misgav Ladach hospitals.“I was extremely frustrated by hospital routines, even as conditions improved,” she says.Shemesh had a reputation in the medical establishment as a radical nonconformist.In addition to home births, Shemesh until recently ran an alternative birth center that was easily accessible to local hospitals.“Alternative birth centers have never been encouraged by the Health Ministry, and home midwives have now received letters demanding that they be closed. The ministry is doing a disservice and actually adding to the risk of home births by this measure,” she asserts.“Women who live in more remote areas in the South could use the clinic, knowing that I could transfer them quickly if necessary. I will only attend home births if the home is within reasonable distance of a hospital, so those women are now unable to have home births or are using unlicensed home midwives who are less selective.”Most transfers are not emergency, she emphasizes, discussing the 10% of transfers during the years that she has been accepting home births. Six percent of these transfers have been during labor because of failure to progress, which she feels is not yet critical but is reaching the limits of endurance for the mother. Out of this 6%, only 2% have needed a cesarean section. More urgent transfer was required in the rarer 4% of postnatal complications of retained placenta or a distressed baby.“Among the obstacles to home birth are lack of insurance,” she says, “and the fact that women who give birth at home still do not get their maternity grant from the National Insurance Institute. Home births actually save money for the government. A hospital birth costs NIS 13,000, whereas a home birth costs between NIS 5,000 and NIS 8,000, depending on whether the midwife works alone or has additional back-up.”She adds that she also calls in a pediatrician to check the newborn infant.Midwife: Mindy Levy, Beit Lehem Haglilit A former New Yorker who made aliya in 1978, Mindy Levy trained at Haifa’s Rambam Medical Center and worked for nine years at Bnei Zion Medical Center, including time as deputy head midwife and clinical tutor. She also coordinated the midwives’ training course at Rambam for two years.“Midwife educators need to be at the forefront of pro-moting home births,” she explains. “When I researched for my master’s degree in women’s studies, I focused on victims of terrorist attacks and sexual abuse that led to a higher awareness of trauma created in the delivery room. Switching to home births, there is a continuum – meeting with clients during pregnancy, being present throughout the labor and follow-up after the birth.”She adds, “It is so much simpler when a woman gives birth at home. In a physiological birth, one without interventions, the second stage is much shorter than the average hospital birth, there is less tearing, rare need to suture, less bleeding after the birth, an easier start to breastfeeding and fewer cases of neonatal jaundice.”Levy is discouraged by the obstacles presented by the Health Ministry.“The first set of protocols for home birth in 2008 allowed for the use of birthing centers, but the review in 2012 stipulated that only the client’s home could be used. These protocols were written by people who do not understand all the issues and without consulting the home midwives. Licensed midwives know when to transfer a client,” she says.And indeed, Levy has a harmonious relationship with the Edinburgh Medical Missionary Society Hospital (known as the Scottish or English hospital ) in nearby Nazareth and is allowed to continue caring for her clients after transfer.“Israel’s home midwives are modern and up-to-date and are qualified to use emergency equipment if required.I am glad that hospitals are there to give top-quality care if needed, but most births are straightforward and progress far better when not disturbed by unnecessary interventions and administrative requirements,” she says.Levy also agrees that finances do not necessarily deter women who want home births.“Women choosing home birth today are those who make a lifestyle choice from emotional awareness and from scientific awareness, having read articles favoring home birth,” she observes.Obstacles to home birth In principle, the issue of maternity grants being given after home births is under discussion in the Knesset following a bill proposed by MK Tamar Zandberg and supported by Justice Minister Ayelet Shaked. At present, the grant is given only if the mother brings the baby to a hospital within 24 hours of delivery. This is totally superfluous if a midwife and pediatrician follow up at home.However, the warning that runs through all these interviews is that the lack of accessibility for home births, the financial constraints and the closing of birthing centers have increased the number of unassisted home births, or those with unlicensed midwives, and it is these births that have hit the headlines when outcomes have been poor.Midwife: Gomer Ben-Moshe, Upper Galilee Head midwife at Haifa’s Rambam Medical Center, Gomer Ben-Moshe made a reverse move. Having worked as a community midwife in the North for many years, she is now head of one of the country’s busiest labor wards.“I trained and worked at Soroka [University Medical Center in Beersheba] and Nahariya [Western Galilee Hospital] and the Nazareth Italian hospital [Holy Family Hospital], and then spent 20 years as back-up midwife and doula for home births,” she says.Ben-Moshe also pioneered a program for supporting parents after loss during pregnancy and the postnatal period.Commuting to Haifa from her Galilee kibbutz is only one of the enormous changes in her professional life, but she made the choice for several reasons.“I think finances do limit home births and, as a socialist, I want to reach all women. I was also very worried about working without insurance. This is one of the many obstacles for home midwives in Israel. And as my family grows, I was finding it difficult to be always on call,” she explains.“Working in a city hospital, we serve a multicultural and multi-socioeconomic population – single mothers, those with physical and mental health issues and those with substance abuse, as well as those who simply don’t know their rights.”Ben-Moshe is meeting many challenges in her career change.“As midwives, we have to deal with all the logistics and administration of running the labor ward, but my main focus is to promote physiological births within the hospital environment. Far more women than necessary are treated as high-risk. Doctors are afraid of litigation, but if they were to witness physiological home births and read the positive research studies, they would realize that most births are indeed normal life events,” she says.With her determination, she hopes to meet all these challenges and continue to make a difference for women giving birth in her labor ward.Ben-Moshe is still very supportive of home births: “When I coordinated courses for midwives, those who had agreed to observe home births with licensed midwives were amazed.“It is true that a home birth can certainly heal a trauma induced by a previous hospital birth, but in some cases the woman and the baby, for social or medical reasons, need everything the hospital can provide, and we midwives have to help the woman have a wonderful birth.”The writer is co-founder and former president of the Israel Childbirth Education Center (from 1981-2010, closed for lack of funding) and author of Life After Birth – Every Woman’s Guide to the First Year of Motherhood.