Saraswathi Vedam ’78

Professor and Director of the University of British Columbia’s Division of Midwifery

‘Fear, Fiction and Fact: Should You Be Afraid of Pregnancy?’

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Vedam: Thank you, Karen. I’m always surprised when people know some things about me that [unintelligible] what I do. I’m flattered by your introduction. Thank you.

I want to talk to you a little bit today about the influences of culture on birth and birth on culture, and how that interaction contributes to the environment that we’re in now which is an environment of a lot of living within [unintelligible], of happy [unintelligible] wife. Since the beginning of time we have always thought of as normalcy and routine and are now overlaid by this culture of fear.

Before I start, it would help me if I understand what your own backgrounds are. How many of those in the room under 25 have witnessed a birth? How many of you have heard a positive birth story? How about a negative birth story? And those of you over 25, how many of you have children? And were you present at your births?

So to understand birth culture, we have to first encounter the loss of the common knowledge of the family experience in normal birth. Now we live in a country and a society where family, and the systems that we had in place for generations to support us through pregnancy and birth, and sexuality are no longer available to us because we’re all over the globe. Birth has become more of a phenomenon outside the home and outside the sources of information that used to reside.

There’s another impact that we have embraced in scientific culture, which sometimes is translated as intervention. It’s not always intervention. There is a lot about science that his holding back from intervention and that’s what I’m going to talk to you about today. The impact of increased intervention and intervention in technology in our entire society creates this idea that the technology that we add to the birth experience, or to even getting pregnant, is normalcy is today’s world.

The last thing that I want to address today is what our responsibility is as providers and as scientists. As people who are interpreting the culture to science and the population. What our responsibility is towards truth-telling. Towards interpreting and helping people who don’t understand, necessarily, the impact of what science is really telling us how to renegotiate the culture of fear. For example, this is not about birth, but we have the understanding now that we can’t let our children walk down the street on their own. We can’t let them go to the library and back because they might encounter a stranger, kidnapping, crime, things like that. And yet, if you really look at the statistics, the reality is crime is at an all-time low and that, in fact, there is much less. But media, the culture, the way they act on the information we get, is more based on the information we get from the outside than the information we get from science. I want to talk a little bit about that as well.

First I’m going to describe to you a study that was done at the University of British Columbia by the former director of the department and a number of the students. They surveyed nearly 40,000 students at UBC and were able to get almost 4,000 responses. They looked at their age; gender; what their educational level was; what their level of study was; whether they were in a relationship or not; what type of maternity care or provider they would like in the future; where they might choose to deliver; what type of labor support would they choose; what kind of pain relief would they choose if they did decide to have a baby; do they want to have babies at all; would they want a vaginal birth or a c-section.

Then they had a number of attitude items that they asked them about. They had statements like, ‘I’m worried about the physical changes that occur to a woman’s body during pregnancy. Or, ‘I’m afraid that I, or my partner, might panic and not know what to do during labor.’ Or the positive statements, ‘Childbirth is a normal process,’ ‘It’s important for all babies to be breastfed if possible.’

It was a qualitative study so they had a 1-5 scale where people had to say ‘I strongly agree’ or ‘I strongly disagree.’ They also were asked to comment in a qualitative section, which means they did kind of an interview style, where they asked them to comment on the feelings they had when they were thinking about pregnancy or sexuality or labor or birth. Or the post-partum period. They also asked students—anyone who had witnessed a birth—to describe the experience and its impact on them. Through this they tracked their attitudes toward reproductive health.

The last section of the study also looked at where they got their information. Was it from their family? Was it from the media? Was it from school-based education? Or was it from another source? They took all the responses and analyzed them using a careful quantitative analysis, which just described the statistics. Then they also did a logistics regressional analysis, which helps them decide if they had a slightly more negative or more positive attitude, which factors were contributing to that. What was predictive.

This is what they found. They found that 40 percent of students are worried about the changes that occur to a woman’s body during pregnancy, and another 27 percent were somewhat worried. A large majority of people. Other concerns that were expressed were a decrease in the quality of sex life—these were their perceptions—fears around sex being safe during pregnancy and concerns over mood swings. The majority of male and female respondents wanted a normal delivery. Over 90 percent. But almost 10 percent of men and women said that they would choose, would prefer, a c-section. That’s a pretty large percentage if you think about it. Ten percent of women. Does anyone know what the rate of c-section is now?

Audience member: About 20 percent?

Vedam:  About 30 percent now in the U.S. The World Health Organization says that any rate that is over 15 percent has seriously crossed the boundaries of benefit versus risk. That when you have a rate in a population of higher than 15 percent c-section, you are increasing the risk to mothers and babies. We’ll talk a little about that later.

For 10 percent of women, before they’ve even gone into labor, to decide that they wanted to elect c-section when many of them may well be in fact well set up to have a birth is a concerning thing. This is the other interesting thing they found out. They wanted to understand what was influencing these. They took out the women and men who had said that they would prefer a c-section, or who had expressed a negative emotion and they found that those students who had witnessed a birth in a hospital, or had experience with a birth in a hospital, 72 percent of those people had positive emotions and about 28 percent negative. Those who had seen a home birth, 82 percent had positive emotions. But those who had only ever witnessed a birth on TV or video were completely the opposite, had only 27 percent positive ideas about birth.

Why is that? What does the media tell us about pregnancy and birth? This is Victoria Beckham. She chose an elective c-section. These women did also—Christina Aguilera, Britney Spears. These women refused to have c-sections. Now which woman would you rather be? How do we depict people and choice around their bodies? What else does it tell us? That labor starts suddenly.

This is from an episode on ER, or Grey’s Anatomy, where she’s breaking her water in the middle of a crowded restaurant. It suddenly starts, there’s a rush to the hospital. Of course she’s laboring in bed, flat on her back. This woman is actually—I’m not tech-savvy enough to give you the clip, but the clip in this is very revealing. This is from Grey’s Anatomy and this woman has a birth plan. She wants to have a normal birth. She wants to follow her birth plan. She wants to have an unmedicated birth and there’s a resident interacting with the fetal monitor strip. And the conversation is them sort of patting her on the head and saying, ‘Well, birth plans are fine but we’re concerned about your baby.’ They completely undermine this woman who is very strong about her beliefs and doesn’t want to have a c-section just for someone else’s convenience.

At the beginning of this episode, you might think that this episode would end up being a triumph for the woman. Everybody around her is against her and they’re afraid of birth or have this sense that it’s a potential disaster and she’s going to prevail. Wouldn’t that be a great thing if she could come out and go, ‘Look, I showed you I could do it! In fact, what happens is they have this clueless father and then they end up, of course, in the OR — with many more people in the OR than I’ve ever seen — but it’s the sense of drama, intensity, and risk that you are somehow selfish if you choose to do things your own way.

We have, of course, the beloved Juno. Here’s another young woman who is depicted as marching to her own drummer, having a lot of self possession, being a normal kid. For the bulk of this movie I had a lot of hope that they were taking a difficult subject like teenage pregnancy and showing that she’s just like somebody you might know. She’s a likable person and she’s making difficult choices. And ultimately, she also ends up with a rush to the hospital. She ends up flat on her back, begging, screaming for an epidural. Here’s this young woman who’s perfectly healthy. Why they couldn’t maintain that sense of power and empowerment and possibilities is a mystery to me.

Post-partum attitudes: Over 40 percent of students were concerned about the physical changes that occur to a woman’s body after pregnancy, another [30] percent somewhat concerned. I found this—this is April 2008, and this was after I had been asked to do this talk, chosen this topic. I walked into this five and dime and this is—it’s so offensive to me. “Winners and losers.” And then the picture has eight pages of actresses. Who here looks worse? The pregnant woman, right? Eight pages, showing their weight.

So we have this culture of skinny. We have these ideas around cosmetic surgery. C-section being not c-section, but cesarean section or surgery, but cesarean birth. That we should try and normalize it. Thirty percent—1 out of 3 women are having c-sections so we should make it a nicer experience. All of which I support. C-sections are not all bad. The technology that we have that is truly helping families who cannot have babies or have a pre-term or babies at risk. It’s a wonderful thing and it’s a wonderful surgery if it’s used appropriately. Perhaps we need to talk and think about how a public education campaign around these self-esteem and the messages we’re giving, not just to the young women, but to the partners that they’re with.

So these are the reasons that the students talked about that they would prefer a c-section. They were worried about pain, about body image. They thought it might be more convenient. Everybody in their family had had c-sections. They believed they were too small. And they believed it would influence their sex life.

‘I have no intention of experiencing a vaginal delivery. I am fully aware of what it entails and I will not subject myself to it, no matter how natural it may be.’ ‘Being able to choose a cesarean birth is the only reason I would ever consent to carry my own child.’ These are real quotes from the qualitative portion of this study. People believe there are less complications, that it’s safer, that surgery’s no big deal. That they’ll somehow get all stretched out or that their partner will no longer please them. And again, in the sense of family history, the loss of the cultural possibility that you can do this.

This phenomenon has been described now in the literature—of course, we have to label things and find something—and they call it tocophobia. Fear of childbirth. Actually it’s got a psychiatric diagnosis now, where 6 to 10 percent of women report nightmares, physical complaints, fear of labor pain. [Unintelligible] never had babies. Fifty percent of the women, however, once they were given a little bit of information to discuss the information about what they were choosing, changed their mind. And then they had normal vaginal deliveries.

The question is, is it really the women? Are we really all influenced by the media and believe those silly stories in ER? Is it just that? I think not. I think it has to do with the stories that we tell. The stories we tell each other, whether we tell positive or negative stories, it has to do with what we encounter when we encounter the people who are going to be our care providers. What scientists choose to report or not report, or highlight what the media then takes their cue from.

A lot of times when you talk in professional meetings they’ll talk about why we’re having this rise in c-section rate. Is it just because of liability? Is it because women are choosing that? Is it because women really don’t want to be—the feminist thing now is to be free of pain when you go through labor. Is it that they are obese? Or that they are having babies older so they’re really more at risk?

Or it’s a technology-loving society. A lot of that is about blaming women again. I submit to you that I think that it’s a much more complicated thing. There is some impact of fear, and we know about the physiology of what fear does for us in all kinds of situations and what kind of belief and hope does. Whether it’s cancer or extreme sport. What you can endure and what you can achieve. In extreme sports they talk about mastering your fear, moving through your fear and moving through your pain. So it’s fashionable in one area, not in another.

I’m wondering if we then talk to women more—whether it is through media, or in the clinic when they come to see us, or in educational settings—about what the reality is about what they believe. So if they believe that it’s about the health of the baby, what if they knew that good quality scientific data, randomized controlled trials and perspective trials have shown that there is, in fact, a higher neonatal death rate with c-section. That the c-sections that are done for elective c-sections often don’t get the dates right and they end up delivering babies who are pre-term who then have other risks.

What if they knew that a woman is 5 to 7 times more likely to die from a cesarean delivery than from a normal delivery? A woman having a repeat section—so if you do one c-section and then you live in a community where you don’t have the option to have a vaginal birth, you’re twice as likely to die with a repeat section. Twice as likely than in a normal birth. Twice as many women require hospitalization, re-hospitalization, after c-section in going home and coming back. Having a c-section means higher rates of infertility, ectopic pregnancy, and really severe placental problems in a future pregnancy. Babies born after an elective c-section have four times likely more risk to develop something called persistent pulmonary hypertension, which is a serious condition that affects respiratory status and heart status. Some of that has to do with not being squeezed and having the lungs emptied as they come through the birth passage. Some of it has to do with whether or not they’re actually term in their delivery.

The risk of death to a newborn delivered by c-section to a low-risk woman, a low-risk woman now, is 1.77 deaths to 1,000 live births. Where the risk of deaths to a newborn delivery vaginally to a low risk woman is only .62 to 1,000 births. The interesting thing is that the fact that you have almost twice, almost three times, the risk of having a problem with your baby after a c-section is not publicized. When recently there was a big study that was published in Washington about planned home birth, they claimed that there was twice the risk of death from planned home birth, which I’ll talk to you about later. It wasn’t even really planned home birth. They were including women who were 34 weeks and on. Pre-term women who you wouldn’t think of as planned homebirth.

But they said it was a difference of four per 1,000 births as two per 1,000, three of the four having been had congenital heart anomalies, which you might understand has nothing to do with the place of birth. But that was widely reported in the media and in the scientific literature as being a big risk of homebirth. Whereas the fact that c-section, which we do all the time, 30 percent of the time, is increasing risk for babies is not publicized. Women also end up having longer hospital stays. They’re more tired, they’ve had major surgery, damage to the body. You get no scar on your uterus or your belly when you have a normal delivery.

Then there is the psychological health of women. Women who have normal delivery and feel like they’ve achieved something, they score much higher on rates of active involvement with their birth, self-esteem, things like that than passive compliance or feeling like something was done to them. This is a family that the mother was a labor and delivery nurse, the father was a rehab physician and director of a center. This is about four or five minutes after they delivered her second child and both babies were born at home. You can see there’s a great deal of joy and that happens in lots of births. It happens in births when you have epidurals. It happens in births when you have c-sections. It is a wonderful thing to have a baby. The kind of appearance of people looking healthy and joyous and just like it’s part of life is rarer in our institutional settings.

I’m going to shift now and talk just a few minutes about what some of the other scientific things—these things about pain, where to have your baby, there are a million areas that we can go into. Only 17 percent of the things that we add to birth, the interventions that we add to birth, have been subjected to scientific evaluation. But we do have quite a lot of data about normal birth. About the physiology of undisturbed birth. We have a lot of information about the progress now of labor, the onset of labor. Methods to increase comfort in labor and what the [unintelligible] aspects may be around the progress of labor that’s undisturbed. So I’m going to talk to you a little bit about that.

First, starting with the area of my evaluation and research. That is about the homebirth literature. What we know from studies about why people choose homebirth is they will list all these things—ideas of privacy and comfort and self-determination—that it’s easier to respect their cultural practices, whether they be from an Orthodox Jewish family or a black Muslim family that feel they cannot provide their rituals or their food.

When I was in Indiana, I served an Orthodox Jewish community quite a lot and in that hospital that was local, which by the way, they had to take a car to because it was far from where their schul [synagogue] was. So if they delivered during one of the holy days or on the Sabbath, which was Saturday, they would have to arrange for someone else to drive them to the hospital. The hospital didn’t keep kosher on the weekends so these families were left without food. Sometimes people choose it for those reasons.

The one word though that is consistently brought out in all of these studies, and these are international studies that happened in Europe, in Australia and New Zealand and North America, is this idea of empowerment. That people feel, women feel, like they have a greater sense of control and ability to call the shots, and that they feel safer in their home. Niles Newton in the 1940s was a woman who did biological research and she took pregnant white rats and she put them—they were all healthy, there was no harm being done to them—put in two sets of cages. A randomized perspective control trial where she had these pregnant white rats. She just watched what happened to them. But the one set of cages had a tiny little sound, a little ping, that went ‘ping’ at random. It was not predictable. It had no shock, and no pain, no consequence associated with it. It was just a sound. But the rats that were in the cages—these were thousands of rats and these were repeated again and again—had significantly more obstructed labors, more complications, more fetal losses. The interesting power of environment on biology.

When we talk about whether or not homebirth is safe, the problem with evaluating whether or not homebirth is safe is you can’t randomly assign women to home and hospital. So we can’t really get what we consider the gold standard of evidence around this. A randomized perspective control trial. Also there’s a lot of misunderstanding about what homebirth is. When people who are trying to evaluate this, they really are thinking about the difference between a planned homebirth and an unplanned homebirth and a planned hospital birth. If you lump in together the women that didn’t make it to the hospital; the women who didn’t have anybody with them; who didn’t have anybody trained; or maybe they have somebody trained with them but they live in a world setting far from any services, then that’s really not what we’re talking about as planned homebirth.

In countries that have very low neonatal and maternal mortality and morbidity rates—that’s illness and death for mothers and babies—all of those countries, including the Netherlands and many of the European countries, Australia and New Zealand, they report much lower rates than the United States and all of them have a higher degree, a higher rate, of homebirth. The country that’s had the lowest rates of mothers and babies being ill or dying for 22 years is the Netherlands and 35 percent of their babies are both born at home with midwives. Of course, it’s not about just midwives or just homebirth. It is about the whole system of prenatal care and total care for the women and education. But certainly homebirth isn’t hurting the statistics. What they define as planned homebirth and what has come to be defined as the planned homebirth is when you have a well-screened woman; you don’t start intubating, it’s pre-term at home, obviously those babies are more at risk.

You have someone who’s not a smoker, who’s well nourished, who’s grown well, she has a qualified attendant—that qualified attendant brings oxygen and the medication to stop bleeding. The basic things that we have in delivery rooms. And it’s not [unintelligible]. We change the plan and if the labor is prolonged. If there’s a complication, if there’s a funny thing on the heart rate, it’s homebirth with access to MD consultation and hospitalization when necessary. When you separate out now the studies that really are talking about planned homebirth that don’t include all those other situations which really are more risky, then you can start talking.

The next thing to do is think about what outcomes are we looking at? In the developed world, everybody talks about death. What will happen? What if something terrible happens? Everybody’s worried about mothers and babies dying. But in actuality, mothers and babies—unless you’re in Mozambique where it’s a 1 out of 13 chance the mother will die—in the developed world that’s not really happening. Maybe we should be really looking at what type of care is producing optimality. Which babies and mothers are healthier. Not just at the moment of birth but long term.

And then there are these other methodological problems where if you try to compare apples with oranges, where you’re comparing midwife outcomes to physician outcomes and their scopes of practice are different, what they’re doing is different, they’re education for even managing normal birth is different. You have these small and homogenous studies. And there’re differences in definitions among countries. Do you call it a fetal loss when the baby dies, or a neonatal loss, within five days of the birth or six weeks of the birth? In the U.S. we don’t track any birth-related complication beyond six weeks. Yet a lot of them happen months out, particularly if you have surgery.

Incomplete data also is a big problem because a lot of the studies done are based on birth certificates and it depends on who fills out the birth certificate. Or if the birth certificate even tracks something like the planned place of birth. The good news is that we now have nearly a decade of studies that have addressed all these problems. They have created prospective trials. They haven’t randomized but they’ve matched like women to like women. So women who’ve had babies with women who’ve had babies. Women who are of a certain age group, from a certain ethnic group, women who have one type of provider. They will do match case controls or they’ll do large population things that are prospective that look at one type of provider.

And we have a number of different studies looking at this issue of location of birth. What have they found? They’ve found for death, really, the outcomes are pretty comparable: about one to two per 1,000. Whether you’re home, hospital or birth center. And what they’ve also found is that when you’re looking at maternal and fetal outcomes—that is, morbidity—that homebirths are associated with less medical innovations. Some of that is because they’re not available, so we don’t use them.

But even when you keep in the group the original, we’re not talking about people who just end up doing it at home. But if you keep the cohort of women who are planning home birth and you include all the people who ended up at the hospital who planned homebirths in that original cohort, that’s the first thing to do, so you don’t just sway the statistics because hospitals look after more higher risk women. You compare low risk women to low risk women. Follow them all the way through; keep them in the same group. You find that even the women who started out at home and ended up in the hospital—and you know when they go to the hospital and that by definition means that they have probably moved form more low risk to high risk—still the babies have better Apgar scores, they have less severe lacerations, induction, all types of things.

People have said also maybe it’s because these are self-selective women. That these are women who are rejecting the establishment. They are the ones who will refuse the intervention. But in fact these outcomes have held true even when it’s considered a fundamental right in Canada now, and in England and all over Europe. When you book in, they ask you, do you want home or hospital? Everyone is supposed to be given the option.

And the socioeconomic diversity, and the lifestyle diversity is great. There’re all kinds of people. I’ll tell you in my practice in North America, I’ve looked after doctors, lawyers, single moms, postal workers, farmers, Orthodox families, academics, the whole range of people. What they find is that how many people end up going? It’s about 5 to 8 percent of people who once they get to term, planning a homebirth, will end up moving to the hospital. That means 92 to 95 percent are delivering normally. What do you think the most common reason for transfer is when they start at home and want to go to the hospital? For pain relief, that’s actually the least common.

Audience member: Failure to progress?

Vedam: Failure to progress, exactly. Eighty percent of the transfers are for first-time moms who have a long labor and after 36 hours of labor, you’ve tried all the bells and whistles, the position changes, the nipple stim and the nutrition and rest, then the kind thing to do is to go to the hospital and get a little help with what we call an augmentation. It’s not an urgent thing. It’s not a rush-rush deal. You hope that the bumpy ride will do it. And the outcomes are generally very, very good. Urgent transfer occurs one per 1,000. Has anybody seen this slide before? This is one per 1,000. You really have to put it into context.

When you’re talking about risk, every time you get into your car you probably have, I don’t know what the actual numbers are, but you’re risk of dying or having serious injury in an automobile accident are probably 50 times or 100 times greater than planning a home birth. And yet, that’s an acceptable risk. We get into our car everyday, put our seatbelts on — don’t even think about that, right? But when we’re talking about choosing normalcy, it suddenly becomes this risk.

So this is the framework for optimal care if you’re planning homebirth for somebody. Screening criteria, basic skills, basic equipments, continuity of care. Continuity of care and strong patient/provider relationships have a lot to do with what somebody said about pain relief. About what women say about what makes them feel their experience is positive. This is me offering one of the most effective pain relief techniques. That is when a woman is about 8 centimeters—the pelvic anatomy becomes more mobile when you’re in labor because you have a hormone called relaxin which actually softens up the cartilaginous joints and if you press on the [unintelligible] you actually end up spreading the outlet and you can increase the pelvic dimensions and you can produce a lot of comfort.

When you look at pain, which is the other big thing—I’m going to tell you a little about this and leave some time for some questions—when you look at the nature and management of labor pain, the other thing I wanted to tell you about is there’s some very exciting physiologic now work that’s being done about the progress, about the hormone and the neuro-endocrine regulation of labor and birth. There’s a lot of discussion in the literature about oxytocin, about endorphins and catecholamines, which are chemicals for those of you who don’t know, which assist us in time of stress.

So you all know adrenaline, right? So what does adrenaline do for you? What do these catecholamines do? They increase your respiratory rate, increase your heart rate, increase your alertness, spare your blood to your central organs so those are protected in case your respiratory rate—all those things are vitally important for who in labor? There are two people involved, right? The baby has to come out and basically at that point it’s on its own as far as its heart rate, breathing, finding food, being alert, mobilizing fuel to keep itself warm.

Those catecholamines, it’s actually the anesthesiology literature that has discussed this because they found when you give an epidural, there isn’t that immediate effect. When a narcotic to a woman in labor to modulate pain, you will see almost immediately — it goes into the bloodstream — and almost immediately you’ll see the heart rate almost go flat for the baby. But with an epidural you don’t see that. So for a long time we used to tell women that epidurals are safe for the babies. There are impacts for the women of course, but for the women the impacts are that you’re more likely to have forceps or a vacuum; you’re more likely to have a prolonged second stage; that you could have an epidural fever; hypotension, drop in blood pressure. There are different risks for the mothers, but most mothers want out of pain and as long as the baby’s going to be okay they’ll accept those risks because they’re focused on two things, the health of the baby and their discomfort.

What we understand now is that they’re starting to see that there is a delay. About an hour after you put an epidural in, babies tended to decompensate. They thought maybe it’s because of the blood pressure drop. And babies would go to the NICU [Neonatal Intensive Care Unit] afterwards with this because the mother had a fever and maybe there’s an infectious process. What’s going on here? What actually is going on is not what we’re adding, cause we’re adding this [unintelligible], this little bit of drug that goes into the epidural space which doesn’t get into the blood stream except in trace amounts and then has to go across the placenta. But what we’re doing is we’re taking away the source of endorphins and catecholamines and all of these things that the mother’s body is producing to protect this baby and to help make its entry into the world. Fascinating stuff.

That’s why we find women who have epidurals later in the labor, maybe 8 centimeters or afterwards, almost when they don’t need it, when they’re about to push their babies out, those babies do better. Women who have their epidurals early on, their babies don’t have all the benefit of that because for about an hour or two hours maybe, this drug is still going to be there in the experience of labor.

These are the kinds of things that were described in this symposium that happened in 2002. They looked also at non-pharmacological methods of pain relief, which are often, people think, natural birth. You must be brave to do that. I’ve had four babies and I can tell you, I would never tell a woman that it’s not incredibly intense.

Some people experience pain, some people talk about it like people do about extreme sports, where it’s an enormous amount of work, they didn’t think they could do it, etc. I wouldn’t say it’s an easy process, but there are lots of things that we do, certainly as midwives, to help people be comfortable.

Contractions never last more than a minute, so you can live through anything for a minute if you have some of these kinds of things. They looked at a number of non-pharmaceutical, acupressure, massage, various things, but what do you think the single, most evidence-based, method of pain relief is? Promoting comfort and progress even when you compare it to epidurals — epidurals, of course, impact progress, they reduce progress — even when you compare it to a method that takes away all pain, or narcotics or nitrous oxide or any of these other things. What is the one thing that promotes comfort, progress and good outcomes?

Audience member: Continuous labor support?

Vedam: You got it. Continuous labor support. It does not have to be a trained person. They’ve done this. They started in South America, replicated it in Texas again and again. It’s called the doula effect. A woman who’s not alone in labor progresses better, has less complications — getting back to those pregnant white rats of Niles Newton — and reports her experience as being better and does not ask, at least, for pain relief as much.

When we talk about position in labor it’s another thing we do. There are a lot of things. There are a lot of advantages to upright birth that have been demonstrated physiologically. Those translate into increased progress of labor.

This is a couple, the two women are the couple. They have a known and beloved friend who was the sperm donor. They wanted him to be involved in the birth. They were afraid that if they went to the hospital that someone would, because he was actively involved, would assume he was the birth father, the primary parent, and would hand the baby to him and reduce the respect for the second mother. So, they chose to deliver at home.

The advantages for the upright birth include the reduced duration of the pushing stage, reduction in episiotomy, pain, etc. What do women say about pain? In the symposium they had a number of systematic views which were very carefully controlled evaluations of the bulk of the [unintelligible]. And not just the latest study, all the studies that have been done on the subject. They looked at 137 different reports. They found that of these four factors, what the woman expected for her birth, the amount of support she got from her caregivers, the quality of relationship she had with her caregiver, and her involvement in decision-making, were far more important as far as whether she thought she had a good birth experience than whether she had a c-section of not, what her socio-economic status was, whether she had interventions or not, when they evaluated them.

This a family, an African-German woman married to an African-American man. She came to America shortly after marriage and expected birth to be happening from her two home countries and was very dismayed that she couldn’t get that. This also, as you can see, moments after their homebirth. I submit to you that the fear that we started talking about may not be fear of birth but fear of neglect, fear of being alone, certainly fear of pain. What do we tell women about pain and what we can do for them and what the benefits of normal birth can be? Not just about being tough or being natural or that’s the way you should do it. In fact, there may be physiological benefits to herself and to her baby. What I’m hoping is that we can, together, start more of a campaign for normal birth.

It’s related to the breastfeeding question. In my field, even midwives will say, there are huge debates about whether or not we shouldn’t make people feel guilty about choosing not to breastfeed. That it is a choice. Everything is about choice. There’s a lot of debate about it but I wonder about that option. It’s not about guilt, really, it’s about information. If women really knew, understood, not just the benefits of breastfeeding but the potential risks of not breastfeeding, would they make those same choices? Do we worry about that when we tell people you shouldn’t smoke during pregnancy? Do we worry about making them feel guilty? No, we tell them about the potential harm to their baby and their pregnancies. It’s the same sort of thing. What about normal birth not being a natural childbirth movement, or about rights as it was in the ’60s, but about truth. Truth about the scientific basis for it. Then how does that influence the media?

I think that we can do it. This is somebody else from Grey’s Anatomy on one episode. As a woman of color, I will say that the one normal birth that they showed on this show, on ER, which you’ve seen a lot, was with this feisty black woman. And perhaps not somebody who the large majority of the population can relate to, or see themselves in. She is seen as somebody who is counter-culture and in your face. It’s not always a positive influence, but she said, ‘I’m going to have my baby my own way.’

There are some other examples. There is this wonderful movement that’s happening on You Tube now — you all will be more familiar with You Tube than I am — where they have these sites which, some of them are worrisome for those who [have pride] about unassisted birth, people who are so alienated by it that they are choosing to deliver completely by themselves.

I am a believer in normalcy. I do believe that about half of what I do is sitting on my hands and it’s not about me producing magic. But I’m a midwife because I believe there are certain situations in which I can help a bit. I wonder about pushing people to that extreme also. But there are people who are in the underground, in the way that even Obama’s campaign has sort of produced a whole different way of communicating. I think that when you talk about activists, I think that they are among all of you. That’s why I chose to bring this idea to you. I invite you to come to us and go to those other sites and educate yourself and your colleagues and people who are entering those things. Talk openly about things like sexuality and responsibility and truth and physiology. Maybe you can all produce something like this.

There are, of course, [opinionators]. I don’t know if those of you have heard about The Business of Being Born. Anybody seen that film yet? It’s sweeping the country. It’s a [popular] analysis—it’s almost a documentary—about what has happened in this country. There are showings all over the country now where Ricki Lake chose to have a homebirth with a certified nurse midwife. We need those people.

This is Suzanne Arms, who wrote Immaculate Deception back in the ’70s and got a lot of us galvanized. ‘If we hope to create a non-violent world where respect and kindness replace fear and hatred, we must begin with how we treat each other at the beginning of life. For that is where our deepest patterns are set. From those roots grow fear and alienation or love and trust.’

Audience member: A few years ago, there was a study that came out and got reported in media quite a lot about urinary incontinence and vaginal birth. It got a lot headlines. I heard that it was later discredited but I don’t know what the story was behind that. I think there’s a widespread perception and there’s all of the press …

Vedam: This is what I was talking a little bit about the design of studies. The study that was done did not factor out how those women delivered. Whether they had forceps or vacuum; whether they had directed pushing or not; didn’t separate out size of birth. In fact, there are more urinary problems, much more serious than incontinence, that happen post-c-section than with vaginal births.

It has been pretty widely discredited at this point. There are people who are pelvic floor experts who tell you that once you’ve had a bunch of babies they have to do pelvic repair, kegels. There are things we can do that are preventative, that have to do with exercise that might prevent that as well.

Audience member: I’ve never seen a live birth. I’ve seen a lot of births on film. My wife, who couldn’t be here today, will be so sorry she missed your marvelous presentation. She’s a nurse midwife. She’s delivered about 2,500 babies. She headed up a pre-term program at a large Los Angeles hospital. She started her own homebirth program down in Georgia.

Vedam: What’s her name?

Audience member: Debbie Sweeney. And I think her difficulty today—and we’ve had a real life experience in terms of one of her daughters—is she feels that the midwifery profession is really being compromised, or letting itself be compromised, by the medical profession in total. To give an example, one of her daughters was going to be delivered by a midwife, she went to see a midwife all during her pregnancy, went into a New York hospital, the pregnancy went wrong, the hospital wanted to take over. The midwife lost all credibility at that point. It was the doctors who took over. She ended up having a c-section. She didn’t have to have a c-section at all. So the concern that Deb has is that midwives now don’t have the same kind of courage to stand up as they did in the ’70s and ’80s, and that the legal profession …

Vedam: I think it is a very, very interesting question that you raise, and one that troubles me as well. I think that there was a vanguard of those of us who were new and young, and new at Amherst as women, and learned to kind of stand up for that. That was a cause as well as a job. The benefit of now normalizing midwifery—and we have many more young women coming into midwifery—you have a wider range of people who are willing to take up a fight or not. Then there also is a sort of a backlash where midwives have been very, very successful in this country. There is an economic backlash where babies are a guaranteed source of income so a lot of midwifery services are being closed because of the liability, costs of providing a number of providers, where the liability costs are higher than OBs, but you need an obstetrician always in case there is … So they will keep the obstetrician and let the number of midwives go. Then you lose power because you don’t have power in numbers.

I think we need a consumer movement. I think what needs to happen is what’s happening in Canada where we have much more discussion about inter-professional communication and how you make inter-professional relationships work better. When you raise them up together, when you educate them together—this happens in England—the mutual respect for the professions and the area of expertise is greater. So then someone can say this is within the range of normal and I’ve given you a head up.

There are many more areas where the length of labor and things like that are well described in literature but not being talked about. If they’re talked about only by midwives, and there isn’t that communication, it’s much more difficult to produce change. I agree with you. It is worrisome but I think it is surmountable because it is happening in other countries and I think that we need to look at the models that are effective there.

Audience member: One of the interesting things is she gave a lecture to medical students at one of the large medical schools, and the kinds of questions that the medical students—these are first, second and third year students—were asking, both men and women, she thought were terribly naïve, which means in that the medical schools are really—this whole thing is not addressed in a proper fashion. Even women OBGYNs, a lot of them had the same [unintelligible] that their male counterparts did, which is really sad.

Vedam: Yes, fear. I didn’t get into that, but the woman, Katherine Heigl, who was in Knocked Up, she had a normal, not a c-section in that movie, but she said she would choose an elective c-section because just playing that role and seeing a friend’s birth has put her off totally to that whole thing. They’re influenced by it. And the Grey’s Anatomy woman had to go through a sort of therapeutic process and really look for a way for her to enter into for when she got pregnant. We as providers, and as media people, are influenced by these issues, too, and then it has a cascade effect.

Audience member: Could you talk a little bit about when you believe c-sections are necessary? I hear from friends, and for myself, I had a c-section, there are a lot of unnecessary c-sections but mine was necessary because of ‘this.’ I don’t even know if that’s true.

Vedam: That’s a really good question and a difficult question. Women need to be able to come to terms with their experience. We never want to disempower them by telling them that if you’d had a midwife maybe it didn’t need to be that way. Then they have to enter another whole grieving process. I’m sitting here talking to you as a midwife and my experience of some thousand births. I will tell you that if I was there I might have handled it differently. I might have hung in there with your daughter. Or if we were at home you would have been able to do ‘this.’ The first answer I think would be that whatever woman had that experience, everybody’s intent is the same for health. And how we get there is different. How we interpret the impact. People will say, ‘But you had healthy babies.’ That doesn’t empower women because it’s not inconsistent.

We can love two children. We can mourn the loss of our parent at the same time we are joyful of a birth of a grandchild. The fact that we mourn the loss of a rite of passage doesn’t mean that we’re not thrilled that our baby is healthy. Nor does it necessarily mean that we had to have a c-section in order to have a healthy baby.

I can tell you what the literature says. When most fetal distress that we identify on an external fetal monitor doesn’t end up being a baby who’s nearly in distress, we want to go to c-section. That is one that we have to get much better at evaluating the signs of reassuring fetal status. Second to that, many women are told that your baby just couldn’t fit. Your baby was too big. In fact, unless you’re a diabetic, it’s very unusual that a baby is too big to fit. We used to do radiologic x-rays to see [unintelligible], size of babies and made all these calculation to decide about this size of a baby can fit through it. What they found out later is that if you squat, you increase your pelvic cavity by 30 percent. There’s a relationship between the mother and the baby, so the baby’s suture lines in the head overlap. If you wait long enough, they overlap more.

There are two things that I’ve been showing you. One is, all take your fingers and go like this. Two fingers, and press them together, and your thumb. While you’re pressing them together try to slide them on each other. Difficult to do, right? Now think about how much space you have to create in order for the top finger to slide. Does it have to be an inch? Half an inch? Can they still be touching? That’s the amount of space that you have to create in the pelvis for the head to slide by and get out.

We, again, blame women that your pelvis is too small. If you didn’t grow up in Africa and were malnourished and actually have a pelvic deformity, it is unlikely that your pelvis is too small. The difference between an 8-pound baby and a 7-pound baby is at most a centimeter in the head. That can be accommodated for with the sliding over. The soft tissue is what makes differences in weight and that’s compressible. Also, you cannot tell that the baby’s going to come through. Sometimes they have [unintelligible] because their head is caught or there’s a different dimension being presented, but you can’t tell that until she’s fully dilated. How many women do you know who’ve had a c-section at 4 centimeters or 5 centimeters? The baby isn’t supposed to start coming out until after that.

Again, that is about fear. It’s about what we teach in medical school, about what we believe. I did a birth once with a medical student there and she had a c-section with her first one and a normal delivery this one. Delivered her baby, had no tears, beautiful intact perineum. The medical student stood beside me and said, ‘How come there’s no episiotomy?’ Like I had done something wrong. It was clear she didn’t need it. She didn’t have a skid mark.

It’s about what we talked about—what’s normal. So if you’re taught that the baby should come down, or maybe we’re worried about that and don’t labor, sit, you don’t see the progressive labor you’re supposed to. Go in and just catch the baby at the end in medical school. Whereas we in midwifery, we’re there the whole time so we have a different sense of the possibility of the signs that we get that she’s not ready.

Having said that, there are women who have babies who are posterior. Or women who have a lot of prolonged labor and are exhausted and after two or three days they don’t, for whatever reason, their body hasn’t responded. Their [unintelligible] muscle is tired, they can’t get to the point to which they can open and push and try. Those women may have failure to progress, but why tell them that it’s because the baby wouldn’t fit? It’s bad enough that it didn’t work and ultimately, if their water’s broken—is it kinder or is it healthier for them to have for days? In the past, people would do that. People did not survive the [unintelligible] of labor or [unintelligible].

Sometimes to get some answers there are a variety of reasons why someone might need to have a c-section, but sometimes the reasons the woman is given aren’t the reason. And sometimes we don’t know why things happen. It’s very uncomfortable for us as providers to say we don’t know.

Audience member: Probably the greatest fear of homebirth in this country is the lack of availability of malpractice insurance for midwives. Could you address that, please?

Vedam: I’ve been trying to address it for about 10 years. For the last several years I’ve been the chair of the homebirth section of the [AC and Gynecology] and that’s one of our top things. I had myself practiced with and without malpractice insurance because of availability. I think that one of the ways to address it is to change what we expect as far as the relationship. Maybe it has to be a no-fault insurance system. Maybe we should honor and respect arbitration and mediation. Things are unpredictable; we don’t always have control over this. Families need to understand.

Midwives don’t get sued as often and homebirth midwives even less because we’re very much in a partnership with our clients and most suits happen because people don’t understand why something happened. They’re angry and don’t know where to place that. Someone tells them that’s the way to fix it. So if they’re involved in the decision making process, they’re more likely to take responsibility for whatever the outcome was. But we do live in a society that expects [certain] outcomes and sometimes mothers or babies need additional help, which is very expensive because our medical care is very expensive.

To me, fixing the problem is much larger. It’s about universal healthcare, it’s about tort reform, it’s about a different relationship with how we negotiate pain and loss. The short answer is, we are right now exploring self-insurance, midwives insuring themselves through a captive insurance program which we would have to buy a piece of a larger insurance company and set up the conditions ourselves.

Audience member: Following up on your question about midwives who were willing to do homebirths, for instance, in this area, we have a lot of midwives who are through hospitals and only deliver there. When I delivered my daughter with a midwife on Long Island, I couldn’t find anybody who would do a homebirth, only midwives who deliver in hospitals [unintelligible]. Is there any sort of organization for homebirth midwives? How you find one who’s sufficiently credentialed?

Vedam: Another excellent question and yes, to all those questions. My current research is about why is it that midwives, who are certified nurse midwives in this country and midwives in North America, are the sole providers and who are educated to offer to serve in all settings, are no longer choosing to practice at home. In fact, there is another class of midwives in the United States, which now are professionalized. They’re called certified professional midwives. I am a certified nurse midwife but I am also involved in Midwives Alliance of North America, which now have board certification and licensure and certified status. Certified professional midwives primarily practice only in the home. Certified nurse midwives can practice in the home but only 1 to 2 percent of certified nurse midwives offer home birth.

We need to bring the two organizations together. If you can only practice in the home and have no option for hospital privileges, then when a woman has to go the hospital you might hesitate a bit before you transfer her, or your role changes and the ability to advocate for your client is stripped. You might change the plan but it may not affect the actual moment of birth. They still want the midwife to deliver. Looking for a certified professional midwife in your area is one thing. I think it is about education, about these same issues of fear. When I was at Yale, the midwives, the students, came through my practice. I had 22 students I was taking through my practice, matching them up with patients for each of them to follow. Sometimes they only saw one or two homebirths or continuity care through their whole education. But it fundamentally changed their attitude towards the possibility of how really our job hasn’t changed that much.

It’s about getting every midwife and every medical student to witness undisturbed birth, or normal birth, whatever setting you’re in and you can’t [unintelligible]. And it reminds us that really what we do, [unintelligible] complication at home or at the hospital, it’s the same stuff. We’ve assigned a lot of weight to the building that we’re in. It’s the qualifications, the access, [unintelligible].

Thank you very much.