Down to Birth

#5 | Preterm Babies & the Case for Midwifery Care: Interview with Midwife/Author Amy Romano

• Cynthia Overgard & Trisha Ludwig & Amy Romano • Season 1 • Episode 5

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Certified Nurse Midwife and award-winning author of Optimal Care in Childbirth: The Case for a Physiologic Approach, Amy Romano, joins us today to share dramatic trends ranging from physiologic to sociologic, which are contributing to poor outcomes in the U.S., especially for black women. 

  • What are the risk factors for preterm birth, and do those risk factors impact black and white women differently?  
  • What mental and emotional factors are contributing to preterm babies? 
  • Finally, Amy discusses the provider/client benefits of a Yale model of care involving group midwifery care.


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Please remember we don’t provide medical advice. Speak to your licensed medical provider for all your healthcare matters.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast.
 Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Today in the studio we have our good friend Amy Romano. Amy is a certified nurse midwife. who has worked in the maternity care system as a research analyst, educator and consumer advocate since 2004. She practiced midwifery in the home, a birth center and hospital settings, and she has taught in the nurse midwifery program at the Yale School of Nursing. Since 2010, she has worked at the national level to advocate for evidence based maternity care, and four care models that support and empower women. a prolific writer, Amy co authored the award winning book, optimal care in childbirth, the case for a physiologic approach. This is such an exciting full circle moment for us here, Amy to have you back because we've all known each other for over 10 years, 12 years. Vanessa is 10 and a half.

So we met back in midwifery school, and then we work together at birth and beyond as home birth midwives. Yes, and we all came together at the birth of Vanessa at Cynthia's home birth.

Yes, you were both my home birth midwives. So it's so special to be together again.

I'm so happy to be here. Thanks for inviting me. Yes, I think we have a lot to talk about today. So should we just jump right in, dive in. Okay. So, before we begin, Amy, I want to just get your background a little bit on how your own pregnancy and birth experience informed your passion for this work that you do now?

Yeah, I have two kids. They're teenagers. Now they're 13 and 15. And when I think about their birth experiences, they were they were both born at home with different midwives because I was living in different states at the time. But when I look back on that time, what's significant to me is That I was becoming a midwife, really at the same time that I was becoming a mom. So as I entered my career, I, it was hard to disentangle those things It was hard to not think about, you know, patient experience to use the term that's used in the literature and so on, from the experience of delivering care. And when I thought about what good care looked like and how I wanted to practice, as I entered the profession of midwifery, I had my own experiences of prenatal care and birth experiences, as well as the postpartum time to frame up what I wanted to give to other women. So I had great birth experiences. They were both fantastic. I had my first baby on Fourth of July. And so that was fun. And I had two midwives. It was really amazing. The birth itself it went really smoothly and I think it was just the good experience that I'd had all along the good midwifery care. I'd had One on one style midwifery care with the midwives. There's just really something special about being able to give birth in your own home and be tucked in at the end of it. And to feel that like on messed with birth high that you get. I can you could just I was walking on cloud nine for like days after that it was really and it felt very hormonal, like physiologically I just felt amazing. It truly is. This Hi, I guess that's why I've always wanted to live in those first few weeks after having a baby I would have baby after baby after baby just to stay there. Yeah, it was the best time Yeah. When uninterrupted?

Yeah, undisturbed. Absolutely. The hormonal physiology of all of it is fascinating to me. I've had an opportunity to work with Sarah Buckley and do some writing and research on the hormonal stuff, which maybe we'll get into but you know, I think we back it up to before birth there really is this hormonal state you get into of just labor land as what we've called her feeling spacey and I feel To the ability to birth with good support and an environment, like a home birth setting, you can just access that more easily. And then that really feeds into the physiology of the actual birth itself. So it was a great experience I had. The second time I gave birth was about two years later. And that was also a home birth, but I was living in Delaware at that time. And there were no licensed midwives to use for that birth. So I ended up using unlicensed Certified Professional midwives, who were fantastic. And it was a real lesson to me that, that good midwifery care doesn't necessarily relate to what initials you have after your title and the care was really, really phenomenal in both cases. And I would say, in some ways, my midwives in Delaware were maybe more focused on nutrition and some of the kinds of things that keep you healthy during pregnancy. So, but overall the experiences were very similar the birth experiences were also very similar. I gave birth at 39 weeks and four days with both babies. my water broke at the beginning with both babies and then contractions came soon after. And then with Lucy It was like four and a half hours beginning to end with Dexter, it was to me Can you explain what you mean? Or what the ramifications are of having a midwife who is not licensed? So it's legal to have a home birth in every state. Yeah, right. So what what does it mean if someone isn't licensed?

Yeah, the different states have different approaches to licensing midwives, certified nurse midwives, which is the kind of midwife that I am and that Tricia is we are licensed all 50 states licensed us but they have slightly different mechanisms and scope of practice rules and so on. And Certified Professional midwives are licensed in I think it's 27 or 28 states right now. It's been and increasing over time. And there's really their education pathways are different but equivalent in terms of they pass a national board exam and there's accredited programs for becoming a Certified Professional midwife, but some of the states are just slower with recognizing it as a licensed way of practicing and so they, you know, it can affect your ability to get insurance coverage, it can affect your ability to get access to different types of care for your on behalf of your patients. My but my midwives even without licenses, were able to order labs and order ultrasounds and, you know, consult with physicians if needed. But midwives can do amazing work at the front line, it's the appropriate first entry into the maternity care system, which you're right, we don't really have a system per se, but countries that have done well with midwifery, you know, or that have done well with their birth outcomes. midwives see everybody and sort out the people who need a higher level of care, the education and supportive care and preventive care and so on that midwives can provide. Let's talk about preterm birth today. It's an important issue and it's one that I've been down the rabbit hole on a lot lately in my thinking and writing. So it's an issue that is increasingly important. It has there are higher numbers of preterm birth.

Yeah, it's really been a persistent challenge. preterm birth was on the decline for a number of years, but now we just had rates and rates typically come out in November. So the rate now is 10 10.2% in the United States, which is the fourth year of increase after a period of decline. And really, if you look back decades, you know, back into the 90s, we were still at around 10%. So we really have not been able to crack this nut as a society. And just to kind Have back it up and start. So people understand what we're talking about preterm birth is any delivery that happens before 37 weeks. So once you get to 37 weeks, that's considered term, it's really optimal and ideal to continue until labor begins on its own or there's a compelling other reason to give birth. But really, what we know about preterm birth is that the earlier a baby is born, the more likely they're going to have both short and long term health problems. preterm birth is in fact the leading cause of neonatal death in this country. Still a serious problem. Despite so much, you know, technology and, and advancements that we've had in the care of sick babies, I think we really have seen some impressive improvements in Nick you care like neonatal ICU care, but really the prevention of preterm birth itself we have not saw but there's interesting things in the literature That, frankly, I think we haven't spent enough time thinking about preterm birth has been exceedingly rare in my own community of clients. And I'm just wondering, do we have risk factors that are associated with it who is having preterm births? What do we know about it? Because I'm just sitting here, I'm astonished. It's at 10%.

Yeah. So it makes sense to me that you don't see a lot of it in your clientele, because I know your clientele is typically sort of educated more Well, well to do I would say them average american. We see very wide racial and income disparities in preterm birth. So it's definitely a problem that disproportionately impacts black women and babies. Also, certain other groups like indigenous groups have higher rates of preterm birth, and also just low income women in general. women that are on Medicaid for Insurance have a higher risk of preterm birth.

But why? So it gets back to sort of what what causes preterm birth. And it's really complicated. We don't actually know that well, what specifically triggers preterm birth. There's a couple of different reasons why preterm birth can happen just generally in like you can put preterm birth in two different buckets. One is, and I think this is the one we think about, you go into labor unexpectedly before 37 weeks or your water breaks or something like that. And that's a substantial amount of it, but actually, a growing segment of it is medically, where you induce labor or have a C section prior to 37 weeks because you're managing a complication of pregnancy like high blood pressure or, you know, growth problems and the baby or those kinds of issues. So, and the risks of going those extra even few days or weeks are greater than the risk of having the preterm delivery. That's To the idea, but there actually isn't a lot of research to specifically guide you know, the exact right timing of delivery for different kinds of complications that develop in pregnancy. So there's a lot of just guesswork frankly in, in figuring out when to deliver babies and I think the framework of a lot of obgyn practitioners is like, let's just get the baby out once we, once we, you know, think it's safe enough because then we don't have to worry about some condition worsening but to get back to racial disparities, and you know, why these high rates in general, there's an emerging body of literature around chronic stress and trauma related stress, experiences of moving around the throughout the world, experiencing racism on a daily basis and those kinds of things, emotional stress, emotional stress, as well as you know, trauma related stress. And real you know, obviously everybody's stressed out All the time, Pregnancy itself can be stressful. And there isn't really evidence that just sort of like episodic stress where you have a stressful day is going to cause you to go into labor. But people who have chronically stressed lives or who don't have periods where their bodies and minds can reset, have an inflammatory response. And, and this is, you know, not just behind preterm birth, you see this overall cascade and mechanism in a lot of health outcomes, like high blood pressure, and diabetes and obesity, and so on. So, the body has a harder time being healthy and vibrant when you're having, you know, chaotic life. So. So that's some of it. And I think that's the sort of emerging explanation for the racial disparity is that it's much more stressful to live in, particularly American society as a black woman. But there's also certain factors that are associated with increased risk. I mean, there are some that are pretty straightforward like twin and triplet pregnancies are more likely to be preterm.

And do we know what percentage of black women are having preterm births because it's got to be greater than --

Yes, it's 14 point something I don't remember the exact number, but it's a substantial increase. So the but Baptists risk factors and there are risk factors smoking during pregnancy is one, poor nutrition or inadequate food security, like people who don't know where they're going to get their next meal. That's one as well as housing insecurity. So people that don't have a stable home environment are at increased risk. I was reading a paper the other day that teens in particular, young women are teens whose families reject them because of the pregnancy. That's a very high risk factor for having a preterm birth. So there's something about Mind Body connection around all of this there's obviously some basic things like nutrition and smoking cessation and so on that can support a healthy pregnancy but there's something happening in the hormonal and inflammatory it's almost like emotional stress is on the same level as infection. Yeah like a physical infection.

I read a researcher called I think her name is Paula brave men she wrote stress gets into the body and it's such a simple thing but it's like it literally gets in and it literally affects your it makes you sick. How you found it's literally acidic in the body. It literally is the it's the foundation for cancers as well. And it's interesting to hear this because we're always looking at this mind body connection. This is very real stuff. We every thought has a bio physical response in the body. So this is affecting one in seven black women. Do we see the same hi Rates of preterm labor in low socio economic white women? Is it inherently because of the lifestyle, the stress? Because clearly, there's no specific reason we're saying, Oh, look at this, there's this relationship between women who seemed to have stressful lives and preterm labor. So it would stand to reason that a woman of any race with a stressful life or in difficult socio economic circumstances would also be at higher risk of preterm labor is that, in fact, true as well, that is also true, and yet, the racial disparity persists even after you adjust for those things. So, so more affluent black women hire educated black women, the type of black women who tend to be my own client, they are not at the same risk as the others than necessarily they are a little bit more risk out of that, by virtue of their improved lifestyle, somewhat, it's so I'm more familiar with this particular way of analyzing maternal mortality, which we Talk about but that is another major issue that disproportionately affects black women. And the research there is really interesting because it is not protective to have, you know, a stable income and a better job and more education, it might protect a little bit, but there's still substantially higher rates of severe maternal outcomes, including maternal death with just by virtue of being black. And I think that's the body of literature where people have really begun to think about racism as the like, agent that is causing the outcome. And so I don't think we have as much of that evidence specifically with regard to preterm birth, but it would stand to reason it stands to reason a little bit and also so it's so obviously, in socioeconomic status as part of it. Also, like pollution has actually been pretty well studied. That's a man's heart. And of course, a lot of these things overlap with each other, right. So You know, a white woman who has poor No, you know, access to food and unstable housing and you know, parents that don't accept her at all is very much at high risk of preterm birth. But all things, you know, the same for a black and white person, the black person is going to be at increased risk of this, and it's because of a lot of factors.

So what can you tell us about what works in regard to preventing preterm birth as much as possible?

I'd love to talk very briefly about some things that don't work as well as we thought they might. And then I'm going to talk about an interesting intervention that does seem to work. So there's been we're sort of coming out of this period of time where a huge amount of emphasis has been focused on pharmacologic and surgical approaches to this problem, which, on the surface of it doesn't really resonate for me personally because of everything we discussed as far as the sort of complex nature of return. Birth and how it's an infectious process. But what really does work is, is taking really good care of women, I think and really supporting their needs in a holistic way. And one of the really consistent things you see in the literature is that midwife led models of care are actually substantially reduced preterm birth rates at the population level. And we've seen it in a couple of different models of midwife led care. European models have been studied in a number of studies, there's a pretty large body of evidence around the models that have continuity of care provider where you're seeing one or two midwives during your pregnancy and it's really you're creating a very strong relationship. That person knows you they're tuned into your whole life. And those studies, you see about 25 or so percent reduction in preterm birth. Yeah, that's incredible. Yeah. And of course, you know,

25% reduction by having continuity of care. Yeah, I think it was 23 actually, but yes, I can't tell you how free Women are in obstetrics practices with six, eight, even 10 doctors. And when I asked How do you like that group? Do they feel right for you? so often I hear well, I really like my doctor, I've met one or two others. Sometimes they really pray they don't get one or two others and then they say, Well, you know, the good thing is my doctor said make sure I set up at least one prenatal with each of the other doctors and I always think what constellation is that? What really, I mean, there are five minute appointments to begin with. For so many women, to technically have met. Each of the doctors is not enough. You have to feel safe with these people. You have to trust them. You have to feel they know you and that they know you what you want for your birth. It's inadequate to say great I've met everyone and now that only reminds me that there are more than one or two I pray don't get that's really what ends up happening. But it's not enough. We really need continuity of care, not a speed dating type of approach.

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One of the things I've done in recent years is how Run a network of birth centers. And as our as more and more people sign up for the birth center, we had to grow our practices and we were really struggling with how do we get this right so that the midwives can have like a balanced lifestyle where they're not on call 24 seven for, you know, special in patients, but that women can get to know the people who are going to be there for their birth because that's so important to so it's, it's hard to accomplish, but it's important and we should not not try to get small teams of people or solo you know, or the ability for women to see one provider or one or two providers through the pregnancy. It gets challenging when now you want that person to be to deliver your baby and and that's hard for the on call lifestyle for doctors and midwives.

Well, this is, in part why your work is so important because we do have to develop a system that works for the provider and the consumer. Yeah, because a home birth is ideal in the sense that you have this provider who's with you from day one. And all the way through your birth and thereafter. But we know that home birth midwives have a What is it five year burnout rate is less than 10? Yeah, sure. I mean, most of them just can't the can't maintain that lifestyle. And so how do we create a system that can provide that continuity, but also protect the provider? Because clearly what you're saying from a 23% reduction in preterm birth with continuity of care, I think we can presume that that feeling of safety with the provider and that feeling of connection is what is protecting these women?

I think so. And there are other models that have been looked at that are also midwife led that also work and so, group prenatal care appointments like Centering Pregnancy is one model of that it's a pretty popular one, but there are others. And so that's where you're with a group of other women. And usually, it's the same midwife or one or two midwives, that leads those groups. So you do get continuity as part of that, but you're also getting this really Incredible kind of social connection experience with other women. And one of the things when we go back to thinking about stress as potentially at the root of all of this, and there's all kinds of interesting research coming out right now about the negative health effects of social isolation. And so with respect to all kinds of health outcomes, you know, including premature death and things like that, but I, I think there's, you know, really something to the toxic effects of social isolation and pregnancy and postpartum. And so, and there has been research into group prenatal care to figure out what is it about the group prenatal care that is potentially having this impact because they've seen and not every study of group prenatal care has found a reduction in preterm birth, but many have and so it's probably population dependent. I would love to see research on lower rates of postpartum anxiety and depression for those women because I would I would theorize that it would exist because the root of all perinatal mood and anxiety disorders is isolation. I would have loved that group prenatals. I've never even heard of that. Where are these taking place? Actually, they the model was developed by a midwife from Yale. And the first clinical trials of the model were conducted at Yale and also at Emory University in Georgia. There have been additional studies at Vanderbilt and other universities. But the model has really spread quite a lot because of the really supportive evidence of it and also the burnout factor, where for the providers, it's a much more pleasurable way of delivering care because you get to connect with people and you get to have time to do the education pieces and that are so important.

Can you tell us a little bit about what goes on in a centering prenatal appointment because it isn't just about the women getting to know each other talking to each other out there actually, aren't they often assessing each other and hands on? Really? That's a part of this.

I thought it was just a matter of benefiting from one another's questions and the midwife not exhausting her resources. But So wait, what are you saying?

Tell us about I'm gonna, I'll tell you about it. You're so you don't assess each other necessarily. I bet some of that starts to happen, but typically, really, it just naturally happened that women had like these little fight myths.

Hands on their belly and I feel the baby's head. No, I can tell that.

Oh, okay. Yeah, nothing beyond. Oh, like checking each other service that's happening in females anyway. Okay, please explain. Okay, sorry.

Typically, you would have your first appointment, which is the kind of close off appointment where you get a full head to toe physical that happens in a one on one and then it sort of picks up usually I think around 16 weeks of pregnancy or Early second trimester, and the rest of your appointments you have with a stable group of other women and often the partners will come as well. And usually the same midwife and it's, I think the appointments, appointments are like two hours long typically, and the first half an hour or so everybody's quickly cycling through to get a belly check. But it's a really brief like, Listen to the baby, measure the belly, check in on, you know, any sort of individual things like lab results or whatever that might have happened. But any of those questions like I'm having this ache or pain, or what do I do about nausea, that's all like, deferred to the group. Like, if you have that question, chances are somebody else has that question and also maybe a solution so you can learn from other people, but also as part of that kind of early part of the visit. People are taking their own weight or measuring their own blood pressure, they're doing those kinds of things. So it's sort of embedded in this model is kind of a self efficacy around I'm like, this is your pregnancy. This is your they're documenting their own results for those things. So just sets this framework of like, you own this process. You're part of this. And we're all in this together. So I personally loved that difference because I left my obstetrician my first pregnancy, I think at around six months or something. And it was so startling to me when I switched to the Connecticut birthing center and then when I planned my home birth and had my appointments with you in your home, you just go into the bathroom yourself, you do that you're in check yourself, you weigh yourself and I remember the first time I sat with my midwives at her desk after I did all that she said, Okay, and what was your weight? And I remember thinking, Wait, you trust me to tell the truth here and I have these crazy thoughts like of course, I'm going to tell the truth. Why did I have a nurse weigh me before?

Why should another adult weigh me? Am I not capable of doing this myself?

And that subtle difference was actually a feeling of empowerment when I just sat there and my regular clothes and facing her at the desk, and she wrote down whatever number I said, of course, I was going to tell her what the weight was.

Those little steps of just taking your own blood pressure, taking your own weight. That's what builds the foundation of trust. And what do we need most of all to have a successful pregnancy and a successful birth is trusting ourselves. Yeah. And those little steps along the way, are what? Start those building blocks.

Yeah. And pregnancy is such a amazing time to actually act. innovate around health in general and be like, Okay, wait, I have a family to look after I'm growing a whole other human being inside of me, maybe I should be thinking about my lifestyle, my environment, my social connections, and so on. So people are really reflective. And I would say, very open to these little things we can do for them that make them realize, Oh, I can be like a steward of my own health care, not just now in this pregnancy, but when I'm managing my child's pediatric care or when I have my own health issues later on. So I have always really looked at pregnancy as a time to flip that switch for people and activate them. And that's a whole concept that's actually been studied in great detail. And, you know, be a partner with my care provider, that when you can increase that those types of behaviors in someone it actually impacts their health outcomes. It actually reduces the cost of care. So when we think from like a policy perspective, people that are more involved in their own health care cost less to the system. And they're healthier as a result. Yep, it's because they're healthy. Amy, for years, I've made the same analogy. I've looked at groups of couples and said, if you haven't already started to view yourself as the own adult in your life. If you're still thinking yourself as the child of your parents, it's time you're about to become the parent in your life. Yeah. If you don't advocate for yourself here, this is a great opportunity to begin advocating for yourself because you're about to be the responsible person for that child. Yeah. So this is your, this is time to become that adult in your life to become the parent. Absolutely.

So I'm putting this all together. We know that the continuity of care and the midwife model of care supports the emotional health of the woman and lowers the stress level and that has an impact on preterm birth. But are there more specific things that we know that why this midwife model of care works that you can detail?

Yeah, I you know, and I do I don't know exactly why it works. These are our best guesses based on what we know about what causes preterm birth. So but it does seem like something about that relationship that forms both the relationship between the woman and the midwife as well as in the case of that group prenatal care, relationships with other folks, those are probably protective and it's probably working at a stress hormones level in the body. But there's other possible explanations as well. You know, midwives do spend more time talking about preventive health care and so we may be more focused on smoking cessation for clients that come to us smoking cigarettes, that's a you know, pretty basic thing you can do to reduce risk, nutritional support and really, you know, diving in deep on nutrition and making sure both that people are making good choices, but also that they have access to food and they're, you know, they're not living in a food desert, those kinds of things. So we you know, we may just do basic preventive kinds of counseling with A little more effectiveness. But then there are, you know, these two types of preterm birth a preterm birth that starts with your water breaking or your contraction starting, or the medically necessary preterm births, but those medically necessary preterm birth are typically some of them are pretty clear cut and these are complicated pregnancies. But sometimes it's like, you've been doing all these tests that may or may not have been necessary late in pregnancy. It's very common in some practices, but not common and midwife led practices, for instance, to do routine ultrasounds in the third trimester of pregnancy. And there isn't really good support to do that. And there's a reason not to, and there's some good reasons not to, and the main reason is that you can get false positives, you can get things that you don't really know what their significance is, but now you have a problem you got to solve.

I know, I know. third trimester ultrasounds are linked to induction rates and in large part unnecessary induction rates but are they linked to a woman spontaneously going into labor preterm.

Now by taking a more low intervention approach in pregnancy where we're not doing ultrasounds in third and third trimester unless we suspect a problem, versus we do them for every client that walks in the door. If we are only doing them when we suspect a problem, then when we find things, that's probably the problem that we suspected, and then we can manage it. But when you're doing an ultrasound on everybody, you're finding like, you know, some, some women who have a baby that seems to be not growing as fast as it should or growing too fast or has too much or too little fluid or, you know, these kinds of things. And then those are may or may not be clinically significant they might resolve on their own. But this decision making then becomes, you know, how, wait, how long do we wait for this problem to get worse versus just do the delivery now and then they look at the clinical guidelines that come from, you know, the OB GYN societies that say Basically, you know, deliver as soon as you think it's safe to get the baby out. And it is true that babies that are born closer to 37 weeks, you know, like in the 3536 week range generally do well, those are not the babies that tend to, you know, die or have these long term health outcomes. But some of them might, they're at increased risk of that stuff.

And they do well on the grand scale of things. But it's the subtleties, you know, they there aren't good press feeders, they, there are challenges, they don't gain weight, and that can add a whole host of problems, right. And nobody's are like following these babies out except for the moms and dads don't have to take care of these babies, you know, that our studies aren't following to see like how miserable was the you know, getting started with breastfeeding or does the baby end up on formula at six weeks because they have slow weight gain, right? Or and all this brain growth happens at the end. So we have no idea what we're messing with when we alter that and, you know, I don't want people to walk away with like, there's never a good reason to deliver a baby before. Third 37 weeks because there are some clear circumstances when you have, you know, severe preeclampsia or, you know, a severely growth restricted fetus there, it makes sense to intervene. But there's so much gray area in there and you increase the likelihood of gray area when you increase the frequency of testing and late pregnancy. So sometimes that gray area is protecting the provider. Yeah, more than the mom or baby.

Exactly. And just to get explicit with that, you know, once you have a test result, you have a potential lawsuit on your hands if you don't do something proactive to manage that test results. So there is sort of an incentive built into that for the provider. A conflict of interest.

Yeah, that's not you know, in the patient's best interest.

I share a metaanalysis in my class in which we see that one in three women who get late pregnancy ultrasounds are till their babies are too big and I don't even want to go down that path because outcome of birth is linked to fetal positioning. Not babies Wait, but one in three women are told their baby is, "macrosomic", which is a term I personally reject. And but one and three are told that their babies are greater than eight pounds 13 ounces, when in fact, after all those babies are born, it's more like eight and a half percent more like one in 12 babies, right? And then we see the percentage of those women who are told their babies are too big. Again, we're focusing on the wrong thing, not fetal positioning, but the weight of the baby. And the percentage of those who are told they have to have a C section. And the rest are told they have to be induced and there really wasn't a category for when or they said, Well, look at that you got a big baby Good for you. You must be eating well, all right on your way. Now. They're told to do something. Absolutely. And it goes further to show what percentage of those women were told they didn't have a choice. So I believe it was one in three were told devotees section two thirds were told to be induced. And I think 40% of those who were told to have a C section top quartile, they have no choice. You always have a choice. And then 20% of those who are told to be induced, were told they had no choice. Yeah, all over the size of the baby, which, by the way, isn't even accurate coming from ultrasound, right? Yeah, all of all of the tests that we have, in late pregnancy to help us understand fetal well being are flawed, and they and they all have some usefulness for certain things, but they're really problematic when we just blanket Li apply them and overuse these tests, because they have all kinds of unreliable results that they can provide. And then they, you know, they they just sort of slot right into all of the fear factor stuff that already exists around birth. Both women and providers carry a lot of fear of what could happen.

So we have the poor outcomes to show for you.

Yeah, and we've invested an incredible amount and in things that don't work very well or only work for, you know, certain high risk situations. But I do them for everybody. And as a society, we've spent over $2 billion, giving progesterone to pregnant women over the last, like seven or eight years, not to their benefit, and probably very few of any of them benefited. Because it's always so much easier if we just have a drug to throw at a problem. Exactly right. It always is the goto.

So I think the takeaway for women is to really seek out care that feels individualized and personalized. It's exciting to me and it feels my optimism to see that actually, policymakers are paying attention to this research. And midwife like care is a path to all kinds of good outcomes for women and babies. We see increased rates of vaginal birth, reduced rates of a PC Atomy we see less use of induction and really better experiences of care too. So there's no downside. Again, it's all upside. And it's a path to a good pregnancy outcome, a positive experience and frankly, better outcomes. We're all for society.

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