Creating More Questions Than Answers

Last month the prestigious New England Journal published the article, “Labor Induction versus Expectant Management in Low-Risk Nulliparous Women” by Grobman, et al. The study looked at 6,106 women who agreed to be randomized into induction at 39 weeks to 39 4/7 weeks (3062 women) or to expectant management with the option of induction after 40 5/7 weeks but absolutely by 42 2/7 weeks (3044 women). The primary outcome looked at was a “composite” of perinatal death or severe neonatal complications. The principal secondary outcome was cesarean delivery. Results showed the primary outcome occurred in 4.3 % of neonates in group 1 and 5.4% in group 2, not statistically significant. However, the cesarean rate in group 1 was 18.6% vs. 22.2% in group 2. Relative risk of .84%. They conclude that induction of labor at 39 weeks in low-risk nulliparous women did not result is a significant lowering of composite adverse perinatal outcomes but did result in a significantly lower frequency of cesarean delivery. 

In the era of fake news, it is sad but true that even science must be looked at suspiciously until proven otherwise. So many “studies” are driven by ideology and economics that it makes it hard for consumers to really know what is true. So now let’s really look into the weeds and dissect what is really going on here. What is the motivation for the push for induction at 39 weeks? Where did it come from? Is it really about “safety” or is there another explanation? While the following is my analysis and opinion I leave it to the reader to decide if I make any sense at all. 

Creating more questions blog fischbein.jpg

The first I heard of the “induce all women at 39 weeks” thing was at a so-called debate at the May, 2016 ACOG clinical meeting in Washington, DC. Up until that day I always thought a debate was supposed to be a cordial discussion of an idea by people holding opposing viewpoints. However, this debate between two professors, Errol Norwitz, chairman of obstetrics and gynecology at Tufts University School of Medicine, and Charles Lockwood, dean of the Morsani College of Medicine at the University of South Florida, became a mutual support meeting with both agreeing it may be reasonable and evidence based to induce at 39 weeks. Prior to this debate, consensus opinion was that induction is done too frequently on low-risk women, especially with poor Bishop’s scores and leads to higher cesareans and complications. That position fit with what most of our experience has shown us. However, since that 2016 debate there have been several published articles on this topic almost all of them finding just the opposite, that induction is not so bad, medically speaking, culminating in this recent NEJM paper. If I was a suspicious person I would say that this is more than a coincidence. Oh, did I say I am a suspicious person? 

Since I have been in medicine, now 40 years, I have witnessed ideas that were thought to be great to have actually caused much harm. Classic stage 1 thinking. Continuous fetal monitoring and Friedman’s curve, immediate cord clamping and lithotomy position just to name a few. Some have been removed but many are still in place. Everyone wants to make a name for themselves by having the next big idea to save women and babies from that terrible obstetrician, Mother Nature, as Dr. Norwitz likes to say. All too often failing to think of the long term, down stream consequences of those ideas. So here we have a phony debate that is suddenly supported by a bunch of articles which will no doubt influence the flock of obstetricians and hospital administrators to cherry pick their data.  They will likely alter their practices and policies and put direct and legislative pressure on those practitioners, OBs and midwives, who might choose to honor the informed consent process in another way.

The NEJM Study:

This is a multicenter, randomized, controlled, parallel-group, unmasked trial at 41 different hospitals. A multicenter study has the strength of detailed protocols and large numbers for statistical analysis but also has the weakness in that some of the centers have small cohorts and are underpowered for statistical calculations. But overall, a positive. What is curious is that of the 22,533 eligible women only 6,106 agreed to enter the study. Why? Why did 73% of eligible women decline? No reason is given. And 94% of the obstetrical providers were physicians with only 6% being midwives. Bishop scores were unfavorable in 63% of women undergoing induction without an indication other than being low-risk and agreeing to the study guidelines. There are many previous studies citing the risks of inducing nulliparas with low Bishop scores and strong recommendations in the literature against doing so. Are we being asked to ignore this information in the future? We know that longer inductions/labors do lower fetal ph and a low Bishop score makes this more likely. Are we to ignore that, also? In this study labor and delivery stays were 20 and 14 hours, respectively. And within the expectant group it is not clear how many of those had spontaneous labor or were just induced sometime after 40 5/7 weeks. 

According to the NIH and The Journal of Pediatrics the expected hypoxic ischemic encephalopathy (HIE) rate is about 2-3/1000 in term infants. We might reasonable expect this to be lower in a study that uses a cohort of low-risk women. However, the rate of HIE is the induction group was 5/1000 and in the expectant group, many of whom were induced after 40 5/7 weeks, the rate was 7/1000. Why? We are given no explanation as to the higher rates seen with these healthy mothers. Could it be the induction, itself? Could it be the hospital model of continuous fetal monitoring (that worked well, eh?), immobilization or limiting oral intake? I found their tendency to compare group 1 to group 2 but not to other well-accepted standards to be a good reason to question their conclusions. My long-time associate, Howard Mandel, MD, writes: “Wasn’t anyone watching their fetal heart rate monitors? Perhaps we shouldn’t be inducing women with bishop scores <5? Grobman’s cesarean section rate is dramatically lower than much of the other literature for induced labor. Could their overzealous quest to avoid a cesarean explain why 1/200 of their babies had HIE?” Very good questions.


One last thing about composite risk. Grouping together outcomes like HIE with need for respiratory support (is that 30 seconds or 3 weeks?) or low Apgar score always concerns me. In a previous letter to the editor about the 2015 Canadian Breech Study I wrote, “Grouping of such injuries into a “composite” risk is problematic. The use of composite outcomes is an area of controversy. While the composite creates a more powerful comparison, some would argue that the composite, while more powerful, is less meaningful. Papers such as this which pig pile on the cascade of other papers which purport to imply a new paradigm for birth management is coming must find a way to convince themselves and the reader that most birth requires “management”. That safety is their motivation and they only have the best intentions. They conclude “that policies aimed at avoidance of elective labor induction among low-risk nulliparous women at 39 weeks of gestation are unlikely to reduce the rate of cesarean delivery on a population level.” They suggest that this new data be incorporated into discussions that rely on the principle of shared decision making. I suggest that when doing so it is our obligation to point out the many more questions posed by this article than answered. 

Interviewing Dr. Stu

Below is an interview with Dr. Stu and Portuguese journalist, Lara Ramos in preparation for the upcoming "Nascer em Amor" in Lisbon, Portugal, next month. You'll notice some items were grammatically lost in translation. We have left those to preserve the authenticity.



1.    In your opinion, what were the main changes in birth in the last decades and what implications will they have to the future of Humanity?


Is this question the entire interview? Because I could probably do a half hour just on this one question? (laughter). Well the main changes is the medicalization of childbirth. In 1971 the C-section rate in the United States was 5%. And now is 30%. So that´s a 500% increase in the caesarean rate. Now if there had been a significant improvement in neonatal outcomes we could maybe say “well there were some benefits to that”, but there has been zero change in the rate of cerebral palsy in the US in the last decades, and in neonatal deaths if anything things have gotten a little bit worst in the United States despite this increase in C-sections. So the main change has been this caesarean increase, this lack of giving options to people, this reliance on technology, and specifically it comes down in my opinion to specific factors. And two main factors have contributed to this. One of them is the advent of continuous foetal monitoring, which started in the early seventies I believe, right at the time that c-section rate began to rise. There were people that put out this idea that if you watch the baby´s heart rate through labour, you could catch things early, and then you could intervene and have better outcomes. And that was a nice theory, but unfortunately this theory was put into universal practice before it was ever tested. So now we have women that are strapped in bed, which interferes with so many different things about labour, the mechanisms of labour, her confidence, the ability to move, to deal with the pain, the ability to shift and help your baby move and all those things, because you have to be on the monitor. And many many hospitals are still doing that. But also many are becoming more lenient about that, and women are doing more of what we in the midwifery world know to be helpful.

The other thing that contributed to the rising c section rate was the advent of the Friendman´s curve. It was put out by a man named Emmanuel Friedman and you know in his later years in life he basically regretted it, and it basically said that all women should dilate at a certain rate. And if you´re not dilating at a certain rate whether you are a primip or a multip an intervention was then necessary, so women in labour got vaginal exams every one to two hours, and if their cervix wasn´t changing at least a cm to a cm in a half an hour  the idea was that you had to intervene, rupture membranes, or start Pitocin, again all these things that led to these interventions which we describe as the cascade of interventions, which leads to eventually epidurals, Pitocin, and a rise in caesarean section rate. As for the future of humanity, there are a lot of things I can´t prove so I don´t want to be accused of making statements of something that´s not proven,  and have it assumed to be true, but, we know that babies born by caesarean section have greater rates of childhood asthma, diabetes, not hugely greater, but significant enough that it´s gonna be long term, there´s gonna be more childhood illness, by lack of exposure to vaginal bacteria , we know how important the microbiome is, and yet many, many hospitals still ignore all that, to this day they´re stll prepping a woman´s vulva and draping her in sterile drapes for a vaginal delivery which is really silly. It makes no sense at all to do that but it´s because they thing of birth in a medical model, as surgery as opposed to a normal function of the body. I mean it´s like you prep your urethra every time you took a pee, no one would do that. So we´re destroying the microbiome, what effect will that have on the future? I don´t know, Will there be more diseases in children, will there be more obesity will there be more autism, you can only speculate on those sorts of things. There are good people, like Michel Odent who believe these things are gonna cause some sort of change long term. The other things too is the epigenetics of it all it´s not a concept I am greatly familiar with, but we know that the body is pliable, and we know that babies born by caesarean section, without labour what is called the pre-labour caesarean section maybe be more likely in the future not to be able to labour themselves. Female babies. Because they didn´t develop oxytocin receptors properly or some other thing that went on there we really don´t understand, so we might be altering the species by interfering so much. (That´s a long answer) ;)


2.    Nowadays, a previous caesarean section, twins or a breech baby are currently an indication for a C-section, at least in Portugal. In what way do you try to make a difference, offering women vaginal birth in such scenarios, and what supports this option you give them?


I was trained in an Era where VBac, Breech and Twins were not considered automatic c-sections. So I was fortunate to have been trained in such an era. I got lucky during my residency I spent four months in what at that time was the busiest hospital in the United States. We were doing about 22000 births a year then which adds up to about 65 births a day. And the resident team was like 12 people, and the chief would sit in his room and never come out, the juniors did all the C-sections and the interns did all the vaginal deliveries the medical students drew all the blood and did all the H & Ps, history, physical, that sort of thing, we put forceps on people that didn´t need forceps, we did breech deliveries, we did breech extractions, it was a different era, and unfortunately that sort of training has disappeared, so it´s harder these days for people to get the training necessary to consider twins, that are perfectly positioned to do a vaginal birth  and breech babies are also sort of taboo, even though the data, and the world literature, and there´s a lot of it, supports the option of vaginal breech birth, and twin birthing, even when twin A is breech. But you would never know that by talking to mainstream medical people, they tend to cherry pick their data and it´s a cognitive dissonance that goes on. So they don´t have to offer an option they don´t want to the women they are taking care of. But that´s our ethical obligation, it´s to offer reasonable choices and even the America College of OBGYNs, and RCOG, the New Zealand and the Australian Colleges all have statements supporting vaginal breech births and twin births in properly selected clients with skilled practitioners, and then they all make the statement that “finding a skilled practitioner is gonna be hard to do, and therefore C-sections will be done most commonly, the problem with these people in Academia is that it´s sort of schizophrenic, because they´ll make a statement like that but then on the other hand they´ll not be teaching the next generation of physicians, how to be that skilled practitioner. So I´m lucky because I can still do all the things that I wanna do. I feel like these options are important because even if a physician doesn´t know how to do breech delivery, his ethical obligation should be to say o that woman, “there are people in my community who know how to do breech delivery, you should go have a consult with them, and then come back and talk to me about it, as opposed to saying “Oh if you have a breech baby the head will get stuck and the head will get brain damage, so we should just schedule your C-section at 38 weeks. So they only give one side of the story. And that´s something that you really should not be doing in our profession one of the things in which I am trying to make a difference in when I teach, and when I write and when I podcast, is to make it clear that it´s not incompetent, it´s not weak to tell somebody you don´t know how to do something. It´s brave to tell a client “listen, I don´t do breech delivery, but that guy over there does breech delivery, so go see them. To not do that…ethics has gotten lost in the system,

And doctors are sort beaten down by the system, at least in the US, between expediency, and economics and legal concerns, and the doctor that speaks out, like me or other doctors like me, or others like me it´s like the old Japanese proverb: “What do you do with the nail that stands out? You pound it back in again.” What happens to doctors who speak out against hospital policy or against risk management, is they get beat up. And they end up just keeping their head down and wanting to make a living and just go home to their wife and kids and not fight for what´s right and I don´t blame them it gets really hard especially when you´re out there by yourself doing it.


3.    Why are health professionals currently so fearful of allowing a breech birth to start physiologically? What are the main risks regarding this?


There´s no skill and letting labour stat physiologically, is inconvenient. Especially if they´re planning to do a C-section anyway, I mean what´s better to do a C~section at 7:30 in the morning on a Tuesday, or to do it at 2 am on a Saturday night? And reason they will people is oh well a foot could come out, or the cord could prolapse, but if you´ve done an ultrasound on a breech and but is sitting in the pelvis, there´s absolutely no way that a cord or a foot could come down, so letting labour start, letting the baby choose its birthday has advantages to that baby, but it´s an inconvenience for the OR crew and the OB, so they don´t support that sort of thing. And as far as one of the risks of waiting for labour and that sort of thing, they´re very small. But like everything else we live in a society that´s so fear based that we always emphasise the one thing that can go wrong. And of course once a physician, or staff has experienced one bad outcome, they try to legislate good outcomes in everything, and by doing so they restrict freedom, liberty, choice, and they have never learned that no matter how much you interfere, you can never perfect safety. We all know that a lot of bad things happen in hospitals, with really intense policies for safety, and still bad things happen.

Many times, the bulling against doing things differently may not come from other OBs. It comes from the anaesthesia department of paediatrics department. Who have no stake on the women´s experience, they just want to minimize (or think they are minimizing their liability and again this is a little cynical, but they´re also increasing their revenue, what´s the incentive for a hospital to lower their C-section rate?
Til insurance companies start paying less for a caesarean, and more for vaginal births, we´re not gonna see any significant change, but we´d see a significant change tomorrow, if they said, we´re gonna pay twice as much for a vaginal delivery and half as much for a caesarean, you´d find that suddently breech delivery, and VBAC delivery would become a great idea.

4. How was it practicing in an environment that did not share your philosophy of care? Did you feel bullied?


Yeah, for sure. My main experience with that is in 1995 I started a collaborative practice with at Ventura county in a hospital we called it the Woman´s place, and initially we had two midwives and me and even though the hospital had allowed midwives some privileges, the OB committee, said that if a midwife was delivering a baby an OB had to be in the hospital. Which sort of defeats the whole purpose of having a midwifery practice. What is really interesting is that if a doctor was delivering a patient, at that hospital, the doctor could be at home. But when I have a midwife at the hospital who is highly trained, I had to be there, so, my patients had two skilled people there, their patents had no skilled people, and they considered that to be just and fair. There was no rime or reason behind the policy they were all punitive. It was what we called a sham pier review. We would have a broken clavicle we´de get pier reviewed and they would get a broken clavicle and would not get pier reviewed. I remember the chairman had a woman who was having her third baby and he had her at the pro operative for breech and I just happened to finish a delivery, and I heard from the nurse they they had taken her for a c-section for a breech. I know for a fact that he never offered her a vaginal delivery, and he probably never offered her a version. And he goes and and he goes and does a c-section on her an oopsss….he baby isn´t breech. So he does a c-section on a third baby on a woman who´s had two vaginal deliveries, that was head down, and he does not get pier reviewed for that because he is the chairman of the department. This stuff goes on constantly, I once got pier reviewed for wearing the wrong scrubs, because I worked at more than one hospital, and I came from on to the other. But they wouldn´t get pier reviewed for you know, 4th degree tears,  or taking out the wrong ovary. There was a lot of bullying, a lot of “circling the wagons for the good old boys. Eventually, after about 15 years  they had enough of us, we had really good outcomes, we had a c section rate of about 7% and we took all covers, and the midwives took care of the normal stuff and I took care of what was traditionally considered the high risk stuff, in those days, and it worked out great. But we got a lot of trouble form anaesthesia, because our clients didn´t want epidurals, and the paediatricians didn´t like us because our clients wanted to go home 4 to 6 hours after giving birth, and the hospital had a silly policy that said every new-born baby had to be seen by a paediatrician.


(By the way I´ll digress for a while, you can edit this out, but the reason that hospitals have policies that babies need to be seen by paediatricians has nothing to do with safety. It has to do with economics. What happened was that in the early 80sthey found that newborn exams were uncaptured revenue. So the paediatric department passed policies on hospitals that said “All newborns have to be seen by a paediatrician” . And the hospitals said fine, that´s more revenue for us, that´s more revenue for you, let´s do that. And then what happened was about 10 years later the management care came in and basically said well we´re not paying for that. So their own policy came back to bite them in the ass. So when our clients want to go home at 10o clock at night, the paediatrician said well I´m not coming in until morning. So it caused this conflict and if our clients wanted to leave they would do so against medical advice, and then the insurance company would be unhappy, and then they call child protective services, you know there´s a lot of threats of that sort of thing. It´s nothing to do with safety, it´s all to do with politics.)


So they banned the midwives eventually, and then they banned VBACs, and they banned breech delivery, and we hadn´t had a bad outcome, I did 3 breech deliveries in the beginning of 2010, and I got a call from the chairman of the department and he said, if you another breech delivery we´re gonna kick you off staff. I said well but I credentialed to do that, I have a paper in my hand here, that you signed that for the next two years I am credentialed to do breech deliveries. “We don´t care”. We were doing really good work. And then it just sort of …we ran into walls. There was just petty issues that triggered animosity. They treated us differently. They instituted a 20 minute rule that I had to be 20 min from the hospital. When I had a midwife in there I had to be 20 min from the hospital. So I lived 19 minutes from the hospital. They didn´t believe me. Even though I map quested it out. They actually had one of the people in the committee, come to my house and do the drive. But when their doctors had somebody in labour, how did we know they were 20 minutes from the hospital? Maybe they were at the tennis club. Or out to dinner in Ventura. They never checked on themselves, they only checked on us. Eventually it go to a point where, I was advised by very smart people that I would not get a civil judgement. The same people that were accusing me were the same people that would trial me. So I would always loose that and it almost always costs a lot of money. Even if I were to win that, all I was gonna win was to stay in an institution that was not gonna let me do what I wanted to do anyway. So at that point, in the fall of 2010, is when I left hospital based practice, and I was encouraged by my midwife colleagues to come and see home births I had never been to a home birth, and I sort of laughed initially and said I am not interested in it. Most physicians would laugh. I was comfortable knowing that I had these facilities with me you know the NICU and the anaesthesia, because that´s how we´re trained. We´re trained in medicine as illness, and something could go wrong at any moment, as opposed to the midwifery model, that trusts wellness, and things don´t go wrong suddenly when you don’t meddle with labour. So I ended up going to a couple of births, and it was the best experience that I´ve ever had, I´ve really never been unhappy looking back, the only thing that ´s  unhappy about is that I´m pretty much the only one doing it, so when it comes to these limitations that California law has put on midwives, I´m pretty well stuck here, when I have a breech delivery I can´t travel, or when I have a twin delivery, if I do, and she goes into labour she ends up getting a c-section. At the hospital, which has happened several times. But you know I´ve tried to clear my slate for the second half of May.


5. Did you ever feel discriminated against or bullied at your job? How did you cope with that? What made you take the next step and work according to what you believed in?

(Answered above)


6. Why do you think there are so many interventions in birth nowadays?

Fear. It´s the way they’re trained. I don´t know how it works in Portugal or other European countries, but I´m pretty sure it´s relatively the same, our residents are trained in high risk obstetrics and see everything as abnormal. That´s mostly what they see. So they look at birth as pathology, they look at birth as if someone´s coming in to have their appendix out. Or their gall bladder removed, or whatever. Not as if it´s a normal function of the body like breathing or digestion. Which you don´t have to do anything with. No OB resident ever sits with a woman in labour, and watches them labour. And does nothing but listen and watch. And when you come to a home birth, that´s all you basically do. And you don´t have to do anything else. And you learn. I still remember my fist home birth. One of my very first experiences with home births was with one of my favourite midwives here and the woman was starting t make some guttural sounds, and I said “should I check her?” We hadn´t checked her the entire labour. That´s a foreign thing to a doctor coming out of a hospital. She said “No”. And then she is moaning a little louder, and twenty minutes later I ask the midwife again “Should I check her now?” and she says: “No”. And then about a half hour later she starts going ohhhggghhhh. And then she looks at me and says “Yeah, now you can check her”. And of course she was complete and plus +3. There was no reason for me to be sticking my fingers in there, but that´s what I was trained to do. So you learn a whole new way of doing things. If our residents, had to learn from midwives, about normal birth, if they had to sit for a month, in labour and delivery and be a labour and delivery nurse, Or go to some home and birthing centre births, and just observe, it would be a tremendous, tremendous advantage to them. Even if they didn´t have to do anything like that in their professional life they would still know, and have more respect for that option. One of the things I teach that is not taught, and when I get to speak to residents which isn´t very often, you see their jaw´s drop when you talk about normal mammalian birth. How does a dear, (more animals) give birth? They find a quiet place, by themselves, and the other dear don´t come and check them and interrupt them all the time, and if they´re hungry they eat, and if they´re thirsty they drink, and no one bothers them and when the baby comes out, what happens it falls in the dirt. So it´s not sterile. And no one rushes in to cut the cord and no one ever separates the baby from the mother, in nature. And mammals won´t labour when they´re stressed out. So everything we do to the labouring female is unethical, and not how Nature designed for mammals. And then we wonder why we have those 30% C/s rates and 85% epidural rate and high Pitocin rate. And then we feel safe because we have an operating room down the hall and say “yeah we just saved your baby”. Well you just saved the baby from the problems you just caused.


7. What suggestions or advice do you give women in terms of preparing for pregnancy and birth?

I would advise all women to at least consult and consider midwifery care. I think that you can see an OB, you know for a consult, and you can see a midwife for a consult, and then compare the two, and see what you think. Some things need an OB. Somethings can collaborate and some things OBs don´t have to get involved with at all. Finding a practioner who answers your questions, who gives you the time, Time is such a huge thing. Educating yourself from good sources, looking at websites like my website, or your website, were we have references for movies, or books that we recommend. Don´t go to Dr Google. Don’t get your information off facebook groups. If your practioner is the same man or women that you´ve been going to for years, and they have one foot in the door, are in a hurry and you do´t feel like your questions are answered, you don´t feel like they remember you from visit to visit, maybe don´t feel like you´re stuck there. People spend thousands on a wedding. But giving birth, which is one of the most significant events in your life, you just think, this is my doctor, this is what my health insurance card says, I gotta go here. Just think about that. If we go to ICAN meetings, all the women are crying because they feel like they weren´t heard, or respected, and that their doctors did not respect them. And they carry this burden for the rest of their life. And no amount of VBACs and other things will ever take away that feeling. So this is such an important time in their life, but how many women actually feel good about their birth? You know, everyone loves their baby but if you ask women, how was the pregnancy, how was the birth, a lot of women will say they were not respected and it wasn´t the way they wanted. We hear this all the time. So we need to take a step back and we need to revaluate how a culture looks at birth as a priority. We don´t make it a priority and it should be a priority because it´s one of those events that will affect you for the rest of your life.

I had no lectures in medical school about nutrition and breastfeeding. None. In four years of residency. I don´t think that doctors get a whole lot of training in breastfeeding, they don´t consider that to be an obstetrical thing. The baby´s out they don´t consider that their responsibility anymore. The baby goes to the nursery, the mother, if she had a vaginal delivery goes home in a day or two, not to be seen again until six weeks, if she had a c-section she might be seen again in two weeks, but you know, in the midwifery model we do a postpartum visit on the 1st or second day postpartum, we do another one about 4 or 5 days later we do another one in two weeks, and in the meanwhile we´re making sure they do to their paediatrician, so that baby is getting all the attention it needs, we´re weighing the baby, we´re counting poops and pees, something that as an obstetrician I never did. But I do now. I am a hybrid now. ;)


8. What would you like to see happen to improve the future medicine?

I would start with changing how we teach the next generation of practiotioners. How we teach birth. 85% of women generally labour normally. And yet OBs are experts in the 15% that don´t. But they´re taking care of the 100%, 85% of which they know very little about. Because they don´t know anything about normal birth. They don´t come until they´re called, and hen they´re called, they´re expected to do something. When I was a doctor at a hospital the nurses would call me and to come. I was expected to do a vaginal exam and if she wasn´t moving fast enough we´d break her bag of waters, or would order Pitocin, you know, do something. As opposed to coming in, look at the monitor, say to the woman “you´re doing great” go sit in a corner in a chair, watch for ten minutes, just say, ok, you´re doing great I´ll be back. No doctor ever does that. They´re not trained to do nothing. It´s hard to do nothing. Granny midwives used to say the best thing you can do to learn to be a midwife is knit. The more we do nothing and the more we leave the woman alone, the better.

Another important thing for the future of medicine is collaboration between midwives and physicians. And not looking at midwives as a lesser area of obstetrics, but as a separate profession. If we start looking at midwives as experts and colleagues, rather than lesser quality, and we made it easier for them to transfer patients, to transfer care or even have a collaborative care where a woman can see a midwife and a physicians during pregnancy, and then if she needs the doctor she is welcome in that practice, but he is fine with her having a home birth. Until we change the attitude of doctor by changing how we teach the OB, we teach them about normal, you´re always gonna have this sort of anxiety.

What´s funny about that is that the doctors in order to have privileges in the hospital have to cover the ER every so often. Once a month, or every other month, whatever the rotation, come up. And when they cover the ER they might get people that they have never met, with no prenatal care, on cocaine, and 26 weeks and pre term labour, and they´ll take care of that person. But a low risk woman who just comes to the hospital for an epidural and pit because she is exhausted, is too high risk for their demands. And they have had great prenatal care with a great midwife, but that´s too scary. Whereas the covering the ER is something they´ll do. And they don´t even think twice about that because you´re conditioned to believe that that´s part of your duties, but why? “The long habit of thinking something wrong, gives it an outward appearance of thinking it is right”. Why do they do things the way they do? Because that´s all they know.


9. What do you consider the best way to communicate risk to your patients?

I consider the best way to do that is to give them all the time that they need. When we have prenatal visits, my prenatal visits are 30 to 45 minutes long. Because I am very confidence with my skill level, I am very confident telling people the skill levels that I don´t have. Give them the time that they need to go over the risks and benefits of this option, the risks and benefits of that option, and give them all the choices. And then let them come to their own decision if they can. If they want help with making a decision, that´s fine. I want them to have the birth experience that they´re supposed to have, I don´t want to try to funnel them down a path, and give them experience that I want them to have. And not everyone´s birth experience is gonna end up like their birth plan, you know. But I want people to feel comfortable about their choices, and so I give them as much time as they need. And I make myself available 24/7 to people, so I am answering questions all the time. I have people six months out that still text me with a question. Because as midwives say “you´re a midwife for life”. And that kind of relationship, no matter how the baby comes out gets people to have a better experience. And a better memory of their experience. And ultimately, it´s such a powerful thing for women, the birth of their children. And I don´t think the medical model allows for that.



10. What are your expectations in regards to the Nascer em Amor Conference and training in two Portuguese hospitals? Is there anything in particular you hope to achieve?

I wanna teach breech skills, so that people will know what´s new. Even if they are not allowed to do breeches, they are gonna encounter people in the ER, or at home, and if you have the skills, and you know what to do, I would feel great. We have to know what to do we are the last resort, we are the practitioner. And can´t always do a caesarean section, even in hospitals. And I want to review the literature so that they can talk with more confidence, about why breech birth is not as scary as people think. And why there´s plenty of evidence out there about breech birth, that supports a woman´s right to choose her ethical right to choose to have a breech birth. Everybody points the term breech trial as an inclusive piece of evidence that says we shouldn´t be doing breech delivery, and anybody who does any research knows that the Term Breech Trail is a bunch of crap. But that´s ll the doctors quote because it meets their desire to justify what they do. No doctor wants to come home at night and say honey I did 3 unnecessary c-sections. They don´t wanna feel that way o they gotta feel that they are doing things that are normal. There are guys who trained with me who knew how to do breech deliveries who don´t do breech deliveries anymore. I also wanna be able to tell people how to properly select breeches, so that they know that are some breeches that shouldn´t be delivered vaginally. And I want them to know how to do the skills and the manoeuvres that you need to do. How to recognize when a baby needs help and when to keep your hands off.


Thank you!



My Breech Birth Story

Mercy Reign was born Saturday, February 3 at 4:43am by way of C-section after 40 hours of intense, unmedicated labor at home. She was frank breech, 9 pounds, 9 ounces and 23 inches long! Mercy was extra-well done (haha) at 41weeks and 3days, extra-large, extra cozy, folded completely in half,  and slightly transverse, likely due to how long she was! This was not the birth story I wanted, it was the birth story God knew we needed. 

Zach and I did everything we could to prepare for a home (water) birth, something we both dreamed of having. We prayed. We took A Heavenly Welcome's Kingdom Childbirth Class and the 8 week Mama Natural Online Birth classWe hired an amazing Christian midwife with 29 years experience who thoroughly cared for, educated and encouraged us from 9 weeks pregnant through the "4th trimester". We both read Ina May Gaskin's Guide to Childbirth book, Hypnobirthing and Supernatural Childbirth. A word on Hypnobirthing for those whose "New Age radar" just went up: Chew on the meat & spit out the "New Age" bones - most of the info on what happens in the woman's body during pregnancy, labor and birth + the breathing techniques in this book were very accurate and helpful though I don't recommend the cd or some of the wierd visualizations.  We also watched endless videos of amazing home births, and once we found out she was breech, endless vaginal breech birth videos. I LOVED The Heavenly Welcome Podcast in my last trimester, listening to all the supernatural birth stories/testimonies!! 

The Lord specifically instructed me on how to prepare my body before getting pregnant, after He gave me  the dream about Mercy. He gave me the words TRUST and DISCIPLINE, and challenged me to get a 1-year chronological Bible to read for 2017 (as of March 2018 I've almost completed it...hahaha...better to finish with grace than become legalistic and ashamed, right?!). I also felt the Lord instruct me to start pilates reformer classes to prepare my structure, as I was just coming off of a serious back injury involving 2 bulged discs and severe muscle spasms. He advised me to lighten my load and work on my adrenal glands/hormones, as my periods had gotten painful and a bit irregular after prolonged high stress.  The Lord also nudged me to finally change over the last of my makeup/skincare regimen. I had been using Bare Esscentuals for years and justified that it was "natural enough." I finally took the time to see how EVERYTHING I was using on my face/body ranked on the EWG- Skin Deep App and did my research to find  the BEST, most pure and complete cosmetic line  once and for all. (I hate changing makeup/searching for new products!) There are hundreds of serious carcinogens, hormone disruptors & other toxins in most makeup/skin care products. I still make my own body butter and anti-aging skin serum, both of which I used (mixed together) for stretch mark prevention throughout the whole pregnancy (and I didn't get a single stretchmark with my 55 extra pounds of  Mercy love!!!). I had pages of birth declarations and scriptures (you're welcome to use them) typed up that I meditated on for weeks to keep my mind constantly renewed and excited versus afraid. Aside from those specifics, I was already eating super clean and healthy, teaching Indoor Cycling classes 2 times per week and working a balanced schedule. I took responsibility and trained accordingly, as I knew childbirth was not something to "just wing". 

Everything the Lord advised me to do paid off and served its purpose. I had a wonderful pregnancy despite the fact that it was "God's plan" and not our own in the end. Mercy was head down until the middle of third trimester when she flipped. My amazing Chiropractor, who specializes in pregnancy and pediatric care,  is who suspected she was breech and referred me out for emergency ultrasound for confirmation on Christmas Eve (35.5 weeks). Praise God for the wise words from a dear friend who reminded me: "Remember, home birth isn't the ultimate goal, a health mommy and baby is". That was Truth I needed to remember for such a time as this. This pregnancy and birth experience took me to another level of surrender and trust, once again reminding me that we are not in control. I so desperately wanted to have this baby naturally at home. I fully believed that God was going to honor "the desires of my heart". My recovery entailed much more than physical healing. 

We prayed fervently through the end of my pregnancy and had so many others praying (even fasting for us). We did everything to get her to turn (Webster technique, Chiropractic care, Acupuncture, Moxibustion, External Cephalic Version 3 times, inversion exercises from SpinningBabies.comessential oils, homeopathies to increase my amniotic fluid making more room for baby to move, etc).  We were still lead to try to have a home birth instead of cave to C-section immediately since there were zero complications, and I was healthy and low risk through my entire pregnancy. We had to hire Dr. Stuart Fischbein (with Dr. Milo Chavira on call, his backup which is who we ended up with because Dr. Stu was out of town when I went into labor... the plot thickens!) the only Obstetricians in the area who specialize in vaginal breech HOME (or birth center) birth. Sadly, California law will not allow a breech home birth with a midwife any longer (don't get me started on that!). It is pretty much exclusively hospital policy here to force women with breech babies to have a surgical birth and not even allow them to try to deliver naturally. God kept opening doors of hope and possibility. 

Something I learned from our amazing and very experienced birth team through this journey: If you are trying to deliver a breech baby vaginally, induction and intervention are major no-no's. (Of course, I'm not a fan of either unless they are truly MEDICALLY NECESSARY anyway. One intervention often quickly leads to a whole cascade of interventions, which can have adverse effects on mommy and baby). Because Mercy could not descend through the birth canal due to her position and size, my contractions never developed a regular pattern into active labor, and I never dilated past 4 cm. I had MANY 10-15 minute, excruciating, back-to-back surges as my uterus did its job to TRY to bring her down. I fought to have her naturally, but it eventually became medically necessary to transfer. My water had been broken for nearly 48 hours.

This was my Garden of Gethsemane. 

“...Father, if it is possible, let this cup pass from Me; nevertheless, not as I will, but as You will.” -Matthew 26:39 NKJV

There were some incredibly HOLY moments late in my labor where tears flowed from the depths of my soul. I was able to dance and worship, feeling almost zero pain for a couple hours!! I had a supernatural breakthrough and clearly heard the Lord speaking to me about restoring the family unit, the ancient ruins (Isaiah 61), and the places that have been long devastated through many generations. He spoke to us about making all things new through us, a fresh start, a new and healthy generation, and encouragement that I don't have to be afraid of me or Zach doing the things I witnessed growing up. These have been deep, tormenting and paralyzing fears throughout my life. The Lord "delivered" me as I was delivering my daughter into the world. I was fully surrendered at that point and HOLY is the only way to describe it.

Perhaps if my birth story had been "easy", I would have missed out on the healing that only comes through the kind of pain that brings you to your knees. I could quickly get caught up in grieving and re-living my birth story, wallowing in the emotions and making it an idol. Instead I CHOOSE to simply trust The Lord and thank Him for this baby girl that was worth it all!! After all, I don't "deserve" anything. Anything the Lord gives is a gift of grace in reality. 

Ultimately we had our home birth...with a cesarean delivery and a healthy mommy and baby. We did everything we could and therefore, will never have any regrets. In God's mercy and grace, Miss Mercy Reign never once showed any sign of fetal distress through the entire labor or birth or postpartum!! Thank you Jesus!!! 

We are in love!!! Mercy is so strong and healthy and BEAUTIFUL and FUN and squishy and delicious!!!! God's MERCY truly REIGNS and we can be grateful His plans are better than ours will ever be!!!

THANK YOU to ALL who have prayed, called, sent cards and gifts, celebrated and journeyed with us!!!

Psalm 136:1 "Oh, give thanks to the Lord, for He is good! For HIS MERCY ENDURES FOREVER."

FUN FACT: A breech presentation is a variation of normal (like us! haha), not a pregnancy complication. It occurs in 3-4% of pregnancies and no one really knows why. Vaginal delivery is ideal for a low-risk breech baby so long as you have a properly trained birth assistant (OB or Midwife). The real problem is that medical schools are no longer training Doctors how to deliver breech babies, so there is a LOT of fear-mongering around this topic. Just as many things can go wrong during C-section delivery of a breech baby if a Doctor isn't properly trained (brachial plexus injuries, etc). It is still wise to avoid a surgical birth whenever possible unless it is truly medically necessary like mine ultimately was. 

A natural birth with twins? Yes You can!

When I found out I was pregnant with twins, I was doubly excited, and knew I still desired a home birth.  However, I realized many practitioners see all multiple pregnancies as high risk, and I would have to advocate for my wishes, while seeking out an experienced care provider.  As a home birth midwife, I have assisted with natural twin pregnancies in the United States, and abroad as a traveling volunteer.  While we are fortunate here to have medical interventions available, such as epidurals and cesarean sections, they are not needed for every birth, including every multiples birth.  So how can you best achieve your chance for a natural birth? Education, maintaining a healthy pregnancy, and trusting in yourself.  Here are my top tips to natural birth success with multiples:


Nutrition - starting in the first trimester, it is important to eat a health diet, including whole foods, lots of water, and a quality food - based prenatal vitamin.  One of the most important nutrients for moms is protein, which provides amino acids, known as the building blocks to cells.  With adequate nutrition, not only will you be growing healthy babies, they may also have a better chance of making it to full term, which also increases your success of a natural birth, while decreasing their risk of NICU time.  Good protein choices are lean meat, eggs, low mercury fish, beans and legumes.  Additionally, it is important to “eat the rainbow,” meaning many colors on your plate - think red peppers or strawberries, green broccoli, kale or spinach, oranges or carrots, yellow lemons or bananas, as each colored whole food provides different key nutrients and vitamins.  Drinking plenty of fluids will ensure babies have enough amniotic fluid, contractions don’t start prematurely, and can  help keep your fatigue at bay.  To combat nausea, try not to get too hungry, and keep bland snacks like cereal or dried fruit nearby.

Exercise - Once given the go ahead from your provider, prenatal exercise is another essential part of maintaining a healthy pregnancy, and will prepare yourself for birth.  Prenatal yoga, walking and swimming are all great options.  A walk outside also gives the added benefit of vitamin D!  When in doubt, consult before trying something new, and avoid heavy lifting, torquing maneuvers or high impact exercises, unless it is okayed.  During pregnancy, the babies need to get in optimal birth positions, and avoiding strenuous abdominal exercises, as well as doing weight bearing activity, can help make that possible.  As your pregnancy progresses, a maternity cradle, or wide, elastic band will offer support when standing or walking for long periods of time.  If you are placed on bed rest, ask if there is still any exercise you can do, such as leg lifts or arm exercises, because even a little movement may be beneficial.  You can also practice gentle breathing techniques, such as longer exhalations than inhalations or blowing, which may be helpful to use during labor.

Childbirth Education - Take a class with a local educator, watch natural birth videos, read childbirth preparation books and talk to experienced parents so that you have the knowledge to make an informed decision about your birth preferences, including place of birth.  A natural birth can happen at home or in hospital!  Research your birth preferences but be flexible.  Decide which aspects are most important to you, and also what part of your plan you could modify, in case things change.  In birth, preparation is helpful so you know what to expect, but the unexpected can occur, and its important to know why an intervention is being offered or recommended.

Self Confidence - now that you’ve ate healthy, exercised gently, and feel informed about labor and birth, hopefully you can enjoy your pregnancy!  I know easier said than done, but remember people have been giving birth forever.  Once you’re pregnant everyone has some piece of advice to offer, so take in the positive, and let the negative stories go.  Find affirmations or images that make you feel empowered and strong.  These can be your mantras during labor and birth.  Another essential is trusted a labor companion, which could be a friend, relative or partner, and statistics show that someone with a birthing person throughout their birth is the best thing you can do to reduce number of medical interventions.  Remember, this is a special time and you can do it!


One of the best parts of an unmedicated birth is the feeling you have once your little ones are in your arms.  In fact it is the highest level of oxytocin, the love hormone, that a person will ever experience in their life!  However, no matter how birth happens, it is transformative and beautiful, and with multiples, only enhanced with each baby.

Here is our first family photo: happy, healthy and at tucked in at home!


Jacquelyn Ingram is a licensed midwife and international board certified vacation consultant.  In addition to serving home birth clients and teaching classes for expectant and new parents, she also runs a non profit corporation, Global Aurora Foundation, which aids individuals and non government organizations around the world, that serve women and children.