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!
