States using midwife-led maternity care have improved birth outcomes

A new study by explores the association between states with midwifery-led care, access to midwife-attended births, and childbirth-related procedures and outcomes. Some states have autonomous Midwifery laws, and do not require Certified Nurse Midwives (CNMs) to have physician supervision. In contrast, many states in the U.S have regulations requiring physician supervision or contractual practice agreements for CNMs.

Midwifery-led care is related to health, cost, and quality of care outcomes comparable or preferable to outcomes with physician-led care. Despite these findings, many U.S. states continue to rely on physician led care.* States that rely on midwife-led maternity care see improved birth outcomes:

“At a population level, women giving birth in states with regulations allowing [midwifery-led maternity care] had 13% lower odds of cesarean delivery, 13% lower odds of preterm birth, and 11% lower odds of delivering a low birth weight baby compared with women giving birth in states with more restrictive policies on midwifery practice. Although these effects were modest in magnitude, they could have important implications at the population level because there are approximately 4 million births in the U.S. each year.”

Previous studies have found that midwives are less likely than obstetricians to use interventions like labor induction and cesarean delivery that may have higher risks for women and infants when performed without definitive medical need.

What does maternity care look like in your state? Check it out here:Screen Shot 2016-03-08 at 9.56.42 AM

When midwifery-led care is available, patients tend to opt for midwifery services as an alternative to physician-led care, and are more likely to use midwifery services in their births.

The authors suggest:

it may be in states’ interests to consider or study efforts to reduce restrictions on midwifery practice to increase use of CNM services for prenatal, intranatal, and postnatal care.

Read the full study here.

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Pregnancy How-to’s from the Middle Ages: Dung Diapers, Barley, and Rabbit’s Blood Cocktails

Get Me Out, by Randi Hutter Epstein, MD, is an insightful history of childbirth exploring the evolution of advice and wisdom in childbirth. The book presents the lineage of childbirth, and helps contextualize the current state of obstetrics. Thomas Forbes once said that the history of obstetrics is “in large part a history of superstition.” Childbirth, then and now, is a “wonderful blend of custom and science.” Perhaps because of the time and space between current day and the Middle Ages, I found Get Me Out‘s chapters on medieval childbirth advice to be, at the very least, captivating. Thus, today we’ll explore advice surrounding birth in the early years in our history: the Medieval Period.

15 pieces of advice for childbirth during the Medieval Period

394px-Eucharius_Rößlin_Rosgarten_Childbirth1. Birth Control: According to the Greek physician, Soranus, who authored the leading text on gynecology for over a thousand years: you could have sex without conceiving if, after your partner ejaculates inside of you, you hold your breath, squeeze forcefully, and then drink ice-cold water. If that fails to work, try the Hippocrates’ abortion method: jump and kick your heels to your bum until the seed simply drops out of you.

2. Looking to get pregnant? France’s 16th century Catherine de Medici had the money and hutzpah to seek out all kids of advice and treatment to get pregnant. After ten years of marriage to the king, she had produced no heir. Her healer told her to drink mare’s urine and to soak her “source of life” (I presume this means her vagina) in a sack of cow manure mixed with ground stag’s antlers. Her husband was never sexually attracted to his wife – no doubt the dung diaper hindered his attraction further. The King was eventually diagnosed with physically defective reproductive organs (aka hypospadias), and recommended specific sexual positions for reproduction. Catherine, so the story goes, had her carpenter drill a hole into the floor to observe her husband having sex with mistress – for educational purposes. Maybe this did the trick, because she went on to have nine children.

3. How conception works: According to Aristotle, a man’s seed shaped menstrual blood into an embryo. Doctors later reconsidered that during pregnancy, menstrual blood flowed upwards and turned into breast milk. In this vein, men produced the life source of what became human. Women were “mere baby-making vessels.” As one sixteenth-century expert eloquently put it, the vagina was an “antechamber to lodge a Man’s Yard.

4. Penis size and getting pregnant: According to Jane Short, a British midwife in the seventeenth century, penis size affects fertility. Too big is just as bad as too small. If the penis is too big (longer than 11 inches), it sprays the womb with seed, thereby rendering conception incredibly difficult. A penis too short (shorter than 1 inch) would not touch the opening of the womb, so male and female seeds would never mix. In cases with an average-sized penis (greater than 1″, smaller than 11″), the vagina acts like spandex. It stretches and shrinks to suit the partner. Or, according to the experts: “the vagina would dilate, contract, extend or abbreviate itself according as it is necessary to bear exact proportion with the bigness or length of the man’s yard.” The clitoris was considered the female equivalent of the penis. Doctors worried about the size of the clitoris – not for fertility – but because women with oversized clitorises were prone to lesbianism.

5. Virginal Conception: According to the monks who wrote Woman’s Secrets, the vagina had powers that lured sperm into it, even without penetration. This explains how virgins become pregnant. The “vagina sucks up sperm like a vacuum”, so a woman could become pregnant if she bathed in a tub where there a man has ejaculated – this “has been attested to by experience.” Woman’s Secrets goes on to assert that, “along the same lines, if a cat ejaculated on sage and then a man ate the sperm-tainted herb, he would grow a cat in his stomach and vomit it out.” So, there’s that.

6. Home pregnancy tests: here’s a do-it-yourself method suggested by Soranus. Women should pee on a bouquet of barley, wheat, dates, and sand. If barley sprouted, you were pregnant. If wheat grew, it’s a boy; if barley, a girl.

7. If you wanted a happy baby, pregnant women were instructed to think happy thoughts. Don’t stare at ugly things, because you’ll get an ugly baby.

8. Most men and women believed that childbirth is a heavenly duty, and women deserved painful labor. This view, of course, stems from the story of Eve. Enticed by that proverbial apple, Eve was cursed with the excruciating pain of childbirth. In 1591, Eufame Maclayne was burned at the stake for asking for pain relief during the birth of her twins.

Sixteenth-century illustrations of fetuses in the womb by Eucharius Rösslin

Sixteenth-century illustrations of fetuses in the womb by Eucharius Rösslin

9. Sex: Sex in moderation is key to successful babymaking. Women were told to have “enough” sex because a “splash of sperm moistens the womb,” but not to have too much sex because “it wears out the baby-making machinery.” Perhaps this is why “whores have so seldom children”: because “satiety gluts that womb.” Too much sex during pregnancy was considered dangerous to the growing fetus, as it drained the vital juices that should flow to the baby. Too much intercourse created children who were “defective in vital and other qualities, ill tempered, sickly, and short-lived.” Smart parents = smart babies, but only if parents didn’t have too much sex. Too little or too much sex would produce smart little ones, but they would die before the age of 10. Too bad nobody ever defined what a moderate amount of sex was.

10. Women have to enjoy sex to get pregnant: Babies are born as a result of a woman’s “voluptuous itch” to copulate. When a woman is in the mood for sex, her womb opens and allows the male seed to enter, which facilitates baby making. Pleasure in sex is explained by four “carruncles” (bumps?) lining the opening of the womb that close more pleasantly around the Man’s Yard, so that the woman is also more delighted. But, if you’re enjoying it, your womb stays closed.

11. If you look at the moon, your child would become either a lunatic or a sleepwalker.

12. Hoping for a baby boy? One guidebook suggests his and hers cocktails to up the odds of having a boy”: red wine tainted with pulverized rabbit’s womb for him; red wine with desiccated rabbit’s testicles for her.” Yes, this seems weird. But when you consider the numerous hormones we shoot ourselves up with today, perhaps dried testicles isn’t as strange as it seems.

13. Bowels: Constipation suffocates the fetus, while diarrhea washes it away. Also from the texts of Soranus, women with chronic bowel issues would never be able to “lay hold of the seed injected into them.”

14. Birth through the Middle Ages was for women only: It was considered obscene for a man to be in the delivery room. While they wrote guidebooks and issued advice, their wisdom drew from “a man-made concoction of myth, herbs, astrology, and superstition.” In 1522, a German doctor – Dr. Wert – was sentenced to death when he was caught dressed up as a woman and sneaking into the delivery room.

15. Forceps: the best kept secret of the 1600’s: The Chamberlen family came to England from France in the 1500s with forceps. Forceps, a medical instrument used to extract babies, were kept secret for over 200 years to preserve steady work and financial success. Nobody saw their instrument, not even the doctors’ closest friends or relatives, not even the women who were receiving their services. Forceps transformed birth from a natural, social event attended by a female midwife to a medical event attended by men. Pre-forceps, midwives would use oils and herbs for the perineum and a birthing stool that allowed gravity to help the baby move down. Post-forceps, doctors didn’t like to use stools, and preferred the patient lying in bed where they could use their tools with ease. Of course, “forceps isn’t the only explanation for why everything changed, but they certainly opened the door for other birthing gadgets.


Randi Hutter Epstein‘s book Get Me Out is not an advice book. Her depiction of the history of childbirth encourages readers to be inquisitive in their health decisions, and portrays the field gynecology as a marriage of medicine and culture.

Read it, and then come talk to me about it.

First hour of life for newborns: a timeline

Photo by Mikaela Wapman

Photo by Mikaela Wapman

Laura Sanders of Science News recently published a post on a Timeline of a Baby’s First Hour.

In the post, she stumbles upon a 2011 study from Sweden regarding observations of 28 of “the most mysterious creatures on the planet: brand-spanking-new humans.”

Sanders goes on,

Videos of babies in their first hour of life gave the researchers an unprecedented view of how newborns instinctually behave, when left to their own devices and nestled skin-to-skin on their mothers’ chests. I found the results, published in January 2011 in Acta Paediatrica, just as fascinating as the Drosophila courtship ritual.

Having supported a fair number of births in the hospital, I have witnessed many of the instincts of the newborn to cry, nurse, and sleep. Sometimes, routine tests or complications in birth interrupt the newborn’s instinctive inclinations and the maternal / infant initiation, as the hospital team performs the necessary evaluations, perfunctory tests (birth weight, length, head measurements, immunizations… the list goes on and on).

In uncomplicated, low-intervention births, new mothers are able to rest with their newborns on their chest and relish in the unique, indescribable joy of skin-to-skin. It is during these moments that the researchers from Sweden noted some key milestones in the first hour and 10 minutes of a newborn’s life, presented in median minutes:

Minute 0: Babies wail a robust, angry birth cry that helps wake up the lungs.

Minute 2: After all that wailing, babies spend less than a minute relaxing, holding perfectly still on their mothers’ chests. The authors speculate that this silent, still break might have evolved to keep babies hidden from predators.

Minute 2.5: As they start to wake up, newborns open their eyes for the first time. Babies gradually start moving their heads and mouths.

Minute 8: Babies become even more active, keeping their eyes open for five minutes or longer at a time. During this active phase, newborns seem to grow interested in eating, looking at their mothers’ faces and breasts, making sweet little “hungry” noises and moving their hands toward their mouths.

Minute 18: That was exhausting. Time for another rest.

Minute 36: Recharged newborns really kick it into high gear and begin scooting toward their mothers’ breasts, relying heavily on a sense of smell to navigate.

Minute 62: Babies nurse, most likely getting small amounts of colostrum, a pre-milk substance packed with protein and immune molecules. This early suckling stimulates the breasts to make milk and also helps mom’s uterus contract back to its pre-pregnancy size.

Minute 70: Babies fall asleep for a well-deserved break.

There you have it: the first seventy minutes of a newborn’s life, as described by science. Of course, these minute markers are median numbers drawn from a small number of newborns (n=28), and even the time tables of the babies included in the study varied substantially. Any single baby’s behavior might fall well outside of these time points.

These quantitative observations are helpful with respect to the introduction and recent emphasis that most hospitals are placing on “baby friendly” practices, designed to encourage breastfeeding and also happen to support the bond between mom and baby.

Photo by Mikaela Wapman

Photo by Mikaela Wapman

“Baby friendly” practices, as outlined by Baby-Friendly USA, state that “health care systems should ensure that maternity care practices provide education and counseling on breastfeeding. Hospitals should become more “baby-friendly,” by taking steps like those recommended by the UNICEF/WHO’s Baby-Friendly Hospital Initiative.” Initiatives to improve breastfeeding rates include forgoing formula and pacifiers, allow the mom and baby to stay together (rather than baby in nursery), and provide hospital staff to instruct and support new moms with breastfeeding.

Sanders refers to another observational study:

In the first hour of birth, babies whose chins touched the underside of their mothers’ breasts were more likely to successfully suckle than babies who didn’t do a chin-brush. These sorts of studies, which rely on carefully watching a newborn, are beginning to paint a more complete picture of what newborns might need in the moments after birth. And that understanding might ultimately be useful to the adults who want to ease the introduction of this new little person to the world.

Observations from these studies regarding the instinctive newborn behaviors – without interference from anyone – might help healthcare providers come up with better ways to encourage breastfeeding, and cut down on some of the routine tests that might be best delayed until the third (or fourth, fifth, or sixth) hour of the baby’s life.

You can read the whole article here. Via Science News.


Questions? Feedback?

Please feel free to comment, or contact me at mikaelawapman@gmail.com, or by filling out the form below:

Birth Videos

So many of us are filled with imagery of births as medical emergencies or otherwise painful, screaming, or distressing visions. These videos of various hospital and home births offer a new perspective and help us imagine that there are many, many possibilities for what birth “looks like”.

French Woman Giving Birth With Joy

A couple of things about this powerful birth:

  1. Notice her perineum. That stretch! The body is made to do this. It will stretch out, and stretch back. We’ve talked about Perineal Massage on the site, but here’s a visual aid for how a vaginal birth without lots of interventions can reduce perineal trauma and pelvic floor damage. For more information, see here.
  2. Consider how little movement and action there is in this film. The mom is free to take on any position that is comfortable to her, and she is calm. The birthing assistants (the doctor or partner, and the second doctor / midwife / nurse) are supporting her, but otherwise not doing much at all. After mom has delivered the shoulders, the male birth partner places the baby on mom’s chest. But there’s no pulling the head, suctioning, episiotomy… mom delivers baby without much assistance!

Natural Unassisted Homebirth

Birth of Sloane

A gentle film of a home birth from Natasha Hance.

Welcoming Theodore

A gorgeous depiction of sibling support during birth. “Waiting, birthing and welcoming Theodore into his new family of five. A homebirth in Tennessee. 9lbs 9oz” via Documentingdelight.org

Arden’s Labor

The calm birth of Arden, or “Sugarbaby” as some of the commenters have asserted, is via the TheLeakyBoob.

Happy watching!!


Please feel free to contact me at mikaelawapman@gmail.com, or in the form below:

“Morning Sickness” vs. Hyperemesis Gravidarum

Photo by Mikaela Wapman

Photo by Mikaela Wapman

Pregnancy-related Nausea or “Morning Sickness”

Pregnancy-related nausea is a common enough concept for most of us: nausea and vomiting during the first trimester, food aversions, and beyond.

Morning sickness – a misnomer, as it’s symptoms strike throughout the day for most women –  usually begins around the 6th week of pregnancy and tends to last for the duration of the first trimester (or until around the 14th week), but many women don’t experience relief from the symptoms for another month or so. And some women don’t feel a lessening of symptoms until they give birth, or somewhere around 40 weeks.

Pregnancy-related nausea affects over 70% of all pregnant womenAccording to Baby Center, more than half of pregnant women experience both nausea and vomiting, a quarter experience only nausea, and the remaining quarter are don’t experience any form of “morning sickness”.

Hyperemesis Gravidarum

Hyperemesis Gravidarum (HG) is a severe form of nausea and vomiting during pregnancy that is characterized by “unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids”. If HG is severe enough, or untreated, it can be associated with:

  • loss of greater than 5% of pre-pregnancy body weight (usually over 10%)
  • dehydration and production of ketones
  • nutritional deficiencies
  • metabolic imbalances
  • difficulty with daily activities

While the majority of women experience some form of morning sickness, around 1-3% of women are hospitalized for HG. That may seem pretty low, but these statistics offer very limited information, as many of the women who suffer from HG are treated as outpatients with mild to severe symptoms. Helpher.org – a website devoted to raising awareness about HG – goes on to say,

There are reports from hundreds, if not thousands, of women who terminated out of desperation when given the diagnosis of morning sickness and given inadequate treatment. One study by Zhang, et al of 1867 women found a 10.8% incidence of severe vomiting. Many women are not represented in current statistics which only report the number of women hospitalized as inpatients. HG is not a rare disorder.

Like more moderate forms of pregnancy-related nausea and vomiting, symptoms from HG can resolve around 21 weeks, though – for less than half of these women – can last for the duration of the pregnancy. The effects of all forms of HG are severe: considering the cost of additional doctor’s visits, outpatient care, consultations, and treatments for consultations, the annual cost could reach to one billion dollars.

Beyond the financial effects of HG are the emotional and psychological impacts: family relationships are disrupted, women could be “misdiagnosed by a disease erroneously presumed to be psychological”, and women could lose their jobs because of the debility. 

While there is no known prevention of HG, there are many ways to alleviate and manage the symptoms. These include: bed rest, acupressure, herbs (ginger or peppermint), IV fluids to restore lost hydration, electrolytes, vitamins and nutrients, tube feeding, and medications.

Distinguishing between Pregnancy-Related Nausea and HG:

Pregnancy-related nausea is what is commonly referred to as morning sickness. Symptoms of those suffering from Hyperemesis Gravidarum are generally more severe, as is depicted in the chart below (source: www.helpher.orgAmerican Pregnancy).

Why do we have pregnancy-related nausea, anyways?

Theories regarding the etiology of pregnancy-related nausea and HG are inconclusive. This is partially because pregnancy-related nausea and HG are influenced by a number of factors, and may vary among women depending on their biological makeup (genetics), body chemistry, and general health.

Theories regarding the cause of  pregnancy-related nausea and HG center on hormonal changes (increase in estrogen during pregnancy) and physical changes (relaxed esophageal sphincter) during pregnancy, since the time period is restricted to pregnancy.

Other half-witted theories include: one’s psychological state may be related to the development of pregnancy-related nausea and HG. In this vein, women who are frustrated, depressed, isolated, and / or have feelings of helplessness are more likely to experience pregnancy-related nausea or HG. Understandably, others respond by pointing to the fact that most, if not all women experience psychological effects (frustration, anger, depression, isolation, and feelings of helplessness) secondarily to  pregnancy-related nausea and HG.

At present moment, there are no conclusive theories as to the etiology of pregnancy-related nausea and HG. Click here to learn more about the many theories of pregnancy-related nausea and HG’s etiology.

Narratives from HG

To get a sense of what Hyperemesis Gravidarum (HG) can look like, check out Huffington Post ‘s post What It Really Feels Like to Have Hyperemesis Gravidarum”. An account of a third time mom who experienced HG so severe that she was hospitalized for 11 days, and spent the remaining duration of her pregnancy receiving IV fluids and medications for HG through a PICC line and stomach pump. Alexa continues,

One of the worst things about HG is how isolating it is. I cannot go out, cannot even talk on the phone for a long time because it makes me feel sick. I cannot cook, everything smells terrible to me, and even walking to the bathroom makes me vomit most days. I also have ptyalism, which is hyper-salivation, and swallowing it makes me vomit too, so I am constantly spitting into a cup. I feel disgusting.

Her account ends happily, with her giving birth to a 9 pound, 11 oz son (described by her OB as “the world’s most effective parasite”). For her, her HG improved after about 22 weeks of pregnancy, though she is the first to remind us that “far too many sufferers are severely ill until they give birth”. Read the whole thing here

For more information on Hyperemesis Gravidarum, visit www.helpher.org and beyondmorningsickness.com.

Why the Long, Difficult Birth for Humans?

Labor for first time moms averages somewhere between 10 – 20 hours. Among other Great Apes, such as Chimpanzees, labor takes on average two hours. In addition to the time in labor, human labor is described as extremely difficult compared to other primates.

What characteristics contribute to such disparate childbirths in humans and other primates?

1. The Obstetric Dilemma

The most significant tradeoffs in human evolution are evidenced at the time of birth: efficient bipedal locomotion promotes a relatively narrow pelvis, while delivering relatively large-brained babies selects for a broad pelvis. In other words, the narrow pelvic opening that is good for efficient upright walking is not so good for the delivery of large-brained humans.

The interaction of these features in our evolutionary history has shaped a female pelvis that reflects a compromise in these selective pressures: the constraints on the human pelvis due to walking on two legs, combined with the exceptionally large brains of human babies make human birth especially long and painful.

2. Bipedalism Promotes a Narrow Pelvis

Humans are the only living mammal to walk on two legs, and bipedalism requires narrow, short, squat, and basin shaped pelvic anatomies. In contrast, quadrupedal animals (like our closest relatives, chimpanzees) have pelvises that are long and two dimensional in appearance. Compare image A (the pelvis of a chimpanzee) to image C (the pelvis of a human female).

Comparison of pelves from (A) Pan, (B) Australopithecus, (C) Human female, and (D) Human male (from Lovejoy, 2005, figure 5).

Comparison of pelves from (A) Pan, (B) Australopithecus, (C) Human female, and (D) Human male (from Lovejoy, 2005, figure 5).

Notice how long the chimpanzee (image A) pelvis is compared to the squat pelvis of a human female (image C)? That humans walk on two legs is one explanation for the pronounced differences between humans and chimpanzees.

3. Big Brains and Birth

One important characteristic of primates as a group is a high encephalization quotient, or a large head and brain relative to body size. For most primates, this means that neonates at birth have heads that are close to the size of the maternal birth canal through which they must pass, making birth far from easy.

From Rosenberg and Trevathan (2002); based on Shultz (1949).

From Rosenberg and Trevathan (2002); based on Shultz (1949).

The image above describes the relationship of the maternal pelvic inlet (outer white ovals) and size of the baby’s head (dark solid ovals).

Think of a hard boiled egg. For gorillas and chimpanzees, the baby’s head is the size of the yolk, while the mother’s pelvic opening is the size of the egg white. Though baby must pass through the muscles and tissue of the birth canal, there is no bony resistance from the mother’s pelvis. For humans, imagine the hard boiled egg as the shape of the pelvic opening, and a golf ball as the baby’s head.

4. Passage through the Birth Canal

It’s not just the tight squeeze that makes birth difficult – the human birth canal isn’t a constant shape in cross-section. Thanks to bipedalism, the the birth canal is twisted in the middle, while the birth canal is described as a “relatively straight tube” for quadrupedal primates. A monkey baby has a tight squeeze through his mother’s pelvis, however her birth is significantly less difficult than a human baby’s. This is because, unlike the complicated cross-sectional area of the human birth canal, a monkey’s birth canal maintains the same cross-sectional dimensions from front to back.

Image by Karen R. Rosenberg and Wenda R. Trevathan

Image by Karen R. Rosenberg and Wenda R. Trevathan

As a human baby makes her way down the birth canal, she enters the birth canal at it’s widest side-to-side, relative to the mother’s body. But midway through, the orientation of the birth canal shifts 90 degrees, and the baby must now navigate a series of twists and turns so that her largest dimensions – the head and shoulders – are aligned with the largest areas of the birth canal.

The baby must rotate through the changing dimensions of the birth canal twice in order to navigate and pass through the differing pelvic dimensions through the birth canal’s entrance and exit. Our unique mechanism of birth is one of the distinguishing features of human birth, and adds an additional source of difficulty for so many mothers and babies.

5. Differing Degrees of Cervical Dilation

Among primates, human babies have exceptionally big brains. Because of this, the female cervix must dilate three times as much as other primates in order to deliver the big-brained, broad shouldered baby.

Image via Dr. Cheryl Knott

Image from Dr. Cheryl Knott via

Chimpanzee mothers must dilate around 3.3 centimeters before they’re able to give birth. Human mothers must dilate 10 centimeters before they’re able to deliver. The extra 6.6 centimeters of dilation takes significantly more time, but later stages of dilation are also experienced as significantly more painful. As described in the Mayo Clinic, the early stages of labor (0 – approximately 4cmaren’t always experienced as particularly uncomfortable, and certainly don’t require the same degree of attention as later stages of labor. Later stages of dilation (around 8, 9, 10 centimeters) leading up to transition and delivery are when women experience the most pain.

In Sum: the Obstetric Dilemma

Researchers eloquently describe the interaction of demands as a “tug of war” exerted on the maternal pelvis, which makes human birth significantly more risky than birth in other primates and mammals. Others have described this tradeoff as a scar of human evolutionary history, or the obstetric dilemma.

The Good News: Delivering with Company

Unlike most primates who seek solitude during parturition, virtually all women cross-culturally seek out assistance during birth from relatives, doulas, obstetricians, midwives, and other supports. While there are stories of women who had successful solitary births, studies of childbirth across cultures find that these stories are exceptional. Across cultures, women seek out both physical and emotional assistance in labor and delivery.

If you’re pregnant, consider giving birth with continuous emotional support: from a partner, family member, friend, or doula. A woman’s desire to be surrounded by familiar “others” has deep roots in our human lineage, is associated with fewer birthing complications.


Please feel free to contact me at mikaelawapman@gmail.com, or in the form below:

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References:

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Tague RG, Lovejoy CO (1986) The obstetric pelvis of A.L. 288-1 (Lucy). Journal of Human Evolution 15: 237–255.

Trevathan, W. (2010). Ancient bodies, modern lives: How evolution has shaped women’s health. New York: Oxford University Press.

Trevathan, W., & Rosenberg, K. R. (2000). The shoulders follow the head: postcranial constraints on human childbirth. Journal of Human Evolution39, 583–586.

Trevathan W. Fetal emergence patterns in evolutionary perspective. American Anthropology 1988;90:674–681.

Oxorn, H. (1986). Oxorn-Foote Human Labor and Birth, 5th edition. Norwalk, CT: Appleton-Century-Crofts.

Wells, J. C., DeSilva, J. M., & Stock, J. T. (2012). The Obstetric Dilemma: An Ancient Game of Russian Roulette, or a Variable Dilemma Sensitive to Ecology? Yearbook of Physical Anthropology55, 40-71.

World Health Organization. 2006. Neonatal and perinatal mortality: country, regional and global estimates. Geneva: World Health Organization.

First Time Moms: Consider Perineal Massage

Tearing during childbirth is common (more than 70% of women experience perineal trauma in childbirth) especially for first time vaginal births, and in vacuum or forceps assisted deliveries (Beckman and Stock, 2014Aashiem, Nilsen et al. 2011). Studies have found that perineal massage before birth has a positive effect on the incidence of perineal trauma at birth among first time moms. Second time moms experience a significant reduction in pain three months postpartum.

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Pregnant [39 weeks]” by Kevin Dean is licensed under CC BY 2.0

What is perineal massage? 

Perineal massage stretches the inner tissue of the lower vagina. Perineal massage teaches you to respond to pressure in your vagina by relaxing your pelvic floor, and can increase muscle and tissue elasticity. It is also thought to enhance the hormonal changes that soften the connective tissue in late pregnancy. I include instructions on how to massage your perineum later in this post.

How do I go about it?

Typically, women start massaging around 34-35 weeks of pregnancy, and are encouraged to spend 5 – 10 minutes 1-2 times a week. Recent studies indicate that the more frequently women use perineal massage, the less likely they are to experience the benefits. Specifically, women who did perineal massage 1.5 times a week experienced a 17% reduction in perineal trauma and a 17% reduction in episiotomy. In contrast, women who massaged between 1.5-3.4 times a week experienced only an 8% reduced risk of perineal trauma. So, the less frequent the massage, the more beneficial the outcomes. 

The research:

In a Cochrane Review, women who massaged their perineum once or twice a week beginning at thirty-five weeks of pregnancy were compared to women who did nothing. Researchers found that women who were assigned to do perineal massage experienced a 10% decrease in risk of tears requiring stitches (aka perineal trauma), and a 16% decrease in the risk of episiotomy, however these findings were only significant for first time moms.

Although second time mothers did not experience the same reduction in risk of stitches and episiotomy in childbirth, second time mothers reported a significant reduction (32%) in the incidence of pain at three months postpartum. More frequent massage in second time moms was associated with a reduction in perineal pain postpartum.

So, for first time moms only, perineal massage 1.5 times a week during pregnancy has been found to decrease the risk of episiotomy, as well as a decrease the risk of trauma requiring stitches. 

For second time moms, frequent perineal massage (between 1.5-3.4 times a week) is associated with a reduction in pain postpartum.

How to do a perineal massage:

  • Find a comfortable position (legs bent outward while lying on the bed, standing with one foot on the edge of a bathtub or counter, sitting on the toilet)
  • Use unscented oil such as olive, sunflower, or sweet almond oil. Insert one or both thumbs in the entrance of the vagina.
  • Pressing towards the back of your vaginal wall, move your thumbs back and forth in a U-shape, focusing on relaxing your muscles at the same time. First downward for 2 minutes, and then sideways for 2 minutes.
  • Massage for around 5 minutes each time. Remember your breath as you do this – count to four on your inhales, hold, and count to four on your exhale.
  • You can try pushing harder each time you do a perineal massage.

Or if you prefer, a medical explanation how-to: “Digitally stretch perineal tissues by inserting lubricated fingers 1.5 inches into the lower portion of the vagina and slowly massaging downward in a U-shaped movement” (Beckmann and Stock, 2014).

Questions? Feel free to check out any of these sources: 

Where are the safest places in the world to give birth?

Tracy Cassels from Evolutionary Parenting recently posted on new research on the current status of maternal mortality around the world.

Where would you rather give birth – in the USA or Albania?  Most of you would probably say the USA yet your chances of survival would then be lower.  Yes, you as a mother are more likely to die from childbirth-related problems in the USA than Albania.  

Do you find this surprising? Here is the research:

New research looking at maternal mortality is out* and the findings are not good for those in the American system.  In 1990, the USA was ranked 22 in maternal health and mortality.  This year, the USA ranks 60th after dropping from 50th in the last assessment.  In fact, the US is one of only 8 countries to have seen a rise in maternal morality, up from 17.6 in 2003 to 18.5 deaths/100,000 in 2013 (the other 7 were Afghanistan, Belize, El Salvador, Guinea-Bissau, Greece, Seychelles, and the South Sudan).  In 1987 that number was 7.2/100,00 […].

Canada and New Zealand have maternal mortality rates that are half of the USA.  The UK has one that is a third.  Australia’s is a quarter of the USA’s.  Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Romania, Kuwait, Lebanon, Iran, and Serbia all have rates that are lower than that of the USA.

What can explain such high rates of maternal mortality? No, it’s not the rise in homebirth.

One of the main factors is a rise in certain diseases that make pregnancy riskier, like diabetes and hypertension.  There are also other heart and neurological diseases that are on the increase that necessitate higher-risk pregnancies.

This possible explanation leads Tracy to ask:

If most of these increases are due to increases in diseases, why are other similar, developed countries not showing the same problems?  How is all the medical technology in the world failing American mothers?  At this stage, it’s hard to know what parts actually work, but clearly the system taken together doesn’t.  Perhaps it’s the lack of integration, the lack of affordable care, or the focus on treatment instead of prevention.  Likely it’s a mix of all of it and more.

Finally:

Oh – to answer the question of where you would be safest giving birth: Iceland with a maternal mortality rate of 2.4/100,000 (nearly 1/8 that of the USA).

 

Read the whole post here.

 

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Image via Every Mother Counts

* Kassebaum NJ et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.  The Lancet 2014; doi:10.1016/S0140-6736(14)60696-6.

The length of human pregnancies can naturally vary up to 5 weeks

Science Daily covers a recently published study from journal Human Reproduction, investigating the variability in the length of human pregnancy:

Normally, women are given a date for the likely delivery of their baby that is calculated as 280 days after the onset of their last menstrual period. Yet only four percent of women deliver at 280 days and only 70% deliver within 10 days of their estimated due date, even when the date is calculated with the help of ultrasound.

Already 40 weeks pregnant? Not to worry, that’s within the range of normal! Researchers found that the average length of pregnancy was 328 days, which is 38 weeks and two days, though the length of pregnancies can vary by as much as 37 days.

“We know that length of gestation varies among women, but some part of that variation has always been attributed to errors in the assignment of gestational age. Our measure of length of gestation does not include these sources of error, and yet there is still five weeks of variability. It’s fascinating.”

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Pregnancy” by Robert Pecino Martinez is licensed under CC BY 2.0

In addition to variation in gestation length:

Embryos that took longer to implant also took longer from implantation to delivery, and that pregnancies that showed a late progesterone rise were significantly shorter by an average of 12 days than pregnancies with an early rise.

Dr Jukic said: “I am intrigued by the observation that events that occur very early in pregnancy, weeks before a woman even knows she is pregnant, are related to the timing of birth, which occurs months later. I think this suggests that events in early pregnancy may provide a novel pathway for investigating birth outcomes.”

Read the whole story here.