Translator: Gillian Kulik Reviewer: Hélène Vernet
Today, I'm going to talk to you, as they said, about birth,
but I'm going to talk a little bit more about what we know of ourselves as humans:
home birth.
Clay Christensen says that disruptive innovation transforms
a practice or a product
that has commonly been traditionally
available only to the privileged few
and makes it mainstream.
It makes it so much more affordable and accessible
that suddenly, everybody's doing it.
So in North America, we believe
that the disruptive innovation was hospital birth.
Isn’t that what made birth safe and accessible to all women?
A safe birth?
Well, it turns out that some women don’t agree.
Some women want to stay in their own homes.
We’ve exported this idea of hospital birth
being the way to get safe birth to low-resource countries.
But even in low-resource countries,
women aren’t coming in droves to the hospital.
Why is that? What's going on?
And is the disruptive innovation hospital birth or is it home birth?
You’re all familiar with this image, that’s DNA.
I’m going to talk to you a little bit about the science,
the physiology of humans and what we’ve come to understand.
You can see those components
that are joining from two human beings' genetic information
to predict what the future will be for this human being.
It turns out that’s the same kind of linkage
that happens between the environment and the physiology of birth.
We’ve learned a lot about it from watching animals.
Animals in captivity, for some strange reason,
when they’re outside their familiar environment,
have a hard time getting pregnant, a hard time staying pregnant,
a hard time staying healthy while pregnant,
and a hard time releasing their babies when they feel like they’re being watched,
when they feel like they cannot get in what position they want,
they cannot access the comfort measures or the food that they want,
they’re fearful, anxious or lonely.
This is Mei Xiang and Lisa is the elephant.
They both successfully delivered in captivity.
How did they do it?
They could get in the position they wanted.
They were given environments that were so familiar to them.
Maybe they were still in a zoo,
but something about it allowed them to do what they had to do,
and part of that was that the zookeepers and the veterinarians weren’t seen.
They were behind hidden video cameras.
So what does that tell us?
What if every time a young healthy man wanted to run a marathon,
he was told, "It's okay. We’re not sure you can do it
and you might have a heart attack in the process.
So why don’t you come into the hospital?
You could run your marathon around the hospital.
But don’t worry, you can bring somebody with you
and your support or spouse can be there.
We will monitor you to make sure that you're okay.
And just in case you do have a heart attack,
the emergency personnel will be standing right there.
Just in case you do have a heart attack,
you'd better not eat, and we probably should restrict your fluids."
Does that make any sense to what you know about the physiology of sports?
Do you think that if he didn't believe he could do it,
he would be able to complete the marathon?
And what about making love?
What about making babies?
Suppose you told this young man
that he also could have a heart attack when he had an orgasm,
some people do.
What if, we weren't so sure about his ability.
We said, "No worries, come to the hospital!
We'll give you a nice quiet room. You can bring your spouse.
We'll just come in from time to time
check your heart blood pressure and your heart rate
and make sure that everything is okay."
Do you think he'd have some sort of performance anxiety?
(Laughter)
I think this is what he'd do:
He'd say, “I know what to do and you guys leave me alone.”
So, what have we learned about human physiology?
There're some very cool things that have been discovered now,
things about when we control birth
and when babies don't come out of the vagina.
Guess what? They don't get the beneficial effects
of the good bacteria living in the vagina that helps them for a long term health.
What about oxytocin, the hormone of love? Why is it called the hormone of love?
Well, it's only released in three times in our life,
three times which are absolutely critical to bonding.
In fact, it does modulate how attached do we feel.
It modulates social behavior.
Oxytocin is only released
when we make love - when we have orgasm -
when we have contractions to open up our uteruses
so that the baby can come out,
and when we let down our milk so we can feed our babies,
so our babies can survive.
Every year, 350,000 women die while pregnant or giving birth.
2 million newborns die within the first 24 hours of life.
This is true.
Is this why we don't recommend home birth to everybody?
Is it home birth?
You know, most of these women live in 58 countries.
They’re low resource countries.
In these countries, women do not have access to lifesaving techniques.
They don't have the medications to stop bleeding.
If they could access it, they can't get there.
They don't have somebody checking their blood pressure.
Sometimes they're exposed to conditions which are dangerous for themselves.
They don't have methods to resuscitate a baby
that maybe just needs a little help.
Is that why everybody should deliver in the hospital?
What does the research say?
For a long time we had a hard time understanding what it really says.
Just like what Carzy said this morning,
you've to ask the right questions in the right way. Guess what?
We weren't asking the right questions in the right way.
We were mixing up planned home birth with unplanned home birth.
When we looked at the difference between home and hospital birth
we had a lot of cases in there
where the woman delivered en route to the hospital
without an attendant, accidentally,
even in high resource countries where all those things are available.
And that doesn't tell us the story.
If we don't know who's attending her, what their skill set is,
if we don't know if she can change the plan when she is in trouble,
we don't know what's really dependent on place of birth
and what is instead dependent on the type of care that she gets.
What we do know now?
The good news is that we have 15 or 16 really high quality studies.
We'll never have a randomized control trial,
because women will not agree to be randomized to home or hospital.
They have opinions about where they want to deliver.
And they've tried!
There was one trial that they tried to run for about 15 years.
They got 11 women to agree.
Not big enough to say something.
So, what we know is that for an essentially healthy woman
and those skilled attendants bring basic equipment and medications
and they have seamless access to specialized care
when a complication arrives,
we actually get healthy mothers and babies
and they experience less interventions.
So what's the problem?
Why don't we all agree that that's the system that we should set up?
I study attitudes
and what leads to attitudes among maternity care providers.
I did this in Canada, a big large national study.
You can see that midwives, obstetricians and family physicians don't agree.
Why does that matter?
Provider’s attitudes matter, because they influence what women choose.
Women want to do what's best for their bodies.
They want to be able to believe their providers.
We know that providers who know more about breastfeeding
and have education about it,
their patients will be more successful at breastfeeding.
We know that women who choose cesarean on demand,
their providers are more likely to have chosen that for themselves.
There's something else going on there.
If we ask the right questions to the right people,
we might ask the women,
what happens when they listen to their providers,
try to access safe care,
leave their homes and familiar environments, and come in?
Well, this is what they say,
“I was told to be quiet and lie down."
"I was put in a room with women I didn't know.”
“I didn't know that man.
He came in and he said to me,
'Spread your legs like you did when you got pregnant.'”
“I had to undress in front of strange men.
They watched me while I got up on the table to have my baby.”
Women in the Philippines will say...
Actually a lot of places in the world where women by droves are coming in now,
- because there're institutional post-policies for institutional birth -
are overloaded by normal cases
and don't have enough resources
to look after the women who really need their care.
This is a labor ward, and a postpartum ward, and a newborn ward.
Is that where you would like to be? Does that feel safe to you?
This woman is an indigenous woman.
She came in because she believed
she was going to have a safer birth in the hospital.
When she got there, they didn't understand her language.
They didn't believe her that she was really in active labor
because she had walked from her village.
So they made her leave.
Shortly thereafter, she delivered on the grass in front of the hospital.
Is that safer care?
If you think this is just happening in low resource countries,
it's happening all over the world!
This is North America:
strangers around, women being told to push.
One woman said,
“I was hooked up and trussed. I couldn't move six inches.
I knew I had to get up to have my baby, but they told me to lie still
because they couldn't hear my baby's heartbeat.
I was worried.
I listened to them, but they didn't listen to me.
So I closed my eyes and I hid in my music
while they stood around and watched me.”
So what is this issue about relocation?
How are we defining safety? And who gets to define what safety is?
We know when all of these silly things happen,
when mammals are not in their familiar environment,
when they're disturbed, have a loss of privacy and dignity,
it can affect their ability to care for their own babies.
Women tell us.
Tiye, who is some of the women I looked after, told me
she had a good job in the hospital.
She was a lab tech.
She said, "Everybody knows everybody's business ; I don't want them to know mine.
The white women I work with don't understand me.
I don't want to be undressed in front of them.”
We looked after a woman when I was at Yale on faculty.
Her husband would not tell us what his name was.
He said his name was Fred. Nobody believed him.
They said, “Maybe he is undocumented, that's why he doesn't want to tell us."
It was 2001, October.
His name was Osama.
He was afraid if he's told the hospital staff his name,
that they would not treat his wife well.
The Hmong women I looked after in California
were used to having all of their elders around,
but the hospital had a rule
that only one person could come with these women.
This lesbian couple knew
that if they went to the hospital with their known and beloved donor,
that it was very likely
that the hospital staff would hand the baby first to him
and not to the primary parent.
Women tell us that when they're home,
they can get in what position they want, they can use gravity
and they can still be assured
that someone will be checking them and their baby's heartbeat.
So what about babies who are fascinated with technology?
What about what women say about technology?
It turns out that they actually don't want
to reject technology or modern medicine.
They want access to all those lifesaving techniques.
They just want to be told the truth.
All of the things I was telling you about were based on studies
that we've done where women have told us what they want
and what's most important to them: comfort, convenience, empowerment.
This study has just come out.
About 2000 women answered a very long survey
about what they thought about their maternity care.
These were all women who planned hospital births.
Guess what? They say the same thing.
They believe they're in charge.
They believe they're choosing the best options for their baby.
They just want to be told the truth.
They want to be told, how does this risk relate to me?
What if I live in a place that does have those resources?
What will it be like when I go into the hospital?
And they also tell us
that some interventions lead to things that they wouldn't choose
unless they were very sure that it would save them or their babies.
40% of women are induced in the United States today.
We have over 30% C-section rates.
Do you think the species would have survived
if that was the needed rate?
In fact, most countries that have much better outcomes
than we do in North America, have much lower rates of these things.
So what about risk?
Who gets to choose?
This is a one-in-a-thousand risk.
When you have skilled attendants at birth
and access to equipment and personnel when you need it, this is the risk.
About one per two to three thousands is what loss will look like,
- not fetal loss, I’m talking about neonatal loss.
And 50% of stillbirths are unexplained,
so we don't really know what's going on there.
So one-in-a-thousand.
That's about the same risk than that man who wanted to run a marathon,
would experience of having a heart attack.
Is that an acceptable risk?
And what about the risk of loss of dignity, of abuse,
of disrespectful care?
How do you define safety? Who should decide?
Who is most invested and most responsible?
How much risk is too much
and whose agenda and whose destiny are you talking about?
You know what women say? What would your mother say?
Do you think she was more concerned about you than the doctor?
Yes, that's what women say:
''We care about our baby’s health.
We are offended when people suggest
that we are choosing home birth or choosing respectful care,
just for our own convenience or for comfort,
like it was some sort of cosmetic option.
We know that if we are not well,
if we're not treated well, if we're abused,
if we feel like we had an unnecessary intervention
or if we're in an environment where we don't feel safe,
that can affect how we feel about our babies, our future.
We're concerned about our baby’s health also.
What about the use antibiotics?
What about with C-sections or any of these things?
Absolutely! Give me a C-section if that’s what I really need.
I want my baby to be healthy.
I value the advances that modern medicine have brought to high resource countries.''
That's what they tell us.
But is anybody listening to women?
Paula Freire said, “Washing one's hands of the conflict
between the powerful and the powerless
means to side with the powerful, not to be neutral.”
Isn't it time we took a stand?
Which is the disruptive innovation we await?
Is it home birth? Is it hospital birth?
Or is it humanized birth?
What if all countries took steps
to facilitate high quality care in all settings?
And all women were told how to access that care
wherever they felt safe?
If the focus was access to safe humanized birth in all settings,
then we'd prioritize the availability of lifesaving measures and skills
everywhere and carry them to the places where a woman feels respect, autonomy,
and the ability to listen to her own body and baby.
I wrote that down because I wanted to say it all.
I wanted to be sure I didn't forget to tell you
that it is about all of those things together.
We can carry those things to her.
They might be packaged a bit differently.
We know most people won't need IVs
if they're cared for and start out healthy,
- we're talking about term pregnancies here.
We could be ready standing by with resuscitation equipment for her baby.
It doesn’t look like the hospital but it’s got all the same stuff.
Meanwhile, the woman could get in whatever position she wanted.
And we could remember that whether or not we're there,
whether or not the interventions are there,
a woman will deliver undisturbed
and will receive her baby and care for her baby,
because that's what humans do.
They would receive their babies with joy
and with the people that they love, with gentleness.
If we attended them in that respectful way,
perhaps they would invite us back into their homes
to help them learn how to care for their babies.
And their babies would come out alert and healthy,
ready to receive the wisdom of their grandparents.
This is what one of my favorite photojournalists said.
This has been around for a long time.
I graduated here in 1978
and I read this book shortly thereafter.
Suzanne Arme said, “If we hope to create a non-violent world
where respect and kindness replace fear and hatred,
we must begin with how we treat each other at the beginning of life,
for that is where our deepest patterns are set.
From these roots grow fear and alienation or love and trust.”
Thank you.
(Applause)