Friday, April 30, 2010

Variability of Uterine Efficiency?

One of the many things that annoys me in obstetrics is when doctors say, "Every cesarean I perform is necessary." Or when laypeople say, "Well, if you had a cesarean, I'm sure it was necessary. The doctors wouldn't do one if it wasn't really needed."
Oh yeah, really?  Every cesarean?  All necessary?

Then why do you have such variability of cesarean rates from one state to the next?  From one historical time period to the next? From one doctor to the next? From one hospital to the next?

State to State Variability

Look at the map above.  (These rates are from 2007; keep in mind that the rates are higher now.) The cesarean rates vary strongly from state to state, and even region to region. 

Do you really think the uteri of women in Utah, Idaho, New Mexico, Wisconsin, or Alaska are more effective and work that much better than the uteri of women in the Deep South? 

Is there something inherently less efficient about the uteri of New York and New Jersey women, who have some of the highest cesarean rates in the country, compared to the uteri of their close neighbors in Vermont?

Or perhaps is there a pattern of practice that varies from one state to the next, from one region to the next, that influences cesarean rates and tolerance of questionable cesareans?

Historical Period Variability

There has also been a huge shift in cesarean rates over time.  How could that be, if all cesareans are "necessary"?  Are modern uteri that much less efficient and effective than uteri from 40 years ago?

No, what's happened is that practice patterns have shifted, technology has improved, and cultural attitudes among caregivers towards cesareans have shifted as well.  See here for a discussion on how cesarean rates have jumped so strongly in the past 30 years and why.

Doctor to Doctor Variability

All doctors are not alike.  Some are so fast to do a cesarean it'd make your head spin; others are really dedicated to doing cesareans only when necessary.  Some would like to do only truly necessary cesareans but feel pressured by medico-legal concerns and "standard of care" issues to do cesareans they find questionable.  Most physicians fall somewhere in between.

Research from a decade ago (when lowering the cesarean rate was still a priority) found significant differences in inter-practice variability between physician groups.  So it really DOES matter which provider you choose to attend your birth.  Your chance of getting cut may vary significantly between Dr. X and Dr. Y.

Alas, studies like this are harder to find nowadays, because few doctors (and fewer hospitals) are interested in lowering the cesarean rate.  Without a glaring spotlight on the practices that increase cesareans, doctors have limited motivation to change their patterns and lower cesarean rates, and strong motivation to go with the choice that is less risky legally and more convenient for their schedules.  As a result, individual doctor cesarean rates may grow out of control with few checks and balances, making the choice of birth attendant even more critical these days. 

Oftentimes an excellent choice is to change the type of birth attendant you choose.  Choosing a midwife or family doctor for your care can significantly lower your chances for a cesarean, probably because of practice pattern differences between midwives, family doctors, and obstetricians.

Some care providers claim that they don't care how many cesareans they perform because their top priority is getting healthy babies.  But this ignores the fact that a high cesarean rate is often associated with considerable harm to babies.  And of course, they should care about both a healthy baby and a healthy mother.  Duh.

It is clear that different patterns of physician practice, different style philosophy, and many other factors influence cesarean rates.  Thus, it is smart to ask a lot of questions about typical practice patterns and attitudes when interviewing potential caregivers.  Your chances of getting cut will vary a lot, based on who you choose.

Hospital To Hospital Variability

What about inter-hospital variability in cesarean rates? The New York Times just published a fascinating article on the difference in cesarean rates between two hospitals, just five miles apart on Staten Island.

One hospital, the Staten Island University Hospital, has a c-section rate of about 23%, and its 2008 cesarean rates actually went down, unlike the U.S. and New York City rates.

On the other side of the coin is Richmond University Medical Center, whose cesarean rates went up and reached an all-time high of 48.3%. For five years running, it has achieved the dubious honor of being the hospital with the highest c-section rate in New York City.

One of the key reasons that Staten Island University Hospital has been able to keep its cesarean rate at half the rate of the other hospital is that they do not allow unnecessary inductions in first-time pregnancies before 41 weeks, and doctors who perform a lot of cesareans "invite scrutiny" of their management.  Having to defend questionable cesareans gives doctors motivation to keep their numbers more reasonable.

Staten Island University Hospital also encourages VBACs, recognizing the cumulative harm that can come from multiple repeat cesareans. Its chief OB states:
"If a woman has a third or a fourth Caesarean, the maternal morbidity and mortality is astronomically higher," Dr. Maiman said. "That's when you see women dying in childbirth from obstetrical hemorrhage."
Compare that to hospitals who force women to have multiple repeat cesareans, even when they don't want or need them. Attitude from the top can make all the difference sometimes....both in primary (first-time) cesareans and in repeat cesareans. 

Some hospitals (like Richmond University Medical Center) like to claim that their cesarean rates are higher because they treat a lot of high-risk women.  There's some truth to this claim, of course, but it's also a way of blowing smoke so people won't question their excessive numbers. 

If high-risk patients increase the cesarean rate a certain amount, then hospitals with similar loads of high-risk hospitals should have similar cesarean rates....yet the cesarean rates differ markedly, even among "high-risk" hospitals. 

Unfortunately, in many hospitals, labeling a woman "high-risk" simply means that no one will question whether or not her cesarean was really necessary and gives doctors carte blanche to cut as much as they want to, regardless of whether the cesarean was truly needed.

In my own city, there are several hospitals that treat the highest-risk patients from all over. The c-section rate in all of them is too high, but one (40+%) is quite a bit higher than the others despite a similar patient load.  Compare that to the "high-risk" hospital on Staten Island with the 48% c-section rate.  Or the hospital in Florida with the 70% c-section rate. 

Cesarean rates will vary somewhat depending on risk caseload, but beware a hospital that uses that as an excuse to justify doing a lot of cutting.  High-cesarean hospitals, even those that serve more high-risk women, should be avoided. 

If you'd like to see the hospital-based c-section rates for your state, see the states documented on The Unnecesarean Blog and on The Birth Survey's website, including:

Some information on Canadian c-section rates is also available.

[Do note that not all of the above links are for the same year. Also note that if you'd like to see YOUR state listed above or updated on The Birth Survey's website, you can join the GACSTAT project and start documenting the c-section rates by hospital across the entire country, one state at a time.]


No one with any sense has a problem with life-saving, necessary cesareans.  If you need one, it's wonderful to have this option, and sometimes it really can save mothers and babies.  Huzzah to the doctors who keep this life-saving option available when needed, and for their skills and tools that help minimize the risk from this procedure as much as possible.

However, there is NO QUESTION but that the current cesarean rate is inflated by many cesareans that are questionable in nature.  There should be NO reason for such wide variations in cesarean usage from one state to the next, from one hospital to the next, or from one doctor to the next. 

Sure, sometimes there are going to be some differences inherent because of high-risk caseloads.....but even among hospitals that handle large numbers of high-risk cases, the c-section rate varies considerably.  Something else besides risk status influences cesarean rates, and that something is birth climate and provider patterns of practice.  Therefore it is absolutely critical that you choose your provider and birth location very carefully.

Lessons for Parents 

Choose your birth provider and birth location with your eyes wide open, not randomly.  Do your research and ask lots of questions.  Choose one that is in line with your birth priorities and philosophies.

Don't choose someone based solely on proximity, recommendations from others, or convenience.  These can all be legitimate factors to consider, but they should be weighed against the practice pattern and intervention rate of the providers you are considering, as well as the style of care you prefer.

Your chances of a cesarean will vary GREATLY from one provider to the next, from one hospital to the next, from one area of the country to the next.  Therefore, it is wise to choose from a basis of knowledge, not ignorance.

Don't assume providers are all the same or that your chances for a certain type of birth are the similar whomever you choose.  A careful look at the data shows that this is not true at all. 

All cesareans are NOT "necessary."  If your chances of being cut vary so greatly from one provider to the next, one hospital to the next, one state to the next.....then something else is going on here.  Be a savvy consumer and choose wisely. 

Most graphics by Jill from The Unnecessarean blog.  U.S. Map by Jessica Turon, published first on  Thanks for permission to use the graphics and data.

Monday, April 26, 2010

Participatory Medicine and Why You Should Know About It

Amy Romano, CNM, posted a while ago on her blog about the "new" concept of Participatory Medicine, and recently commented on it again.

I've been ruminating on this topic for quite a while now but just never got around to finding the links I needed to finish the original post. 

I think the topic still bears commenting on, even if it's not a very timely response to her original post.  This is what I originally wrote, adapted and re-edited recently. 

Participatory Medicine is a new paradigm in healthcare that has particularly resonant implications for childbearing women and for people of size. 

Here's the definition of Participatory Medicine from the e-patients website:
"Participatory medicine is a cooperative model of healthcare that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care. The 'participatory' concept may also be applied to fitness, nutrition, mental health, end-of-life care, and all issues broadly related to an individual's health. The Society was founded to learn about and promote Participatory Medicine through writing, speaking, social networking, and other channels."
Participatory Medicine is really nothing new to us in the birth activism movement, nor is it really anything revolutionary to those of us in the Health At Every Size (HAES) movement. Both have been advocating patient collaboration in their own care for many years.

But even so, this movement formalizes what we've been saying for years and is definitely something we should be paying attention to.

Those of us who have had children know how often we have faced condescension from caregivers about the idea that we could become knowledgeable about and have a say in our own children's births, and those of us who have tried have frequently faced a great deal of resistance.

And those of us who are people of size know how often we have searched for a provider who could see beyond our weight and into our individual circumstances, who understood the starkly unlikely chance of permanent weight loss, and who was willing to shift their care paradigm from a weight-centered model to a health-centered model instead.

Participatory Medicine and Birth

Here's a link to Amy's post to the Participatory Medicine site, proposing that maternity care is the perfect place to start as an "e-patient":

Basically, it's what many of us in the birth movement have been encouraging for years....empowering patients to do their own research, question their healthcare practitioners, look into alternatives, find a new provider if needed, make decisions in partnership with healthcare providers, and take responsibility for their healthcare decisions. Only now it has an official "name" and a whole movement behind it.

Of course, some doctors are threatened by the Participatory Medicine model. In particular, obstetrics providers seem to be extremely threatened by it, partly because of the vulnerability to litigation they feel in this field, and partly because of the high level of paternalism and misogyny in the field (even from women physicians). 

Participatory Medicine has been going on in the cancer field for years (see the story of Intel's Andy Groves' experience with prostate cancer years ago) and is fairly accepted there now......and frankly, I observe that many of the voices I see in the Participatory Medicine groups are from the cancer field.

Interesting that Participatory Medicine is SO very resisted in the maternity care field when it's relatively accepted in the cancer field.

Even the same OB-GYN who is open to working in partnership with a woman on decision-making if gynecological cancers occur, often did not give that woman any meaningful say in her choices when she was giving birth.

This is part of the paternalistic view of birth, one that now sees the baby as the primary patient and the mother's needs as endangering the safety of the baby; one that sees the mother as a hysterical, overly-emotional person who is not competent to make her own decisions near the end of pregnancy or while in labor.  [Yes, there are doctors that argue this.]

In this worldview, the mother is the enemy, the culprit and scapegoat if anything goes wrong.  The caregiver is seen as needing to save the baby from the mother's "hostile" uterus, selfish personal habits, or narcissistic desires for a "good" birth.

When a caregiver views mothers as the main source of harm to the real patients (the babies), is that caregiver going to see that source of potential harm as a real partner in decision-making? Or the main obstruction in the way of "saving" the baby?

Another barrier to Participatory Medicine in obstetrics is the cultural training for patients to turn over all personal responsibility for medical choices to their physicians.  This is particularly prevalent in obstetrics, where the woman gives all the power for decision-making to the doctor because of the doctor's extensive training in the field, thinking, "Who am I to disagree with such an expert if he says I have to do this for the baby's sake?"

Obviously, doctors do have a great deal more training and expertise in these medical issues than most patients do and their opinions must be considered carefully, but just ceding over all decision-making powers ignores the fact that doctors disagree with each other all the time about the best course of action. 

Go to one doctor, and you'll likely get one recommendation about what you should do.  Go to another, and you'll likely get different advice.  Go to enough doctors, and you'll probably get totally conflicting advice about what your best course of action cancer, in heart disease, in chronic illness, even in pregnancy.  Most patients don't recognize just how much medical advice can vary from one care provider to another because they never bother to get a second or third (or more) opinion.

Either you are blindly willing to trust your health and your baby's health to whichever doctor you randomly picked first by praying that you picked well, or you are going to have to do some research and make some decisions based on your values, knowledge, and priorities.....even if that means getting second opinions, exploring alternatives, or seeking out a different care provider who is more in alignment with your priorities.

Some pregnant women don't want any responsibility for these difficult choices, so they cede all decision-making to their doctors.  Such compliant patients are very convenient for obstetricians.........until it bites the doctors back when something goes wrong and the patient sues.

What most maternity field providers don't yet see is that Participatory Medicine benefits doctors too. When parents are involved in active decision-making.....when they really understand all the benefits and risks of a particular choice.....they take on more responsibility for these choices and are less likely to blame the doctor and sue if something goes wrong.  We see this in midwifery care, and we would probably see this in obstetrics too --- if more doctors were willing to practice that way.

Maternity care is the perfect field for Participatory Medicine, but it is probably one of the least participatory of all fields of medicine. Fortunately, caregivers who follow the physiological/midwifery model of birth (regardless of actual job title) do usually practice Participatory Medicine, and this is placing pressure on the medical model like never before to start opening up the decision-making process. 

But as always, it is the consumers who will lead the way in pushing for the participatory model.  Vote with your feet and with your pocketbook.  Choose a maternity care provider who, while providing valuable expertise and perspective, actively shares the decision-making with you and respect the choices that you make.

Participatory Medicine and Health At Every Size

The Participatory Medicine movement also has great implications for the HAES (Health At Every Size) paradigm and people of size.  It also has major implications for the "Bariatric" and Endocrinology fields, if they were only open to seeing it.

Those of us who have really looked at the research know that the rate of long-term success in weight loss is extremely low, and often, weight fluctuations do more harm than good. If the long-term results are examined, many folks end up weighing more in the long run than they did at the start of a diet, and a repeated pattern of dieting is often a major source of increasing obesity and disordered eating.

In what other field would medical experts keep recommending a treatment that has such a low degree of long-term success and a strong chance of making the patient worse off than when he/she started?

Would such poor results be promoted or even tolerated in the cancer community?

Many people of size have long taken charge of their own medical care by opting out of the radical weight loss paradigm, and instead choosing a health-based model over a weight-based model.  This dovetails nicely with the HAES approach of reasonable nutritional and exercise habits for improving or maintaining health, independent of weight.

Many of us refuse to buy into the common medical-paradigm idea that weight loss is always a good idea and is always helpful, and that any means used to achieve it is worthwhile, no matter how radical.

Many of us know from painful experience that the dieting and weight cycling often does more harm than good. Many of us know that we are healthier, mentally and physically, when we do not actively try to lose weight but rather choose to emphasize reasonable nutrition and exercise instead. Many of us ascribe to the radical idea that emphasizing reasonable, healthy habits will improve our health far more than trying to reach some unrealistic and arbitrary weight goal.

Alas, despite research backing up the HAES model, this is a difficult sell to those in the Bariatric and Endocrinology fields, whose training is usually laced with deeply fat-phobic biases against people of size.  Most are trained to think of obesity as the cause of most evils, as weight loss as the only "cure," and to make many assumptions about how fat people "must" be eating and living in order to be fat. 

To share decision-making with patients means actually listening to and believing them about their condition and habits, and this contradicts everything most of these healthcare professionals have usually been taught to believe about fatness.  Thus, those in the Bariatric and Endocrinology fields are unlikely to buy into HAES and Participatory Medicine anytime soon.  It requires too much change to their worldview about fatness.

Alas, the HAES model may also be a difficult sell to some of those already in the Participatory Medicine movement. 

Some Participatory Medicine advocates may have bought into the "magical thinking" mindset that if they can only improve their diet enough, lose enough weight, get enough exercise, etc. that the cancer (or whatever) will not return or would never have occurred in the first place. 

Others have been listening to the mainstream media distortions about the "obesity epidemic" and will find it difficult to consider the seemingly counter-intuitive idea that dieting may actually worsen health in some cases and that not losing weight may actually be a better choice for some people. 

Therefore, the idea of questioning the efficacy and benefits of weight loss may be particularly difficult to some in the Particpatory Medicine movement.

I'm sure many Participatory Medicine followers believe that weight loss is the right way to go for their own health.  And of course, if that's the choice that they want to pursue, they have every right to do so.

But the good thing about Participatory Medicine is that it pushes people to look at things from a more evidence-based point of view.  Hopefully they will read the research and see just how poor the odds for long-term weight loss are among chronic dieters, how it may increase the risk of certain problems, and recognize that as with many other diseases, sometimes the "cure" may be worse than the "disease."

More than that, hopefully the folks embedded in the e-patient movement will remember the principle of self-determination that is so important in the concept of Participatory Medicine --- that pursuing weight loss or not is a choice we deserve to make for ourselves, not have forced upon us as a requirement for care (mandatory weight reduction before organ transplants or surgery, for example).

In the end, we should get to decide whether or not a prescribed course of treatment is right for us or not, we should get to decide whether another round on the diet merry-go-round is going to be helpful or harmful for our individual situation, and we should get to decide whether or not to pursue alternative paradigms of care (like Health At Every Size). 

And that's the heart of Participatory Medicine, isn't it?  People taking the evidence, making decisions in partnership with their care providers, and taking responsibility for them.


Really, there is a great case to be made that Participatory Medicine is one of those innovations that is going to change medicine as we know's a model rapidly taking over, and protesting it is trying to shut the barn door after the horse is already out. It's coming whether doctors want it or not, and they might as well get on board and embrace the positive facets it brings to patient care.

Participatory Medicine has been quick to catch on in cancer and related fields, but has been slow to be adopted in Childbirth, "Bariatric" and Endocrinology fields.  In fact, in these fields, it is often actively resisted on the basis of condescending and paternalistic attitudes that women giving birth and fat people cannot be trusted to make these kinds of major life decisions, that they are too compromised by their own conditions to see the choices objectively.

But the barn door is open, the horse is galloping off, and Participatory Medicine is rapidly taking over.  Its influence is even being felt in the highly-resistant field of Childbirth; it is only a matter of time until it is heard more in the even-more-resistant fields of Bariatrics and Endocrinology. 

Here is a link to the Seven Preliminary Conclusions of Participatory Medicine:

Here are a couple more links to an opinion piece from a doctor called "Doctors Are Killing Their Profession, The Healthcare System, and Their Patients with Paternalism."

Personally, I think this is pretty important stuff, and something that has the power to really transform the practice of medicine.

Please, go check out the e-patient website. And whether you are a birthing person, a person of size, a cancer patient, or whatever.........start making yourself an empowered and informed health consumer!

Friday, April 23, 2010

Elective Inductions and Elective Cesareans - No Big Deal?

Think elective inductions or elective cesareans are no big deal?  Check out the abstract of this recent study.  [And remember the higher rate of inductions and "elective" cesareans in women of size and consider the implications there too.]

Outcomes of elective labour induction and elective caesarean section in low-risk pregnancies between 37 and 41 weeks' gestation

Dunne C, Da Silva O, Schmidt G, Natale R.  J Obstet Gynaecol Can. 2009 Dec;31(12):1124-30. Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.

OBJECTIVE: To compare maternal and neonatal outcomes after elective induction of labour and elective Caesarean section with outcomes after spontaneous labour in women with low-risk, full-term pregnancies.

METHODS: We extracted birth data from 1996 to 2005 from an obstetrical database. Singleton pregnancies with vertex presentation, anatomically normal, appropriately grown fetuses, and no medical or surgical complications were included. Outcomes after elective induction of labour and elective Caesarean section were compared with the outcomes after spontaneous labour, using chi-square and Student t tests and logistic regression.

RESULTS: A total of 9686 women met the study criteria (3475 nulliparous, 6211 multiparous).

The incidence of unplanned Caesarean section was higher in nulliparous women undergoing elective induction than in those with spontaneous labour (P < 0.001).

Postpartum complications were more common in nulliparous and multiparous women undergoing elective induction (P < 0.001 and P < 0.01, respectively) and multiparous women undergoing elective Caesarean section, (P < 0.001).

Rates of triage in NICU were higher in nulliparous women undergoing elective Caesarean section (P < 0.01), and requirements for neonatal free-flow oxygen administration were higher in nulliparous and multiparous women undergoing elective Caesarean section (P < 0.01 for each).

Unplanned Caesarean section was 2.7 times more likely in nulliparous women undergoing elective induction of labour (95% CI 1.74 to 4.28, P < 0.001) and was more common among nulliparous and multiparous women undergoing induction of labour and requiring cervical ripening (P < 0. 001 and P < 0.05, respectively).

CONCLUSION: Elective induction leads to more unplanned Caesarean sections in nulliparous women and to increased postpartum complications for both nulliparous and multiparous women. Elective Caesarean section has increased maternal and neonatal risks.

PubMedID: 20085677

Simplified Glossary: 
nulliparous - no previous births
multiparous - previous births
elective - (in this context) not medically necessary
NICU - Neonatal Intensive Care Unit

Friday, April 9, 2010

Healthy Birth Practices: Get Upright and Follow Urges to Push

Unfortunately, in our society we think of birthing as something done while lying down--Michel Odent

This is number 5 in a series on the Lamaze Healthy Birth Practices, why they are important in birth, and how they are less commonly "allowed" in women of size. The previous entries have been:
  1. Let Labor Begin On Its Own
  2. Walk, Move Around, and Change Positions During Birth
  3. Bring a Loved One, Friend, or Doula for Continuous Support
  4. Avoid Unnecessary Interventions
The new featured Healthy Birth Practice is:

5. Get upright and follow urges to push

You can find a care practice paper summarizing this Healthy Birth Practice, complete with research citations, here.  You can find a handout summarizing the information, here.  You can find a handout illustrating various labor positions here.

[Only one more Healthy Birth Care Practice to go!]

Alert: Be aware that this post has some graphic birth pictures in it, pictures in which ladybits are clearly visible. If that bothers you, don't look at the last section of this post. Also keep in mind that the photos are copyrighted and may NOT be reproduced elsewhere without permission.

Our Pervasive Cultural Image of Birth

Turn on any TV birth show like "A Baby Story" etc. and you will see women primarily delivering while on their backs or lying a bit propped in bed. Their legs are either in stirrups, or their knees are being pulled back and held in place by others. They are usually encouraged to curve their chests into a "C" position, chin to chest, while rounding their backs forward.

Some birth shows have women who are propped up into a semi-sitting position in bed, with their knees pulled back.  This gets them a little more upright but again they are sitting back on their behinds in bed, pushing the tailbone into the space where the baby has to come out.

Are these really the best positions for birth? Do they have the best outcomes? Why is every woman shown in these positions for birth?  Women are so different; isn't there any variety in how they choose to give birth?  Left to their own devices, are these the positions most women would give birth in, or are these positions an artifact of outdated medical and cultural norms?

And do we really need to have everyone yelling at the mother to hold her breath and puuuuusssh while they count to ten, then to take a quick breath and do it again? Is it really necessary to "purple push" in order to get a baby out?

The Healthy Birth Care Practice Paper #5 describes the results of a recent national survey, Listening to Mothers II.  They found that 57% of women surveyed gave birth lying on their backs, and 35% more gave birth in a semisitting position. They reported, "Only 21% of women in the survey followed their own urge to push. The rest of the women reported that nurses or other health-care providers told them to push a certain way."
Although this type of birth is obviously a very common scenario, the answer is no, women absolutely do not need to push this way in order to get the baby out.  And in fact, most outcomes tend to be just as good or better for women who don't follow the current media norms about what birth "should" look like or how support personnel "should" coach women during pushing.

Types of Pushing Positions

There are other positions women can use to push out their babies. 

For example, many women find they like kneeling positions for both laboring and pushing.  In this type of position, a woman might kneel on the bed, facing backwards and leaning on the raised head of the bed.  Or she might kneel while leaning on a birth ball, chair, or support person.  Leaning over keeps her hips mobile, tends to be less painful than laboring while on the back, and lets her support people apply counter-pressure if needed. It also utilizes gravity to help bring the baby down with less force from the mother.

Many women like to give birth on all-fours (another kind of kneeling position) because it gets the weight of the baby off their backs and tends to lessen pain. It also creates more room by allowing the sacrum and tailbone to move freely up and out of the pelvic outlet (the space between the pelvic bones where the baby comes out). Counter-presure is also easily applied in this position, which many women find helpful.

Some women prefer a squatting or semi-squatting position for giving birth.  Because this can be a tiring position, it's helpful to use it intermittently and have a resting position you can return to as needed.

In a hospital, women can use a squat bar to help them with squatting.  Most hospital birthing beds break down into various positions for pushing, and although it's not used that often, most include a squat bar that can be set up and utilized. 

Another option for squatting is for a woman to labor in water so that supporting a semi-squatting position is easier and can be maintained longer.

Another alternative is for a partner or support person to support women from behind while they dangle in a squat, as in this picture.  Although this position looks very tiring for the partner, if done right it is actually very practical.  Dr. Michel Odent (author of Birth Reborn and many other books) often used this position to support birthing women in his clinic in France.  It can elongate the trunk of the body and create more space for the baby to move as needed.

Birth stools often promote a kind of modified squat.  It may look like a semi-sitting position, but the angle of the mother's legs and pelvis is often closer to a squat, the mother has more freedom of movement (she can get up and go forward to deepen the squat and then sit back down to rest), and she is much more upright than most women in hospital positions get.

You can find many illustrations of birth stools in history in the Western artwork, from the Middle Ages on.  Since it was so commonly used, it obviously was a position that worked well for many birthing women.

This scene from a pioneer-era birth shows a human birth stool.  The mother sits on or between the father's spread legs (with her own legs also open).  Assistants help her by holding on to her arms/hands and giving her something to "pull" against during a pushing contraction, while the midwife catches the baby below. 

Many women like to tug against something to help them bear down during pushing.  In many traditional societies, women squat while holding on to a rope or a bar, or play "tug of war" with labor assistants (via hands or a rope or sheet).  Pulling with the hands while pushing with the lower body can be incredibly helpful because it gives you more leverage and force for pushing.

Sidelying is a great position for when the mother has limited mobility, has a strong epidural, or is very tired and needs a rest.  It gets the weight of the baby off the mother's back, opens up her pelvis, and can be maintained for long periods if the mother has help supporting her upper leg. 
A vastly underused set of positions for pushing are the asymmetric positions.  An example of this might be one knee up and the other knee down, one knee on a chair while you stand straight on the other leg, or leaning into an exaggerated lunge.  These are all great because they create more space in the pelvis, especially to one side, which often helps facilitate rotation of malpositioned babies. 

You can also adapt an asymmetric position when semi-sitting, as in this illustration.  This could easily be done on the side of a bed, on a couch, or a couple of chairs.  They key is to try a number of asymmetric positions; your body will tell you which one will be best for your particular needs.

Illustrations of all these pushing positions can be found in this great handout, which shows how these positions can be done in the hospital as well as at home.  Sometimes people think that these positions are something you can do only out-of-hospital, but with a little creativity (and flexibility from the staff), these positions are usually do-able in the hospital as well. 

Disadvantages of the Semi-Sitting or Lying Down Positions

There is a fair amount of research that shows that the traditional semi-sitting or almost lying-down positions usually used in the hospital actually have significant disadvantages.

Damage to Perineal Tissues

Pushing in the semi-sitting position, especially when pulling the knees back sharply, places a great deal of stretch and pressure on the perineum, the tissues "down there" around the vagina. It often is associated with a greater rate of vaginal tearing and damage, especially when accompanied by an episiotomy (deliberate cutting of the perineum to "widen" the vagina). 

One study found that women had significantly less tearing and swelling "down there" when in non-supine positions (sitting, squatting, or kneeling/hands-and-knees). A larger study found that the semi-sitting position was associated with a greater need for perineal suturing, whereas the all-fours position was associated with a reduced need for it. Another study found a lower rate of episiotomies, perineal repair, and instrumental delivery (forceps, vacuum) in women who used a side-lying position instead of a sitting position for birth.

Shoulder Dystocia

Although research is limited, semi-sitting positions may be implicated in some cases of shoulder dystocia -- what some midwives call "bed" dystocia.  Being in a semi-sitting position for pushing means that the woman's weight is pushing her tailbone into the pelvic outlet, making the space the baby needs to get through smaller and causing a tighter fit.  In addition, the baby must negotiate a sharp curve under the pubic arch and back up again, which is more difficult to negotiate.  In essence, you are pushing "uphill" in these types of positions.

Some research suggests that non semi-sitting positions may help prevent some cases of shoulder dystocia.  One study of macrosomic (big) babies attended by nurse-midwives in the hospital found a trend towards less shoulder dystocia if the mother was side-lying for pushing.  The number of women using that position was not high enough for the results to reach statistical significance but the trend was clearly there.  Yet few subsequent studies have been performed to confirm or disprove this relationship, because such a position is outside the realm of most hospital "culture" and therefore rarely researched. 

Pain Levels

Many women find that the pain of labor is less intense and easier to endure if they are able to move with their labors instead of staying in one position.  One study found that women reported less pain during labor and afterwards when they used a kneeling position instead of a sitting position for pushing.

When given full, free mobility, many women prefer to stand, lean over a chair, sway, get on all fours, or push with one foot up and one foot down.  Some do choose to lie on their back but often will arch their back instead of round it forward. 

If allowed to move their bodies in response to their pain cues, most women find they are able to tolerate the pain of spontaneous labor without drugs.  Having labor-strengthening drugs and being stuck on your back in bed with a fetal monitor that doesn't allow you to move means that most women "need" some kind of drugs or epidural to get through the pain of labor, which present their own risks to mother and baby.

Having more access to warm water and full mobility during labor and pushing could probably significantly lessen the number of women who need pain relief drugs, and therefore the associated complications that go with them.


If a mother is laboring in the usual hospital position with a baby that is in a poorer position for birth (for example, back of the head against mother's back, or occiput posterior), it is very difficult for that baby to turn and get into an easier position for birth. Getting up and moving freely can often open up the pelvic dimensions and help the baby turn. 

Studies on the use of alternative positions to help a posterior baby turn are generally small, underpowered, and contradictory, but some research does show that being on all fours during labor with a posterior baby may result in a higher rate of babies turn into the easier anterior position for birth, although the trend in that study did not quite reach statistical significance.  It did significantly lessen back pain for the mothers involved, however, which is very useful in and of itself.

Being on all fours may or may not help before labor, but may be more effective if done during labor in women with a suspected posterior baby, and especially if done for longer periods of time and more consistently than currently studied.

Even side-lying positions, properly done, may result in a higher rate of posterior babies turning to anterior during labor and possibly a lower cesarean rate

More (and better-designed) research is needed to determine just how effective maternal positioning really is, but anecdotally, many midwives find that if a baby is still posterior during the pushing phase, turning the mother and getting her more mobile can actually help turn the baby, at which point the baby is often more quickly and easily born. An old midwives' credo is "If you can't turn the baby, turn the mother."  At the very least, it may help lessen the mother's pain and help her labor longer without drugs or other risky interventions.

Positioning with Epidurals

What about women who get an epidural during labor? Do they have to give birth in stirrups or with their knees pulled back to their ears because of less control of their legs from the epidural?

Most women who have epidurals are not given a choice, but side-lying is still a position compatible with an epidural.  One small study found that women with epidurals had less chance of getting an episiotomy and a better chance of a spontaneous vaginal birth if they were in a side-lying position for birth rather than a sitting position. The small size of this study was a limitation, but another larger study also found that women with an epidural needed less perineal suturing if they assumed a side-lying position for pushing.

Is Semi-Sitting Really So Bad?

This is not to say that women shouldn't ever be in the semi-sitting position.  Some women want to be in this position because it's the position that feels best to them---and if so, it's perfectly fine to use it!  It's a good position for resting between contractions, and certainly, many women have successfully given birth just fine in this position over the years. 

It's not that women should not give birth in the semi-sitting (or even the lying down) position, if that's the position their bodies tell them to be in.  It's that women should not be forced into this position whether they want it or not, and that care providers should be actively offering the use of other positions because outcomes are improved for baby and mother

So Why Aren't Alternative Positions Used More Often?

Question: So why is lying down or semi-sitting used almost exclusively in most hospitals?  If outcomes improve, why aren't more women encouraged to squat, use all-fours, kneel, use asymmetric positions, or be side-lying for pushing?

Answer: Because it's not part of routine hospital culture, because doctors are more comfortable attending birth in the traditional position, because doctors are not trained to catch babies any other way, and because other birth positions are not part of most birthing women's cultural expectations. 

Hospitals historically promoted lying down for birth because for many years, women were heavily drugged during labor and couldn't be trusted to move around safely.  Even today women are confined to bed because of the heavy use of epidurals or narcotics in most births; it's still seen as "safer" regardless of whether or not the mother is actually drugged.

In addition, lying down gave the doctor easy access to the mother's perineum to do the episiotomy that was mandatory in hospital birth for many years, and he could sit down in comfort for the birth and the perineal repair afterwards.  Furthermore, this position promoted the hierarchy typical of hospitals.....the patient as dependent and subordinate, the hospital staff as in control and making the decisions. Basically, traditional positions are more comfortable for the staff, both physically and emotionally, and sadly, the staff's comfort is a higher priority than the mother's comfort.

Over time, this position became the "culture" of the hospital as the "right" way to give birth, and other positions were seen as bizarre or unscientific. 

Doctors are trained in catching babies from the lying-down or semi-sitting position, and often have difficulty understanding how to catch babies in other positions.  When a woman is in the all-fours position, up is down and down is up to the doctor; the orientation for fixing any problems is upside down and many doctors are not comfortable with that re-orientation.

Many doctors simply don't know how to attend women in any other position because they most likely have not seen women in any other position than semi-sitting or lying-down during their training, and many resist any changes from the way things were done during their training.

When prodded, some doctors will tell women that they can push in any position they want, "upside down if you want to".....but that when the baby is actually coming out, the mother has to be in bed with her knees pulled back or in stirrups.  Unfortunately, this is the time when the most room in the pelvic outlet is actually needed and when the alternative position is most important.  Letting a woman have freedom of mobility during the pushing phase for everything but the last bit is not the same as true freedom of mobility. 

Women's cultural expectations also play a role in the positions they assume for birth.  If the only images you ever see of birth are of women in the stranded beetle position, you have a cultural template for expecting to be in that position during labor, even when offered alternatives. 

Another unconscious expectation some women have is that birth will take place in the "missionary" position, much like sex may often have been for them, and like gynecological exams always are done.  And to some, birthing in other positions may not seem ladylike or "right."  Cultural expectations and experiences assimilate women into a certain view of how birth is done, and this can be difficult to break out of.

A hospital's physical layout also has an influence.  Having a bed in the middle of the birthing room as its dominating feature means that most women head there at some point in labor, because their cultural expectations tell them that's where they should be.  But if you give a woman a birthing room with the bed de-emphasized, more women will utilize alternate positions and avoid the semi-sitting position so common in Western culture. 

Women in other parts of the world who give birth outside the hospital usually give birth in "alternative" positions.  When women in Western culture are given access to non-traditional birthing suites that de-emphasize the bed and have other equipment (like water tubs, ropes, birthing balls, squat bars, etc.) available, they give birth less often in the bed and more often in the "alternative" positions.

Women can overcome a lifetime of cultural conditioning and be willing to try other birthing positions if they have supportive staff who are flexible and open, but it takes active education during pregnancy and proactive reminder of position choices during labor for many women to overcome that cultural norm.  If the attending staff is not on board, it most likely won't happen.  And that's how these harmful practices get passed on.

Pushing and Women of Size

"Obese" women in the hospital are "allowed" to push in truly upright positions or according to their own urges even less often than women of average size.  Many report they are required to indulge in purple pushing  while curled into a "C" and straining to bear down. This stresses the baby, makes the mother more likely to tear, and makes it harder for the baby to get out safely.

Some providers automatically assume that all fat women are "poor pushers" because they "must" be out of shape and will therefore have less efficient pushing strength. Therefore these providers may be quicker to augment labor contractions or to move to a cesarean without an adequate trial of labor first.  However, research shows that "obese" women push with just as much force as average-sized women, yet interventions based on anticipation of "poor pushing" is another reason why the cesarean rate in fat women is so high.

Some providers keep "obese" women in bed and in the traditional semi-sitting position out of the mistaken belief that fat women are too unsteady, too weak, or too unfit to push in alternative positions. Others keep fat women immobilized out of the belief that they are all about to stroke out, or because they are worried about injuries to nurses trying to support fat women in alternative positions. 

And of course, the movement to mandate placement of epidurals early in labor in fat women "just in case" means that most of these women are then relatively immobilized for the pushing phase.  This is yet another way that the rules and beliefs around attending "obese" women inhibit freedom of movement for them. 

Sometimes the lack of willingness to try new positions comes from the mother.  Inhibition about size and weight may keep some fat women from trying out some of these alternate birthing positions, even when they are "allowed" to try them.  They may be too self-conscious about their weight or what's considered "feminine" to try some of these positions in front of others, especially those who may be judgmental about their fatness.

[I understand this because I felt it too.  Personally, the thought of getting on all fours and waving my big naked behind in other people's faces was a little off-putting, and I've heard other fat women express similar thoughts. And yet the all-fours position is one of the best positions for women of size.]

Ideally, birth attendants who attend women of size will encourage them to be extremely mobile in labor. The mother will have a good sense of what kind of positions she is physically able to assume, and her body will instinctively tell her how she needs to move in order to get the baby out.

Waterbirth is particularly ideal for women of size, because the buoyancy of the water makes it easier to shift position, especially if the woman has any physical limitations (like knee problems) or difficulty moving around.  Yet many women of size are denied access to water for labor and birth. 

The issue of mobility in labor is a crucial one for "obese" women.  While important for all women, full mobility during pushing may be especially important for women of size for a number of different reasons. 

First, fat women tend to have larger babies as a group, and thus may need the maximum amount of space in the pelvis to get the baby out efficiently.  Making fat women birth on their backs or behinds means that the available space is being compressed instead of maximized, exactly the opposite of what may be needed.

Second, some research suggests that fat women have more malpositioned babies, and this can result in longer, harder labors and more cesareans.  Being immobilized during pushing makes it very difficult for a malpositioned baby to correct its position, while being able to move more freely might help create more room for the baby to move.

Third, some providers believe in the idea of "soft tissue dystocia"....the idea that extra fat pads the pelvic outlet and may prevent the baby from being able to fit through easily. Some fat women have actually been told that their "fat vaginas" (actual phrase) caused their cesareans. However, very little research exists to support the idea of soft tissue dystocia. Mostly, it's a concept that gets taught in medical school as if it is a reality and no one questions whether or not it is true. [More on that in a future post.]

However, if soft tissue dystocia were real, then how much more important would it be for women of size to be using positions that maximize pelvic space most efficiently and use gravity to help the baby be born.

Care providers who attend "obese" women often worry about the fit of the baby into the mother's pelvis because of the generally bigger fetal sizes, possible malpositions, and soft tissue worries. But if they are truly concerned, they should be using more alternative positions with women of size, not less. 

Nancy Wainer, a midwife from Massachussetts, often gives the demonstration of putting on a too-small shoe as a metaphor for getting a hard-to-fit baby through the pelvis.  When Nancy rams her foot straight-on into the shoe, she cannot get her foot to fit (the baby would not be able to fit through the pelvis).  But when Nancy starts wiggling her foot all around, turning sideways and wiggling this way and that, the foot begins to squeeeeeeze into the shoe. Given enough time and wiggling, she shows that she is able to get her foot into the shoe (the baby can fit through the pelvis).  She acknolwedges that this is not always true for every baby and pelvis, but if there is any doubt about the fit of the baby, she stresses the importance of free, unlimited movement during pushing in order to give that baby the best chance of getting out naturally. 

And yet, it is women of size that are most often prevented from having access to full, free mobility during labor and pushing.

My Pushing Stories

I have had four births, and I have pushed in all different positions for them, with varying results.  Only in the last one did I truly have unlimited mobility and freedom to use any pushing position I wanted.

In my first birth (induced at 40 weeks, epidural for the pain), I pushed mostly in the semi-sitting position common to hospitals.  My legs were in stirrups and my chin was to my chest.  My epidural was not working very well and I had enough feeling in my legs to try the squat bar at one point, but we didn't try for very long.  Because the baby was positioned poorly, pushing in any position was incredibly painful and after 2 hours I consented to a cesarean. 

In my second birth (membranes stripped at 39+ weeks, water broke shortly after, natural labor), I labored mostly in the all-fours position in the tub at the hospital; that was the only tolerable position for me and the midwives were very supportive of me laboring there.  However, when I was ready to push, I was required to go back to the bed in my room.  I tried several pushing positions on the hospital bed, but spent most of my time in the side-lying position.  Alas, baby was big and posterior and nothing budged him; we ended with a cesarean after 5 hours of pushing.  I wish I had been allowed to stay on all-fours in the water, or been encouraged to get up and move around and try some of the asymmetric positions, but despite supportive nurse-midwives, none of these options were tried. 

In my third birth, I finally had an anterior baby after seeing a chiropractor near the end of pregnancy.  What a difference!!  However, baby still had an arm up by his head.  This birth was induced (to get a smaller baby--augh!) and the combo of his arm by his head and the induction made labor very painful.  I opted for an epidural eventually and was scooting my butt across the bed when my "cheek crawling" helped him get his arm out of the way and suddenly I was pushing.  I pushed him out in 12 minutes, sans epidural. 

I would have pushed him out even faster except that the nurses made me push in the "curled forward C" position.  In this position, he just kept hitting my pubic bone and couldn't get out.  I kept trying to lift my butt off the bed to arch my back---what my body was screaming for me to do----but they kept telling me I was doing it wrong and had to curl my chin to chest.  Finally the midwife with me lowered the bed to flat so I could lie back; I lifted my butt and arched my back over my fists, and baby was born lickety-split after that.  This is a good illustration of the fact that sometimes a lying-down position can be useful, especially when the mom wants to arch her back. The arching created enough extra room for the baby to get out, and I had my first VBAC. 

In my fourth birth, I gave birth at home in the water.  I loved that because I was able to shift positions as desired.  I labored in all kinds of positions, especially all-fours, asymmetric positions on the stairs, and leaning back on the birth ball.  I pushed mostly in a semi-squatting or forward-leaning kneeling position in the water, then leaned back and arched my back in the water at the end.  Again the baby's arm gave us some problems, but after the midwife fixed her arm position, she shot out quickly.  I pushed for a total of 24 minutes with that VBAC. 

For me, I think I may have a narrow-ish pubic arch that makes pushing in the traditional "rounded C" position in the hospital a big mistake.  I think my pelvis has plenty of room, but has the most room further back, which gets closed off in the semi-sitting position.  Arching my back creates more room where it's needed, and being off my back makes sure there is optimal room all around.

For me, birthing vaginally is a combo of making sure my babies are well-positioned (chiropractic care was tremendously valuable for that) and making sure I had full freedom of mobility during labor ---especially being able to arch my back. 

Pushing Photos of Women of Size in Non-Traditional Positions

Here are some photos of real women of size birthing their babies in positions other than the traditional lithotomy or semi-sitting/knees-pulled-back-in-a-hospital-bed you see on TV.  

Mind, I don't have a lot of these photos, because while women are willing to share their pregnancy and labor photos with me, most don't want to share the really intimate shots for all the internet to see.  And who can blame them for that?

[If any of you want to share your pushing photos with me, I'd be happy to have some more!]

Other big moms have labor photos but may not have had photos taken of the actual emergence of the baby because they were too self-conscious.  If some of us can hardly bear to have our pictures taken in full clothing and normal circumstances, imagine the inhibitions some may have for taking photos at one of the most intimate times of our life. 

So I don't have as many pushing photos as I would like.....but I do have shots of a few positions, and hopefully that will be enough to inspire other women of size to experiment a little too.

My profound thanks to the women who were willing to share their stories and their photos with the world. 

You will never know how many lives you touch, now and in the future.  Bless you for being willing to share and inspire others.

You will probably notice that all of the photos here so far are of women of size giving birth in the water.  That's partly because that's just what's been sent to me, at least for the pushing phase.
But it's also because water is one of the best places for women of size to labor and give birth, because the buoyancy from the water helps us change positions and hold them more easily (like this semi-squat position). It helps us be more mobile and flexible, which is often just what we need most to get our babies out.

Many women of size who have had waterbirths swear by water for the pushing phase as well as for the laboring phase. It's truly heaven-sent.

Be aware that if you are a newbie to birth, your inital reaction to some of these positions may be to be taken aback. Our cultural conditioning around birth is so strong that our reaction to seeing a woman give birth in alternative positions (or in the water!) can be strong because it just doesn't seem right or even ladylike.
And sometimes those feelings may be even stronger towards a woman of size using alternative positions.

Some care providers who are perfectly fine with using alternative positions and/or water for women of average size shy away from doing them with women of size.  It's part of that cultural conditioning of fear around "obesity." 

And even sometimes the women themselves secretly believe themselves to be "too high-risk" to try anything a little out of the ordinary. 

So seeing these images may make some viewers squirm a bit.  It may make some providers squirm even a bit more. 

Yet these are some of the best positions for women of size, and the fact that so many of the vaginal birth pictures I have of women of size involve water or the hands-and-knees position speaks volumes about its efficacy and comfort for us.  Providers, take note.

But just as making love does not need to take place in the missionary flat-on-the-back-and-legs-spread position, neither does birth need to take place in that position.  Any position you can use to get the baby in is a position you can use to get the baby out. Be as creative in birthing as you are in lovemaking....maybe even more so!

In particular, close-ups of a woman giving birth on all fours may be seem strange to some readers because, let's be frank, you get a close-up shot of her behind. 

Our society prefers to ignore the fact that that part of our anatomy is quite close to where we give birth. It seems very strange to some people to see a baby's head coming out right by your behind, yet they forget that it comes out that close to "there" whether you are facing up or down. 

Either way, the proximity is the same, but when a woman is on all-fours, we are forced to emotionally recognize that same proximity, and some people are grossed out by that fact.

But look closely.  Some of these photos illustrate the very advantages we've been talking about.  When a woman is birthing on all fours, oftentimes witnesses will exclaim later about how the shape of her behind changed.  [One husband described it memorably....."Your butt got really square!"]  That strange shape is the mother's bones moving out of the way to create more space for the baby.  Ask yourself....would that have happened if the mother had been sitting on her behind instead?

Although it's an unfamiliar and even strange sight for newbie observers, the truth is that the all-fours position is an awesome position for women of size.
So challenge yourself and your perceptions. If you have a negative reaction, remember that this is because of cultural conditioning, and all you need to overcome this cultural conditioning is exposure to different images and ideas.

Consider the possibilities.....all of them. 


As the healthy care birth practice paper on pushing notes:
Throughout history, images depicted in art show that women have used many positions to give birth to their babies, including standing, sitting, hands-and-knees, and side-lying. Until doctors began using forceps in the 17th century, women rarely were shown giving birth lying on their back. With the support and encouragement of family members and community midwives, laboring women used objects such as posts and ropes to gain leverage during pushing. They often used birthing supports or stools to help them squat, crouch, or kneel.
Historically, women usually used a wide variety of positions for birthing.  In traditional societies, you still see many women using these positions for birth, but in medicalized birth, they are rarely used.  Instead, women in Western hospitals most often birth on their backs or propped up a bit, with knees pulled back or their feet in stirrups.

This kind of birth is a recent cultural artifact, not a medical necessity.  In fact, a reasonable amount of research suggests that outcomes are usually just as good or better with alternative positions. 

No, there's nothing wrong with birthing on your back or in a semi-sitting position if that's what feels best to you at the time.

However, there is something wrong with birthing that way because that's what most comfortable or convenient for your doctor, that's the only way he/she was trained to deliver babies, because a nurse tells you to stop moving a different way, or because you are too inhibited to follow your body's cues and get up and move.

Women should not be forced to birth in any particular position but should be able to move at will

The important thing is to move freely while birthing and to respect and follow your body's internal "knowing" about how best to move to get your baby out.

Alas, this kind of mobility is not promoted in many hospitals, and especially not for women of size.  That's why it's particularly important for fat women to find size-friendly providers who understand and actively promote freedom of mobility during all of labor and pushing, whatever the mother's size.