 Good afternoon, good afternoon. It's, how shall I put it, the afternoon after. On behalf of the McLean Center for Clinical and Medical Ethics, the Department of Obstetrics and Gynecology, and the Bucksbaum Institute for Clinical Excellence, I welcome you to today's lecture, the sixth lecture in our 2016-17 lecture series on reproductive ethics. Peter, can you hear me in the back there? Good, OK. It is my pleasure to introduce today's speaker, Anne Drapkin Lyrely. Dr. Lyrely is Associate Director of the Center for Bioethics, is a professor in the Department of Social Medicine and a research professor in obstetrics and gynecology at the University of North Carolina in Chapel Hill. Dr. Lyrely's research examines socially and morally complex clinical and policy issues relating to women's reproductive health. Dr. Lyrely co-founded the Obstetrics and Gynecology Risk Research Group, an interdisciplinary group that conducts research on how risk is assessed and managed in the context of pregnancy. She also founded something called the Second Wave Initiative. This is an effort to ensure that the health interests of women are fairly represented in biomedical research and drug and device policies. Dr. Lyrely is the principal investigator on the NIH-funded phases study that addresses the ethics of HIV research and pregnancy and is a co-principal investigator on a welcome trust-funded project that addresses the ethics of research involving pregnant women in the context of Zika and other public health emergencies. Dr. Lyrely, a former Greenwall fellow at Johns Hopkins, has served on numerous national committees, including the American College of Obstetrics and Gynecology Committee on Ethics, which she was chair of from 2007 to 2009. Currently, Dr. Lyrely serves on the NIH Advisory Committee on Stem Cell Research and on the March of Dimes National Bioethics Committee. In 2013, Dr. Lyrely authored a book entitled A Good Birth, a book which aims to describe what constitutes a good birth from the perspective of the woman herself. Today, Dr. Lyrely's talk is entitled Ethics and the Pursuit of the Good Birth. Please join me in giving a warm welcome to Anne Drapkin, Lyrely. Well, thank you, Dr. Siegler. It's just a huge pleasure to be here at the University of Chicago and the McLean Center, which I have admired for so long. I also want to thank Julie Chor for inviting me to be a part of what I think is really a stunning array of scholars who will be speaking over the course of this year on reproductive medicine. I mean, they are the people whose work I've looked to, admired, and responded to over the years. And it's just thrilling to see them all coming together in one organized effort. And it makes me jealous of all of you. So I think I have to just say, I woke up this morning thinking, what could I possibly say this afternoon after all of the events of the last couple of days? I'm supposed to give an aspirational account of where we should be heading with regard to birth. And I sat on the bed next to my husband and with, admittedly, my two smallest children and curled up in the corner and said, I'm not really sure I can go today, honey. And he basically took his foot and kicked me off the bed and said, you have to go. It's exactly what you have to do. You have to keep going, kind of like the who's, singing on Christmas Day, if you will. But truly, as I got on the plane and I took the cab here, I felt emerging gratitude for the opportunity to talk right now about what I believe in and what I find meaningful. And furthermore, to the extent that birth and the debates that surround it are, as many have contested, a faithful mirror of how we regard women in our society at large, I felt like, oops, sorry, that what I have to offer might be useful to our broader collective conscience today. Again, as I was making my way here in the cab, I remembered a quote from the late Sheila Kitzinger, who has written long and hard about birth. And she said, in any society, the way a woman gives birth and the kind of care given to her and the baby points as sharply as an arrowhead to the key values of the culture. So I just thought keeping that in mind today might be useful. So what I'm going to do today is three things. Give you some background and rationale for the Good Birth Project, which is form the basis of the book that I wrote that Dr. Siegler mentioned earlier. I'm going to describe the findings, including the five domains of a good birth, and point to some of the implications for clinical care and ethical analysis. So many of you here know that birth is more than certainly an area worth addressing and for many reasons. 4.3 million women give birth in the US every year, probably more now. Birth constitutes 23% of hospital discharges and 15 of the most common hospital procedures are related to birth. It constitutes upwards of $86 billion in health care costs every year. Also big are the debates that surround birth. Debates about mode of delivery, whether birth should be vaginal, the proper rate of cesarean delivery, whether and under what circumstances women should be allowed to or given the opportunity for a VBAC or not. Place of delivery, there are heated debates about whether birth should take place in the hospital and birth centers or in homes. I know you had a heated discussion about that previously this fall. Pain control. Usually we think about pain as something we should dispense with, but in birth it's much more contested. What is the role of an epidural, of narcotics, of nitrous oxide, an area that's gaining a lot of interest recently, and of comfort measures? What do they mean and what's their proper place? And then the role of technology. What's its proper place in the context of an area that some would contest, whether it has a proper place in medicine? So many of you are no doubt aware of these debates. Many of you in bioethics and obstetrics and other areas. What is less often discussed, however, is the fact that many women, whether or not they have the kind of birth they were expecting, whether or not their baby and they are healthy, emerge from birth with a sense of sadness, feelings of uncertainty, wonderments of how birth reflects on them as women, as mothers, and as people. As Molly, who was one of the participants in the Good Birth Project, offered after she underwent a C-section, I felt like a failure. Maybe my expectations were too high. I was like the biggest advocate for natural birth, and I was the only one in our Bradley class that ended up with a C-section. It was depressing. The whole time you have all these doubts, well, what did I do wrong? So read any literature on the topic of birth, and you'll sense a lean, a sort of bias. Either that birth is normal and natural and not the proper place for medicine, or that it's a high-risk endeavor and it is properly undertaken only in the hospital. Many, including I, have called these divisive debates the birth wars. They are embedded in many of the ethical analyses, the policy analyses, and the clinical guidelines that we see from various organizations. At the root of these differences, and I've thought about them a lot, I think are, at their core, divergent ways of understanding and valuing birth, competing paradigms for understanding what makes a birth good. Barbara Katz-Rothman, a sociologist, articulated what she called the midwifery and medical models. Anthropologist Robbie Davis Floyd described holistic and technocratic model. Each model has a different metric for quality when it comes to birth. For the midwifery model, a good birth is a normal or a natural birth. One that has less technology is better. Of course, safety and outcomes are good, but they are presumed, so normal birth is a good birth. On the other side is the medical model. And in the view of the medical model, a good birth is a birth in which maternal and infant outcomes are optimized as long as the mother is healthy and the baby is healthy, the birth is good. And if you want something else other than that, then that's icing on the cake. Here, quality is linked with the absence of pathology. So, across all the debates, you see these two competing paradigms. The result has been, as my late friend and dear friend, Beau Burt, who was a professor of law at Yale, really a dialogue of the death. We can talk to each other, but we're not making any progress. What nobody has paid attention to or when I started the Good Birth Project was what mattered to women. What do women say constitutes a good birth? This is an observation that was made decades ago by the feminist scholar Adrienne Rich in her landmark book of Woman Born, but the one group whose opinions and documentation we long to have the mothers are, as usual, are almost entirely unheard from. So there's another piece to this puzzle that captured my attention, which is a parallel between this sort of evolution with regard to birth and with regard to the other book, End of Life, Death. So, both have strained relationship with modern medicine. Both reflect movements toward normalizing. For both, process is important. People think there's something relevant about the way that death happens and the way that birth happens. Both have bodily and existential meaning, and to that extent, preferences matter and matter deeply. And also, for both, the good is somehow recognized, but also elusive, but nevertheless pursued, right? As I was in the early days of writing my book proposal, I came across this quotation in a magazine in an airport lounge, but I think it's quite beautiful. Birth is very close to death. The two things move terrifyingly near to each other, like two huge planets, their conjunction unthinkable. In addition, as Ira Bayak, who's worked a lot on End of Life care and doesn't like to talk about the good death, but he talks about dying well, that he indicated that 20 years ago, while people thought about the good death, there was not a consistent language or conceptual model for the range of experiences at life's end, a taxonomy to label what we clinically saw. So it was as if the phenomena did not actually exist. So much important progress has been made around compassionate care that honors patients and their wishes at the end of their lives, that allows for a notion of the good that isn't simply tied to the presence or absence of technology, that isn't tied to where death happens necessarily, but that incorporates the viewpoints of dying patients and their families. And it struck me that it was well beyond time for the same sort of work around life's beginning. And so began the Good Birth project. As I mentioned to Dr. Siegler earlier today, one of the things that I really found interesting when I started this project is that if you looked at the literature on End of Life care, which was quite robust, they oftentimes pointed to and romanticized birth and said, if only we could do it as well as people do at the beginning of life, then we would have hit it. And for those of us who work in obstetrics and midwifery and ethical issues around that, I just can't, I couldn't believe how wrong they were about that one part of their efforts. So the Good Birth project is a project I started many years ago when I was at Duke, I'm now at UNC, but I started it at Duke. It was a large qualitative study involving in-depth interviews. I chose a qualitative study because I found, I've done qualitative work, I've done quantitative work, but I found that what I really wanted to do was start from the ground up, be a blank slate, try to hear from women in their own voices what they thought the Good was. There was a fair amount of literature that asked women, what do you think control is important? Do you think epidurals are important? Do you think it's better to give birth in a home or a hospital? But what I wanted to do is unearth notions of the good that weren't necessarily being talked about or that were embedded in our own understandings as practitioners or advocates on one side or the other. So I also would say that I was inspired by many people, but I was particularly by the work of Carol Gilligan who, in listening to women, offered a radical reframing of how we understand moral development and for some of us how we understand moral theory itself. So I was hoping that we could get at some of that. So we did interviews with 101 childbearing women, 39 primiparas, 62 multiparas who we the latter we affectionately called our wise women because when women had the opportunity to layer one birth upon the next, then they had an opportunity to reflect in perhaps sharper relief on what really meant something to them. I think time lends that to the primiparas or people who have a single baby, but the multiparas were very articulate in being able to compare and contrast and then find meaning there. We had a highly educated but fairly diverse population and we interviewed women who gave birth in a variety of centers, I mean a variety of settings, 76% in the hospital, 20% in a birth center, a freestanding birthing center, and 13% at home. These birth experiences ranged from one woman who had a cute fatty liver of pregnancy and almost died and was in the intensive care unit for a week to somebody who did a free birth at home and opened up her spiritual midwifery book and had her partner there and went for it. So we had the range of birth experiences and many, many in between. We also interviewed a handful of maternity care providers including maternal fetal specialists, general OBs, nurse midwives, direct entry midwives, labor and delivery nurses and doulas. So what we found, so we had reams of rich data and I can still say to this day I have not done it justice in writing about it and I'll just give you some snippets of what we learned, but what I will say is what struck me, time and again, was not just what distinguished one story and the other because a lot of people would say what makes a good birth, well it depends, right? But what I saw and was struck by and wrote about was the ways in which different birth, in different birth stories, women articulated very similar things that were important to them. Even though to the outside observer, the birth would look strikingly different and so to me it gave some hope for addressing the stark battle lines that often reflect the dialogue between the midwifery and medical models of birth. Okay, so the first thing I will offer and sometimes I talk about this and sometimes I don't but today I will because it could take quite a while for me to kind of tell you how I understood this was the most common theme that we heard about was control and nearly half of the women mentioned it in interviews and many more endorsed its importance when we asked them about it. But looking closely at this articulation of control we noticed two things. First, that there was this deep ambivalence about the term. People said that it was very important and they also said that it was essentially out of reach. There we go. So what do we do with that? The second is that there was this notion of control was characterized by something my anthropologist colleagues call polysemy which was that the notion of control was really a placeholder for all sorts of things, concepts that we ended up identifying in the rest of the data as important to a good birth. So being in control could mean having everything be calm and feeling controlled. Being in control was getting to say what happened. Being in control could be feeling connected to your partner. So it was the word was used but then it was deployed as almost a marker of the good which raises these interesting questions about accessibility of the good when it comes to birth, right? So we wrote about the polysemy of control in paper in social science and medicine a while back. So but what I'd like to move into, I'll make sure I've got some, okay. What I'd like to move into now is the domains that we identified as relevant to a good birth. So we had again scores, reams of data and we coded these data and we ended up identifying about 20 themes that seemed relevant to the good birth and then we clumped them together and into five different domains that again cut across various kinds of births. Those included agency, personal security, connectedness, respect and knowledge. And I'm gonna take you through these themes some more in depth than others to give you a sense of what we learned. So let's begin with agency. So agency is of course a word that sociologists and philosophers use to describe the capacity of a person to act in the world, to make his or her own choices as opposed to being acted upon. The idea is that a good birth is one that we have a hand in shaping, that it's informed by the things that we value, a birth in which we've been able to decide among options, a birth in which we feel involved and present. So it really has three pieces and I'll go through those one at a time. So the first piece really relates in a large part to the concept that many in bioethics will be familiar with which is autonomy or respect for autonomy. The idea that you're presented with choices, respected for your ability to choose between them and this is a pretty common theme when we're talking about the sort of midwifery critiques of the medical model which has tended to be paternalistic. So Lainey who had a hospital-based feedback valued the fact that she got to say when she wanted medication, when she didn't and appreciated her PCA. I got to say when I wanted pain medicines, when I didn't, I didn't have the nurses saying, here take these drugs and don't ask why, which is something that women do fear based on the literature they read going into birth. The important thing here is that choice and options matter and in birth as in death, there ought to be a wide range of reasonable options. In the interest of getting beyond the device of debates, we heard compelling narratives in which women found this sort of agency both in refusal of rootinized intervention, right? So people wanted to be in birth centers so that they wouldn't have epidurals, et cetera, forced on them and women who were like Lainey in a hospital and could have a patient-controlled anesthesia in their hand. So in a way, it disrupts this notion of one versus the other. Lainey's quote also brought up another piece which is a little different than our traditional notions of autonomy which has to do with being the deliverer. So it's funny to imagine but we heard this a lot. What made her birth good is that she felt like she was an active participant. I felt so incredibly involved and in control. So I always think about this patient that I took care of in the early years that I was on labor and delivery and she was having a lot of trouble getting her baby's head beyond the pubic synthesis. And I was trained in days that we learned for better for worse to use forceps and they were feared and they've been demonized by many in the midwifery community. But my patient had her tennis shoes on, she had her feet in the stirrups, I slipped the forceps around her baby's head and she pushed that child out. And there was a way in which we could together use forceps in a way that allowed her to feel like an agent of her birth versus having to undergo a cesarean or another kind of procedure. So even technology here you see has a valence if it's used in the service of someone to make them feel like the deliverer or like they're being delivered. Sharon is another woman who talked about her good birth. This was somebody who had had like dreams of, you know a kumbaya moment and unfortunately had her bag of water break at 36 weeks. And so she presented to the hospital and wasn't laboring much so got a whiff of pitocin and while that was happening her physician took a quick shower and missed the delivery and she delivered her child into her labor and delivery nurses' hands. Not what she had in mind, not really a natural birth but she said, you know I had a good birth, I really did, I felt like I contributed to it, I could feel my daughter coming and I pushed her out. So there's this notion that I have worked to shift and it goes back to somebody who I met here, I don't know, 18 years ago named Mary Mahowald, many of you may know Mary but she will get up in a podium and say, you know doctors don't deliver babies, women do and it struck me a long time that a long time ago that that was exactly right but we get stuck in the language of I did a delivery, I delivered this baby, even my mom who has read my book and she's throughout the pages of the book would has asked many times, how many babies have you delivered and I always say five mom, I've delivered five, remember? So anyway, it's worth, words matter so it's worth emphasizing that it is women who deliver babies, not doctors. There's a third element to agency which we call presence and to tell you the truth, presence was a slippery concept I wasn't exactly sure which category to put it in but it was really important. So it was this notion that women felt that a good birth was one in which they were present and able to bear witness to the birth, right? So this also kind of upended this notion of the presence or absence of technology or the presence or absence of, the presence or absence of technology, right? So Rebecca said, I got through it without any pain medicine, I held my own, I was aware of what was going on so it was the absence of any pain medicine that made Rebecca feel that she had a good birth. On the other hand, and we heard this a lot, Natalie had two births, her first birth for reasons that are really interesting and if you wanna know what they are, you can read the book but really wanted to have a medication-free birth but it wasn't really about presence or awareness, it was about proving that she could do it but she felt that she missed the birth because she was in so much pain. Second time around, she got an epidural and she said, it took my mind off the pain, I was able to really focus on the rest of it, be present, really present for our daughter's arrival and I didn't feel present for our first daughter's. So this notion that an epidural doesn't just relieve you of pain but it allows you to bear witness in a way that many women find meaningful. Okay, so it gives you a little sense of what I mean by agency. The second piece is personal security. So as much as we wanna insist on the notion that birth is normal, natural and safe or that in the hospital, if there are risks, we can press them away, there is a way in which birth raises concerns for us, it's a liminal state, it makes us, it's a locus of, as anthropologist Mary, Douglas has noted of both power and danger, right? So we wanna be able to feel safe in pregnancy. So what does that mean? So we heard women articulate that in three ways. One is that they wanted to feel physically safe. The second is what we call the security trio of comfort, privacy and calmness and the third is trust. So safety again tends to be what we in medicine focus on, but when it comes to women's experience of safety, it can have, again, a flipped valence, right? So Liz gave birth in a hospital. She felt very safe there. She had an induction. I felt very safe the first time around with it being induced. It was so structured and I felt like it was so monitored that baby's heartbeat was monitored. I was monitored. There were people coming in to check on a regular basis. So being in the hospital made Liz feel safe. So Vicki on the other hand gave birth in a freestanding birthing center down the road from my house. It turns out, and she said I felt very safe at the birthing center. I always felt like I was in a place where nobody was gonna try and force anything on me that I didn't want. So both are risks. The risks are real, but some loom large for some women and some loom large for other women. And it depends on who they are, what their situation is, and what strikes them as most threatening. Now we move on to the first element of the security trio, which remember is comfort. And comfort came up, the language of comfort came up quite a bit when we analyzed our findings as well. But it was almost as polysemus as control. So for some people comfort meant the absence of pain. I wanna be comfortable, and that's how anesthesiologists usually put it, are you comfortable? For others comfort had more to do with being at ease, maybe at home. So Donna midwife, who I quoted quite liberally in my book says labor is work, otherwise it would be called picnic. What are the things that make you feel more comfortable? Some people would say an epidural, but no. Donna said a lavender candle, certain music, a rice stock at your back, holding your teddy bear, a certain blanket, what are those things that make you feel comfortable? And even though you might be hurting, what are the things that are going to make you feel at ease that you can do that work? So different notions of comfort. Also calmness, I mean most people thought a good birth was a calm birth, right? Natalie, the woman I had mentioned before who had also felt that her second birth was her really good birth because she was present also appreciated how calm that birth was. It was a really good experience, not at all what I expected. It was very peaceful, it was very gentle. Second experience was a lot more positive. So people talk about the low light and the soft voices and the way in which everybody felt seemed to be calm. And third is trust. And trust is something again that you might think, well of course a good birth is associated with feeling trust of your providers. And Stephanie talked about what that meant to her. It's the feeling of security that you're taken care of. You wanna look up at your doctor and your nurses and have the feeling like I'm in your hands and you're gonna help me through this. But I really, really worry about trust actually. So I think that one of the unintended consequences of the birth wars is that women come into birth with mistrust. So they mistrust what they are told about the importance of technology. They mistrust their practitioners. They're told that they are responsible for their own birth that they are the experts and trust is undermined. And I think this notion of sort of take back your birth undermines the need that we all have to feel like we're taken care of. One of the women we interviewed talked about a really harrowing experience in which she was having a postpartum hemorrhage and her doctor told her that she needed some cytotech and her doula told her that she didn't need it. And she said, you know, in the end she didn't use it and she lost a lot of blood and ended up on iron for several months. But still in the aftermath she said, well, what was I supposed to do? How was I supposed to make the decision? I didn't know who was right about that, right? And so there's a way in which there's this double edged sword of trying to empower women to think proactively about the data and ask their providers questions about what's necessary. But again, birth is a time when we need to be held, right? Feel like we can trust the people taking care of us. So how do we empower and care for at the same time? So a little wonderful quote from Annette Byer. Okay, the third piece, am I third? Yeah, third piece of a good birth is connectedness. This includes connectedness to the baby, to intimate partners, healthcare providers, and those that we know outside the birthing suite. So at first blush, hardly surprising. The notion of being alone in birth as in death is almost a universal source of dread. I remember talking to one of my medical student from my friends from medical school and telling him that I was doing this project, and he launched into the saddest birth that he'd ever been a part of, which was a woman that came in by herself and gave birth by herself, the saddest. So, but forging meaningful connectedness in birth is no simple matter. Intimate relationships are in flux. Families of two become families of three. We become mothers, fathers, so our identities are shifting. So we need help bringing children into the world. Even my free birther interviewee needed a partner there to help her a bit, right? And most of us invite strangers into intimate spaces. So women's reflections on what connectedness means to them and how it relates to a good birth were some of the most profound of the project. I'm not sure I'm gonna be able to communicate them well to you, but one thing we heard time and again, and I think I'll probably just stick to the baby here, is feeling connected to the baby. Many people valued and deeply those first moments post-birth when a baby is placed on a mother's belly so that immediate skin to skin or that immediate post-cessarian cheek to cheek. But the problem is, I think, that the script has taken hold in so many women's hearts and minds that when it doesn't quite go right, it seems like, oh, well, maybe a good birth is out of reach for me if I can't get that immediate, lovely, romanticized notion of connectedness to my baby. And so many women we interviewed ended up wondering if that didn't happen for me, what's gonna happen to me and my baby was my birth problematic, and it does have an enduring effect. I will say that my husband blames that for us having two children. My fourth delivery was characterized by a little disconnectedness, and he blames that for my last two children being in bed with us, but there's a lot of other reasons for that, too, but anyway, if there's any pediatricians in the room, sorry about that. So, but what we heard, interestingly, and I think this may be a potential source of healing for folks, is that many women themselves did not ascribe to that romanticized notion of immediate bonding. So, and not only did they not ascribe to it, when they didn't, they felt guilty about it. So Leslie said that first hour, I don't feel like myself, I just wanna roll up and cry. You see these videos of women who are so elated, so how come it's not like that for me? I don't have these Goo Goo Gaga feelings the first time I see my babies, and I feel guilty. Or Christina was someone, I thought this was a really interesting story who talked about, she'd had quite a traumatic birth, and she said, I was shaking, and I didn't want my baby to feel my shaking. From my first experience with my daughter, I didn't want her to feel me shaking, I wanted her to feel me strong. So, women are producing their own narratives here and to have that other sort of romanticized narrative was not necessarily that helpful, even though it's helped in advancing sort of mother, baby, bonding in a way that most people think is productive. The other piece of connectedness that I thought was really striking was that for many women, giving birth doesn't feel like an arrival, but it feels like just a rending and reforming of one of life's most intimate relationships. So, it's not just this occasion to connect, but the inevitable fact of separation, right? I mean, I have given a lot of talks while I'm pregnant and it's very reassuring to have somebody up here with me. So, Carla talked about I remember with my first child very distinctly crying with sadness, sadness because this person's not inside me anymore. Literally, it was such a separation anxiety. It was like, wow, I'm really gonna miss that person inside me. And then Brenda said, what bothered me most was having to wait and see my baby again. I was like, I really need to see my baby. I feel like something is missing, like something has been disconnected. So, just this idea that birth is not, like it is for all the rest of us, a joyful union, a joyful meeting of a person for pregnant women, it's something that's much more complex and we need to find a way to honor that. Okay, let me see what I'm doing for time. Not so great, but respect. The next element, respect for birth, for the woman, for the baby and self-respect. So, one of the really important things that came up was that birth is something else. It is not just a mere medical event. It's an event, as we know, with bodily and existential meaning, it's associated with ritual and it has an enduring, it becomes part of an enduring narrative. So, Maisie, who was a great interview, talked about how her physician, when they had an agreement that her partner was gonna cut the umbilical cord, her physician just snipped it and because he forgot about that. And I mean, I've done that, I'm sorry. But she talked about the fact that he just cut us apart like that. Uh-oh, did you wanna do that? Sorry, it's almost like saying to a dad, you mean you wanted to walk your daughter down the aisle? Oh, gee, oops. But so, the notion is really that we need that process matters, that we need to respect what is sacred for many women in birth. I remember one time a patient told me in a previous births, one of my partners said to her, maybe in an effort at Tough Love, come on, push the baby out so I can go home and read to my kid. So, the offense seems particularly stark if you think about birth in the context of death, right? Hurry up and pass so I can go have dinner with my family, right? But birth is in that category for many people. But I think that there's another angle to this. So there's been such a harsh dialogue about the relationship, about the importance of ensuring women getting the kind of birth they want and presuming that technology is imposed, that people have come to understand cesarean deliveries as non-sacred events, as non-important events, as surgical events and non-births. And I can say that having had five cesareans, my husband and I both struggled against that. But there was an interesting interview we did with a woman who had an elective cesarean, had two elective cesareans, which she loved and she said, I do ask that question, I get asked that question a lot. Like, don't you want to experience the birth experience? And I say, I have experienced the birth experience, it's just different than yours. And I don't think people understand that. They're like, don't you want a real delivery? And I'm like, it is a real delivery. See, I don't think I need to push her out at the birth canal in order for it to be considered any more meaningful to me. So this notion that a good birth is a vaginal birth, a real birth is a vaginal birth, wreaks havoc on women who undergo cesareans by necessity or sometimes by choice, right? Then there's this notion of dignity that comes up. People want to have a dignified birth, like Ren. I didn't want to scream, I didn't want to yell. I wanted to be very ladylike about the whole birthing process. I did say shit once, but that was it. And then getting back to where I started in the beginning, this notion of self-respect. Kira had, went on and on. She was the second quote here. She was a woman who tried to have a home birth and that was transferred to the hospital in a helicopter. And everything was fine with her and her baby, but she said, I had this complete acceptance for how things happened outwardly, but it wasn't there for my own performance. I felt like I let myself get in the way. So the last element is knowledge. So knowledge is kind of, in many ways, something that the midwifery and obstetrics communities can agree on is important, although what the facts are and how to communicate them is often marked by differences. But when people talked about the importance of knowledge when it came to birth, they really talked about three different things. But so in quickly going through those things, I want to point out just two pieces of that. One is that knowledge has a valence, so more knowledge is not always better and some information, whether it's sort of unnerved or misled, did not always improve birth. And second, this idea that as much information as we might gather in anticipation of birth, women found that there was nothing like going through it and that one of the great gifts of birth is the knowledge that it imparts. So Maria talked about preparation. I just feel it's a decision people need to make based on some knowledge or experience. So people say, are you prepared for your birth? And people think it's really important to have some knowledge of what's gonna happen going into it. Communication, people talk a lot about the importance of communication and how that made birth good. Duelas are increasingly being allowed into Caesarean deliveries and Cara was one of the early beneficiaries of this. And she talked about how important that was because her Duelas could explain everything that was going on. We thought she was gonna help us with the natural labor and she helped us have a good C-section. And then finally, this lovely quote from Sally who said, who kind of upends this notion of preparation and said, I would say, I thought I was mentally and physically prepared for my first baby but that was a lie. I lied to myself. I just don't think you can prepare for something that you have no experience with. So as many books as you read, there's nothing that can prepare you for that first contraction, nothing. So that leaves us in a kind of space of ambivalence as all of these themes do. So again, we identified these five elements of good birth. Agency, personal security, respect and knowledge. So the idea that I have and have tried to promote is that when we're thinking about policy, when we're thinking about ethics, when we're thinking about clinical care, that we shine a light on and take notice of what we're going for with birth, right? Are we going for something that we think is most important, whether that's a mode of delivery, whether that's medical outcome, whether that is keeping somebody in place, whether that is delivering the kind of birth that they say they want at the beginning or whether we could center these things around the items that women say are most valuable. You know, the first step I think is acknowledging that there's nuance and that the polarized views that usually show up in books neither capture what most women want nor do they capture how many providers see an approach birth. So one of my most articulate obstetricians noted, I still believe that everybody deserves a midwife and not everybody needs a doctor. She happened to be a midwife turned to MFM, so she had it all. But Donna, who's a midwife who runs a freestanding birthing center, said I don't want a bad mouth technology, it's wonderful when you need it. So I will end by, I mean, wrap up this piece of the conversation by saying, I think there is hope in the last five years or so, there's been a growing interest in something called family centered cesareans, advanced by what I think is a pretty forward thinking team in Boston of anesthesiologists and OBs. It marries what I think are the best lessons of midwifery with medical necessity to facilitate a shift in understanding of cesareans as failures and complications to understanding them as the major important life events that they are. So what these are are, I mean, they've been called sort of natural cesareans or gentle cesareans, which I think it's hard to imagine cesareans as either, so I like family centered cesarean as language better. One of the things they do is they do a slower, more physiologic birth. The other thing that they do is they do early immediate skin dissonance. So the baby is born, it is put immediately on the mother's chest before the umbilical cord is cut, just as if she had delivered her baby vaginally. It's hard to imagine, but it's quite a profound change for some women and requires really modest changes in the approach to anesthesiology. The blood pressure cuff is on the non-dominant arm, the EKG leads are on the back. And sometimes they use clear drapes as you can see here. But the goal in the end is to engage the parents as active participants in the birth of their child. And I don't know if you can recognize that person, but that's me and my baby girl. And I actually was, it turns out that my maternal fetal medicine doctor for the birth of my fifth, Gracie said, you know Annie, let's see if we can make you have a good birth, what do you wanna do? And I said, I don't know. And she said, well, for some of our, we've been talking about doing this family centered cesarean thing, do you think we should try it? And so I didn't have a clear drape, but I did have a team that was focused on making that cesarean a good birth and had a great labor and delivery nurse in the room, had the drape pulled down, saw her come out of my body and got her onto my chest right away. Now I'll tell you, I had some kind of strange reaction to the anesthesia, so it was really cold and shivery. She was really slippery, and so I was kind of worried that she was gonna fall on the floor, but I really, really, really, really appreciated that birth because I felt that the whole team cared about the experience, not just that they had not nicked my bladder in my fourth C-section. It really made a big difference and I felt like it was time to pour the champagne, just like everybody else got. So anyway, that to me, even though it was a complicated, potentially delivery, it was also very, very good. You can see they even put a little bow on her hat. Isn't that cute? So what can we do to cultivate good births? There are many, many lessons for providers. Engage parents as participants. Give credit where credit is due. Don't talk about delivering babies. Congratulate women for delivering their children, even if they have a C-section. Yes, women who have cesareans still deliver their babies. We all need help. Congratulate them all for giving birth. So that fosters agency. Create a safe space and cultivate team-wide trust. Don't badmouth people in other professions. Get moms and babies together quickly, but don't force it. Engage partners and the family in delivery. Treat birth as a life event, not a mere medical event. Don't apologize for an indicated delivery mode if somebody has a C-section. Don't say, I'm sorry. Say congratulations. You can recognize their disappointment in not having the kind of delivery they wanted, but don't apologize. Don't presume your ideal is their ideal and do, as I say, acknowledge loss if there was an ideal that was lost. Listen, answer questions, offer explanation. So there are many lessons for how we should think about bioethics questions when it comes to mode of delivery, but I think we need to recognize a few of them. One is that when we're talking, for instance, about questions of mode of delivery, data are very important, but the data don't speak for themselves. They need to be understood in the context of a procedure or a medical process and a bodily and existential process in which preferences are particularly important in which there are a range of reasonable options. So keeping our eye on what we consider the key goals of birth is critical to ensuring that our analyses are robust. I was gonna read a little passage from my book because I think I wrote it better than I can usually say it, but you can see that this is an Amish quilt and one of the things that has always, one of the questions that I get when we put forth this conception of a good birth is that, okay, so now you're just replacing the responsibility associated with a hospital-based birth or the empowerment and the romanticization that's associated with a natural birth, with a new conception of a good birth and what if people don't hit all those marks that you've just articulated? It's just a new way for women to feel disappointed. And so to that I would say it's important to understand, well, to that I would say, and again I don't have my book to get back to what I usually think on this, but is that this is a place in which birth and death also have important things to teach each other because birth and death both involve loss. It's not necessarily a bad kind of loss, but there is a loss associated with birth. So you had that baby inside of you, you had that idealized baby and now it's your baby who doesn't really, when you give birth it's no longer really a part of you physically and this child is different than the one that you imagined, right? You had imagined a birth experience, maybe it was an idealized birth experience and then you get the birth experience that you had, many women learn to embrace it in all its messiness and imperfection. So just because things don't turn out perfectly and things don't turn out exactly the way we imagined them it doesn't mean they're bad because what we're not, this is not, the goal is not a perfect birth, goal is not an ideal birth, but the goal is a good birth. And so the Amish, it is said when they make quilts they leave a little imperfection and the historians question its intentionality and they question even its being there, but the notion is that something that is not perfect gives us access to something that is beautiful and that is our very own. So I think one of the goals of getting ourselves to a good birth is helping to remind women that a good birth is not a perfect birth, a good birth is something that they can hold on to and remember. So that is all I have to say and I'm happy to answer any questions. No, no, no, please. Thank you so much. That was lovely and such a nice way to take our minds away from everything else. So thank you so much. One part of this, you know, this is wonderful because it was very much woman-centered. As physicians, you know, we struggle to figure out how we can help our patients in their birth experience and something that I think we struggle with especially in academic centers is the number of different providers, you know, at the attending level, resident level, all the learners. And so one thing that I was curious about is the sense of the doctor-patient relationship. Was that a theme that came out? It seems like the physician was pretty peripheral to your findings which I'm fine with, but I was just curious if that's something that came up that just hadn't been discussed so much in your talk. So we did, I mean, like many of sort of preconceived notions, women thought often going into birth that they, a good birth meant a birth with the person that they had imagined they would give birth with. And I think obese to some extent as practice is changing as we're experiencing or we are dealing with duty hours or we're just taking on a more realistic format for our practices, we wonder if are not being able to offer to patients that kind of continuity undermines their access to a good birth. And I would say women reflected on that in a way that they were surprised that it didn't matter as much. So they, some would say, I thought I really wanted this person but this other person was attending my delivery and she seemed grumpy at the prenatal appointments but she ended up being amazing and she helped me do whatever. So I think that people were pleasantly surprised that having that known person there didn't necessarily matter as long as the person there was facilitating things that were meaningful to them. Thank you very much. That was a fantastic talk, I appreciate it. I'm a critical care fellow and my wife's a geriatrician. We've often reflected on the dying, the care of dying patients, how much it depends on the circumstances. That is to say how much a good death depends, the definition of a good death depends on the circumstances. If you're critically ill, that might be one thing if you're not critical or in a nursing home to dementia or not with dementia, it'll mean something potentially quite different. We also had our own experience of a complicated delivery that by many medical accounts wasn't good but when we reflect together we've said it was actually pretty good given the circumstances. So what I wanted to ask is I mean, I really like the constellation of themes that you pulled from this great qualitative data. Whether or not you could hypothesize or whether you have any data about correlating those themes with specific circumstances, i.e. the presence or absence of medical complications, prematurity, et cetera. I think I'd be really interested to know what's a good death in X, Y, or Z setting. Ah, death, good birth. I do it all the time. X, Y, or Z setting. Yeah, so I don't, I can't speak, we didn't do any quantitative work. I think it would be really interesting to do some but we didn't. But what I would just say is that we, again, women found their way and partners found their way to the good in a variety of circumstances. So as an example, the woman who had a cute fatty liver really missed being present for the delivery but what she did instead was when she woke up, she said I got a yellow pad and I started asking everybody around me to describe my birth and I took, thank goodness I took notes because I still had some verset on board but she did, she interviewed everyone and she heard the stories and she cultivated her own form of her birth narrative by doing that even though she essentially missed it, right? And so I think the big lesson for me, I mean I don't know what the correlation would even mean. I think there's a way there for many people even if things don't turn out the way they seem and it's just the idea also that I would love to promote is that people have to press back the notion that their birth was bad, right? That it wasn't something to be celebrated and that if there is sort of a lexicon for them to describe how and why their birth was something that was full of joy and something to be celebrated and precious to them, then it may be that they can embrace it more and feel better about it rather than sort of disabusing everybody of their need to console, right? So I don't know, but it'd be great to do a study and get some numbers too. Annie, thank you, a great project that's both scholarly and poetic at the same time. So thanks for the presentation. One question I had is towards the end, you clearly have kind of implications of next steps. Have you been able to use this to develop curricular materials, both for trainees as was sort of mentioned and practitioners and pediatricians? I think that all those people could learn a great deal from these insights. Well, that's a great question. I haven't done that. I do my last, my epilogue of my book which took me literally like two days to write because it came out in one big sort of, is lessons for providers. And there are sort of, you know, what I felt were the most important lessons that I'd learned from the book and that we all should take heed of, but I think it'd be great to turn it into something more useful, but I haven't. Thanks. Yeah, I was interested in the sort of disagreement between the doula and the physician and how that got mediated and it seems like the team, there is often a team and it seemed like it was, in the case of a C-section, if they're really directed at the mother and making her experience positive, it's a really good thing. But I would think just the notion of having a team with different specialties that there would be areas of disagreement and a woman at that stage having to make decisions, it seems like a very difficult moment. So have you thought about how to sort of mediate those conflicts? I mean, did things like that come out of the book at all? Yeah, I mean, well, I think, you know, the doulas that I know hate when I tell that story because I don't think it is emblematic of what doulas think is good doula care or what they aspire to. I mean, I think it's kind of a what not to do kind of situation, but nevertheless, it's not like it doesn't happen. So, you know, I think to some extent, if there are disagreements, they shouldn't happen at emergent moments if they can possibly be avoided, although sometimes they do in obstetrics and so. But I also, so what I also think it speaks to is what is so deeply problematic about and troubling to me with regard to the current dialogue that is directed at women. So this notion that in order, so it's sort of this fine line between the kind of advocacy that's needed to push along obstetrics in a way that is more women-centered and then to encourage individual women not to trust their practitioners and to take on an advocate that is inclined to support them in a way that undermines that kind of authority. And I would say, you know, I don't have, I mean, some of what I've done here is just point to deep problems rather than offer solutions, but it is really important not to undermine trust even if you're going to empower in labor and delivery. And I guess I don't really have the answer to that, except that that was not the right moment to do that. But I think it's like, I think it's a little bit of a marker for what the literature has done with regard to upsetting the sort of process for women who want to have a birth process in which they feel safe and cared for in which they feel like they can trust their practitioners. So I don't know if I've answered that at all, but it just kind of marks a deep worry for me rather than points to a concrete solution. Yeah, I think in some way that the overlap between birth and death is that there is often a knee jerk reaction against technology in death as well, no tubes, and people know machines and when you explain things and deconstruct them, people say, okay, that would be okay to have for a little bit. And I think it's very similar, sort of distrust of technology that gets annoying. Also, just a quick question, what's a slow delivery in a C-section look like? I don't know, what did that mean? It's not pulling the baby out quite as fast. Did you just do it slow? Yeah. It's easing the baby out. It seems to me that the ultimate good birth is one that leaves the mother alive. And in the century between 1900 and 2000, the maternal death rate in the United States declined by 99%, 99% from roughly one in a thousand to one in 10,000. My question about these five elements of control agency and personal security and the like, and you also know that among 23 of the developed nations in the world, only the US currently has a rising maternal mortality rate among the 23. So my question is among these five do we have any correlations that have we studied how let's say agency correlates with the survival of the mom or one of the other factors? In my research any farther than to describe, right? And I do, you know, I'm with you that we have come in a way, the unthinkable connection between birth and death which was a very familiar one 100 years ago, right? So we, you know, birth evokes a deep fear in us right now, oftentimes, but it reasonably did 100 years ago. But I think, you know, all of the ways in which we have, I mean people would say all the ways in which we have made progress when it comes to maternal morbidity and mortality are not only due to the interventions that are characterized by hospital based birth, right? So some of them have to do with hand washing, right? And things like that. So I think just to be more precise about the ways in which technology has been vital and then the ways in which technology has overreached and caused some morbidity and mortality itself is just important, you know, to be clear eyed about that. But I also think, you know, women, it's not simply, I mean, we want people to emerge from birth alive, but we also want people to emerge from birth in a way that they're not traumatized by the experience. And we're at a point right now that, I mean, I think at a very minimum it's non-traumatized, right? And then able to celebrate and feel good and to feel agential in their very important job of being a parent, right? Thank you very much. Please join me. Thank you.