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Today, I'm going to talk to you,
as they said, about birth,

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but I'm going to talk a little bit more
about what we know of ourselves as humans:

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home birth.

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Clay Christensen says
that disruptive innovation transforms


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a practice or a product

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that has commonly been traditionally


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available only to the privileged few

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and makes it mainstream.

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It makes it so much more
affordable and accessible

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that suddenly, everybody's doing it.

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So in North America, we believe

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that the disruptive innovation
was hospital birth.

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Isn’t that what made birth safe
and accessible to all women?

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A safe birth?

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Well, it turns out
that some women don’t agree.

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Some women want to stay
in their own homes.

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We’ve exported this idea of hospital birth

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being the way to get safe birth
to low-resource countries.

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But even in low-resource countries,

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women aren’t coming 
in droves to the hospital.

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Why is that? What's going on?

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And is the disruptive innovation
hospital birth or is it home birth?

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You’re all familiar
with this image, that’s DNA.

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I’m going to talk to you
a little bit about the science,

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the physiology of humans
and what we’ve come to understand.

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You can see those components


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that are joining from two 
human beings' genetic information

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to predict what the future will be 
for this human being.

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It turns out that’s the same
kind of linkage

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that happens between the environment
and the physiology of birth.

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We’ve learned a lot about it
from watching animals.

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Animals in captivity,
for some strange reason,

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when they’re outside 
their familiar environment,

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have a hard time getting pregnant,
a hard time staying pregnant,

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a hard time staying healthy
while pregnant,

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and a hard time releasing their babies
when they feel like they’re being watched,

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when they feel like they cannot get
in what position they want,

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they cannot access the comfort measures
or the food that they want,

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they’re fearful, anxious or lonely.

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This is Mei Xiang
and Lisa is the elephant.

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They both successfully
delivered in captivity.

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How did they do it?

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They could get 
in the position they wanted.

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They were given environments
that were so familiar to them.

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Maybe they were still in a zoo,

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but something about it allowed them
to do what they had to do,

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and part of that was that the zookeepers
and the veterinarians weren’t seen.

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They were behind hidden video cameras.

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So what does that tell us?

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What if every time a young healthy man
wanted to run a marathon,

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he was told, "It's okay.
We’re not sure you can do it

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and you might have 
a heart attack in the process.

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So why don’t you come into the hospital?

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You could run your marathon
around the hospital.

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But don’t worry, 
you can bring somebody with you

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and your support or spouse can be there.

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We will monitor you
to make sure that you're okay.

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And just in case
you do have a heart attack,

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the emergency personnel
will be standing right there.

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Just in case you do have a heart attack,

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you'd better not eat, and we probably 
should restrict your fluids."

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Does that make any sense to what you know
about the physiology of sports?

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Do you think that if he didn't
believe he could do it,

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he would be able to complete the marathon?

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And what about making love?

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What about making babies?

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Suppose you told this young man

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that he also could have a heart attack
when he had an orgasm,

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some people do.

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What if, we weren't so sure
about his ability.

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We said, "No worries, 
come to the hospital!

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We'll give you a nice quiet room.
You can bring your spouse.

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We'll just come in from time to time

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check your heart blood pressure
and your heart rate

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and make sure that everything is okay."

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Do you think he'd have some sort
of performance anxiety?

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(Laughter)

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I think this is what he'd do:

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He'd say, “I know what to do
and you guys leave me alone.”

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So, what have we learned
about human physiology?

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There're some very cool things
that have been discovered now,

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things about when we control birth

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and when babies 
don't come out of the vagina.

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Guess what? They don't get
the beneficial effects

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of the good bacteria living in the vagina
that helps them for a long term health.

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What about oxytocin, the hormone of love?
Why is it called the hormone of love?

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Well, it's only released 
in three times in our life,

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three times which are absolutely
critical to bonding.

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In fact, it does modulate
how attached do we feel.

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It modulates social behavior.

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Oxytocin is only released

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when we make love -
when we have orgasm -

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when we have contractions
to open up our uteruses

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so that the baby can come out,

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and when we let down our milk
so we can feed our babies,

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so our babies can survive.

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Every year, 350,000 women die
while pregnant or giving birth.

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2 million newborns die
within the first 24 hours of life.

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This is true.

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Is this why we don't recommend
home birth to everybody?

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Is it home birth?

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You know, most of these women
live in 58 countries.

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They’re low resource countries.

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In these countries, women do not have 
access to lifesaving techniques.

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They don't have the medications
to stop bleeding.

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If they could access it, 
they can't get there.

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They don't have somebody
checking their blood pressure.

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Sometimes they're exposed to conditions
which are dangerous for themselves.

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They don't have methods
to resuscitate a baby

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that maybe just needs a little help.

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Is that why everybody 
should deliver in the hospital?

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What does the research say?

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For a long time we had a hard time
understanding what it really says.

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Just like what Carzy said this morning,

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you've to ask the right questions
in the right way. Guess what?

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We weren't asking the right
questions in the right way.

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We were mixing up planned home birth
with unplanned home birth.

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When we looked at the difference
between home and hospital birth

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we had a lot of cases in there

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where the woman delivered
en route to the hospital

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without an attendant, accidentally,

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even in high resource countries
where all those things are available.

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And that doesn't tell us the story.

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If we don't know who's attending her,
what their skill set is,

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if we don't know if she can change
the plan when she is in trouble,

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we don't know what's really
dependent on place of birth

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and what is instead dependent
on the type of care that she gets.

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What we do know now?

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The good news is that we have
15 or 16 really high quality studies.

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We'll never have
a randomized control trial,

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because women will not agree
to be randomized to home or hospital.

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They have opinions 
about where they want to deliver.

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And they've tried!

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There was one trial that they tried
to run for about 15 years.

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They got 11 women to agree.

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Not big enough to say something.

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So, what we know is that
for an essentially healthy woman

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who has attendants with skills,

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and those skilled attendants
bring basic equipment and medications

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and they have seamless access
to specialized care

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when a complication arrives,

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we actually get healthy mothers and babies

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and they experience less interventions.

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So what's the problem?

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Why don't we all agree that that's
the system that we should set up?

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I study attitudes 


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and what leads to attitudes 
among maternity care providers.

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I did this in Canada, 
a big large national study.

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You can see that midwives, obstetricians
and family physicians don't agree.

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Why does that matter?

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Provider’s attitudes matter,
because they influence what women choose.

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Women want to do
what's best for their bodies.

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They want to be able
to believe their providers.

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We know that providers
who know more about breastfeeding

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and have education about it,

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their patients will be 
more successful at breastfeeding.

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We know that women
who choose cesarean on demand,

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their providers are more likely
to have chosen that for themselves.

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There's something else going on there.

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If we ask the right questions
to the right people,

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we might ask the women,

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what happens when they listen
to their providers,

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try to access safe care,

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leave their homes and familiar
environments, and come in?

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Well, this is what they say,

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“I was told to be quiet and lie down."

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"I was put in a room
with women I didn't know.”

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“I didn't know that man.

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He came in and he said to me,

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'Spread your legs like you did
when you got pregnant.'”

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“I had to undress in front of strange men.

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They watched me while I got up 
on the table to have my baby.”

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Women in the Philippines will say...

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Actually a lot of places in the world
where women by droves are coming in now,

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- because there're institutional 
post-policies for institutional birth -

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are overloaded by normal cases

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and don't have enough resources

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to look after the women
who really need their care.

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This is a labor ward, and a postpartum
ward, and a newborn ward.

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Is that where you would like to be?
Does that feel safe to you?

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This woman is an indigenous woman.

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She came in because she believed

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she was going to have
a safer birth in the hospital.

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When she got there, 
they didn't understand her language.

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They didn't believe her
that she was really in active labor

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because she had walked from her village.

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So they made her leave.

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Shortly thereafter, she delivered
on the grass in front of the hospital.

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Is that safer care?

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If you think this is just happening
in low resource countries,

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it's happening all over the world!

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This is North America:

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strangers around, 
women being told to push.

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One woman said,

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“I was hooked up and trussed.
I couldn't move six inches.

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I knew I had to get up to have my baby,
but they told me to lie still

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because they couldn't hear
my baby's heartbeat.

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I was worried.

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I listened to them,
but they didn't listen to me.

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So I closed my eyes
and I hid in my music

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while they stood around and watched me.”

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So what is this issue about relocation?

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How are we defining safety?
And who gets to define what safety is?

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We know when all 
of these silly things happen,

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when mammals are not
in their familiar environment,

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when they're disturbed,
have a loss of privacy and dignity,

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it can affect their ability
to care for their own babies.

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Women tell us.

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Tiye, who is some of the women
I looked after, told me

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she had a good job in the hospital.

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She was a lab tech.

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She said, "Everybody knows everybody's
business ; I don't want them to know mine.

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The white women I work with
don't understand me.

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I don't want to be undressed
in front of them.”

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We looked after a woman
when I was at Yale on faculty.

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Her husband would not tell us
what his name was.

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He said his name was Fred.
Nobody believed him.

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They said, “Maybe he is undocumented,
that's why he doesn't want to tell us."

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It was 2001, October.

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His name was Osama.

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He was afraid if he's told
the hospital staff his name,

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that they would not treat his wife well.

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The Hmong women 
I looked after in California

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were used to having 
all of their elders around,

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but the hospital had a rule

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that only one person
could come with these women.

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This lesbian couple knew

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that if they went to the hospital
with their known and beloved donor,

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that it was very likely 


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that the hospital staff 
would hand the baby first to him

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and not to the primary parent.

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Women tell us that when they're home,

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they can get in what position they want,
they can use gravity

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and they can still be assured


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that someone will be checking them
and their baby's heartbeat.

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So what about babies
who are fascinated with technology?

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What about what women say
about technology?

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It turns out that they actually don't want

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to reject technology or modern medicine.

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They want access
to all those lifesaving techniques.

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They just want to be told the truth.

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All of the things I was telling you about 
were based on studies

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that we've done where women
have told us what they want

244
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and what's most important to them:
comfort, convenience, empowerment.

245
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This study has just come out.

246
00:13:20,997 --> 00:13:24,937
About 2000 women
answered a very long survey

247
00:13:24,937 --> 00:13:27,577
about what they thought
about their maternity care.

248
00:13:27,577 --> 00:13:30,187
These were all women
who planned hospital births.

249
00:13:30,337 --> 00:13:32,267
Guess what?
They say the same thing.

250
00:13:32,267 --> 00:13:34,237
They believe they're in charge.

251
00:13:34,237 --> 00:13:37,407
They believe they're choosing
the best options for their baby.

252
00:13:37,647 --> 00:13:39,377
They just want to be told the truth.

253
00:13:39,377 --> 00:13:42,527
They want to be told,
how does this risk relate to me?

254
00:13:42,817 --> 00:13:46,397
What if I live in a place
that does have those resources?

255
00:13:46,667 --> 00:13:50,697
What will it be like
when I go into the hospital?

256
00:13:52,033 --> 00:13:53,873
And they also tell us

257
00:13:53,873 --> 00:13:58,493
that some interventions lead to things
that they wouldn't choose

258
00:13:58,493 --> 00:14:02,533
unless they were very sure
that it would save them or their babies.

259
00:14:03,233 --> 00:14:06,683
40% of women are induced
in the United States today.

260
00:14:06,712 --> 00:14:09,862
We have over 30% C-section rates.

261
00:14:10,022 --> 00:14:12,312
Do you think the species 
would have survived

262
00:14:12,312 --> 00:14:14,922
if that was the needed rate?

263
00:14:15,125 --> 00:14:17,655
In fact, most countries
that have much better outcomes

264
00:14:17,655 --> 00:14:22,295
than we do in North America,
have much lower rates of these things.

265
00:14:23,178 --> 00:14:25,118
So what about risk?

266
00:14:25,399 --> 00:14:27,239
Who gets to choose?

267
00:14:27,239 --> 00:14:29,569
This is a one-in-a-thousand risk.

268
00:14:29,739 --> 00:14:33,959
When you have skilled attendants at birth

269
00:14:33,959 --> 00:14:39,679
and access to equipment and personnel
when you need it, this is the risk.

270
00:14:39,779 --> 00:14:43,489
About one per two to three thousands
is what loss will look like,

271
00:14:43,629 --> 00:14:46,639
- not fetal loss, I’m talking
about neonatal loss.

272
00:14:46,639 --> 00:14:49,419
And 50% of stillbirths are unexplained,

273
00:14:49,419 --> 00:14:51,569
so we don't really know
what's going on there.

274
00:14:51,779 --> 00:14:52,949
So one-in-a-thousand.


275
00:14:52,949 --> 00:14:57,269
That's about the same risk than that man
who wanted to run a marathon,

276
00:14:57,269 --> 00:15:00,209
would experience of having a heart attack.

277
00:15:00,499 --> 00:15:02,039
Is that an acceptable risk?

278
00:15:02,039 --> 00:15:06,009
And what about the risk
of loss of dignity, of abuse,

279
00:15:06,009 --> 00:15:08,149
of disrespectful care?

280
00:15:08,609 --> 00:15:11,029
How do you define safety?
Who should decide?

281
00:15:11,039 --> 00:15:13,989
Who is most invested and most responsible?

282
00:15:13,989 --> 00:15:15,749
How much risk is too much

283
00:15:15,749 --> 00:15:19,189
and whose agenda and whose destiny
are you talking about?

284
00:15:19,829 --> 00:15:22,869
You know what women say?
What would your mother say?

285
00:15:22,869 --> 00:15:26,529
Do you think she was more concerned
about you than the doctor?

286
00:15:26,829 --> 00:15:28,739
Yes, that's what women say:

287
00:15:28,739 --> 00:15:30,789
''We care about our baby’s health.

288
00:15:30,789 --> 00:15:33,189
We are offended when people suggest

289
00:15:33,189 --> 00:15:36,629
that we are choosing home birth
or choosing respectful care,

290
00:15:36,629 --> 00:15:39,979
just for our own convenience
or for comfort,

291
00:15:39,979 --> 00:15:44,489
like it was some sort of cosmetic option.

292
00:15:44,609 --> 00:15:46,459
We know that if we are not well,

293
00:15:46,459 --> 00:15:48,469
if we're not treated well,
if we're abused,

294
00:15:48,469 --> 00:15:51,549
if we feel like we had 
an unnecessary intervention

295
00:15:51,549 --> 00:15:54,259
or if we're in an environment
where we don't feel safe,

296
00:15:54,259 --> 00:15:57,599
that can affect how we feel
about our babies, our future.

297
00:15:57,837 --> 00:16:00,787
We're concerned
about our baby’s health also.

298
00:16:00,867 --> 00:16:02,417
What about the use antibiotics?

299
00:16:02,417 --> 00:16:05,397
What about with C-sections
or any of these things?

300
00:16:05,617 --> 00:16:08,497
Absolutely! Give me a C-section
if that’s what I really need.

301
00:16:08,597 --> 00:16:10,037
I want my baby to be healthy.

302
00:16:10,037 --> 00:16:16,917
I value the advances that modern medicine
have brought to high resource countries.''

303
00:16:17,277 --> 00:16:19,117
That's what they tell us.

304
00:16:19,117 --> 00:16:21,433
But is anybody listening to women?

305
00:16:21,503 --> 00:16:24,080
Paula Freire said, “Washing
one's hands of the conflict

306
00:16:24,080 --> 00:16:26,010
between the powerful and the powerless

307
00:16:26,020 --> 00:16:29,790
means to side with the powerful,
not to be neutral.”

308
00:16:30,000 --> 00:16:32,600
Isn't it time we took a stand?

309
00:16:32,774 --> 00:16:35,184
Which is the disruptive
innovation we await?

310
00:16:35,314 --> 00:16:38,634
Is it home birth? 
Is it hospital birth?

311
00:16:38,864 --> 00:16:42,654
Or is it humanized birth?

312
00:16:43,416 --> 00:16:45,196
What if all countries took steps

313
00:16:45,196 --> 00:16:48,596
to facilitate high quality care
in all settings?

314
00:16:48,596 --> 00:16:52,466
And all women were told
how to access that care

315
00:16:52,486 --> 00:16:55,386
wherever they felt safe?

316
00:16:56,287 --> 00:17:00,637
If the focus was access
to safe humanized birth in all settings,

317
00:17:00,637 --> 00:17:04,090
then we'd prioritize the availability
of lifesaving measures and skills

318
00:17:04,100 --> 00:17:09,590
everywhere and carry them to the places
where a woman feels respect, autonomy,

319
00:17:09,590 --> 00:17:12,552
and the ability to listen
to her own body and baby.

320
00:17:12,642 --> 00:17:15,552
I wrote that down
because I wanted to say it all.

321
00:17:15,552 --> 00:17:17,842
I wanted to be sure
I didn't forget to tell you

322
00:17:17,842 --> 00:17:21,422
that it is about
all of those things together.

323
00:17:22,219 --> 00:17:23,799
We can carry those things to her.

324
00:17:23,799 --> 00:17:25,749
They might be packaged a bit differently.

325
00:17:25,749 --> 00:17:28,489
We know most people won't need IVs


326
00:17:28,489 --> 00:17:30,579
if they're cared for
and start out healthy,

327
00:17:30,579 --> 00:17:32,809
- we're talking about 
term pregnancies here.

328
00:17:32,809 --> 00:17:37,819
We could be ready standing by
with resuscitation equipment for her baby.

329
00:17:38,590 --> 00:17:42,130
It doesn’t look like the hospital
but it’s got all the same stuff.

330
00:17:42,410 --> 00:17:46,550
Meanwhile, the woman could get
in whatever position she wanted.

331
00:17:47,270 --> 00:17:51,340
And we could remember
that whether or not we're there,

332
00:17:51,340 --> 00:17:53,410
whether or not 
the interventions are there,

333
00:17:53,410 --> 00:17:56,430
a woman will deliver undisturbed

334
00:17:56,430 --> 00:17:59,250
and will receive her baby
and care for her baby,

335
00:17:59,270 --> 00:18:02,120
because that's what humans do.

336
00:18:02,300 --> 00:18:05,070
They would receive their babies with joy

337
00:18:05,085 --> 00:18:08,515
and with the people that they love,
with gentleness.

338
00:18:09,647 --> 00:18:14,417
If we attended them
in that respectful way,

339
00:18:14,417 --> 00:18:16,967
perhaps they would invite us
back into their homes

340
00:18:16,977 --> 00:18:19,838
to help them learn
how to care for their babies.

341
00:18:20,218 --> 00:18:24,398
And their babies 
would come out alert and healthy,

342
00:18:24,398 --> 00:18:28,598
ready to receive
the wisdom of their grandparents.

343
00:18:31,490 --> 00:18:34,830
This is what one of my favorite
photojournalists said.

344
00:18:34,900 --> 00:18:36,940
This has been around for a long time.

345
00:18:37,030 --> 00:18:41,050
I graduated here in 1978

346
00:18:41,050 --> 00:18:44,060
and I read this book shortly thereafter.

347
00:18:44,742 --> 00:18:49,072
Suzanne Arme said, “If we hope
to create a non-violent world

348
00:18:49,072 --> 00:18:52,560
where respect and kindness
replace fear and hatred,

349
00:18:52,560 --> 00:18:55,820
we must begin with how we treat
each other at the beginning of life,

350
00:18:55,820 --> 00:18:59,100
for that is where our deepest
patterns are set.

351
00:18:59,110 --> 00:19:03,930
From these roots grow
fear and alienation or love and trust.”

352
00:19:04,150 --> 00:19:05,490
Thank you.

353
00:19:05,490 --> 00:19:07,040
(Applause)