Reclaiming Birth with Allison Yarrow

According to a recent survey of over 1300 women, 56% experienced dissatisfaction with their births. Unfortunately, this statistic reveals only a glimpse into a very broken system and the reality for birthing women in our country where 30% report some form of trauma in their birth experience.

So, where do we go from here?

On this On Health episode, I'm joined by award-winning journalist Allison Yarrow, who is on a mission to change this. Allison work centers on exposing how modern maternal healthcare strips women of power, causing harm to not only our physical well-being but also our mental well-being. Together, we break down the complexities of birth, from trauma in the hospital to exploring home birth as an option, lack of evidence in common obstetric practices, and the importance of postpartum support.

Join us as we discuss:

• How Allison’s home birth opened her eyes to the flawed maternal healthcare system
• Birth trauma and the importance of trauma informed care
• The problem with electronic fetal monitoring – and how much technological intervention is really needed for birth
• What Allison’s ideal prenatal and postpartum support model would look like
• The benefits of midwifery care
• The internalized fear surrounding birth and how to minimize it
• Why birthing women are the real experts
• Diastasis Recti, pelvic floor therapy, and the pressure to “bounce back”
• Allison’s mission with her new book – “Birth Control”
• And more.

Whether you’re pregnant and feeling anxious about giving birth or have given birth and experienced trauma, I hope this conversation brings you peace in knowing that you aren’t alone, and that it's not your fault – and that gives you confidence to embrace your power, heal, and seek the care you deserve going forward.

Thank you so much for taking the time to tune in to your body, yourself, and this podcast! Please share the love by sending this to someone in your life who could benefit from the kinds of things we talk about in this space. Make sure to follow me on Instagram @dr.avivaromm and join the conversation. Follow Allison @aliyarrow and get a copy of her new book “Birth Control” here!

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Aviva: Throughout the book you really beautifully write about your personal birth experiences, two of which were in the hospital, and a third of which was at home. So I have this stacked set of questions for you, which is, can you talk about your different birth experiences and what led you to choose a home birth after your hospital birth? And as part of that, I'm really curious, were you already researching the book and that's what led to that decision or did your different experiences lead you to research the book?

Allison: Oh, such an amazing question. I mean, the truth is birth control would not exist without that third home birth. I don't think it would. I needed to have that experience to be able to sort of see a bird's eye view everything about giving birth in this country, in my body, in my experience. Once I learned about what home birth really was and I got through all of the fear that's created around this actual natural, fabulous, person-centered practice, once I could get through all of that, it was very clear. It was an experience I just wanted to have in my life.

I think I wanted it from the get-go. I think I wanted it from the moment I watched The Business of Being Born, which I watched when I was pregnant with my first child. Then I kept having these conversations and folks would say, well, I mean, you know, can do all of that, but just why don't you have a level one NICU just in case? And that narrative in my head, well what if something goes wrong that’s sort outside of me, but with my baby? That held a lot of water. So my husband and I did a Bradley Method birth class. We did sort of an eight-week long preparatory. We spent a good time, three hours a week, on practicing relaxing, practicing feeling contractions. That was what was so frustrating, I think to me, being pregnant. I wanted someone in my care to tell me what was going to happen in my body when my body went into labor. No one really had that information for me, despite a lot of asking and trying to get it. That ended up being really important to know. It was really important to know what a contraction would feel like and how to practice having one.

So, I ended up having a precipitous labor with my first child. She was born in two and a half hours from water to baby in my arms. We rushed to the hospital cause that's where we had planned to deliver. That was, in retrospect, really silly. We should have stayed put, but I was afraid of being swarmed by emergency folks who were coming to save lives, usually they get these phone calls. I didn't want that element. So we went with the plan. Then the second time our doula said to us, you're a perfect candidate for a home birth. Really you are. It's going to happen so quickly. Why don't you just do it at home? But I had all of these, again, all this externalizing and fear of what the neighbors would think, would they hear me? Would I make a mess? Who would clean it up? All of this stuff that really had very little to do with me and birth and everything to do with society and other people. And then I was of course afraid of who's going to look after my less than two-year old, who's at home, what's going to happen with her when the baby comes? That ended up being the biggest thing that I was stressed about was who was going to come take care of her. And had I just stayed home, that could have been accounted for a lot easier. But no, I had to go to the hospital.

So, I went to the hospital again, and I had a more textbook labor my second time. But by the time my son was born, I wanted be out of there. I wanted to be home in my own environment. And there were moments certainly of not receiving the kinds of things that my body needed, the laboring body, we know from evidence and experience, needs certain things like quiet, concentration, darkness and solitude and all of this stuff that's really denied in hospital settings cause of how they are.

 By that time I realized if I'm doing this again, I'm 100% doing this at home. And from the second I made that decision, the second I was pregnant, the care was all at home. My midwife came to me, my kids got play with her fetoscope. It was just so fantastic preparing for those births and then doing them here in this safe space. I had a friend who's a birth photographer there photographing. When people see these images, I wish everyone could see them cause they're so peaceful and quiet and it looks just completely different. I'm a huge home birth proponent for this reason because you just get to be in control in a way that you don't elsewhere.

Aviva: It sounds like the births that you had, particularly the home birth, is what led you to say, okay, something's amiss here with the hospital environment, even though I had a great experience. What was your inner process that led you after the home birth to say, I need to write a book about birth?

Allison:  Yeah, I mean I had these ideas in my head of all of the things that were less than perfect before I chose home birth. For instance, when I was taking that Bradley class, I was really surprised that we were doing so much work to sort of defend ourselves against traditional hospital practices. I didn't understand why as a birthing person you would need to go in armed with all of this information and a birth plan saying, no, actually I don't want to do all of the things that you often will do in this situation. I don't want a vaginal exam. I don't want pitocin. I don't want to be on a clock. My journalist’s antenna went way up with that. to support me in this experience. Why am I having to learn how to fight the people who are supposed to support me in this experience? It wasn’t so combative in that way, but it was suspect. Why was I learning this? Why was I not learning what a contraction feels like and how to relax through one and these kinds of things.

I was learning that too. Then I realized it was because you have to sort of go into the hospital armed with all of this information and what you want. I realized that people giving birth should be centered in their birth and that is not happening. That's a big reason I think that birth is so broken in this country is that people doing it are not centered as the experts, are not considered to be the experts in our own body. I think if that shift were made sort of in every care setting – home, hospital – that would be such an important step.

There are folks who are certainly doing this. I mean, listen, I want to speak to people who are pregnant, who want to become pregnant, who need to understand what they're up against when they become pregnant and want to give birth. They need to understand how to advocate for themselves. But at the same time, they're in incredibly vulnerable positions as people giving birth and they're not really able to advocate when they're in labor themselves. I think also I really wanted to speak to people who have given birth, and who have had experiences that were less than perfect, were coercive, were abusive, were not the sacred experience that we know birth to be and that everyone deserves.

And I also want to speak to people in healthcare. I mean certainly midwives and doulas who've been doing this work for eons and really know what sort of the safe person-centered birth looks like and how to give it to people. And also, I mean certainly obstetricians and nurses, these people are heroes and they're being thwarted by a system that's not allowing them to care for people the way that people want and need to be cared for.

Once I sort of connected all the dots of everyone has a stake in this and I personally have skin in the game. I mean not only do I have these experiences that I can't help but talk about here, I wanted to talk to other people. And so I surveyed 1300 people who've given birth and wanted to ask them, is it just me or could this be better for a lot of people? And it turns out that most people have some area of their birth, their pregnancy, their postpartum experience that they really wish had been a lot better. I really think this is possible and it’s something that people deserve.

Aviva: Let's talk about birth trauma because first of all, it's now thought that as many as 45% of birthing people in the United States report something in their birth that was significantly uncomfortable, unhappy, or didn't sit okay with them. Depending on the study you look at between one and six or one and nine actually can be diagnosed with PTSD, actual PTSD on the basis of their birth. You cite an obstetrician who I also recently cited Alison Stuebe who said America treats new moms like candy wrappers. Once the candy is out of the wrapper, the wrapper is thrown away.

I'd love to hear from your survey, from the people you've been talking to, what are some of the key elements that they have described to you as contributing to their experience of trauma? Cause we know it's not just the birth, it's how a woman is treated in labor and birth. And what are some of the symptoms and impact on her life that you've been uncovering?

Allison: This is such an important area and I'm so excited to hear that you're doing even more work on this. I was really taken with the work of the researcher, Cheryl Beck. She's just done so much survey work about birth trauma over time. Something that she sort of said that her study subjects have said that stuck with her and that has stuck with me is people say that they feel raped on the table and that no one was around to help. That line, sort of in any context, is a harrowing thing to hear someone say about their experience, but certainly when they are giving birth, when they're in this moment of struggle and should be safety. And to hear that that's been a common experience. Beck has found that about 30% of people experience birth trauma. In my survey we found about 40% of people say that they've experienced birth trauma. I think the numbers could be higher. I think sometimes the idea of trauma is sort of diminished or stigmatized in our culture. And I think honestly before I began to do some deep work on this myself, I would say, oh, that was traumatizing about something that happened to me. Just sort of throw that away and say that.

Aviva: Let's unpack a little bit for listeners – this term birth rape. Another term that we hear is obstetric violence. I think people who have had sexual trauma who have not birthed, or people who are just listening who have not been pregnant or birthed or who had a very smooth birth may hear that and say, well that's really extreme. And so I just want to emphasize a couple of things here. Birth is very sexual; it is a sexual experience. And what women also describe is something happening…women will often say down there… that they were not asked, consented for, that was aggressive, that felt violent or violating or that was painful. I also want to just share something which is that there are many states in the United States currently in which vaginal exams unconsented are legal. So that if it's in a teaching hospital in some states nobody has to ask you, including if you're under anesthesia. So this is not a hyperbole, this is not an exaggeration. When people talk about birth rape, they have really experienced something that feels on par. Studies have looked at women's physical experiences and physical responses including in brain imaging and found many of the same, both hormonal on blood work and imaging changes that you can see with these various types of trauma being commensurate. So I just really want to emphasize this is a very real phenomenon.

Allison: Thank you so much for that. I think it's so important to validate this for people. Anytime anyone wants to touch your body, certainly in a medical setting, I think in any setting, consent is incredibly important. Consent has to be the top line. And in pregnant people's experiences – in my survey, myself, others, I've interviewed my friends – this is not often happening. We're not being asked, can I touch your body? Is it ok for me to perform this exam? Let me explain to you what this exam entails, what it's going to feel like. And also as a provider, let me make sure that as I'm examining you, I continue to check in to make sure that this is still ok. Cause I myself have had a vaginal exam where I dissociated during the exam. I was not comfortable with what was happening, I was starting to have a contraction, and I started to freak out a little bit. I think really a skilled provider would see that and would say, ok, wait a minute, I'm going to back off here. She does not seem comfortable with what's happening right now, but that's not common enough. And so it's really important that providers who examine women and birthing people have the training to understand this sort of multi-layered consent piece and also have a trauma-informed care background. That is not commonly happening. You're incredibly lucky if you enter a hospital as a pregnant person and you encounter some provider who has some trauma-informed care experience.

Aviva: I just want to emphasize that you said that the consent is a bottom line, and I just want to emphasize that it is a legal requirement. So it's not even just an emotional salve or a nice thing to do. It is a full-on legal requirement. Let's talk about, just so folks who are listening know what trauma informed care is, do you want to explain that?

Allison: My understanding of trauma-informed care is that as a provider or as an individual, you go in with the understanding that everyone has experienced some form of trauma in their life. And so let's treat every person who comes in for care with that understanding and that sensitivity.

Aviva: Absolutely. And it's a lens of that and also knowing how to support and work with people who have experienced trauma. It comes down to, as you were saying, reading body language, right? If somebody's shifting up the bed while you're doing a vaginal exam, it usually means they're uncomfortable. If their face is changing or if you see them just look off to the side and check out, they may be dissociating. It may be asking what words are safe words for you for me to use? So, one of the things that often happens with birth is when we're about to do a vaginal exam, you have to tell someone, open your legs, relax, breathe. For many people who have had certain kinds of trauma, particularly sexual trauma, that can be extremely triggering. It may be a male provider saying, would you prefer to have a female provider? Simple things that can go a really long way to making someone feel safe.

It's also understanding that trauma can be triggered and re-triggered so that somebody may seem fine, they may have had all the therapy in the world and feel like they're fine, but it doesn't mean that when they're in that setting. And again, coming back to birth as a sexual experience, we don't think of birth in our culture that way. If you were to be outside a birthing room and somebody was in the throes of active labor and making all kinds of sounds and you recorded it, you could be recording a couple having sex or porn. It's very similar sounds and same parts of body. So, understanding that is critically important.

Allison: Yeah, it's interesting that you bring up the sound. That sound and making sound was so important to me, and all of my labors really helped during labor. But I want to go back to what you were asking earlier about trauma and about some of the findings in our survey. Because one thing that was fascinating, we gave folks a list of adjectives that they could choose from to describe their births. They had all kinds of different adjectives. You could choose as many or as few as you wanted. Of the 1300 people who took the survey, 50 people only chose the word traumatic. That was the one word that they selected. They could have selected many other words. And so with some help from researchers at the New School, we wanted to look at that group because what else does that group have in common with each other to have an experience that was so traumatic that that's the only way they would describe it.

It turns out that back to not caring for the mom and the candy wrapper analogy, many of the things that were lacking in these people's experiences were breastfeeding support, were proper support from either a partner or a doula. People were prevented from being in the room with them. Providers didn't ask before performing exams. It was a lot of these sort of smaller but accumulating factors that said to these women and birthers that the baby was important, but they were not important at all. I mean, that's really where I think a lot of attention belongs. It's really just developing a relationship with someone and considering them to be your equal. I think that would go a long way into the care improving. But I know it's so difficult. I mean, you know better than I, it's so difficult to be in a hospital environment or even a home environment where you're not feeling supported, to give the kind of care you want to give.

Aviva: Absolutely. I think it isn't that complicated though, to extend kindness and compassion and sensitivity and treat people as the equals they are. And actually, I mean, they're really not the equal. They're the expert on their own body. And the birth worker really is there to support the needs and expectations and goals of the birthing person. I think what's difficult in the hospital environment, and I think even home birth midwives feel pressures around this, is a lot of the legal issues. So, it may be one thing for an OB in a hospital to want to support a woman and being off monitor and walking around and eating and being on her birthing ball and all the things. And then risk management is saying, yeah, but if something goes wrong, the only proof we have that it wasn't your fault or the hospital's fault is that fetal monitor. So we need to get that on the mom's belly or the scalp electrode into the baby's head. I was once told in part of my OB training, the only C-section you get sued for is the one you don't do. And that's a really significant pressure. So, even the best providers, their goals and knowledge and hopes for that mother can be completely obliterated by a system that doesn't support that.

Allison: It's really unfortunate because a lot of women believe that that monitor is actually there to keep them safe, to keep their babies safe, but if in fact the monitor is there so that you have a tether on and a leash and a clock, and it can be proven in court that everything was done to support you, that needs to be disclosed. I mean, monitors don't really have a whole lot of evidence at all supporting their use.

Aviva: So let's talk about that. In the book you talk about the history and the flaws in the scientific basis. I can do air quotes – “scientific basis” – for example, around the electronic fetal monitor, and then these terms like failure to progress which are just so mother blaming too. Thankfully we're moving away from some of that. Talk about some of the data around the electronic fetal monitor.

Allison: The electronic fetal monitor was introduced, I think in the 1950s. And the way that it got into hospitals was by advertisers actually, not doctors or scientists who wanted to hook up people to this device and were going to be able to tell you that your baby's healthy. The original goal was to prevent cerebral palsy, which it turns out it didn't do. Then all kinds of other goals were sort of foisted on this technology, none of which have ever really born out at all. What it does is it provides kind of a murky data point. It's not a really clear indicator of what's going on with mom or baby. Heart rates rise and fall during labor in both mothers and babies. What it does and what it did for me when I had to wear one, when someone put one on my stomach, it made me feel like I was tethered to a machine. Like I was on a leash and it didn't feel good. But we become so addicted to this technology in the hospital, it's been nearly impossible to get it out of there when it's not actually doing anyone any good, when it's causing more C-sections.

Aviva: Yeah. And that's the problem, right? Because there are those births where you do want to monitor, where it really does make a difference, but those are the exception, yet everyone gets one. It becomes sort of the requirement. And then as the mother, you might be coerced and somebody might say to you, but you don't want to harm your baby, do you. You don't want your baby to die, do you, or to have anoxia, do you. So then what do you say to that? Of course, I don't. Okay, do the monitor. But you're right. I mean the data has shown that for most people there is an increase in intervention based on either misinterpreted or faulty or over-interpreted heart monitor tracings. And I've seen many births when I was in my training in the hospital where it was time to rush to the C-section because the baby was in distress. The C-section happens, baby is totally fine.

Allison: It was fascinating to me to see all the ways in which low or no intervention was actually supported across the scientific evidence. What midwives know and do, the way they touch people to prevent perineal tears, monitoring intermittently instead of constantly. I mean, I would love to see what would happen if just the sort of the six basic needs of laboring women were given to people in the hospital – the darkness, the quiet, the solitude, the comfort, access to food and water if you need it. These really basic things that actually don't cost anything at all. What if we just did those? I mean, there's a basis for them in science, but also in anecdote and narrative. That's always been sort of an interesting piece of this for me too. It's like we want all the science and all the data to be able to prove often what we sort of know in our life experience is better for us.

And we actually have that with low to no intervention birth. Most people are fine with that, but they're told things like, you're risking the life of your baby. We're going to put you on the clock. And when the timer says, ding, it's going to be time for a C-section, it's Labor Day weekend, or I have a golf tournament, I've got to be somewhere. I think it would really behoove everyone to sort of just take a step back and say, we don't have to go for the maximum amount of intense medicine. But that's sort of how obstetrics was created initially. Doctors came over from Europe, they wanted to learn how to deliver babies because it seemed like that was a big thing that was happening here. And they learned about it from midwives, and then they stole the work and the clients and then they sort of developed their tools and said, well, our tools are better than yours. And midwives, what you're doing is ignorant and it's unclean and it's not safe, and we should put birth in the hospital and everyone will be safer there. That didn't bear out initially, but that's the historical trajectory. And really you can sort of see it now in how hospitals operate. I would love to see what they have in Europe where home birth is part of a system. You don't have to leave the system to have a birth in a place of your choosing. It just doesn't seem like hospitals just now are the best place for most people giving birth, but 98% of births happen in hospitals. So what do we do about that?

Aviva: Yes. And we absolutely know from all the western countries that are resourced where women are birthing with midwives outside the hospital, there is usually a very seamless integration between home and hospital. It's not like here in this country where you're picking either or – either you have the home birth or you have the hospital birth, and it's very polarized. It's changing in some states where home birth midwives are licensed. But even there, it's challenging. One of the areas I know that women report traumatic birth experiences when they have had a transfer from home to hospital and they're treated with judgment. They're mistreated when they get to the hospital, emotionally condescended to, judged, et cetera. And often their care may be delayed too.

When we look at every country that has midwives and generally good resources, they have far lower maternal and infant mortality and morbidity rates and far happier new mothers. Those are also countries that typically have extended maternity leave and often paternity leave, and they also have happier providers. You mentioned timing and how would it be different if time restrictions were suspended? We know that one of the kind of gold standard measures of labor progress, if you will, has been something called the Friedman Curve. But that is also incredibly antiquated and we know it to be false and inaccurate. And yet women are still told when they come into the hospital, if you're this far dilated, you should be this far dilated in one hour, two hours, three hours. That leads to a lot of induction and intervention. And then we know induction and those interventions increase risk of experiencing emotional trauma from birth as well as physical trauma.

Allison: I was surprised I couldn't find a study of labor that hadn't been intervened with to kind of compare to the Friedman Curve studies that had come later to sort of say, well, if what Friedman said was if the dilation he predicted per hour is wrong, what if we look at other labors and births and try to get a better metric? And some did do that, but all of those labors had been induced or had used forceps, they had all sort of had additional medicine involved.

Aviva: I think the study on Friedman Curve came out somewhere around 2010 to 2012. And I remember…

Allison: The Zang data maybe?

Aviva: Yes, the Zang data. And what Zang said in the beginning of that study was that they were unable to find a cohort of women in the United States who were birthing without intervention that was large enough to be meaningful. And I just remember reading that and just my jaw dropping. It was, at that moment, I remember wanting to write an article on birth becoming extinct.

Allison: Yeah, we're just never going to really know. I believe what people have to say about their own experiences is just as important as these studies. But I would love to see that study of a cohort that has birthed without intervention and sort of what that looked like and how that went. And listen, I mean, that is in, I'm sure, the minds of the midwives who have absolutely,

Aviva: We've all seen so many. I had a birth, this is a really funny story, and it's sad and tragic at the same time, but when I was in my medical training at Yale, I was on the OB rotation and I just happened to be on the rotation that day when the OB team was getting ready to graduate. So they were having an outing, they were having an excursion, and they left one OB fellow on the floor and the midwives, and I got to be in the hospital that day. It was just the way it rolled. And I was one of the only residents that the midwives would welcome into their births because they knew I had been a midwife. So I was on with a very senior midwife, and we had a mama come in. She was from Central America. She came in with her sister and her best friend, one who had been a midwife back in their village.

Long story short, they just were doing their thing. They had pillows on the floor, mama was kneeling. They brought an herbal tea. It was a traditional type of basil that the mamas sip in labor. She was drinking it in a Dunkin Donuts coffee cup. And after four or five hours – we're periodically checking in, we're not doing vaginal exams – it's really a midwife birth in the hospital as much as one could get. But it's because the OBs were gone. And ultimately she just tells us when she's ready to push, she pushes her baby out. Her friend's sister team is assisting her. Next morning, I have to present the birth on morning rounds, and it's the head of the obstetric department who was presiding over that morning rounds. So I'm explaining the birth. Did she have an IV in? Oh, well, she had the line in because it's hospital policy, but she didn't have an IV running. What was her dilation rate? We didn't check her cervix, and on and on and on. Then at the end of the report that I gave the OB, who was the head of the department said, you should do that as a case report, Aviva. Now a case report is when you write up something extremely rare that happens. It's like the weird finding, you see one in a million. And that was his response to this 100% non-intervened-with birth.

Allison: I think that is an incredible story. If we were to sort of widely acknowledge, and our providers and our hospital systems were to widely acknowledge that what you attended at that birth, was normal, physiologic birth that was possible in most cases, I think that would go a huge distance to helping solve this. I mean, everything from the maternal mortality rate to people's experiences of their childbirth, not appraising them is traumatic. I mean it's so many things, but I think it boils down to really trusting the person and what she has to say about what's happening in her body or what she wants. I think that that's really getting lost. And part of it is the legal piece, right? Part of it is no one wants to get sued for a tragedy. And part of it is, I mean, birth is the most expensive thing that happens in a hospital.

C-section is the most common surgery in this country. And those suites, those surgical suites where birth happens…. I mean, this was fascinating for me to understand in my reporting. I waited in triage for a very long time, or I waited outside of triage. I waited in the waiting room. I had a source who was laboring on a bench outside a hospital for way too long. And you wonder, well, it's a big place. They’ve got to have rooms that you could go to when you're in labor, you're ready to push your baby out. There's got to be somewhere where you can go if you can't go to a birthing room. And it turns out you can't go somewhere else because all of these rooms come with a charge. They come with a fee. And that fee is because they can be turned into a surgical suite. Whether or not you need surgery as a woman or birthing person, you have to give birth in the hospital in a room that can be converted into a surgical suite, and that comes with a premium and a cost. So you can't go into a regular room because they can't charge you for that fee, and that's why you have to wait to go into a surgical suite. So even that sort of cost dynamic is really feeding a poorer experience for those who are doing it.

Aviva: Back to this piece that you started with, I face both as a midwife, physician and educator, the dilemma that you experience, which is why do I have to go in with this list of things I don't want. I sometimes say to people who I'm working with for perinatal support, well, if you're birthing in the hospital, it's a little bit like you want Chinese food but you're going to an Italian restaurant. So you're going to have to keep saying, I don't want that. I really do work with people around finding the places and the people with whom and at which they feel the most comfortable birthing. But for so many women, so many birthing people, that is a privilege that they cannot exercise. And it may be because they live in a community where midwives aren't legal and accessible, may live in a community where most midwives are out of pocket and too expensive or the deductible is too expensive, or they may have personal medical reasons or family history and stories that just make them uncomfortable birthing at home, or baby has a need to be born in the hospital. So we're having a pretty intense conversation that I would imagine could be really scary for somebody who's not yet pregnant, or who is pregnant and figuring all this out. How do we have these conversations in an honest way so that we really can help people be protected and safe and know what to look out for and know how to exercise their rights without putting that entire physical and emotional burden on somebody who needs to be focusing on the task at hand, and without increasing fear because fear itself can kibosh physiologic labor? Big, big question.

Allison: Yeah, it's an excellent question. Something I heard, a refrain I heard from interviewing women and birthing people was that no one asked me to share my experience, but when I did share it, I didn't want to scare anybody and I didn't want to foist my own experience onto someone else who's going to have an entirely different experience at their birth. So I think part one is we have to share openly and honestly our birth experiences with other people, as people. And we also need to be asked if you've given birth, tell somebody about what it was like for you. Ask them about what it was like for them. Come meet the baby, but say, what was it like? How was it for you? And you'll understand quickly in their body language and eyes probably more than even what they're saying, but we have to start sharing these stories more widely and we have to give people information.

I mean, I was the kind of pregnant person the first time that needed every piece of information I could get my hands on. I know not everyone is like that. That's what I wanted and needed for me. I also think there are many resources that can be accessed that can improve birth experiences for people at all sort of levels and all backgrounds. In New York City, there's an incredible program that if you qualify for Medicaid, and Medicaid pays for half of the births in this country, and your salary is at a certain level, you can access a free doula. The City will pay for a doula for you. This program is going incredibly well. I think they've done a thousand births this first year. I mean, they exceeded their goal hugely. And there are programs like this all over the place. They're sort of privately funded. It's sort of a patchwork and finding that care can be tricky, but it's understood that support in birth matters and improves health outcomes. It reduces the chances of C-section and of trauma and of all of these things that we've been talking about. And so getting that support network is really important.

I ask everybody about their birth. That's what I do. I go around asking people about their birth stories. Today I was getting my computer repaired at the Apple store, and I saw a little cute baby on the phone of the person who was helping me. And I said, oh, is that your baby? She said, no, my sister. And so we started talking about her sister's birth story, and she told me that her sister gave birth on Saturday and they let her sister's partner in, but they wouldn't let her sister's sister or her mother in the room. And this is still happening, this keeping support out. It doesn't cost anything for your mother to be there. But if that's who you need, if you need someone there who can advocate for you, don't let them tell you that you can only have one person. Fight to get that other person that you love and trust and knows you and can advocate for you in the room with you. That's a doable thing. Hospitals need to be amenable to support people in the room and not limiting the amount of support people in the room.

Aviva: Absolutely. I really want to explore these words that are used in medicine. Let and allow are two words that just piss me off when it comes to pregnant birthing people because we're talking about adults here. We're talking about policies that are not based on medical evidence, that don't inconvenience anyone. So this letting and allowing, I feel like anytime we're hearing providers using those words, we need to put a hand up and almost have a response phrase that we come up with. I'm an adult, you don't get to let or allow me, this is a service I'm here for and paying for. I get to choose.

Allison: Yes, these are consumers. And this is something we hear about a lot when people are pregnant. How long will my doctor let me go? How long will my doctor let me stay pregnant or allow me to stay pregnant before they will encourage me to come in and be induced when clearly my body is probably not ready for the baby to be born yet. Let and allow also sort of light a fire under me and we have to figure out another way of sort of communicating that we're in partnership with our care providers in this experience.

Aviva: So I'm personally super curious because I'm currently building out a new prenatal birth postpartum education and support platform that I preliminarily launched during Covid, but now it's a thing, and I am so deeply curious. You did Bradley. There are many different wonderful methods. Bradley was consistently historically called the partner-based method. We have Hypnobirthing.

Allison: Husband-coached

Aviva: Husband-coached. Yes. That was originally what it was called. It was originally husband coached. We could just go on about that but what do you see as an ideal? And of course it'll be different for different people, but if you could dream up your vision of what an amazing prenatal-birth-postpartum education and support model would look like and what are you hearing from the women that you are working with and interviewing?

Allison: Everyone wants more postpartum support. I think that's the biggest sort of shock in the moments after birth happens. Everyone sees they've been surveilled and supported in some way for nine months. They've been the center of attention because this baby was cooking and the baby's coming out and then all of that really disappears overnight. And so I think most people don't have a visit again with a care provider for many, many weeks.

Aviva: Again, back to candy and wrapper, right? Baby gets an enormous number of visits in the first and first few weeks of birth for weighing and all kinds of things. And mom gets seen at six to eight weeks, which by then if she's experiencing postpartum depression, if she's having milk supply problems, hopefully she's found a lactation consultant or someone to support her, but has often a thyroid problem. Any number of things. Birth trauma may surface then, but it may be six months later before someone realizes that’s going on. But again, we're back to that mom getting discarded as if she's unimportant. And yet we know the health of the mom is intrinsic to the health of the baby.

Allison: The importance of the dyad, as they say in research, the mother and the baby. The dyad is really who needs to be seen and the touchpoint sort of have to be there for both, right? Six to eight weeks later it's too late to catch some stuff. And especially if you're being kicked out of the hospital like 24 to 48 hours after you've given birth, you milk hasn't come in. Then you have to find a lactation consultant. You're sort on your own and at home. And by the way, I mean subsidized childcare and paid leave would go a tremendous amount here too to supporting people in their breastfeeding journeys and their postpartum recoveries. Certainly if you had a surgical birth, you're going to need a different kind of and more recovery time and support for that.

Aviva: And let's compare that to a home birth where a typical midwife will come back two or three times in the first 10 days, to your house to support you, and more if needed.

Allison: Yes, the midwife care after a home birth is definitely there's more care. And even the doula program in New York City, I found out that they get four doula visits after birth. That's a lot. Yeah, that's great. Four points of access with someone who cares about you, who has experience with this, that's really important. So I think the postpartum piece is big, sort of making sure that everyone's aware. And that was actually, I think that was a full one of the eight Bradley classes I had. I think the full class was about do you have the meal train? Do you have your parents coming? But it's so important. It really is.

Aviva: It's huge for me. Actually, my favorite book, which is kind of one of the lesser known books for whatever reason, came out in 2000, is my postpartum book. I just feel like postpartum is so unsung.

Allison: I love your postpartum book

Aviva: Thank you. I emphasize postpartum care a lot. One of the things is, as you had in your Bradley, you can't wait till you're postpartum to plan your postpartum, but so much emphasis gets placed on birth and birth preparation. So, thinking about what do you want that experience to look like, talking with other moms who have been through it, having a postpartum doula if you can access one either out of pocket or through a publicly paid and supported system. And if for some reason you can't, working with your community, your friends, your mother, your mother-in-law to set boundaries on what you do and also don't want because that can be really hard to have people kind of all up in your space thinking they're helping when what you really want is just some quiet with your baby or your baby and your partner or your other kids.

Allison: That's so true. It is important to sort of center your own wants and needs at that time. And many of us have a problem with that throughout our lives because of the cultural environment that we're raised in. And it's kind of a moment to really step up and say, this is what I need and this is what I want. But I think it really also goes back to sort of the expert piece. The people who are pregnant and giving birth or the expert in the room. And you don't have to have read all the studies or my book or your book. You're still the expert. That is so important. We really value science and expertise and we should. But I think people becoming pregnant and giving birth, know more about what's going on in their bodies. They know more than they believe they know.

And most people will find a way to resource themselves even further and decide this is the kind of birth experience I want. The key here, I think, for people is finding that provider team and that support network that is on board with that and wants to do what you've decided that you want to do. It's knowing C-section rates and episiotomy rates of your providers in your hospitals cause are the biggest indicators of whether or not. But it’s also saying, I want my pillows and my tea? I don't want Pitocin or I do want Pitocin. It's being able to sort of speak what you want and have that be supported and heard by those you choose to be at your childbirth.

Aviva: I'm glad you included that because I also feel it's really important for us to honor. Somebody might want the epidural or the Pitocin or need it, for us to stop this polarization of natural versus interventive birth. And we have to be able to talk about both and what the physiologic model is and without judgment whatsoever.

In your survey, 40% of respondents agreed that doctors, nurses and specialists didn't give them the postpartum care they needed. This neglect means women's postpartum mental health struggles are often woefully overlooked, but even their physical healing challenges can get neglected as well. You personally experienced a physical healing challenge, and I'm wondering if you would mind talking about the diastasis recti you experienced and also the pelvic floor dysfunction that comes with it that so many women experience and don't talk enough about – pelvic floor prolapse, for example, which I personally experienced. I know how traumatic that can actually feel.

Allison: So I did experience diastasis recti, which is a separation of the abdominal muscles. Most people, I think everyone who's pregnant, your abdominal muscles separate so that your baby can grow. That's just part of the experience in the body. But my muscles did not sort of knit right back together. It was a condition that I had heard about from a friend who taught Pilates, but it sounded so abstract and I didn't have any sort of understanding really of what it is or why it would happen. And so I just sort wrote it off as something I didn’t need to worry about. But I ended up having a lot of back pain after my first childbirth and eventually I sort of blew a disc in my back and it was really debilitating. I couldn't walk. And after that happened was when I actually found that I had this abdominal separation. I had no sort of support in the front of my body. And so my back was overcompensating. All of these muscle groups were sort of in overdrive and it was incredibly painful and challenging. I also did have pelvic floor weakness that I needed to work on. I finally, after I think about a year, got to a pelvic floor physical therapist and occupational therapist to sort of help me figure out what was going on and try to remedy it. And I feel really lucky for that. But one thing that I think prevented me maybe from getting help sooner and I think actually prevents a lot of women from getting help for these kinds of conditions sooner is the diet-industrial complex piece of this, right? I read about mom pooch and jelly belly and how can we sort get back to your waist size.

Aviva: Bounce back, right?

Allison: Bounce back. Exactly. And I didn't know that all of that was actually kind of talking about diastasis recti, which is a real condition. It can cause pain in people's bodies and in the way that we move and function. But I was very focused on getting back into my pants, bouncing back, having my body look the way it used to look. But that prevented me from finding this condition and treating it. And I hope others can sort of see the distinction here and sort of get to that assessment and do the work to understand what's going on in the body. I mean pelvic floor physical therapy, some kind of assessment like that, should be part of postpartum care. It isn’t routinely.

Aviva: Absolutely. I am so big on postpartum pelvic support and care and physical therapists. Pelvic floor physical therapists can really make a huge difference in physical comfort, symptom reduction and surgery avoidance, which is often what becomes recommended

Allison: And for years to come. I mean, we found there's research that shows often women will go into nursing homes for end of life care for disorders that are related to the pelvic floor.

Aviva: That's actually one of the single biggest reasons for admission of older women to a nursing home or a nursing care facility is pelvic floor dysfunction and the urine leakage that leads to odors. And family members can't manage it anymore. Or odor or sores or infections. So it's a topic that I am really committed to bringing more education to.

Allison: Don't you think that some of this which is harming women and families later in life, goes overlooked sort of postpartum. It's work could be done then to set people up better for later?

Aviva: Well, even prenatally. I mean, sometimes I cringe and I'll look at a picture of a pregnant done by a prenatal photographer and I'm just like, oh my gosh, the posture. Like that exaggerated arc of the back and I'm just like, oh, posture, bellies, diastasis, pelvic floor, educating even before we become pregnant about how to have healthy pelvic floors, how to breathe, how to release tension during pregnancy, postpartum. And again, we didn't really talk much about this directly, but there are so many taboos that still persist due to shame and embarrassment. Or things that we just accept as normal. Oh, everyone does it. Like 40% of women over 45 do it, so it must be normal. But then we have these downstream impacts that are very significant.

Allison: Yeah, it's really important to sort of demystify and destigmatize all of this. We should know what a pelvic floor is long before we are pregnant. I don't know that I totally did, but I do now and we should all, and I think we would all be better off and healthy and we should demand this support. We should demand this be part of routine prenatal care and routine postpartum care.

Aviva: Well, this is another issue that comes up, which is, for example, I had mild pelvic floor prolapse, uterine prolapse after my second was born. And I'm pretty sure it was because I was always carrying my toddler in a backpack and doing all the things while I was pregnant. But my home birth midwives back in the day had no idea what it was. They just didn't know. And it was very scary. I thought my uterus was going to fall out. It was terrifying. And the medical response was surgery.

I dug around, found some pelvic floor exercises I could do at home. Over time thankfully it resolved. But so often different care providers are just not knowledgeable enough about the different nuances of support and symptoms that can come up. So a lot of home birth midwives don't know about how to care for diastasis or aren't knowledgeable in diagnosing and helping a woman get care for more moderate postpartum depression or even mild postpartum depression or pelvic floor problems.

So even if people are asking, which they're often not because it's not part of their wheelhouse, they don't know what to do. And even OBs, I mean they'll refer to the urogynecologist. So there's a lot of decentralization even amongst the knowledge of care providers. And there are rare few of us that really have made it kind of our specialty that we really take all of this in. And a lot of midwives, a lot of home birth midwives, it's in many states, most states, it's actually out of their scope of practice to do anything but the prenatal care or the birth and the sort of immediate postpartum. And a lot of nurse midwives don't do that full scope care either. So I think bringing more of that full scope care into midwifery and reproductive health is going to shift a lot of this conversation around these more subtle things but that are actually really common.

Allison: Everyone should have this exam. And it's so interesting, I talked to physical therapists who were getting their training very recently and they only did one day on pelvic floor and their entire physical therapy training one day on pelvic floor. Yeah, that's not enough. I mean, everyone has a pelvic floor. It's not just people who are giving birth. So we should probably have more sort of knowledge and understanding. But also what if this kind of assessment could happen in whatever setting you give birth, pretty immediately after, to sort of understand what's going on. I did very little core work at all when I was pregnant with my first child because I thought you weren't supposed to. That was sort a misconception that I had. So I did nothing to sort of support my core during my pregnancy. I did tons of yoga, but I didn't do any sort stabilization work that could have helped me later. And then, yes, of course the first recommendation you get from someone who doesn't really necessarily know what they're looking at is surgery. Like you should just go get surgery. And sometimes I'm sure that's needed, but I bet in most cases it's not. It certainly wasn't needed in my case.

Aviva: Well, and that kind of gets back to having more frequent postpartum care in a way that's convenient because it's not that easy to just get somewhere with your baby and your other kids for a postpartum visit, for someone to look at your pelvic floor, see if there's a prolapse, or look at your abdomen to see if there's a diastasis. So that's a limitation too. And so we just often end up putting these things off. And with pelvic floor dysfunction, fortunately mine was really mild, but I've worked with so many women now where it has led to or contributed to postpartum depression, physical nagging, discomfort, and also affected their return to sex, which then sometimes had an impact on their self-concept and also their relationship, especially if they're not explaining why it's happening.

Allison: Right. That's all so interconnected.

Aviva: One of the things you've talked about, and of course this is one of the premises of how I think about birth and health, is that the birthing mother, the pregnant mother or person, the new mom, is the expert on their own health. One of the things that I find challenging is that we are not being acculturated in a sort of intergenerational female focal learning about birth as a normal life event from the time that we are born. I interviewed one of my best friend who happens to be my midwife mentor. I was at her grandbaby's birth as one of the midwives, and I later interviewed her daughter for my podcast. And she said she never really considered birthing any other way than at home. And the three midwives who were there were her mother, the midwife who trained her mother, and then me, who I was trained by those two midwives. The father of the baby being born was midwifed by those two midwives. This was really a community experience and event.

When I interviewed the daughter she's like, I just never even thought of, I mean, of course if I had a complication, I'd have my baby in a different setting. It was so intrinsic. And then on the other hand, as the experts on our own body, there's so much noise out there. I often feel like rather than learning birth, I talk about unlearning birth because we've internalized so much fear. We've also just been influenced so profoundly by the images we see, right? The woman who's screaming her head off and her face is bulging and she's screaming at her husband. Yup, that happens too. But the water breaks and it's an emergency to get to the hospital. And then the true dire emergencies, which unfortunately shows like ER, and even though I love Grey's Anatomy, have really shown some of the worst of the worst. So from your perspective as both a journalist, but also probably most importantly, as a woman who has birth three babies, how can women, birthing people, pregnant people, tune into their own expertise and own it and trust it when we haven't had that intergenerational learning? The visual experience of birth is natural and normal, and we've had all this other really negative acculturation.

Allison: That's a great question. I mean, I think I was absolutely shaped by that negative acculturation. I remember Knocked Up and even the What to Expect movie? I mean so many movies. It was like birth was like the door is flying open, a gurney flying down a hall, a woman screaming. It's actually about this guy in the story, it's not even really her story, but she seems crazy. And that was sort what birth was supposed to be like. And even now, I mean there lot more examples of birth on TV and in film. Maybe some of them are more near to what actually happens, but they still I think do cause a lot of fear. I was really afraid of pain. I mean, my mother did not have an epidural because she wanted to sort of feel it. That's how I went into my births too. I sort of like whatever was going to happen I wanted to feel it.

But I was really afraid of the pain. I was so afraid of the pain, and something I wanted to do in the book that I did, I actually have two chapters, one is called Fear of Death and the other is called Fear of Pain. I wanted to go right to those fears that we feel when we get pregnant and that my survey respondents talked about and those I interviewed, talked about. And in the fear of pain chapter I write about what is happening in the body when you're having a contraction. To me, reading that description, hearing about actually the uterus squeezing and that moving the baby down and visualizing what was going on in my body really took a lot of the fear away from me.

Aviva: Absolutely. That knowledge component, yes.

Allison: It's so important. And I think those are not conversations that are happening at most prenatal visits. Perhaps they are with midwives.

Aviva: Definitely.

Allison: Right. So that knowledge saying, what is happening in my body? Can I understand? Can I learn this about birth? Can I unlearn what I've seen? Screaming woman, crazy person, drugs, and everything is sort of coming at her. And can I learn about the actual process that's going on in my body that I'm part of, that is not happening to me. I mean, to some extent it will, right? The fetal ejection reflux is a real thing. Studies have shown us you can just leave somebody alone and let them push with their own urges and give them the conditions they need. The baby's going to come out.

Aviva: And it's a model that I think a lot of us as midwives use, even when it comes to when you see pushing in a movie or on a TV show and labor, it's very different than what happens.

Allison: When you count and push. Yes. That was another allow moment for me that I was so surprised by – this, ok, we're going to let you push now, right? You've reached a certain amount of dilation. You have our permission now to push and we will now coach you and count and listen. For some people that's important, they need some direction and they need some help. And maybe I did too at one moment or another, but I do remember with my second birth feeling like – I had had a precipitous labor and I had experienced the fetal ejection reflex, so I knew that this baby could just fly out of me. Cause that had happened to before. And so I was so surprised by this, okay, we're going to count for you now. All of these people are swarming at me and counting and oh, you did it wrong the first time I felt this tremendous urge to push. And then she just came out. And then the second time, I hadn't felt that yet. So I was waiting for that. But I think people should just know this is what's going to happen in your body. You can support this with making sounds and with a peanut ball, with massage, with all of these other factors are not sort of accoutrements. They're not things that you just should have cause it would be nice for self-care. They actually are necessary in helping you work with your body to push your baby out. And that stuff is somewhat simple, too.

Aviva: Well, and I think even if you do need guidance, I mean even for myself as a home birth midwife and as a physician working in hospital, I just don't love the term delivering baby. Attending birth is what I say because I feel like delivering is something that you do to someone and it's not what birth is meant to be. But even there, I've had moms occasionally who – usually a first time mom, she's getting the urge to push but can't quite figure out how to coordinate it – so a little breath, holding and counting every now and then for the occasional mom rather than breathing the baby down is important. Even then you don't need eight people screaming at you all at once. And that's often what it's like. It's like hold your breath 1, 2, 3, and you've got all these people just yelling, and we just calm it down and hear little library voices.

Allison: And why are there so many people and who are all in this room? Yes. Do I know any of your names? Everyone who's there, we should have a relationship and we should sort of understand what's going on and what this person giving birth needs. Does she need the coaching and the counting help? If so, yes. Awesome. Great. Let's get it for her. But if she would be better served by tuning in and closing her eyes and having the lights off and pushing with her own urges, let's support that.

Aviva: Alison, I have another big question for you. So often journalists who write successful books and receive enormous accolades and awards become perceived as the expert in a space. And yes, we've established that all birthing people are experts, but often what happens is the people who are on the ground, the midwives especially who have historically been marginalized in this country, remain so. I'm curious, how do you hope that your book will shine the light on those birth workers who are the experts at maintaining physiologic birth in every country where midwives are working, who are continuing to sometimes hold it down in illegal states in inhospitable environments? Have you thought about what this journey is for you? Is it birth activism?

Allison: That's such an interesting question. I think for me, the book is about giving voice to the real experience of childbirth in this country, in all of its brokenness, in all of its beauty, its potential. And part of that I think is absolutely celebrating the ways in which this works. It's celebrating the midwifery model of care that we know centers the person doing it and doesn't introduce interventions unless they're absolutely necessary. And it's telling the story of my survey respondents and of the women and people that I interviewed and whose stories I'm charged with telling so that we have not just my own personal story, but we have this data set and we have the stories of the people who have given birth in all kinds of ways all over the country in every setting imaginable. I wanted all that in one place.

I mean, I wrote the book I wanted when I became pregnant. I wrote a book that gives readers the opportunity to see birth in all that it could be, celebrates what's working, criticizes and critiques what's not working, and weaves science with narrative to give voice to my desire to see this be improved, to overhaul the system as it exists now, and to do right by people who are our future, who bring life into the world and who deserve a sacred experience in doing it. And I think we can all agree that every family needs this and this does have a real trickle-down effect. It shapes families for generations and we need to treat it in that way.

Aviva: You talk about your own birth experience being profoundly empowering for you, particularly your home birth experience. How do you feel that owning your expertise and having that transformative, powerful experience continues to influence you as a mother and as a woman?

Allison: I want everyone to have the feeling of an empowered birth because it really truly was just the best experience of my life. I have the capacity for better decision making for myself and my family. I know what I want and need. I can sort of center that better. I can advocate for myself better, better. And frankly, I mean, anytime I see a pregnant person, I can pass a little bit of that along and I can sit next to somebody at the nail place, see that she's pregnant, start talking to her and say, you know what? You can do this. You can do it. You can absolutely do it. I know you can. And I think sometimes people need to hear that. And it's not prescriptive and I don't have a path for you on which you should walk to do it. I want to be a voice in the world for supporting people in this experience and validating people for whom they experience was not what they hoped it would be.

Aviva: That's so beautiful. I love that. We need your voice. We need those voices. We need to hear all these stories. So I'm so happy that you're adding to the gathering of those. One of the questions I love to ask every guest at the end of my podcast is, if you could tell your younger self anything, how old would she be and what would you say? But I'd love to reframe that question for you. What are the top three things that you wish your younger self or someone who is pregnant for the first time and preparing for birth knew about birthing, particularly in this country?

Allison: Everyone giving birth today can do it, first of all. You don't need someone else to do it for you, right? That's a criticism, I would say, of birth in this country, that babies are being birthed for people. And honestly, I should've had three home births. I was afraid. That's why I didn't have three home births, because I was afraid. And I think I would tell my younger self, you can do it. You can do it at home. It's going to be beautiful and fine. Everyone should decide the setting, the people, the experience. It's all every individual's decision and right. But for me, I would say, yeah, I wish I had done home birth because I love the midwifery care. I really loved the aftercare and the support and it happen at home. I didn't have to go into an office to be weighed and to be looked at. And all of that felt so affirming and so beautiful, and I just felt more comfortable personally in my own space if I could eventually get out of my own way and grant myself that.

Aviva: Allison, thank you so much for joining me on the show. I'm really excited for this book. I get to say now that I got a little sneak preview of it in the galley early on, it was really fun to read. It's a delight to have you on the show. I'm feeling strongly that this book is going to have a big impact for its readers. The stories are important, the guidance is important. Honoring women as their own expert is so important. So thank you for taking the time essentially to have another baby, a book baby, and bring it out to the world for all of us, and we'll put everything in the show notes for folks to find you.

Allison: Thank you so much for having me. I love this conversation with you and I love all of the work that you're doing, and your expertise has been so important to me over time. So thank you for this and for having me.