Postpartum Exercise: Creating Your 3rd Body

Recently, while talk­ing with some moms in our post­par­tum exer­cise class, DTP’s Mom-Baby Fit­ness™ pro­gram, I real­ized it has been a while since I have addressed the notion of what we call “the 3rd body.” This stems from the idea that before you are preg­nant, you live in your 1st body; then, while preg­nant, you live in your 2nd body. After giv­ing birth, many women feel their options are to try to get their first body back or live in what they are left with after birth. We sug­gest another way:  cre­ate your 3rd body.

We dis­cov­ered this 3rd body in work­ing with women to gain the fit­ness nec­es­sary to have a healthy recov­ery and enjoy moth­er­hood. What we found was that women were often becom­ing more fit than they had been before preg­nancy, with less body fat and more mus­cle, yet their clothes did not fit the same.  Some­times the flar­ing of the ribs and/or hip bones made for a larger waist – despite less fat!

Many clients also feel a new, deeper sense of their core devel­oped. In fact, over time they real­ized they actu­ally liked this body bet­ter in some ways! After all, they came into the world with the pre-pregnancy body, but this body they actu­ally cre­ated out of the pro­found expe­ri­ence of the phys­i­cal self that preg­nancy and birth pro­vide. It extended the empow­er­ment of birth into motherhood.

Extend­ing this metaphor even fur­ther, of course, leads to the 4th and 5th bod­ies, if you have another child. Even­tu­ally, there are more bod­ies as women go through per­i­menopause, menopause, post menopause, and what I like to call the phe­nom­e­nal wis­dom stage. Each body rep­re­sents a new oppor­tu­nity to become some­one strong and profound.

I fig­ure I am to body #8 now, and in each stage I have found some­thing incred­i­ble that I could not have at other stages. Long ago I gave up look­ing for my past bod­ies. Each one has been bril­liant in some way, but in the end it had to be left behind if I was to enjoy life’s path to the fullest.

Liv­ing in the moment does require know­ing where you are in time, space and energy. So, dis­card your past bod­ies with delight and move on. Use your energy to cre­ate your­self in the present.

It’s a process and you won’t fully live in your next body until you own the toll of the last one. A post­par­tum mom may expe­ri­ence hair loss, big­ger feet, a mal-aligned spine, con­stant thirst if she is breast­feed­ing, exhaus­tion and a jelly belly. But, all these things will pass with time, if you eat right and exer­cise reg­u­larly. Oh, and you can bring the baby, who will have a blast meet­ing other babies!!

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High Birth Weight: The New Adverse Outcome

While pub­lic aware­ness of low birth weight and pre­ma­ture infants is becom­ing — at long last — inter­est­ing to the main­stream cul­ture and media, another phe­nom­e­non is begin­ning to shake the pro­fes­sional birthing world:  high birth weight. Because it is occur­ring in a more afflu­ent ele­ment of soci­ety, it is alarm­ing. This tells us that you can­not buy your way out of preg­nancy risks that are cre­ated by a seden­tary, toxic food life-style.

Here is the dilemma:

Nor­mal weight and some over­weight women who eat too much in preg­nancy tend to have babies who are, basi­cally, already obese at birth. There­fore, these infants already have meta­bolic and car­dio­vas­cu­lar dys­func­tion. Babies born over 8 lbs. 14 oz. are at increased risk for Type 2 Dia­betes and heart disease.

Inter­est­ingly, the Insti­tute of Med­i­cine  recently issued new guide­lines on preg­nancy weight gain. After nearly 20 years of adher­ing to the “nor­mal” weight gain being 25 to 35 pounds, the Insti­tute rec­og­nized that pre­na­tal BMI plays a role in how much weight gain is nec­es­sary for a healthy pregnancy.

The evi­dence that under­lies this change demon­strates that gains greater than 22 pounds — for all clas­si­fi­ca­tions of pre­na­tal BMI — is the demarka­tion point for increased health prob­lems.  More infor­ma­tion on this is avail­able at:  New IOM Guide­lines.

We have known for a while now that obe­sity in preg­nancy puts mother and infant at risk for a num­ber of prob­lems from car­dio­vas­cu­lar, meta­bolic and immune dis­or­ders to pre­ma­tu­rity, low birth weight, increased need for cesarean birth and slow recov­ery. Add another one:  Obese new­borns with increased risk for heart and metab­o­lism problems.

Ref­er­ence on weight gain and high birth weight:

Lud­wig DS, Cur­rie J. The asso­ci­a­tion between preg­nancy weight gain and birth­weight: a within-family com­par­i­son. Lancet. 2010 Sep 18;376(9745):984–90. Epub 2010 Aug 4.

A good ref­er­ence for issues sur­round­ing obese pregnancy:

Leddy MA et al. The Impact of Mater­nal Obe­sity on Mater­nal and Fetal Health. Rev Obstet Gynecol 2008;1(4):170–178.

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Fetal Programming

What is fetal pro­gram­ming? Every per­son liv­ing on earth was first exposed to a uter­ine envi­ron­ment that helped deter­mine their life­time health and devel­op­ment. The term for this phe­nom­e­non is fetal pro­gram­ming. It is a hot topic and deserves attention.

Accept­ing the impor­tance of fetal pro­gram­ming places respon­si­bil­ity on the mother-to-be to do all she can to insure her body pro­vides nutri­ents and oxy­gen to her grow­ing infant while avoid­ing pos­si­ble risks and tox­ins. At the same time, genetic and envi­ron­men­tal fac­tors con­tribute greatly to the poten­tial for some dis­or­ders and prob­lems that arise. Thus, we must be care­ful in assign­ing guide­lines for accept­able behav­ior or blame for poor out­comes to preg­nant women.

On the one hand, we can all see the neg­a­tive con­se­quences of some­thing like fetal alco­hol syndrome…clearly the result of mater­nal behav­ior. Is a preg­nant woman whose baby has been dam­aged in this way guilty of abuse?

But, what if a mother is obese, eats poorly and ends up with an infant with a dis­turbed metab­o­lism. Is this abuse? What if the mother has an infec­tion that results in cere­bral palsy? Or what if she lives near a high­way and invol­un­tar­ily inhales fumes that neg­a­tively affect the placenta?

How do you get a healthy baby? Of course, there are no guar­an­tees. There remain many unknown fac­tors that can affect the course and out­come of a preg­nancy. Some fac­tors we are aware of, such as avoid­ing cer­tain fumes or chem­i­cals.  There are some behav­iors we know can max­i­mize the poten­tial for a good out­come, such as eat­ing ade­quate pro­tein, aer­o­bic con­di­tion­ing and strength train­ing. [Note for new readers…lots of these fac­tors have been cov­ered in our pre­vi­ous posts.]

But, what about all the things we don’t know about?

If these goats eat the wrong grass, will they go into labor?

Here is a cau­tion­ary tale:  There is a species of goat that, if they eat a cer­tain type of skunk grass on day 14 (and only day 14) of preg­nancy, will not go into labor. Why? Plant tox­ins in this grass inter­fere with the devel­op­ment of a small por­tion of fetal brain, the par­aven­tric­u­lar nucleus. This nucleus is involved in the sig­nal­ing cycle of labor. With­out it, the mother will not go into labor!

What are the take-home mes­sages here?

  • Prob­a­bly no one is ever a per­fect fetus…too many pos­si­ble threats.
  • There are some threats we can avoid…being lazy, over-eating, smoking.
  • There are some threats we can­not avoid, so we do the best we can.

Do the best you can by your baby…aerobic fit­ness, good nour­ish­ment, sleep, good hygiene and de-stressing your life.

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More on Preventing Childhood Obesity!

Rachael Blum of Santa Mon­ica, CA, has alerted us to an excel­lent arti­cle in the New Eng­land Jour­nal of Med­i­cine con­cern­ing the evi­dence for the role of exer­cise in preg­nancy in help­ing pre­vent child­hood obe­sity:  http://healthcarereform.nejm.org/?p=3321&query=home. Rachael, our newest DTP fam­ily mem­ber, has also alerted us to an LA Times arti­cle on this sub­ject:  LA Times arti­cle.

With the recent empha­sis on the impor­tance of move­ment in the fight against child­hood obe­sity, there is recog­ni­tion that ben­e­fi­cial fetal pro­gram­ming through mater­nal exer­cise can make a big con­tri­bu­tion to this effort. A com­bi­na­tion of proper mater­nal nutri­tion and mater­nal fit­ness may well prove to be most effi­cient and poten­tially effec­tive way to help chil­dren develop an appetite for motion!

One fac­tor in this is the find­ing that reg­u­lar, moderate-intensity exer­cise helps pre­vent obe­sity in the new­born: http://www.nlm.nih.gov/medlineplus/news/fullstory_97212.htmlt. This, may in turn, help pre­vent child­hood obesity.

Recess for everyone!!!

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Value of Postpartum Fitness

Here are two impor­tant facts regard­ing phys­i­cal activ­ity fol­low­ing birth:

1. Women who return to vig­or­ous (vig­or­ous, as in jog­ging or aer­o­bic dance) prior to six weeks postpartum…

  • have less weight to lose
  • expe­ri­ence a more joy­ful state of mind
  • do bet­ter on the Led­er­man Mater­nal Adap­ta­tion scales (how well they adapt to motherhood)

…than women who are seden­tary dur­ing this period (Sampselle, 1999…this is not new information)

2. Post­par­tum obe­sity is a dan­ger­ous short and long term health risk (Leddy, 2008).

Who should exer­cise and when, fol­low­ing birth?

Day 1: If you have a vagi­nal birth, begin your “body scan” the first chance you get. Within the first day, the first chance you get to focus on your­self, take a men­tal trip through your body. See if you can squeeze the kegel mus­cles. Try exhal­ing and suck­ing in your deep abdom­i­nal mus­cles. Note if your shoul­ders need to relax. Take some deep breathes and begin to help your body recover.

If you had a cesarean: Wait a few days to 2 weeks at most to work on this.

After that: As soon as you can, get up and walk around. Start walk­ing in 5 or 10 minute strolls sev­eral times a day (ask some­one to hold or watch baby so you can allow your body to recover a non-pregnant upright). If you had a cesarean, hold a pil­low to your abdomen until you have con­trol of your abdom­i­nal mus­cles and stand tall.

How can you get more infor­ma­tion on this?

Go to our website:

http://dancingthrupregnancy.com/take-a-class/postpartum-exercise/

Find a class. If you had a typ­i­cal birth and your baby has been slowly and safely exposed to new peo­ple, by four to six weeks you and baby should be ready for a struc­tured activ­ity ses­sion that includes baby. It will also pro­vide focus and adult inter­ac­tion dur­ing the week.

You have to teach your abdomen to be flat.
How do you know if you did too much?

Your lochia, or the bleeding/discharge from the pla­cen­tal site, will increase if you have been too vig­or­ous. If you are healthy and have no ane­mia issues, your lochia will likely cease by three to four weeks, six at most.

What are safety issues?

Don’t exer­cise if you have a fever, a warm red spot on your leg that may be painful (or not), or sore nip­ples that need atten­tion. Call your care provider. If you or your baby are sick, it is best not to go into a group set­ting. If your baby is not well or just doesn’t seem right, call your pediatrician.

The most impor­tant rea­son to join a mom-baby fit­ness pro­gram may be that it will help keep you sane.

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Weight Gain in Pregnancy — New IOM Guidelines

In May 2009, the Insti­tute of Med­i­cine (IOM) issued new guide­lines on weight gain in preg­nancy. You can find this report at the URL listed below. As you may be aware, they are rec­om­mend­ing lower weight gains than previously.

Here is the link to the Guidelines:

IOM Preg­nancy Weight Gain Guidelines

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Pregnancy Pathway, Pregnancy — Nutrition

Fresh fruit = vitamins & minerals!!

Fresh fruit = vit­a­mins & minerals!!

Ques­tion:

How many extra calo­ries do you need in each trimester to off­set the meta­bolic cost of pregnancy?

Answer:

First trimester — 0; Sec­ond trimester — 300; Third trimester — 500 (source: Insti­tute of Medicine).

Keep in mind that you may also need calo­ries for any fit­ness pro­gram you are doing. If you are con­tin­u­ing a pro­gram, the only change is due to the pregnancy.

If you begin or increase your activ­ity, you need to take that into account. One yoga class = 100 — 150 calo­ries. One aer­o­bics class = 200–400 calo­ries. Walk one mile = 100 calories.

1 slice whole grain bread = 50-100 calories

1 slice whole grain bread = 50–100 calories

Be sure you read food labels so that you can bal­ance your food intake and your calo­rie out­put. A small woman (under 5’3″ & 130 lbs.) prob­a­bly needs about 1200 calo­ries per day as a base. A medium sized woman needs about 1400, and a large woman (over 5’9″ & 160 lbs.) prob­a­bly needs 1600 to 1800 calo­ries. Add your activ­ity and preg­nancy needs to your base amount.

Ques­tion:

What foods are nec­es­sary for a healthy pregnancy?

Answer, part A:

PROTEIN. Lean pro­teins like turkey and those with omega 3 fats like ocean fish and eggs.…yes! EGGS!

Turkey is a good protein

Turkey is a good protein

Ocean fish 1 or 2 times/wk = good protein & omega 3 fat

Ocean fish 1 or 2 times/wk = good pro­tein & omega 3 fat

Eggs are a perfect pregnancy food!

Eggs are a per­fect preg­nancy food!

70–90 grams of pro­tein are nec­es­sary each day, along with  ade­quate water.  These are needed to make an extra 40% blood vol­ume required to sup­port the placenta.

Answer, part B:

WATER. Two (2) quarts of water…more if you are very active…are needed to make extra blood and to pre­vent dehydration.

Ques­tion: What else?

Fresh vegetables also provide fiber

Fresh veg­eta­bles also pro­vide fiber

Answer: CARBS. Fresh, col­or­ful fruits & veg­gies pro­vide nec­es­sary vit­a­mins and min­er­als, as well as fiber. Eat 5 serv­ings a day from all the col­ors:  yel­low, orange, red, pur­ple and green, and you will get live vit­a­mins all day long that help your baby develop prop­erly! Fruits, veg­eta­bles and whole grains are low glycemic index car­bo­hy­drates — the good ones!

Dairy provides calcium

Dairy pro­vides calcium

Ques­tion:

Do I need dairy prod­ucts and red meat? Can I get the needed min­er­als in other ways?

Answer:

Cal­cium is needed in ade­quate amounts for bones and teeth. It is most eas­ily obtained by drink­ing milk or eat­ing cheese, yogurt or cot­tage cheese. Soy, dark green leafy veg­eta­bles and cal­cium for­ti­fied juice are alternatives.

Iron is nec­es­sary for red blood cells to take up oxy­gen. It is found in high amounts in beef,  and lesser amounts in raisins, spinach, and prune juice. Pre­na­tal vit­a­mins are your insur­ance against defi­cien­cies of these essen­tial minerals.

Ques­tion:

Any­thing else that’s essential?

Answer:

Yes! Healthy FAT!!

Avocado is an excellent source of omega 6 fat

Avo­cado is an excel­lent source of omega 6 fat

In addi­tion to omega 3 fats found in fish, wal­nuts and flax seeds, you need also need omega 6 fats, which are found in avo­ca­dos, olive oil and other veg­etable oils. Healthy fats help bal­ance car­dio­vas­cu­lar con­stric­tion and dila­tion, reduc­ing the risk for hypertension.

Last Ques­tion:

What is a healthy weight gain?

Answer:

In 2009, the National Acad­emy of Sci­ences revised its rec­om­men­da­tions. It now bases desir­able weight gain on pre-pregnancy BMI (Body Mass Index…google this!).

BMI less than 18.5 (low) — 28 to 40 lbs.; BMI between 18.5–24.9 (nor­mal) — 25 to 35 lbs.; BMI 25.0 to 29.9 (high) — 15 to 25 lbs.; obese women (BMI over 30.0) — 11 to 20 lbs.

Com­ing Next: Avoid­ing Risks.

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Pregnancy Pathway — Exercise cont’d

MORE?!! You didn’t think that was it? Only a few com­ments on evi­dence as to WHY mov­ing around, burn­ing calo­ries, being strong and learn­ing to relax while preg­nant is ben­e­fi­cial? No, of course not. You know there is more to it, like WHAT move­ment is safe and effec­tive dur­ing pregnancy?

So, what is safe? Well, first, unless you have a very few con­di­tions that your health care provider con­sid­ers unsafe, every woman — fit, cur­rently seden­tary, young or a lit­tle older — can exer­cise safely in preg­nancy. How much of what kind depends on your fit­ness level and exer­cise his­tory. Get med­ical screen­ing first.

If you are fit, you can do vigorous exercise

If you are fit, you can do vig­or­ous exercise

If you are fit, you just need to learn how to mod­ify some move­ments to accom­mo­date your bio­me­chan­ics. As your body changes, stress on the joints and tis­sues means a lit­tle less jump­ing or bal­lis­tic motion will be more com­fort­able and safer. If you are fit, you can con­tinue with vig­or­ous exer­cise and it will be of ben­e­fit to you and your baby.

If you are not so fit or are seden­tary, find a cer­ti­fied pre/postnatal instruc­tor and join a group where you will have fun, get some guid­ance and be mon­i­tored for safety. How do you find such a per­son? Try our Find A Class or Trainer page.

What is effec­tive? Don’t spend your time on things that may be nice to do but don’t help you focus and pre­pare for birth, relieve dis­com­forts or have the sta­mina for birth and par­ent­ing. There is sub­stan­tial sci­en­tific evi­dence and infor­ma­tion from large sur­veys that these things are helpful.

Car­dio­vas­cu­lar or aer­o­bic activ­ity is the most impor­tant activ­ity you can do. Already fit? Keep work­ing out; join a class if you want sup­port or new friends. If you are seden­tary or some­what active, you can improve your fit­ness by doing at least 20 — 30 min­utes of aer­o­bic activ­ity 3 times a week. Work at a mod­er­ate pace — some­what hard to hard — so that you can talk, but not sing an aria! If you are more than 26 weeks and have not been doing car­dio, you can walk at a com­fort­able pace. Aer­o­bics is key because it gives you endurance to tol­er­ate labor and pro­motes recov­ery.

Strength and flex­i­bil­ity exer­cises that do not hurt and are done cor­rectly are also safe. There are some spe­cial preg­nancy exer­cises that actu­ally help you pre­pare for birth. Essen­tial exer­cises that aid your com­fort, align­ment and birth prepa­ra­tion include:

Kegels (squeez­ing and relax­ing pelvic floor mus­cles) — squeez­ing strength­ens them and thus sup­ports the con­tents of the abdomen, and learn­ing to release these mus­cles is nec­es­sary for push­ing and birth.

Abdom­i­nal hiss/compress and C-Curve® - con­tract­ing the trans­verse abdom­i­nal mus­cles reduces low back dis­com­fort and strength­ens the mus­cle used to push and later to recover abdom­i­nal integrity after birth.

Squatting

Squat­ting

Squat­ting — get­ting into this posi­tion strength­ens the entire leg in a deeply flexed posi­tion; start seated and use arms for sup­port, sta­bil­ity and safety. Leg strength improves mobil­ity and com­fort in preg­nancy and post­par­tum; plus, deep flex­ion is a com­po­nent of push­ing in almost all positions.

Strength­en­ing for bio­me­chan­i­cal safety — strength­en­ing some parts of the body helps pre­vent injury to bone sur­faces, nerves and blood ves­sels within joints re-aligned in preg­nancy. This can be done using resis­tance rep­e­ti­tions (weights, bands, cal­is­then­tics or pilates) or iso­met­rics (yoga or bal­let). A respon­si­ble class will focus on upper back (row­ing), push-ups, abdom­i­nals, gluteals, ham­strings, and mus­cles of the lower leg.

Stretch­ing of areas that tend to get tight — reliev­ing some dis­com­forts through flex­i­bil­ity helps you main­tain a full range of motion. Sta­tic stretches, used in com­bi­na­tion with strength exer­cises or fol­low­ing aer­o­bics, is most effec­tive. Stretch­ing prior to exer­cise tends to pro­duce more injuries than not stretch­ing. Areas need­ing stretch­ing include the chest, low back, ham­strings and hip flex­ors (psoas).

Mind/Body skills are very impor­tant. There are two activ­i­ties that exer­cis­ers con­stantly tell us are a big help in preg­nancy, birth and parenting.

• Cen­ter­ing employs a bal­anced or neu­tral pos­ture, deep breath­ing and mind­ful­ness to help you work in a relaxed way. Ath­letes and dancers call this “the zone.” Start­ing your work­out in asso­ci­a­tion with your body estab­lishes econ­omy of motion, some­thing very use­ful in birth and par­ent­ing, and reduces risk of injury.

• Relax­ation is another key activ­ity; it relieves stress, pro­motes labor in the early stages and helps you enter the zone!

Remem­ber: Birth is a Motor Skill™

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Pregnancy Pathway — Exercise

How lucky is this? Just a few days ago, yet another study was released and has been cir­cu­lat­ing on Med­scape and other med­ical sites that indi­cates exer­cise is ben­e­fi­cial in preg­nancy, whether the mother is a pre­vi­ous exer­ciser or not. Just in time for this entry!

Behavior Affects Pregnancy Outcome

Behav­ior Affects Preg­nancy Outcome

Phys­i­cal exer­tion (we call it “exer­cise” nowa­days) is a nor­mal state for healthy humans. Only in the last cen­tury has the desire to rest or the need to store extra calo­ries as fat become more pos­si­ble to achieve than our need to move about to survive.

Preg­nancy is a state in which both of these fac­tors (rest­ing and stor­ing calo­ries) are enhanced through organic changes in body chem­istry, adap­ta­tions that favor fetal sur­vival. The cur­rent seden­tary lifestyle exag­ger­ates these meta­bolic changes and results in syn­dromes that increase the risk for a num­ber of meta­bolic, car­dio­vas­cu­lar and immuno­log­i­cal dis­or­ders of pregnancy.

When con­fronted by the idea that it is coun­ter­in­tu­itive to think exer­cise in preg­nancy might be safe (let alone ben­e­fi­cial) I am dumb­founded. To me, it is coun­ter­in­tu­itive to think that a seden­tary lifestyle in preg­nancy might be safe!

Burning Calories in Pregnancy Improves Outcomes!

Burn­ing Calo­ries in Preg­nancy Improves Outcomes!

What is the evi­dence that exer­cise in preg­nancy is ben­e­fi­cial? Keep in mind that some stud­ies have been exe­cuted more expertly than oth­ers. But, what is com­pelling is that numer­ous well-respected researchers have sought to test the hypoth­e­sis that exer­cise is not safe, but come away with results that indi­cate the opposite!

Here are some of the major findings:

• The pla­centa is larger and has more trans­port sur­face in exer­cis­ers than seden­tary women

• The fetuses of (aer­o­bic) exer­cis­ing moth­ers make ben­e­fi­cial car­dio­vas­cu­lar adaptations

• Women who do aer­o­bic exer­cise are less likely to develop severe preeclamp­sia or ges­ta­tional dia­betes, and the long term health prob­lems that accom­pany these disorders

• Women who are aer­o­bi­cally fit recover from birth 10 times faster than seden­tary women (as mea­sured by time needed to metab­o­lize free rad­i­cals pro­duced in labor)

• Women who exer­cise in preg­nancy are more likely to be phys­i­cally fit in midlife

• Babies of aer­o­bi­cally fit women are at reduced risk for pre­ma­tu­rity and low birth weight
DTP_mover2
So, we have arrived at the take-home mes­sage: MOVE!! Preg­nancy works best when you move and burn calo­ries in a mod­er­ate to vig­or­ous fash­ion. But, alter­nate this activ­ity with rest and good nutri­tion, and be sure to stay well hydrated.
If you want more specifics and resources on this topic, try these:
“Women and Exer­cise” in Varney’s Mid­wifery.
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Rant: Health Care Reform/Pregnancy

Since Health Care Reform is a hot topic, let’s look at it from the per­spec­tive of preg­nancy and birth.

What revi­sions would most ben­e­fit preg­nant women, their off­spring, fam­i­lies and communities?

1. Reward healthy behav­iors. A sys­tem that pro­vides reduced pre­mi­ums for health care for women who exer­cise, eat well, do not smoke and are in a nor­mal weight range is evidence-based.

Yes! We could pro­vide finan­cial incen­tives for being healthy dur­ing preg­nancy. Why? Healthy moms have healthy babies; healthy babies cost the payer less money.

2. Review best prac­tices. Is a 40 or 50% cesarean rate the best prac­tice?  Accom­pa­ny­ing the rise in cesarean births is grow­ing infor­ma­tion that babies born by cesarean are at increased risk for a num­ber of immune dis­or­ders. But the busi­ness model of med­i­cine rewards cesarean because it both pays the provider more and is defen­sive med­ical practice.

Fetal mon­i­tor­ing to deter­mine if a cesarean may be nec­es­sary, is wrong 3/4 of the time. In an effort to change this, guide­lines are chang­ing for the use of mon­i­tors dur­ing labor. What is the evi­dence that this change of prac­tice is ben­e­fi­cial? Will it lead to more or less mon­i­tor­ing, which may itself be an inter­ven­tion that can dis­rupt nor­mal labor?

3. Change the busi­ness model for health care. When we make finan­cial incen­tives for care providers, base them on best prac­tice, not on enrich­ing the mid­dle man. Cur­rently the pay­ers (insur­ance com­pa­nies) are mid­dle men, mak­ing money (i.e., con­duct­ing busi­ness) by charg­ing fees. They ration pay­ments for ser­vices in order to pay their own salaries and over­head. They do not actu­ally do any­thing pro­duc­tive. This is why sin­gle payer, gov­ern­ment, and health care coop options have been pro­posed. They elim­i­nate most of the cum­ber­some mid­dle layer.

Why does insur­ance pay for cesare­ans? Well, they will do it once. After all, the care providers have to prac­tice defen­sive med­i­cine. But, once you have a cesarean, you become a risk for the insur­ance com­pany (they know what the research says about cesare­ans and off­spring health prob­lems) and may be denied insur­ance. They can no longer afford you.

Because care providers are paid fee for ser­vice and must prac­tice defen­sive med­i­cine, preg­nancy and birth have become increas­ingly bur­dened with inter­ven­ing pro­ce­dures that do not nec­es­sar­ily pro­mote a healthy preg­nancy or birth process. How is this play­ing out? Increas­ingly, we see women giv­ing birth in what they per­ceive as a more sup­port­ive and health-inducing set­ting:  their own homes. Think of it this way:  many women now believe that it is safer to stay home than go to a hos­pi­tal to give birth.

Unless health care becomes about best prac­tices and healthy out­comes — not price, size, and get­ting paid for pass­ing money back and forth — the U.S. will con­tinue to have some of the worst maternal/infant out­comes in the devel­oped world.

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