At eighteen, I left for college with an embarrassing stain on my reputation: I had never been kissed. I found this so mortifying that when—at band camp (yes, I am a proud former member of the Band of the Fighting Irish)—a freshman initiation forced us to share our first kiss story, I simply made one up. I claimed that a guy I’d flirted with as a counselor at Catholic Youth Camp had kissed me. In reality, I’d only gone as far as sitting in his lap, and even that was painfully awkward.

I think I pulled it off. Everyone believed my story and no one accused me of being a kiss virgin, at least not to my face. Thank God—because the idea of admitting the truth to my brand-new friends (people I was desperately trying to impress) had been keeping me up at night. Strangely, a few years later I was a senior, and during the same freshman initiation, a girl admitted exactly what I was afraid of, and—crickets—nothing happened.

But being a lot less confident and comfortable in my own skin than that girl, I wanted to remedy the problem of never having been kissed as quickly as possible once I got to college. I was in luck! During our first semester, a guy took interest in me and asked me on a date. He was a junior who had a car so we went to a movie off campus. Then, on the long walk back to our dorms from the campus parking lot, we were walking around a lake and he kind of pushed me up against a tree and started kissing me. We made out for a while (maybe 5 minutes?)

It was…not a great kiss. Mostly because I wasn’t that into him and had no clue what I was doing. I assumed I could learn how to kiss in the typical “fake it till you make it” sort of way. Maybe I had practiced on my arm in imitation of my favorite movie at the time (My Girl)—I can’t remember. I expected it would feel good, because people in the movies looked like they were having fun. But, as I would later learn, that nice feeling is contingent on the comfort with and attraction to the person you’re doing it with. Somehow, this fact was glossed over in sex-ed class.

Despite this lackluster debut at kissing, there are a couple things I’m grateful for in retrospect. First, the guy was at the base of it a good person, and he didn’t push me any further than kissing. When it became clear a few days later that I wasn’t interested in continuing to date him, he might have been a little hurt, but he didn’t make a big deal about it or pursue things further.

It would have been hard anyway, because we lived in single-sex dorms and couldn’t visit each other after 10 p.m. on weekdays or 12 a.m. on weekends. Our dorms did have 24-hour lounges if you wanted to “study” with a boy—but they were monitored, ours by a nun rector who was a former elementary school principal and didn’t really see much difference between kindergarteners and college girls. She ruthlessly enforced the “two feet on the floor” rule at all times, which I hear puts a damper on a lot of make-out sessions.

The second thing I’m grateful for is that by diving in for my first kiss, I could check a box that made me feel normal and move on. For all the bad things people say about Catholic teachings on sexuality (you know—that it’s judgmental, shame-based, sex-negative), the fact that sex was considered sacred and off-limits until marriage turned out to be extremely protective for me. As I would learn later, other girls at other colleges were not so lucky.

Outside certain religious bubbles like mine, where “hooking up” just meant kissing, in other places it meant having sex with someone you didn’t know very well. Maybe someone you’d just met at a party. Maybe a guy you’d only interacted with a few times who was drunk, handsy and several times stronger than you. Or perhaps someone who was perfectly unthreatening—but who you weren’t attracted to at all. In this case, hooking up was mainly to prove you weren’t a frigid, prudish loser. Given these possibilities, it really doesn’t surprise me that only 10% of women in one large study reported having an orgasm during a first-time hookup.

In my experience talking to women about their sex lives, it’s hard to have an orgasm when feeling stressed or overwhelmed because the house is dirty or the kids have unmet needs—let alone when you’re with a strange partner you don’t even feel safe with. Sexual pleasure depends a lot on feeling attracted to and relaxed around the person you’re doing it with.

Yet, in that era, casual sexual relationships were becoming the expected starting point for romance rather than the exception. This was well-explained by ’s post about hookup culture, which as a Xennial, I agree was a really thing in the aughts. Emphasis in bold is mine:

Hookup culture was the normalization of casual sex as the default within certain secular, young populations (especially college students) and the rejection of the idea that sex should carry any particular emotional weight. If you wanted monogamy, hooking up for a while beforehand without any discussion of commitment became a normal, expected stage before you became a couple. You didn’t have to do this in the sense that nobody would imprison you for abstaining, but it made dating a lot harder outside of religious communities, especially for teenage girls and college-aged women who never knew anything else.

And honestly, these cultural beliefs die hard—I don’t believe hookup culture is a thing of the past. It’s not just about the Sex in the City era that I came of age in—a lot of popular books, TV shows and movies still contain some version of the “free-love,” “sex-positive” ideal that people should go ahead and have sex with people they don’t know very well because this is good practice for real romance later, and is also the best avenue toward finding an actual great relationship.1

Look—I’m not saying it never happens! Maybe some people really do meet the love of their life through a casual hookup. But I’m just pointing out that for a lot of people (especially women) the bond with a partner needs to happen first for the sex to be any good. But our culture often treats sex as though it can reliably be detached from attachment and attraction, and put before commitment and relationship formation. This is asking people to behave as though those things don’t matter even though for the majority of us, they really do.

Why Was Hookup Culture So Bad For People (Especially Women)?

I argue here that hookup culture rests on a completely unrealistic model of human sexuality. It normalizes a less common pattern (casual sex) that carries greater physical and psychological risks, and devalues a more common pattern (having a strong bond with your partner before becoming sexually involved) that is associated with greater happiness, health, and well-being for both men and women, and for the children they eventually create.

Before someone stops me: I acknowledge that there is variation in human sexuality, that men and women don't necessarily experience sexuality the same way, and that procreation is not the only goal of sex.

But pair-bonding is a real thing in our species. It is not just a repressive concept invented by the conservative patriarchy to force people into its preferred model of nuclear families. Anthropologists note that some form of socially recognized, long-term romantic and economic partnership—often called pair bonding—is a human universal found in every known society. And evolutionary biology makes a fairly strong case that romantic love and pair bonding are deeply intertwined with the human reproductive strategy, particularly given the extraordinary length and demands of human childhood. Alloparents matter for human survival, dads being among the most important. And if you don’t believe me, read Dad Brain by .

I suspect that hookup culture illustrates another case of evolutionary mismatch. Culture can change much faster than biology, and in a remarkably short period of time, contraception and effective treatments for sexually transmitted diseases have dramatically reduced some of the immediate consequences of sex outside of a committed relationship. But humans are still left with the evolutionary drive to secure a pair-bond, and the psychological consequences when those attachment needs are ignored or written off.

As an example of what this can look like, I would present this essay by , which I hope she doesn't mind me quoting. Phetasy is hardly a stereotypical opponent of sexual liberation. Yet looking back on years of casual sex, she describes a profound conflict between what she told herself she was supposed to feel and what she actually felt:

I know regretting most of my sexual encounters is not something a sex-positive feminist who used to write a column for Playboy is supposed to admit. And for years, I didn’t. Let me be clear, being a “slut” and sleeping with a lot of men is not the only behavior I regret. Even more damaging was what I told myself in order to justify the fact that I was disposable to these men: I told myself I didn’t care.

I didn’t care when a man ghosted me. I didn’t care when he left in the middle of the night or hinted that he wanted me to leave. The walks of shame. The blackouts. The anxiety.

The lie I told myself for decades was: I’m not in pain—I’m empowered.

Obviously, humans are flexible. We have always used different sexual strategies in different circumstances, and there is no single human sexual behavior that everyone is biologically compelled to follow. But like Phetasy clues us into here, flexibility doesn't make attachment irrelevant. We can tell ourselves that sex is “just sex” but it doesn’t follow that our capacity to feel unfulfilled, hurt or jealous due to difficulty securing or maintaining a pair-bond will just disappear.

Wanting to have a bond as a prerequisite to becoming intimate with someone is normal. It’s also healthy, and probably adaptive. I also think it’s normal to form a progressively stronger bond when you become sexually active with someone, even if you didn’t mean to. And when that bond is broken due to physical or emotional infidelity, it’s normal to experience that as psychologically devastating. For proof: see the thousands of breakup songs written in human history.

On Demisexuality: Why Is Wanting Emotional Intimacy Before Sex Considered Abnormal?

In one of my fav romantic comedy books (which will soon come out as a movie!) there is a scene where Olive and Adam, who have been slowly falling in love while “fake dating,” finally end up sharing a hotel room at a conference together. After kissing for a while, Adam clues into the fact that Olive is tense, and when she admits she has only had sex “a couple of times,” he tries to put the kibosh on the encounter. But she likes him and wants him to keep going, so she tries to explain herself (emphasis in bold mine):

It’s not that I want to not have sex. I just…don’t particularly want to have it. There is something weird about my brain, and my body, and—I don’t know what’s wrong with me, but I don’t seem to be able to experience attraction like other people. Like normal people. I tried to just…to just do it, to get it over with, and the guy I did it with was nice, but the truth is that I just don’t feel any…” She closed her eyes. This was difficult to admit. “I don’t feel any sexual attraction unless I actually get to trust and like a person, which for some reason never happens. Or, almost never. It hadn’t, not in a long time, but now—I really like you, and I really trust you, and for the first time in a million years I want to—

Olive’s devastating, embarrassing confession here shows that she believes her own experience is somehow abnormal or pathological. Yeah, Olive’s fictional. But this sentiment is something myself and many women I’ve known have experienced.

But why would a woman who doesn’t want sex with people she doesn’t know very well interpret that as evidence that something is wrong with her? Probably because she has internalized the hookup culture baseline. Like me and my first kiss, Olive reveals that she felt the societal pressure to “just get it over with” to be considered “normal” even outside feelings of love or attraction.

The sexual pattern she is describing—not really being attracted to people sexually without first establishing a sense of trust—is sometimes described as “demisexuality.” Recall that “demi” has Latin roots and means “half” or “partly.” When I first heard this word used to describe a sexual pattern, I was confused, so I googled it. Here’s what I learned:

Demisexuality is a sexual orientation where a person only experiences sexual attraction after forming a strong emotional bond with someone. It sits on the asexual spectrum, serving as a bridge between asexuality (feeling no sexual attraction) and allosexality (regularly feeling sexual attraction).

Wow. “It sits on the asexual spectrum.” So, a woman who is married to the same person for almost 20 years, has sex 2-3 times per week and orgasms in over 90% of sexual encounters might be considered “asexual” because she doesn’t regularly see attractive guys on the street or at the gym and want to jump them? Whereas a person who frequently hooks up with random people she meets at parties (but rarely has an orgasm) is someone practicing—what—normal human sexuality?

I’m sorry, but whatever we ultimately decide about the usefulness of the label “demisexual,” the underlying pattern it describes—sexual attraction that depends heavily on emotional intimacy and trust—is plainly not pathological, or unusual. In fact, it is probably highly adaptive, especially for women.

Field Notes From Twenty Years Working in Women’s Health

By now, you might be thinking, “What qualifies a random midwife to make an argument like this?” While I really don’t want to over-generalize, I’ve had a lot of conversations with women about sex, relationships, contraception, and sexually transmitted infections. In the aftermath of these things, I’ve noticed some recurring patterns that I will share here. Some of them are just my subjective observations, but others are patterns that have also been documented in the medical literature. I’m less confident and competent to speak for men, but some of the same patterns experienced by women with multiple sexual partners are also experienced by men.

Casual Sex Doesn’t Make People All That Happy

Some people who have lots of sexual partners may already have depression, substance-use problems, impulsivity, or trauma. It is my overwhelming experience that when I have a patient who has a lot of unsafe sexual behaviors (like hooking up frequently with new partners), she nearly always has other serious problems as well.

Having multiple sexual partners is strongly associated with substance use. And this relationship appears to go in both directions: people who have many sexual partners tend to have more substance-use issues, while people with substance-use problems tend to have more sexual partners.2 In some people, drugs, alcohol, and sex can all become ways of coping with distress, seeking validation, or meeting emotional needs.

The same problem applies when we look at the relationship between having multiple sexual partners and poor mental health: the causality may run in both directions. For example, this study of more than 4,000 sexually active American middle and high-school students found that depressive symptoms predicted subsequent sexual risk-taking. In girls, higher levels of depressive symptoms were associated with subsequently having three or more sexual partners. In other words, at least for some people, having a lot of sexual partners may not be the thing causing their distress—it may be a behavior that emerges from distress that was already there.

But this doesn’t mean that the relationship between sexual behavior and mental health is only correlational. There is some evidence that the relationship may run in the other direction as well. One study found that the earlier sex was initiated, and the greater the number of sexual partners, the more likely a person was to be depressed later in life.

The point isn’t that everyone who has casual sex will become depressed, or that depression and substance abuse can be explained by someone’s sex life. The point is that the evidence does not support the assumption that people can simply have large numbers of casual sexual encounters and expect no meaningful psychological consequences. The relationship is complicated. An association rather than slam-dunk causality—yes.

But hookup culture presents frequent casual sex as compatible with uncomplicated flourishing and satisfaction as if it had no impact on mental health. Young women having lots of casual sex (hookups, sex on the first date, etc.) are thought to be living their best lives. The evidence does not support this. My anecdotal experience doesn’t support it either.

Nearly always, when I am caring for a patient with a lot of unsafe sexual behaviors, a walk through her history will show other serious problems: history of childhood abuse, history of sexual abuse, substance use, addiction, overeating leading to severe obesity, and/or mental health problems.

I don’t share this as some kind of “gotcha.” Obviously, it makes me really sad and I wish there were more I could do to help these women. But this association between casual sex and poor mental health is a reality I wish more “free-love” and “sex-positive” folks would acknowledge.

Casual Sex Can Be Kind of Dangerous

One of my least favorite parts of the job is calling someone to tell them that their sexually transmitted disease (STD) test came back positive.

Most of the infections I diagnose—chlamydia, gonorrhea, trichomoniasis, syphilis—are treatable. But “treatable” does not always mean “no big deal” or “no major consequences.” Even the most common, benign infections like chlamydia can cause pelvic inflammatory disease, infertility due to tubal scarring, increase the chance of an ectopic pregnancy, and increase the risks to both mother and baby in pregnancy.3

And some sexually transmitted infections are not something you simply take an antibiotic for and forget about. Herpes can bring with it lifelong recurrences, require suppressive antiviral medication, and has implications for pregnancy.4 Human papilloma virus (HPV) can cause genital warts which pop up at the most inconvenient times (during a period of immune compromise—like in pregnancy or during other illness), and certain high-risk types of HPV also cause cervical cancer which is blessedly treatable, but can require years of follow up and painful procedures to deal with (colposcopy, LEEP, conization).

Obviously, there have been advances in recent years—and that’s great. HPV vaccines have been shown to dramatically reduce the chances of cervical cancer. There are also medications that can dramatically reduce the risk of acquiring HIV from partners. HIV is now a chronic disease that, with effective treatment, people can live with for decades. Considering that it used to be a death sentence, this is progress! But it is still a lifelong infection requiring ongoing care and medication. No one wants that!

Yes, condoms can also reduce the chances of an STD. Through a lot of my training as a healthcare provider, I have been exposed to the failures of abstinence-only education, with a lot of focus on being non-judgemental about patients’ sexual choices. Trust me—I understand that we can’t simply tell people not to have sex and expect that to work!

But I think that in our effort to make sex education nonjudgmental, we have omitted an important fact that medically true: the more sexual partners you have, particularly when those partners have a lot of sexual partners themselves, the more risk you have of being exposed to an STD that can have lifelong consequences.

We have gotten very comfortable telling people how to make a high-risk sexual behavior safer, but are far less comfortable being honest about this basic truth: the number one thing that would reduce the risk of a dangerous STD while still enjoying the pleasure, excitement and fun that is sex—is to have only one partner who has no additional partners.

Yet a healthcare provider saying “Well, actually, having sex with a lot of people is dangerous!” comes off as schoolmarmy. A lot of my training focused on sharing the preferred message: use condoms, get tested for STDs, take PrEP if appropriate. I live in the real world, so I will continue to recommend things that are scientifically proven to reduce STD transmission. But if I’m honest, I think the best way to reduce a risk is to stop doing the risky thing. In this case, that means not having casual sex with multiple partners, who are very likely to have had multiple partners themselves.

What About Men?

Most of this essay is about women. That’s intentional—I know far less about the sex lives of men and don’t want to speak out of turn. But if we are going to take evolutionary biology seriously, there is no reason to think that pair-bonding is something women evolved to want while men merely tolerate it in exchange for sex, domestic labor, or certainty that the children they are investing in are biologically their own. That feels a little too cynical or “red-pilled” to me.

Because it turns out men also form attachments and friendships. They also experience loneliness. They want to love and be loved. And despite the popular stereotype that men are fundamentally driven toward an endless variety of sexual partners, I see a lot of them spending a significant portion of their adult lives focused on finding—and then keeping—a relationship with one particular person. Men care about their families. They grieve the loss of people they love. And they seem to want not just sex but someone to make a life with.

Since I’m not a guy, I’ll let do the talking here. I highly recommend his essay about what it feels like to be a young, single guy who longs to find someone. It’s about sex—yes. But it’s not only about sex. For a sarcastic, contrarian, dad-joke Substack commentator, I was pretty impressed at how he brought this emotional reality to life. Not gonna say I cried but 🥺:

Have you ever been lonely?

Have you ever been a twenty-three-year-old man who recently graduated college and entered the workforce? Have you ever come home to your bare-walled studio apartment after work and not speak to another human being for the next fourteen hours when you go back to work? Not open your mouth for anything other than eating a frozen pizza you cooked in the oven? Not utter a single sound until you see your coworkers the next day, bright and early, and finally say the first words you’ve said out loud since you told them to have a good night — good morning? Have you ever done that day in, day out, for many weeks at a time?

Have you ever desperately craved human touch? Have you ever laid in bed at eleven o’clock at night, looking up at the ceiling, and be overwhelmed with the need to hold someone in your arms? To be held? Have you ever been lonely? Have you ever realized that the last hug you got from someone was three months ago, and that it made you feel so good in that moment that you were actually sad when the hug was over? Have you ever lingered in a hug because you knew that it was the only touch you’d receive for a while? Have you ever sobbed alone on a mattress on the floor of your bare-walled studio apartment?

Have you ever wanted companionship more than sex? Have you ever been so horny that your desires cross the threshold from wanting sex to wanting romance?

When it comes to guys, there is no denying that they are—on average—more into casual sex, and less likely to be hurt by it. But it does not follow that men, as a class, are secretly dissatisfied with the idea of having one consistent sexual and romantic partner, as is the frequent cultural argument depicted by t-shirts like this one I saw in Vegas last year:

Close, committed relationships (like marriage!) may close the door on some sexual possibilities, but my guess is that a guy who finds a lifelong partner with whom he genuinely bonds will end up with a more satisfying sex life than a man who spends decades cycling through casual relationships. Statistically, he will also live longer and report being happier.

And maybe that’s why I’ve always hated the term incel. There is, obviously, a whole culture built around that identity—one that is angry, bitter, and deeply hostile toward women. But the literal phrase involuntarily celibate strikes me as pretty reductive. It makes it sound as though the central tragedy of being lonely is simply that you aren't getting enough sex. I mean, sex is nice—yes! But why is someone a loser because they didn’t want to settle for a series of meaningless hookups to prove that they are capable of attracting another human being?

I wish we had a better way of talking about people (men or women) who aren’t sexually active because they prefer to wait for sex that is attached to trust, affection, commitment—in short, an actual bond. The aspirationally celibate, perhaps. Aspircels. I like it.

Call me a naive, Pollyannaish, idealistic loser, but I don’t think it’s so impossible to wait for something real. And I don’t think it’s abnormal to want that before getting sexually involved. It doesn’t make you dorky, prudish or undesirable. It just makes you a pretty normal human.

What If You’re Not Super Religious?

This post really isn’t about “sex before marriage.” It’s about sex in the absence of a strong bond—the kind of bond that would actually matter to both people if it ended. Marriage can certainly represent that kind of commitment. I am very pro-marriage and I really like mine. Would recommend marrying your best friend to anyone. Five stars! But obviously, marriage itself doesn’t guarantee a strong bond. Some people get married in the absence of one, or lose it and stay married anyway. Other people have a super strong bond for years and never get married.

Like I said before, I grew up Catholic, and living together before marriage was frowned upon—something I knew from childhood. But once I got into my late twenties, I saw plenty of couples from religious families maintain two apartments before marriage with a wink to please their parents. By the time my friends were in their thirties, though, some got engaged, moved in together, and just told their parents to stuff it. After all, it was silly (and a waste of money) not to live together when your lease was up and your wedding was in 4 months.

And honestly, I was never particularly worried that my thirty-five-year-old friend’s fiancé was going to call off the wedding because he was “getting the milk for free,” as the elders used to warn during my childhood. By that point, my friends had built a life together. If he backed out of the wedding, he would be hurting himself just as much as her.

I don’t mean to poo-poo religious beliefs here—I maintain some of them myself. But I’m trying to get at something we miss when we talk about sex outside of highly religious communities. You don’t have to believe sex is sinful outside of marriage to decide that you want sex to come after you’ve established a committed relationship.

Anyone who wants to can have this expectation!

You can just say to yourself: I am a normal human being, and I need to trust and know and feel committed to a person before I have sex with them.

But there seems to be a common assumption that women outside of highly religious communities—Catholic, LDS, evangelical, Orthodox Jewish, whatever—can’t really afford to take their time getting to know someone or ask for some kind of commitment before sex (as expressed in the CHH note below) because men will just seek out someone else.

And within some religious communities, sex can be treated like a bargaining chip or forbidden fruit that a woman must leverage to keep her man interested—because, according to the stereotype, the only thing he really wants out of the marriage is sex, anyway.

But can we give men some credit here? Do we really think a man will always choose the woman who is immediately available for sex over the woman he actually knows, likes, and has bonded with? The reason you would “buy the cow” even though you’re “getting the milk for free” is that you’re fond of the cow.

Ok, wow. That analogy went somewhere I did not intend it to go, and I hereby vote to retire it forever. But you get the point: we shouldn’t assume that sex with different people is interchangeable to men. The bond matters to them too.

In Conclusion: Wanting A Strong Bond With Your Partner Before Having Sex Is Normal

To this day, I still feel a little bit lied to by both hookup culture and the sexual and religious moralizing of my youth, because neither side really explained something that seems pretty obvious to me now: for most people, sex is really good when you actually know and love the person you’re having it with. It can take months or sometimes years before you’re ready for that.

But following those feelings—that powerful evolutionary drive to form a bond—is probably more likely to lead to a life of happiness than just hooking up with random strangers.

Humans are equipped with some pretty powerful instincts to seek out other people and form attachments. We can certainly try to override those instincts, or get pulled in wrong directions by our culture. But let’s try something different: just listen to those instincts!

Writing is definitely my prefered medium!

In this podcast, I talked about my research article "Observed versus predicted vaginal birth after cesarean for patients of a community health center.” If you don’t have 31 minutes and 40 seconds to devote to this topic, here’s the TL;DListen version of this conversation.

When I first started as a midwife, I noticed that many of the doctors I worked with relied on a VBAC probability calculator to estimate a mom’s chances of having a vaginal birth after a previous cesarean. If a mom was Black or Latina, the calculator automatically predicted a lower chance of VBAC than it would for an otherwise identical White patient—with the same age, weight, and obstetric history.

It wasn’t exactly based on bad math. It looked out the outcomes of 7,660 people who attempted a trial of labor after cesarean (TOLAC) between 1999 and 2002. But it only looked at patient characteristics. It didn't account for factors like the C-section rate of the hospital, or whether someone gave birth with a doctor or midwife, or RACISM—things that can ALSO have an impact on whether a VBAC actually happens.

It looked like this:

I never liked the calculator because I watched it systematically dock my Latina patients before they'd even gone into labor. More than once, I found myself advocating for someone who wanted a VBAC while an obstetrician colleague pointed to the calculator as evidence that she wasn't a good candidate to even try.

Then, in 2020, I got one of the most satisfying forms of validation a clinician can experience: an article (Hidden in Plain Sight—Reconsidering the Use of Race Correction in Clinical Algorithms) came out in the New England Journal of Medicine challenging race-based medicine, and the VBAC probability calculator was on the list of concerning algorithms that might contribute to racial discrimination. I felt vindicated!

The developers responded by acknowledging the potentially problematic nature of such an algorithm, and redid the calculator by removing the race variable and adding a “history of chronic hypertension” variable instead. Today, that’s the version you’ll find online, and based on my experience, it is widely used and rarely questioned. I understand the appeal. People love the idea that you can just plug some numbers into an algorithm and get a good sense of the likely outcome. Heck, I wish it were possible too! I could save my pregnant patients a lot of trouble if I just knew which ones were gonna end up with a C-section anyway.

And...racism solved, right?

Personally, I wasn’t so sure. And by that point, I realized I had access to exactly the kind of patient population that could put the revised calculator to the test. If you want all the details, you’ll have to read the paper. But here’s the gist of it: in a community health center where nearly 90% of patients attempting a trial of labor after cesarean were Hispanic, the updated calculator underestimated VBAC success for two groups in particular—people with no prior vaginal birth and people with an “overweight” or “obese” BMI.

In fact, the only BMI category where our patients didn’t outperform the calculator’s predictions was the “normal weight” category.

When it came to prior C-section moms with no history of a prior vaginal birth, our AUC was 0.6, meaning that the algorithm performed only slightly better than a coin flip at predicting VBAC for these moms.1

That raises an uncomfortable question: if removing race didn’t fix the problem, what was the calculator still failing to capture in our population? Glad you asked. We talked about this a little in the interview. My suspicion is that one of the biggest missing pieces is the role of hospitals and providers themselves. Firstly, these moms overwhelmingly had midwifery care. Second, they were giving birth in a hospital with a pretty low C-section rate overall.

The calculator focuses almost entirely on patient characteristics—age, BMI, prior birth history, and other clinical factors. But a VBAC doesn’t happen in a vacuum. It happens in a place with a specific culture, specific resources, specific staffing patterns, and specific people present, all of whom have their own approaches to risk.

I’m incredibly grateful that our clinic and hospital were able to offer VBAC to our patients. As I’ve mentioned before, this is far from guaranteed. Many hospitals in the U.S. do not offer VBAC at all, as I complained about in the note below.2

This has serious consequences for moms, particularly those who want larger families. Because our study period spanned eleven years, some patients in our sample had multiple trials of labor after cesarean. In those cases, supporting VBAC didn’t just mean avoiding one cesarean—it potentially meant avoiding several.

If we had discouraged patients with lower predicted VBAC probabilities (<70%) from attempting labor, our overall VBAC rate would have dropped from 82.2% to 39.4%. Several patients would likely have gone on to have multiple cesareans instead of multiple VBACs—a very high risk scenario—or potentially just wouldn’t have chosen to have those babies. I don’t want to beat a dead horse, but C-section overuse is suppressing the birth rate, and access to VBAC affects family size! If you want people to be able to have the number of kids they want, you should care about this issue.

I would love to see us move beyond the idea that cesarean rates are primarily a reflection of patient risk. At this point, the variation in cesarean rates across American hospitals cannot be explained by differences in the patients walking through the doors. What we are seeing is the effect of different medical cultures: each hospital developing its own norms around intervention, risk tolerance, and what constitutes a “safe” birth—and women being forced to deal with the consequences of those hospital policies.

So anyway, that’s my research in a nutshell. If you’re interested in this topic, I hope you take a listen to the podcast. And for the nerds among us, below is my favorite graph from the manuscript!

Questions, comments, experiences with VBAC? ✌️A.L. And as always…

1

If you’re like me and don’t really speak stats, this explanation from a powerpoint presentation I did on my research may be helpful:

A Frustrating Birth (For Me). Hopefully It Was OK For Her.

A few weeks ago, I attended a very normal birth. She was a first-time mom in spontaneous labor without an epidural who pushed for three hours in various positions before giving birth to a healthy baby with Apgar scores of 8 & 91 and a normal cord pH.2 Great birth story, right?

Well, it wasn’t for me because I spent the last hour of her labor in the frustrating position of not seeing totally eye-to-eye with coworkers who wanted to intervene because of the fetal heart rate tracing, even though I felt confident her baby was fine (moderate variability, and all that). We worked it out privately (I begged for “just 30 more minutes”), continued pushing, and the baby was born without a problem.

But the next day I stopped by to see the mom in her postpartum room, and she said to me “They wanted to do a C-section, didn’t they? You saved me.” I just smiled at her. I don’t throw my coworkers under the bus, and, well, teamwork matters. These nurses and doctors would have my back in an emergency, and differences of opinion in the workplace are part of life. I’m just not the kind of person to say “I told you so.” 😉

The Problem With Continuous Electronic Fetal Monitoring (cEFM)

When it comes to disagreements over the interpretation of fetal heart tones, it turns out to be extremely common. There’s even a name for it: “interobserver variation in the assessment of fetal heart rate recordings.” It's a well-documented, decades-long problem in hospitals that use continuous electronic fetal monitoring (cEFM)—which is basically every hospital.

A systematic review published in 2023, which included 49 studies measuring provider assessment of fetal heart tones in labor concluded the following:

There is great variation in reliability and agreement measures for continuous intrapartum FHR monitoring, implying that intrapartum CTG3 should be used with caution for clinical decision making given its questionable reliability.

Translation: even experts often disagree about what these tracings mean. That's not a great foundation for making major clinical decisions. This tool isn't particularly reliable.

And disagreement isn’t the only problem: cEFM also performs poorly as a screening test for serious neonatal injury. Evidence shows cEFM to have a 99.8% false positive rate at detecting cerebral palsy, which probably has a lot to do with a very low baseline prevalence of cerebral palsy (~0.2%) and the fact that most cases are thought to originate during the pregnancy rather than during birth.

Unfortunately, unreliable interpretation of fetal heart tones has a big impact on what actually happens to moms during labor. The diagnosis of fetal intolerance of labor, also called fetal distress or non-reassuring fetal status, is the second most common reason for C-section in the U.S., accounting for approximately 27.3% of all primary cesarean deliveries4.

Notably, this proportion has been increasing over time: in a Canadian population study, the proportion of cesarean births done for concerns about fetal heart tones rose from 30.1% in 1992 to 51.1% in 2018. A similar trend has been documented in the U.S.: C-sections for nonreassuring fetal status increased from 3.4% of all births in 2000 to 5.1% in 2019. When it comes to rising primary cesarean rates, this reason was the single largest contributor, accounting for 32% of the total increase.

There is also well-documented evidence of variation in frequency of this diagnosis between hospitals that cannot be explained by patient factors alone, and does not result in improved outcomes for babies. An older US study of 6,440 deliveries across multiple institutions found cesarean rates for fetal distress ranged from 0.9% to 3.0% of all deliveries, with significant variation by time of day — rates peaked between 9 P.M. and 3 A.M. suggesting physician fatigue influences interpretation.

In a more recent study called Drivers of Racial Differences in C-sections, a group of economists found further evidence that provider discretion—not just medical need—plays a major role in unplanned cesarean delivery. Black women attempting vaginal birth were 25% more likely than White women to undergo an unplanned C-section, and this disparity persisted even after accounting for medical risk factors and sociodemographic characteristics.

But the infuriating part is, when an operating room was already occupied with a scheduled C-section—making it more logistically difficult to perform another surgery—the disparity completely disappeared. The authors concluded that this pattern is difficult to reconcile with differences in fetal condition and instead points to provider discretion as an important driver of unplanned cesarean delivery. Even more concerning, the additional C-sections performed when hospitals were unconstrained were associated with worse maternal and infant outcomes, not better ones.

So when it comes to the important question of whether all of these additional C-sections have actually improved outcomes for babies, the answer appears to be “not really.” Despite a fivefold increase in cesarean delivery rates over the past several decades, rates of cerebral palsy have remained essentially unchanged. Continuous fetal monitoring does reduce the risk of seizures in a newborn baby, but the absolute benefit is small and has not been shown to matter for neurological outcomes in the long-term. Furthermore, the tradeoff is striking: one analysis showed that preventing one case of neonatal seizure with continuous monitoring would require monitoring 667 patients, and would cause an additional 15 C-sections.

At the hospital level, centers with higher cesarean rates for abnormal fetal heart rate tracings do not have better neonatal outcomes than hospitals that intervene less often.

In other words, while cesarean delivery is unquestionably lifesaving in true obstetric emergencies like cord prolapse, uterine rupture, or placental abruption—which, importantly, can often be recognized with electronic fetal monitoring—performing more cesareans for equivocal fetal heart rate tracings5 has not produced the population-level improvements in newborn outcomes one might expect. Yet nearly 60 years after its introduction, continuous electronic fetal monitoring remains the standard of care for almost every laboring patient in the United States.

Finally, the Media Is Asking Questions

For decades, these concerns about fetal heart tone interpretation were discussed in medical journals but not well-understood by the public. But with increasing concerns about high C-section rates in the U.S., the issue has undergone more scrutiny. I’ve even had the chance to contribute to that conversation.

Here’s a snippet from my Scientific American article, published in July 2023, called “C-section Rates Are Way Too High. We Need to Hold Doctors and Hospitals Accountable.”

As a nurse, I remember surgeries done because the doctor “had a flight to catch” or “didn’t want to be up all night.” My experiences must not be unique; the timing of unplanned C-section shows that the surgery is performed at times of day that are convenient for medical staff, even in the case of fetal intolerance of labor, a reason for the surgery that is supposed to protect the baby from imminent harm consequent to not getting enough oxygenated blood from the placenta or umbilical cord. Yet this diagnosis is inconsistently made based on continuous electronic fetal monitoring technology that has poor ability to predict newborn outcomes.

But the issue reached a much wider audience in November 2025, when The New York Times published Sarah Kliff's investigative report, “The ‘Worst Test in Medicine’ is Driving America’s High C-section Rate.” Drawing on interviews with physicians, patients, researchers, and decades of evidence, the investigation illustrated just how deeply this flawed technology shapes modern birth.

Here’s the opening of that article, which absolutely hits the nail on the head (emphasis in bold, mine):

Nearly every woman who gives birth in an American hospital is strapped with a belt of sensors to track the baby’s heartbeat. If the pattern is deemed abnormal — too slow, for example — doctors often call for an emergency C-section.

But this round-the-clock monitoring, the most common obstetric procedure in the country, rarely helps baby or mother. Decades of research have shown that the tool does not reliably predict fetal distress. In fact, experts say, it leads to many unnecessary surgeries as doctors overreact to its ever-changing readouts.

The obstetrics field has long ignored these problems. Now, it’s putting more trust than ever on the flawed technology, often prioritizing business and legal concerns ahead of what’s best for patients, The New York Times found.

This fall, the American College of Obstetricians and Gynecologists updated its guidelines on continuous monitoring, sanctioning it even as some other wealthy countries have cautioned against its routine use. Some large hospitals have opened remote monitoring hubs, where nurses spend their shifts watching screens of pulsing squiggles beamed in from many miles away. Software companies have also jumped at the opportunity, selling unproven artificial intelligence algorithms that claim to pluck useful signals from the heartbeat noise.

If cEFM Is So Bad, Why Do We Keep Using It?

If you've made it this far, you might reasonably be wondering why virtually every hospital in America still uses continuous electronic fetal monitoring if it’s really so bad. Well, the truth is, fetal compromise in labor is a real thing that can sometimes be caught by continuous fetal monitoring. And obviously the vast majority of parents would accept a C-section over a dead or brain-damaged baby.

An unnecessary C-section has significant downsides, but it’s nearly always survivable.6 In contrast, the cost of a missed hypoxic injury to a baby, who may die o suffer serious lifelong disability, is catastrophic. So, you can forgive those of us in healthcare for sometimes erring on the side of intervention. Or, as a I’ve heard repeated over and over by obstetrician friends over the years:

You’ll never get sued for the C-section you did do. You will get sued for the C-section you didn’t do.

While I don't always love the logic of making decisions based on legal risk rather than what is probably best for the patient, I also understand this reality because it’s one I face myself.

Surveys show that 89% of OB/GYNs and 32% of certified nurse-midwives (CNMs) have been sued. When a baby suffers a devastating injury, malpractice payouts can reach into the millions of dollars, and electronic fetal monitoring strips often become the centerpiece of the courtroom. With the benefit of hindsight, attorneys and expert witnesses scrutinize every deceleration and every clinical decision, asking, "Why wasn't this baby delivered sooner?" Never mind that another baby could have had an almost identical tracing and been born perfectly healthy, and that there’s no way to prove the baby wouldn’t have had the same outcome even if he’d been delivered sooner.

The truth is, bad things can and do happen in birth, even with excellent care. Yet the legal system treats every bad outcome as predictable and avoidable. The acceptable margin for error is zero. So it's not hard to understand why medical professionals sometimes err on the side of doing a C-section.

In short, while cEFM has serious downsides, missing the rare baby who truly needs intervention is legally, emotionally and professionally catastrophic.

And as I stated above, a frustrating reality about cEFM is that we don't really have anything better. Despite decades of research, no technology has reliably distinguished the fetus experiencing true hypoxia during labor from the far larger group with merely concerning-looking heart rate tracings. Until that changes, our field will likely remain stuck with this imperfect tool.7 Personally, I’m excited for the idea that software companies could use artificial intelligence tools to remove human bias (“I’d like to just do the C-section and go home for the night”) and error (“those look like lates8 to me!”) from fetal heart rate tracing interpretation. But whether these systems will ultimately improve care remains to be seen.

Why Isn’t Intermittent Auscultation (IA) Used More Often?

Perhaps you've heard of intermittent auscultation (IA). This alternative to continuous electronic fetal monitoring (cEFM) is frequently used during home births and in birth centers. And yes—it can also be used in the hospital. When I am working with a mom planning an unmedicated, non-induced birth who is low-risk and has a nice looking strip on admission to the hospital for labor, I always recommend IA!

Yet despite being supported by guidelines and evidence, this approach remains surprisingly difficult to access in many U.S. hospitals—including mine. To be completely honest, I feel like we only pull it off, like,10- 20% of the time. 😔

First, the mom needs to not have any risk factors known to increase the chances of a poor outcome (for example, a prior cesarean, hypertension, gestational diabetes, abnormal bleeding, or concerns about fetal growth). Second, she needs to be in spontaneous labor rather than being induced (about one-third of U.S. labors are induced). Third, she needs to plan to labor without an epidural (approximately 75.4% of laboring moms in the U.S. receive one.)

The other challenge is that IA requires a completely different infrastructure than cEFM. It needs a skilled nurse who can stay close to the bedside, assess fetal heart tones at regular intervals, and interpret those findings within the context of the entire labor—noticing if something is amiss. In contrast, cEFM allows a nurse to observe multiple patients from a central monitoring station. In the face of a severe nursing shortage, it becomes much easier for labor and delivery units to just hook the mom up to a monitor and leave the room. So, in many U.S. hospitals, use of IA is limited by staffing constraints.

This creates a frustrating disconnect where professional organizations like mine (the ACNM) recognize IA as an appropriate option for low-risk patients, and research suggests it can reduce cesarean delivery without worsening newborn outcomes, yet many patients never receive the option.

Can You Avoid An Unnecessary C-section for Fetal Intolerance of Labor?

I realize I’ve spent the last several sections explaining why cEFM is ubiquitous in hospital birth despite being such an imperfect tool, and I hope that was helpful.

But at the end of the day, many of these forces are outside of an individual mom’s control. Chances are if you’re a pregnant person in 2026, you can’t single-handedly change hospital staffing or policy, influence the medical-legal system, or change the fact that the hospital near you has a high C-section rate. Yet, I don’t think that individual moms are powerless. There are some practical things you can do both before and during labor to decrease your chances of a C-section for fetal intolerance of labor.

To be clear, I am not suggesting that it is a pregnant person’s responsibility to become an expert in fetal heart rate interpretation. Nor am I suggesting that you should ignore or overrule the recommendations of your medical team based on your own interpretation of a monitor strip. What I am suggesting is that moms deserve to understand the reasoning behind major decisions (such as cEFM, vacuum, forceps, C-section) that may permanently affect their health, and should feel comfortable asking questions before consenting to them. So let’s start here:

Suggestion #1: Be as healthy in pregnancy is possible. Your baby’s ability to tolerate labor depends, in part, on the health of the pregnancy before labor even begins.

Conditions like obesity, high blood pressure, diabetes, fetal growth restriction, and post-dates pregnancy can all affect how well the placenta functions and, in turn, how much reserve your baby has during labor. And needless to say, smoking and using drugs or alcohol won’t do your baby any favors (I doubt this applies to many of my Substack readers, but in the real world I have seen many a pregnancy go south for these reasons ☹️)

This doesn’t mean you can’t have a healthy pregnancy if you have risk factors, and obviously some things are outside our control (advanced maternal age comes to mind). But there is also a lot that is within our control. If you have diabetes or chronic hypertension, getting those conditions under good control before or during pregnancy matters. Eating well, staying active, and avoiding excessive weight gain during pregnancy matter too.

None of this means that someone with risk factors has somehow failed or caused their own C-section. Birth is unpredictable, and sometimes cesareans actually are the best outcome, especially in a high-risk scenario.

Suggestion #2: Choose your maternity care provider (doctor or midwife) and hospital carefully

There is a lot of variation in how hospitals practice. And as we’ve already discussed, there is tremendous variation in how clinicians interpret fetal heart rate tracings, and cesarean rates vary dramatically from one hospital to another—even after accounting for differences in patient populations.

High C-section rates don’t automatically mean a hospital is providing poor care (they could also care for a higher number of very high-risk patients), but very high rates can reflect a culture that is quicker to intervene when fetal heart rate tracings fall into the gray zone (and remember, this does not on average result in better infant outcomes). If you have more than one hospital available to you, it’s worth looking into their primary cesarean rates, asking early in the pregnancy where your provider expects you to give birth, and figuring out their approach to fetal monitoring and labor management.

During pregnancy, ask questions that help you understand your provider's philosophy about labor. For example: "How often do you use intermittent auscultation for low-risk patients?" "How do you approach a Category II tracing that is concerning but not clearly an emergency?" "If my baby develops recurrent variable or late decelerations but still has moderate variability, what kinds of things do you usually try before recommending a C-section?" These questions may help you figure out whether your provider tends to be patient with the normal uncertainty of labor or has a lower threshold for intervening.

It’s a good idea to be specific about your wishes and ask questions like “Will this hospital accommodate intermittent auscultation (IA) instead of continuous fetal monitoring if I want that?”

Asking about the normal routines and policies, as well as the C-section rate of the group with which you plan to give birth may also be helpful. In most modern maternity care, there is no guarantee that the doctor or midwife you pick will actually be the one there when you give birth, so it’s helpful to understand the hospital and group culture as a whole rather than just the philosophies of your individual clinician.

And here I’m just going to go ahead and state my bias: if you’re a good candidate for midwifery care, I would strongly encourage you to consider it. Midwives are generally more likely to use intermittent auscultation for low-risk patients and, as we discussed earlier, midwife-led care has consistently been associated with lower rates of cesarean delivery without worse outcomes for babies. Home birth and birth center birth, usually attended by midwives, are a great option and I’ll refer you to post on that one to learn more about why.

To hear my argument for midwifery in general, read the post below:

Suggestion #3: Avoid unnecessary induction of labor. But consent to necessary induction of labor! And to know the difference, please read the post below. The TL;DR is that while induction without a medical indication can lead to a longer, more intervention-heavy labor experience, it can actually improve outcomes in many medium or higher-risk situations.

Suggestion #4: If you are a good candidate, consider intermittent auscultation (IA) instead of routine cEFM. In low-risk pregnancy, it is not shown to protect your baby any more than intermittent auscultation. In fact, IA seems to reduce emergency cesarean deliveries in labor without increasing bad outcomes for mom or baby.

If fetal heart rate interpretation were an objective test that always yielded one obvious answer, there would be less reason to avoid cEFM. But because there is so much gray area where reasonable clinicians can disagree about what a tracing means and what the next step should be, this intervention should not be taken lightly.

Suggestion #5: If you cannot avoid cEFM (due to risk factors, induction, epidural use), and are told the fetal heart rate is concerning, letting your team know that avoiding a cesarean is important to you—while also making it clear that you want to keep your baby safe—can help them tailor their recommendations when there is genuine clinical discretion and “gray area” in fetal heart rate interpretation.

If this happens, one of the most common suggestions you'll hear is: move. Your nurse may ask you to get on your hands and knees, turn from side to side, use a peanut ball between your legs, or sit upright in the throne position. These things can be done with or without an epidural. If position change is recommended to you (and honestly, even if it’s not), do it!

I’m going to be honest about something I see all the time on labor & delivery. Despite the stories I hear about patients being trapped in bed during labor by nurses and providers who try to keep them there, my experience has often been the opposite. I am constantly encouraging people to move, get out of bed, and advocating for the use of wireless monitoring for those who need cEFM. Yet when I check on moms in their labor rooms, I often find them….laying in bed on their backs! Which is, literally the worst position for both labor progress and fetal heart tones.

Position changes are one of the safest, most effective tools we have for both helping labor progress and helping babies tolerate labor. But I run into moms all the time who just want to stay still, and while I completely understand the impulse—labor is exhausting—this is one of those moments where pushing through the discomfort can really matter. I’ve seen so many “borderline” situations where a baby’s heart rate improved significantly because the mom agreed to keep changing positions every 20–30 minutes instead of lying flat on her back.

Just the other day, I had a birth where the mom started having deep variable decelerations9 after her water broke, but I was working with an amazing nurse who was really on it. By keeping the mom on her hands and knees (it was the only position the baby tolerated), the heart tones stayed reassuring with moderate variability (a sign of normal acid-base status) and the variables became less deep than when she was on her side or her back. A few hours later, baby was born with the cord wrapped around her neck several times. No harm, no foul—she came out crying and was just fine! In another situation with a less skilled nurse or a more overly-interventional hospital culture, that birth probably would have been a C-section.

To be totally honest, I’ve also been in situations where a mom’s resistance or unwillingness to keep trying position changes and working with staff contributed to a cesarean that might have been avoidable. So, if position changes are being recommended by your care team, please listen!

Suggestion #6: Have a doula or continuous labor support.

I’ve talked a lot here about the limitations imposed by healthcare systems and staffing. By hiring a doula, you have someone on your side whose entire job is to support you through labor. A doula is not there to interpret fetal heart tones or make medical decisions, but she can help you with position changes, coping through a long labor, understanding your options, and communicating your preferences.

That whole “I’m exhausted and done. I want a C-section” moment that I talked about earlier? I’m going to be honest—it is something I see less often among people who have strong support in labor. A doula can help you keep going when things get hard, remind you of your goals, and encourage you through the exhausting parts of labor. Doulas are the ultimate cheerleaders. They’ve been through this before with other clients, and statistically, they will reduce your chances of having a C-section.

If you can’t afford a doula, or the idea doesn’t appeal to you, don’t discount the value of having a loving support person (your partner, sister, mom, friend) at your birth. These people can also advocate for you during a difficult labor. And as I’ve written before, dads make a difference!

And, After All This, If You Need A C-section, It’s Gonna Be OK

Here at “A Moderate Midwife,” I have built my brand around claiming that it is possible to have a nice hospital birth; that there is a happy medium between free birth in your home with no birth professionals present, and a hospital birth with every unnecessary intervention imaginable, and that yes, some people really do benefit from hospital birth, including people who end up needing a C-section. In the essay below, I stated it like this:

There is something in between intervening too much and intervening too little. It is called “intervening the right amount.”

But I realize that statement isn’t very helpful to people who don’t work in maternity care. After all, how would an average mom know what “the right amount” is in her individual situation? I hope this essay has shed at least a little light on what a fetal intolerance of labor diagnosis actually means, and helps you ask the right questions if you ever find yourself in that situation.

Because the truth is, it's fine for moms to ask questions, make decisions, request certain interventions, and decline others. But it's also good to place a certain amount of trust in your caregivers during pregnancy, labor, and birth. And if you find yourself struggling to do that—and it's early enough in your pregnancy to make a change—it's not too late to look around for a doula, or find another provider or a birth setting that better aligns with your needs.

You were not meant to do this alone. Humans have been assisting each other in childbirth for as long as our species has existed. And lucky you—you're giving birth in the year of our Lord 2026, when childbirth has never been safer. The C-section rate may be too high (and trust me, some of us are working on it) but historically speaking, both maternal and neonatal mortality are extremely low.

Closing Time

Let me close by sharing a story about my friend. She was pregnant with her first kiddo and went to the hospital in early labor. In triage, they determined she was only 1 cm dilated and were getting ready to send her home. Then, all of a sudden, her water broke.

She felt completely fine. She wasn’t having severe pain, and she wasn’t bleeding. But because she was still on the monitor, the nurses immediately noticed a steep, sudden drop in the fetal heart rate. They spent the next 2–3 minutes trying the usual interventions—position changes and everything else they could think of—but nothing worked. Her baby’s heart tones had absolutely tanked.

So they rushed her to the operating room and performed an emergency C-section under general anesthesia. When she woke up, she learned she had a velamentous cord insertion,10 and her amniotic sac had ruptured directly over one of the baby’s unprotected blood vessels, severing it and abruptly cutting off his blood supply. She was lucky to be in the right place at the right time (the hospital) otherwise, her baby would not have made it. He’s 14 now and doing just fine. 😊

Happy to hear all of your labor, birth and fetal intolerance of labor stories! Questions, comments, disagreements? Please share, and as always….

1

Apgars are a rating system we use to decide whether a baby needs resuscitation after birth by ranking several characteristics:

2

Umbilical cord pH testing measures the acidity of a baby's blood immediately after birth to determine how well they tolerated the labor and delivery process. A pH value below 7.00 indicates severe metabolic acidosis, which means the baby's tissues experienced a significant decrease in oxygen supply during labor.

5

Equivocal in this case usually means the heart tones are Category II. The problem is, the vast majority of babies (up to 80%) will have Category II FHTs at some point during labor. A small percentage (0.1%) of babies will have a Category III tracing and require immediate intervention (C-section or forceps/vacuum if close enough to vaginal birth). because these patterns indicate oxygen deprivation.

8

Late decels are concerning because they can indicate placental insufficiency, but there is often disagreement among clinicians as to what qualifies as a “late decel.” The textbook definition looks like this:

9

Variable decelerations are deep, V-shaped decelerations that generally indicate cord compression. This can happen after the water breaks (or is broken) because there is less cushioning around the cord. They’re generally not a big problem, unless baby loses moderate variability (the baseline looks flat rather than jumpy) because that indicates compromised oxygenation.

We can’t always know what is causing them, but there are different cord abnormalities that can come into play:

10

I’ve seen this more than once, and it usually isn’t catastrophic like it was for my friend. But you can see why it’s dangerous! Look at this placenta pic after a normal vaginal birth with a velamentous insertion. Do you see how unprotected those vessels are compared to the vessels in the cord?

She sighed and said, “Well, I guess I have no choice.”

I shook my head and responded emphatically, “You absolutely have a choice!”

She looked surprised, so I went on.

“Well, if you’re not ready today, we can schedule you to come back another day. And obviously, I’m not going to do a pelvic exam without your consent. So if the idea of getting a pap smear frightens you, you can choose to never do it.”1

She stared at me with a confused, blank expression, as if to say “What’s the catch?”

“I wouldn’t recommend that,” I continued, “Because pap smears are a pretty simple, preventative thing you can do to avoid cervical cancer, which used to kill a lot of women. Most likely, the result will be normal, and then you don’t have to worry about it for 5 years, when the next pap would be recommended. And if the result is abnormal, well, that will be annoying, but follow up and treatment can basically reduce your chance of dying of cervical cancer to zero.”

She nodded, admitting that sounded like a pretty good deal. She consented to the pap smear, but before she hopped up on the exam table, she laughed nervously and said something that I’ve grown accustomed to hearing over my 20 year career in women’s health:

“It’s so hard to be a woman, isn’t it? Men are so lucky! They don’t have to deal with any of this stuff.”

An Argument Against Biological Self-Pity

This essay is a response to that statement—and to a lifetime of feeling expected to laugh along with a joke I don’t find funny (or true).

As observed by the woman in my opening story, female biology is indeed more involved than male biology, and it makes demands of us. I don’t want women to feel guilty for acknowledging this. But there is a difference between acknowledging a burden and building an identity around it, and in my opinion, our cultural interpretation of female biology as inherently disadvantageous has overplayed its hand. And this has consequences.

As a midwife, I hear talk of women’s biological disadvantage shared often while attending births. A sympathetic father will remark “Gosh, it’s so hard what women go through,” or a mother-in-law will joke, “If men had to give birth, there would be no children!” And they’re not wrong about one thing: childbirth is an incredibly exhausting, painful (though this can be mitigated)2, carnal experience. So, if we’re comparing reproductive effort—yes, men’s role is undeniably easier, as illustrated by comedian Jim Gaffigan in the clip below:

As someone who has spent years caring for women throughout the life cycle, I’ve come to believe that the stories we tell about our bodies matter a lot. If women are constantly told that their bodies are weaker, more troublesome, more vulnerable, and biologically disadvantaged, they start to inhabit that story. Women stop asking what their bodies are capable of and start assuming they need to be rescued from themselves, which can lead to worse physical and psychological health.

And when we repeatedly describe female biology as a collection of inconveniences and liabilities, we shouldn’t be surprised when women come to see their own bodies as obstacles rather than assets.

This is a perspective I expressed in a recent Substack notes exchange with . I reached out to her before resharing this note, because while I can tell we have pretty different world views, I respect her writing and didn’t want it to be seen as some kind of personal take down. Her response was to say that she welcomes disagreement, and that arguing the other side of this issue could be very fruitful. So here goes!

How Disadvantageous Is It To Be Female?

My argument is simply that culture has a habit of viewing female biology almost exclusively through the lens of its costs, while rarely noticing its benefits. Many people interpret male biology as the default model of perfection and strength. We notice that men are generally taller, stronger, and faster, but spend much less time considering the advantages that come with female biology: greater flexibility3, greater precision in fine motor tasks, and a smaller physical frame that can be an advantage as often as it is a limitation, as any six-foot-tall man folded into an airplane seat in the back of the plane can attest.

Pregnancy, birth and breastfeeding are huge biological investments—yes. But they are paired with corresponding forms of influence, certainty, and control over the end reproductive outcome that men just don’t have.4 Yet we are primed to pay attention to the visible burdens of female biology while ignoring the evolutionary strengths that make it a very successful survival strategy, such as lower caloric needs, and better ability to survive disease or famine.

We also tend to focus on these “burdens” of female biology without considering the larger systems they belong to. Menstruation is often discussed in isolation, only as an inconvenience, rather than as part of a cycle that is not universally negative. Many women notice a very pleasant increase in energy, mood, confidence, and libido particularly around ovulation5 but this is barely talked about in comparison to the focus on the discomforts of menstruation. Also, because it has become so culturally normal to suppress cycling with hormonal contraception, many women don’t regularly experience these benefits. I discussed this rarely considered downside to birth control in a recent post:

While scientists continue to debate exactly why menstruation evolved, it is increasingly understood as part of a complex reproductive strategy rather than a biological flaw.6 One leading idea is that cycling allows women to invest heavily in pregnancies that are likely to succeed rather than carrying every conception forward indiscriminately, allowing for healthier offspring.

Similarly, menopause, which gives older women a reprieve from reproduction that most other mammals don’t experience, may allow them to increase their impact through investments in existing children, grandchildren, and broader social networks rather than additional pregnancies—a perspective that contrasts sharply with the common depiction of menopause as little more than a period of decline, with menopausal women melting into obscurity and uselessness once their reproductive potential has ended.

Moving Away From A Biological “Battle Of The Sexes”

Male biology is remarkable in its own right, so I am in no way arguing that men’s bodies are worse. Nor do I want to make a “girl power” argument that ignores the way women’s biological experiences can be difficult. But I’m skeptical when people imply that biology empowered men while shortchanging women. Men and women are not rival species competing for evolutionary advantage; we are one species, and our success has always depended on one another.

Every woman carries half of her father’s genes, and every man carries half of his mother’s. The genes that influence a woman’s breast size or ability to lactate are inherited from her father as well as her mother. Likewise, many of the genes that contribute to a man’s strength and athletic ability came from his mother. So while evolution certainly produces areas of conflict between male and female interests, it would be surprising if it consistently favored traits that optimized one sex while systematically undermining the long-term reproductive success of the other.

I am not going to argue that the costs of female biology are imaginary, or that biology has always served women equally well in every cultural context. As I discussed in the essay below about the difficulty of childbirth for some humans, a trait can be evolutionarily successful and still come with real physical and social burdens, and serious risks.

I would also point out that we tend to emphasize the benefits of male biology while paying much less attention to the costs. Men die younger, suffer more injuries, have higher rates of infant mortality, require more calories to maintain their larger bodies and greater muscle mass, and high testosterone levels come with immunological as well as behavioral trade-offs.

For example, men were more likely to die of Covid and are more likely than women to be murdered or commit suicide. In fact, despite the justified attention paid to high maternal mortality in the U.S., men aged 15-44 (the range that is often used for childbearing women) actually die at higher rates than same-age women do, even when pregnancy and the postpartum period are included in the comparison.7 If female biology were truly the evolutionary short straw, that would be a surprising outcome.

This does not take away the truth that, in many ways, our culture has been designed in a way that disadvantages women’s bodies and considers their reproductive systems a liability. I have been reading ’s book The Dignity of Dependence and in the early chapters she lists a litany of ways in which the female body is poorly fitted for a material culture designed around men’s bodies. She offers several compelling examples, including pharmaceuticals that have been developed and tested predominantly on men, and crash test dummies modeled on male physiques, resulting in cars that make women 17% more likely to die and 73% more likely to be injured in a crash. Even kitchen countertops, which are presumably used more by women than men, are optimized for the height of a typical man.

But many of the disadvantages women face are not consequences of female biology itself, but of living in a material world built around male bodies as the default. And yet, even within that world, women consistently exhibit remarkable biological resilience. For example, even though a woman is more likely than a man to die in the same car crash, mile for mile, men are 63% more likely to die in this way than women, probably due to differences in substance-use and risk-taking behavior.

Across history, across cultures, and at nearly every stage of life, women have higher survival odds than men. So if we judge biology by one of evolution’s most fundamental metrics—the ability to survive long enough to reproduce and help the next generation survive—it becomes difficult to maintain the assumption that female biology is inferior.

Women—The Consummate Survivors of History

If you look at a list of the richest people on the planet, they are nearly all men. If you look at a list of the 50 oldest people on the planet, they are nearly all women. So if female biology is fundamentally disadvantageous, it’s striking that women are so much more likely than men to reach exceptionally old age.

It is also hard not to notice the irony that some of the richest men in the world have become obsessed with longevity, spending extraordinary sums in pursuit of a few extra years of life, while countless women continue to have a biological advantage while just living ordinary lives.

Personally, I think living five years longer on average8 is a pretty nice perk of being female. But beyond making reasonable lifestyle choices, how long any of us lives is not really under our control, so it's not something I spend much time dwelling on. And I certainly don't mean to dismiss longevity research. If science can reduce age-related disease or extend healthy life, that's good news for everyone.

In fact, one reason scientists are increasingly studying why women outlive men is because they hope those biological insights can help improve healthy aging for both sexes. Researchers are investigating women's generally stronger immune responses, the protective effects of estrogen on the cardiovascular system and brain, and the ways that having two X chromosomes may provide greater genetic resilience.9

The main point I want to make here is that our culture is fascinated by male displays of power—wealth, strength, speed, dominance. History documents them well. But survival itself is arguably one of the greatest biological achievements, and women of all ages, through all stages of life, are really good at it—nearly always better than men.

I often find myself thinking about things written by of The Great Gender Divergence because I appreciate her fresh, honest takes on gender throughout history and in the current day. In particular, she is willing to raise difficult truths that conflict with my feminist sensibilities. In a recent note, she said the following:

And in another recent post, In Confining Insiders, Raping Outsiders, she said the following:

Julius Caesar famously encapsulated imperialism as veni, vidi, vici, but that is perhaps too benign. Veni, rapui, genui may be more accurate: I came, I seized, I begot. Throughout the historical record, militarised male coalitions have seized territories, slaughtered rivals, captured women and achieved disproportionate reproductive success.

She goes on to give several examples of this throughout history, but the one of most interest to me came from Latin America:

In the 16th century, when Iberian men colonized the Caribbean, Central and South America, they not only seized land, minerals, and labour, but also gained an extraordinary reproductive advantage. Today’s Latin American populations exhibit sharply sex-biased ancestry: paternal lineages are disproportionately European, while maternal lineages are primarily Indigenous. In countries with long histories of African slavery, the maternal line is often substantially African.

While it was hard to read this essay, filled with examples of violent, oppressive, and cruel men, it also struck me that there are two ways to interpret this history. Historians naturally emphasize the first: powerful rulers and militarized male coalitions shaped the course of civilizations. But for me, the phrase, "maternal lineages are primarily Indigenous," really sticks out. If we unpack what those words mean, we see that countless Indigenous women survived conditions of extraordinary adversity: conquest, rape, slavery, racism, displacement, starvation and physical abuse. And not only did they survive—they managed to raise children who themselves survived long enough to leave descendants.

One could argue that these women and their children survived only because conquering men “let them.” But modern evidence consistently shows that abuse, coercion, chronic stress, malnutrition, and violence undermine women's health and reproductive success rather than enhance it.10 Violence is not an adaptive gift bestowed upon women. Rather, female biology—and female resilience more broadly—repeatedly proves capable of enduring extraordinary hardship despite harsh conditions. Throughout human history, the female body and psyche, so often dismissed as fragile or defective, turn out to be pretty resilient.

When I read historical sources like those presented by Evans, I can’t help but think of my own sons. We tend to romanticize history by identifying with its winners—the conquerors, the emperors, the dominant figures who are almost always men. But the fact is, these empires were often built on the idea of male expendability. Most men were not doing the conquering. They were peasants, laborers, or soldiers whose lives were cut short by conflicts they did not choose, serving at the whim of a small number of corrupt, powerful men. What we call "reproductive success" in certain epochs of history was built on the murder and disenfranchisement of less powerful men.

So when I consider my maternal investment in my sons—the time and energy I poured into raising them—I can’t imagine how awful it would be to parent in an age where they were viewed as expendable. Even the idea of them signing up for the draft when they turn 18, making them vulnerable to the whims of whatever potential war-mongering president we may have in the future, makes me feel kind of ill.

We should be honest about historical events in the past, yes. But I think we can also acknowledge that, for the vast majority of people throughout history, it was not conquest that carried human lineages and achievements forward. It was peace, cooperation, and caregiving—during which women did a lot of the heavy lifting. And our female biology probably helped. Being more prosocial and having less intimidating (and potentially more attractive) physical features probably helped.

As stated by one of my favorite anthro profs from college, Dr. Agustin Fuentes in the excellent TED talk below:

We have this notion that might makes right, survival of the fittest, meanest, baddest. Is that true? Are humans naturally aggressive at our core? Are humans really aggressive, violent and selfish? Actually, no. I’m going to show you today that it’s not all about sex and violence. Rather, the key to human evolutionary success is all about cooperation and getting along.

A Better Story About Women’s Bodies

Do you remember my opening story about the woman who implied that it’s so unlucky to be a woman? I hope I have convinced you that it’s not really worse-just different, in both some good and bad ways. But I understand why my patient said what she did. Female biology asks a great deal of us: menstruation, pregnancy, childbirth, lactation, menopause and even uncomfortable pap smears! But it also gifts us with other wonderful things: flexibility, resilience, longevity, babies, breastmilk!

Personally, I would argue that the female body is not an evolutionary mistake, nor is it a defective version of the male body. It is one of evolution's great success stories: it is astonishingly good at keeping both itself and the next generation alive. What more could we ask for?

Please comment below, especially if you answered “no” or “maybe” to the above poll question. And please subscribe!

7

This chart shows male vs female mortality for the same age range, plus the same rates for maternal mortality and pregnancy related mortality specifically:

Field Notes From A Family Cruise

What follows are several parenting reflections inspired by a week of observing children of all ages (some related to me, some not) on a family cruise. That’s right—last week, in celebration of her upcoming 80th birthday, my mom took us all on a cruise out of Boston headed first to Nova Scotia, then Bermuda. For seven days my siblings and our families had the run of this amazing ship, which is basically a floating city where you have no responsibilities, tons of entertainment, and access to an all-you-can-eat buffet from 6 a.m. to 10 p.m.

And if you’re the kind of person who loves to observe parents of young children having a hard time and judge them for their parenting failures, you have come to the right place. That’s right—whatever “Kids, these days!” assumptions you’d like to make, there will be ample evidence for them on a cruise. It is an excellent place to observe children at their absolute limits: overstimulated, overtired, over-sugared, and occasionally melting down because the pool closed early or someone else got to the ping-pong table first.

Seventeen people from my family attended—a motley crew ranging in age from 6 to 79. Miraculously, this ship managed to meet all our needs. Handicap accessible! Kid-friendly! Everyone can find food they’re excited to eat! Grandma and Auntie can sit and play cards (with kids being dealt in at various times) while the tween boys check out the high-ropes course. Grumpy teenagers can hide in their cabins and watch the World Cup. Parents can sneak away to the gym, or better yet, the bar for an espresso martini. So yes—fun times had by all. But there was something else I noticed on this particular vacation that felt very different from vacations of years past.

It was waaaaaay easier.

It was easier in comparison to trips we did years ago when my kids were younger. Watching my siblings and other parents navigate meals, activities, and logistics with younger kids reminded me just how much work those years required. Meanwhile, my own kids were largely entertaining themselves, making their own decisions, and generally acting like people I could trust in public. None of this is because I’ve unlocked some secret parenting strategy. It’s because they’re older.

You see, they don’t wear diapers. They don’t take naps. They don’t have tantrums. They don’t run away in a crowd at top speed. They can stay up late or get up early for a flight and not act like little jerks the next day. They refrain from hitting every button in an elevator. They dress appropriately for the obligatory family dinner and, if asked an annoying question by an adult relative, will usually respond politely. When we go on a hike, I am now the person most likely to whine (wet socks are the worst).

Now that my kids are all 11 and up, they don’t need a babysitter. In fact, on this trip they could pretty much wander the ship at their leisure. My 11-year-old was technically eligible for the “Splash Academy Kids Club,” but he and his same-aged cousin thought it was kind of lame, so they checked themselves out early. At that age, no parental pick-up is required. My 13-year-old met some fellow recent eighth-grade graduates from Maine. They became fast friends and spent much of the week hanging out in the hot tub together. My husband and I amused ourselves by walking by frequently, waving and calling his name while he pretended not to know us.

Another way this vacation was easier is that my kids mostly got along with each other. That doesn’t mean there are never incidents….

A Story About When Siblings Stop Trying To Kill Each Other

Because I have very active (and older) kids, we booked a tour in Bermuda that included some pretty adventurous activities: cave exploration, cliff diving, and snorkeling. Grandma and the younger cousins couldn't have participated, and honestly, these activities would have been a stretch for our kids just a few years ago. At the beginning of the tour, the five of us piled into a small van with two other unrelated families, and we squeezed into the back two rows. Being crammed into the back of a van with no leg room would have been a recipe for disaster a few years ago.

In fact, before we even left the parking lot, my older son said something vaguely insulting to my younger son, who is quite sensitive to his brother’s opinion of him. So naturally, he slapped him. But what happened next surprised me.

First, my younger son instantly realized he’d made a mistake, felt remorse, and started apologizing.

Second, my older son—get this—DID NOT HIT HIM BACK.

He accepted the apology, stopped insulting him, and the incident was over. A little while later I said to the boys, “You know, I’m kind of impressed. I think just a couple of years ago that would have turned into an all-out brawl in the back of a tour bus.”

My older son rolled his eyes and responded: “Of course I’m not going to get in a fight on this bus. There are other people here. That would be so embarrassing.”

Then it hit me: Wow. The boy cares what other people think.

For years, I had tried to teach concepts like self-control, conflict resolution, and considering the consequences of your actions. Apparently what finally worked was a few years time and the possibility that complete strangers might witness him behaving like an idiot.

In fact, he now cares more about avoiding public embarrassment than getting revenge on his little brother. Somewhere along the way, he developed a sense of shame—the very quality I had spent the previous five to seven years trying unsuccessfully to instill.

And when it comes to my younger son, of course I’m not proud of the fact that he hit his brother. But after years of trying to force apologies that my kids did not genuinely feel, it was refreshing to see him actually acknowledge he’d made a mistake without being prompted.

My Kids Are Basically Civilized Now (But Didn’t Used To Be)

As a fairly self-conscious person, I used to find it extremely stressful to take my children out in public.I've detailed this in other posts, but they were genuinely difficult to keep safe and contained. For years, leaving the house felt like a calculated risk. Staying home all day with energetic kids was its own challenge, but going out meant facing the possibility of chaos, public scrutiny, and some new disaster I hadn't anticipated.

One child might run away in a parking lot. Another might decide to climb something that was clearly not meant to be climbed. Someone would refuse to wear appropriate shoes. Someone else would refuse a coat despite sub-freezing temperatures. As I’ve argued before ⬇️⬇️⬇️

There was one particularly infamous incident in my hometown when I took the kids to visit the cemetery where my father is buried. While I stood at his gravesite trying to have a moment of reflection, my younger son managed to slip away and began climbing a centuries-old stone cross. Unfortunately, the cross was less sturdy than it appeared and it toppled over on him. No one was seriously hurt, and the cemetery keepers were very understanding when I wrote to explain the incident and offered to pay for the cost of fixing the cross. But obviously, it was horrifying. Some families bring flowers to the cemetery. My family brings a wrecking crew.

And YES, I know I should have been watching him more closely. I am aware. In my defense, I was trying to have a peaceful moment at my father’s grave—but I guess my six-year-old wasn’t feeling particularly reverent or sympathetic to my goal that day. Apparently I overestimated his ability to refrain from scaling historical monuments for approximately ninety seconds. You’ll be happy to learn that the same child can now walk through an entire cemetery without toppling a single religious monument.

A Lot of Parenting Problems Are Solved if You Just Wait Longer

One evening on the cruise, I was getting ready to have dinner in one of the ship’s fancy dining rooms—you know, the kind where the waiter unfolds your napkin and places it in your lap if you don’t do it quickly enough yourself. Getting to go to a fancy dinner was a nice perk. My siblings with younger kids mostly ate at the buffet, wisely avoiding the challenge of asking small children to sit patiently through a multi-course meal.

But my kids no longer need to order chicken fingers off a kid’s menu or toddle around the room. They could join us for a real dinner, sitting still for a whole 90 minutes! And even though I know my 17-year-old is tired of answering questions about where she'd like to go to college and what she'd like to study, she politely recites her stock answer whenever an adult relative asks.

As I stood in front of the closet deciding what to wear to dinner, I reached for a pair of white linen pants. This may not seem like a momentous occasion to anyone else, but to me, it was huge, because for most of the past seventeen years—basically, since I became a parent—I have been unable to wear white clothing.

Parents of young children understand this instinctively. Wearing white around babies and toddlers is pointless. It won’t stay white for long, and I only needed one glass of chocolate milk spilled in my lap to learn this lesson. Over the years, I gradually stopped buying white altogether. As the person who does most of the laundry in our house, I knew exactly how this story ended. Someone was going to vomit breastmilk on my shirt or wipe their sticky hands on me.

But on this vacation, during seven days on a cruise ship, my children managed to spill exactly zero beverages on me. This may not sound like a major milestone, but I assure you: it is.

In fact, there is a long list of annoying behaviors my kids eventually outgrew, all of which I observed parents of younger children dealing with on this cruise. Here are a few:

• running away in crowded places

• dressing inappropriately for the occasion or the weather

• having embarrassing public meltdowns

• beating up and/or fighting with siblings in front of strangers

• climbing everything in sight

I don’t want to give the impression that all problems disappear. My 11-year-old still rocks backward in chairs like he’s conducting a physics experiment which, as you may guess, frequently ends badly. My 13-year-old has an expensive habit of losing cash, headphones, and clothing. My 17-year-old loves to give her opinions on my fashion choices (spoiler alert: she doesn’t like them). But overall, I can live with these small inconveniences. No one’s perfect—including me, and my current parenting problems are far less stressful, time-consuming and embarrassing than they used to be.

My point is, parenting influencers often imply that every bad behavior displayed by young children is a referendum on your parenting choices, but my experience is that many behaviors are simply developmental stages with natural expiration dates. Sometimes a bad behavior is just a referendum on the child being four, not eleven.

But I’m Not Saying That Parenting Doesn’t Matter!

I have dabbled in parenting posts mostly just trying to be funny, and unfortunately, have provoked backlash from people who are pretty sure I did everything wrong. The argument usually goes something like this: I let my kids “get away with” bad behavior. I wasn’t strict, regimented or consistent enough, and I just happened to get lucky by having kids who turned out fine. Most of my hard days and nights as a parent of young children were hard because I made them that way, and could have been prevented through better parenting…⬇️⬇️⬇️

Of course, we’ll never know for sure who was right and who was wrong. Parenting is frustratingly hard to evaluate because we only get one version of our kids, and we never get to run the experiment again with a different approach.

But I don’t regret choosing to prioritize having a good relationship with my children over “winning” battles like who is going to pick up the carrot they annoyingly dropped on the floor. And I believe there is a lot of wisdom in reminding yourself “this too shall pass” during life’s most difficult moments, both inside and out of parenting.

Recently, I’ve loved reading takes from .1 She has real credentials as a neuroscientist and physician, so if you’re going to take parenting advice from someone, take it from her, not from me!

But—just sayin’—she seems to agree with me that sometimes, She’s Not A Better Parent. Her Child Is Easier.

One of Manuela’s recent posts discussed evidence for what researchers call differential susceptibility—the idea that some children are simply “harder” and also more affected by parenting that others. In other words, parenting mattered most for the hardest kids.

Kids with more difficult temperaments were hurt more by harsh parenting than easy kids were, and they also gained more from warm, supportive parenting. It showed up across aggression, across anxiety, across social and cognitive skills, and it was clearest when the difficult temperament was measured early, in infancy.

The long-term studies that follow the same kids over years say the same thing. Stright and colleagues tracked babies into first grade. The ones rated temperamentally difficult as infants became the most capable kids in the classroom (schoolwork, friendships, relationships with teachers) when they’d had high-quality parenting, and among the least capable when they hadn’t. For the easier babies, parenting quality seemed to matter less.

Parting Thoughts

Obviously, I can’t promise that your kids will be easier when they’re older. There is always the possibility of hard seasons ahead. Many teenagers and young adults genuinely struggle with depression, anxiety, risk-taking behaviors, difficult relationships, and other challenges.

And if you’re the parent of really young kids, perhaps you find my conclusion a little annoying—or maybe just not very helpful—because your 3-year-old is currently having two-hour tantrums every day. I realize those phases are hard. My kids went through a lot of hard phases.

But I think the parents of hard kids are the ones who most need this reminder: a hard season does not mean your child is destined for a hard life. And sometimes, what you need isn’t necessarily a different parenting strategy, just more time!

In my opinion, the best thing you can do while you wait is keep your sense of humor. You will know things have gotten better when you can finally wear white pants again.

1

is also my friend and collaborator on this piece!

My Fertile Brain

What Actually Makes Birth Feel Safe

This piece is a collaboration between Manuela Kouakou and Ann Ledbetter…

Read more

8 months ago · 32 likes · 3 comments · Manuela Kouakou, MD-PhD and Ann Ledbetter

I should know by now never to try to predict birth. I started my shift at 8 p.m., she began pushing at 8:30 p.m., and we had a healthy baby by 9:00 p.m. The mom was incredibly grateful for her care, and the long labor was water under the bridge once that beautiful baby was in her arms. When we finished up, I texted my coworker to thank her for letting me vent, and apologize for being such an insufferable grump. Then, I slept the rest of the night because no one else went into labor.

Sometimes I love it when I’m wrong.

Why Inductions Make Me Grumpy

But there’s a reason that inductions put me in a foul mood. A lot of reps attending birth have taught me that they can be really difficult—for the mom, for the baby, and (least importantly) for me. Obviously, I want moms to come away feeling satisfied, empowered and well cared for. But inductions are linked to women reporting a worse birth experience than with spontaneous labor.

I don’t want to overstate this finding, because a lot of inductions are done for medical complications or risk factors, so these surveys of women are not comparing apples to apples. If asked, moms would probably prefer no preeclampsia to preeclampsia. No gestational diabetes to gestational diabetes. Spontaneous labor at 38 weeks to induced, meconium-saturated, prolonged labor at 42 weeks. You get the picture.

And if I could order up a short, physiologic labor at a reasonable gestation for all the moms I care for, I obviously would! Unfortunately, that’s not how birth works. As I covered in the post below, human birth can sometimes be prolonged, difficult and complicated—especially the first time. Both gestation (40w0d vs 40w5d) and labor lengths (~6–12 hours vs ~12–18 hours) are longer for first time moms.

But it’s not really surprising to me that, overall, most women prefer to avoid induction. It’s an open secret that inductions can be miserable. In fact, of the 22,533 low-risk, first-time moms who were eligible for the ARRIVE trial—the famed study in which half the group was randomly assigned to be induced at 39 wk for no medical reason—73% declined to participate. I think this also has important implications for how we interpret the study’s results.1

Personally, I am very pro-research, but I never would have signed up for a study where I might randomly get pulled into a long, difficult process that had previously been linked to higher C-section rates in several prospective and observational studies.2 Furthermore, having worked night shift as a labor and delivery nurse, I’d witnessed many elective inductions end in C-section in the evening hours, often seeming to coincide with a doctor wanting to go home for the night. And my experience must not be unique, given the temporal patterns of unplanned C-section in the United States.3

Even more important to me, none of the women in the ARRIVE trial were cared for by midwives. The trial asked whether inducing low-risk women at 39 weeks could reduce cesareans within a highly medicalized model of birth in both arms of the study, while ignoring one of the clearest existing pathways to lower C-section rates in the first place—midwifery care. This has been shown to result in lower C-section rates in both home4 and hospital settings.5 So the fact that the NIH poured money into a study about elective induction but has never conducted a randomized controlled trial (RCT) comparing outcomes for low-risk women assigned to midwifery versus obstetric care says a lot about our maternity care system’s biases and priorities.

So I want to state my bias early in this essay: I don’t like inductions. I didn’t like going through one myself with my first birth, and I don’t like watching my patients go through them. I would not willingly sign up for one without a legitimate medical indication, and I don’t encourage my patients to do so either. That being said, there are a lot of legitimate reasons for induction.

Furthermore, pregnancy and birth are highly individual experiences with a strong psychological component, and I acknowledge that what makes me feel safe and fulfilled isn’t necessarily what makes other moms feel safe and fulfilled. Just recently, a dear patient begged me for an elective induction. I thought she was a little crazy to want that, but in her particular circumstances—a multiparous mom with a favorable cervix, a prior uncomplicated vaginal birth, and difficult child care logistics for her other child—there was no real reason to tell her no. She had a lovely induced birth with Pitocin and an epidural and was very satisfied with the experience.

What’s The Difference Between “Elective” and “Medically-Indicated” Induction?

Let’s take a moment to clarify something: An elective induction is one that’s chosen by the patient and/or her care team even though there isn’t a clear medical reason to give birth. A medically-indicated induction is done because continuing the pregnancy poses increased risk to the mother or baby. Sounds black and white, right?

But some medical indications for induction are strong and extremely well-supported by evidence. In certain situations, remaining pregnant is genuinely dangerous or even life-threatening (e.g. preeclampsia with severe features, uncontrolled gestational diabetes, cholestasis of pregnancy with very high bile acids, or severe fetal growth restriction).

Other times, there are less clear-cut indications for induction that shouldn’t be dismissed out of hand. The risk of stillbirth does increase with factors like advanced maternal age, obesity, and continuing pregnancy into later gestational ages.6 Unfortunately, induction is often presented to mothers as a requirement rather than a risk-reducing choice. The message is “You can say no, but you’ll be risking your baby’s life” which can feel really coercive, especially because the absolute risk of stillbirth, even in higher-risk groups, remains relatively low.

But no one wants to get to the end of a pregnancy and lose their baby, and induction can sometimes prevent that horrible outcome. So even if uncommon, the stillbirth threat looms large. It also weighs heavily on obstetricians, who face the highest malpractice risk of any medical specialty, with stillbirth or neonatal death the second most common reason they are sued.

On the bright side, the U.S. stillbirth rate does seem to have fallen modestly over the last twenty years, and increased induction could be one of the reasons.7

But when it comes to considering the risk of stillbirth, two moms—or two medical professionals—can look at the same statistic and come to different conclusions. For example, the graph below8 shows the risk of stillbirth with advancing gestational age. In the U.S., including in my hospital-based midwifery practice, induction at 41 weeks is considered medically-indicated rather than purely elective.9

But reasonable people could disagree about when it makes sense to stop waiting and induce labor, especially because this intervention is not without its own risks.

What Inductions Look Like From My Perspective

I consider myself one such reasonable person, and—as I stated earlier—I dislike inductions, so I don’t recommend them until 41-42 wk unless another medical complication or risk factor pops up sooner. My knowledge of the benefits of physiologic labor and the fact that, left to nature, about 95% of women will enter labor before 42 weeks, give me the confidence to recommend that low-risk moms10 let their babies choose their own birthdays.11

That being said, as a midwife caring for a fairly high-risk population, I collaborate with my obstetrician friends on a lot of inductions. So I’d like to explain what they look like from my perspective, and why this leads me to avoid them unless medically necessary. If you’re not into boring, sciency stuff, feel free to skip this part!

Cervical ripening

When you begin an induction, you are often fighting against nature—trying to get a mom’s rock-hard cervix to soften, dilate, and give up a baby before it wants to. A lot of first-time moms come in for induction like this—though not all. If you’re lucky enough to have a soft, thin, 2-3 cm dilated cervix at the beginning of your induction,12 WOO HOO! You can skip ahead to the “oxytocin” part knowing that your chances of induction ending in vaginal birth are a lot higher.13

Cervical ripening often starts at night: a mom goes into the hospital around 8 or 9 p.m. with the idea that she will sleep through the first part of the induction. In reality, she has an IV and continuous fetal monitoring cables, and a nurse is coming in every 30–60 minutes to reposition monitors, take vitals or give medication. Some moms get a nap here or there, but I would not call it a great night of sleep. So a mom is often starting a 24–48 hour process already exhausted.

One cervical ripening option is misoprostol (Cytotec), which can be given orally or vaginally every two or four hours. What makes me uneasy about this drug is how variable the response can be. I’ve had patients get three or four doses and have almost nothing happen. I’ve also seen crazy, intense labor contractions every 1-2 minutes come on very suddenly. We call this tachysystole, and while it’s usually manageable, it can become dangerous if contractions become too frequent or prolonged. But once Cytotec has been given, you can’t take it back. Most of the time that’s fine, but the edge cases are very memorable and have left me with a certain discomfort and fear when using this drug.14

The alternative drug for cervical ripening is dinoprostone (Cervidil)—a vaginal insert placed next to the cervix and left in for up to 12 hours, or removed sooner if necessary. I tend to like Cervidil more because it is removable, although at my old hospital we were discouraged from using it because it was more expensive than Cytotec (like, $700 vs 25 cents. It is also FDA approved, whereas Cytotec is used off-label.) It also doesn’t require the same frequent dosing that Cytotec does, so it can allow the patient more time to rest with fewer interruptions from staff. Some clinicians find it less effective than Cytotec, though this is debated.

During cervical ripening with either agent, the patient has to remain in the hospital. That’s because pharmacologic cervical ripening can occasionally cause excessive uterine activity or changes in the fetal heart rate that require prompt intervention, and because continuous fetal monitoring is standard during this phase. In patients attempting a VBAC, misoprostol and Cervidil are contraindicated because they are linked to increased rates of uterine rupture—which should serve as a reminder of how powerful and sometimes unpredictable these drugs can be.

Personally, I’ve always found it hard to fully square the idea that “these drugs are perfectly safe” with the reality that we insist on hospital admission and continuous fetal monitoring while using them. That being said, if induction is being recommended for a legitimate medical indication, the risks of continuing the pregnancy probably outweigh the risks of these medications.

The other way to help dilate the cervix is a cervical ripening balloon (Foley or Cook catheter). These are mostly mechanical methods of dilation—a balloon is placed through the cervix and gradually inflated to physically stretch it open—but there is also some secondary hormonal effect because stretching the cervix can trigger local prostaglandin release.

Having a cervical ripening balloon put in can be very painful. Moms often hate the placement, and I hate putting them in because I feel like I am torturing someone. At the same time, most people are tough, and can handle it—and we can always ask the anesthesiologist for help if medications are needed to tolerate the procedure. And once it’s in, it doesn’t bother people too much. Some clinics and hospitals are even allowing patients to go home for the night after it’s placed! I love this idea, because it shaves some time in hospital off of what can be a long induction process.

Cervical ripening balloons sometimes fall out on their own when the cervix has opened sufficiently, but otherwise they are usually deflated and pulled out after 12 hours. They can also be used in conjunction with low-dose Pitocin. When the balloon is out, we usually find the cervix significantly more dilated and thinner.

My complaint about cervical ripening balloons is that they seem to create a “fake four” or “fake five” centimeters dilation after a patient is done using them. By that I mean, the cervix may technically be more dilated than before, but the texture remains the same—it’s firm, rather than soft, which means it still doesn’t open easily with contractions. The bulb can also seem to displace the baby’s head, making it less engaged in the pelvis, and more likely to come down in a funny way that causes difficult descent. It has also been linked to cord prolapse in the literature15, but this is still an extremely rare event. Furthermore, these ripening balloons don’t usually change much hormonally, so even if more dilated, it doesn’t guarantee that continuing the induction with Pitocin will go well. So basically, they help, but are not a slam dunk.

Oxytocin (Pitocin)

After any of these cervical ripening methods, the next step is oxytocin (Pitocin). Normally, labor appears to be initiated by signals from the fetus. As the fetus reaches maturity, hormonal and inflammatory signals (including signals associated with fetal lung maturation) stimulate prostaglandin release and make the uterus increasingly responsive to oxytocin. The mother’s body then releases increasing amounts of oxytocin, creating the powerful positive feedback loop that drives labor contractions. We don’t know exactly what determines the precise timing of labor, but this coordinated maternal–fetal signaling process plays the central role.

So by giving synthetic oxytocin, we are basically giving your body the hormone that causes labor contractions. Some moms respond quickly and move into active labor with strong, regular contractions. Others can be on escalating doses for hours with minimal cervical change. A person’s response has a lot to do with how many receptors for oxytocin her uterus has. Because these receptors naturally multiply as pregnancy nears its end, an early induction or an unripened cervix often requires higher doses and more time to stimulate effective contractions.

The problem with synthetic oxytocin (and why I prefer endogenous oxytocin!) is that your body is no longer directing the process—we are. Nurses, midwives, and physicians decide how quickly to increase the medication, how strong contractions should be, whether labor is progressing “adequately,” and whether fetal heart rate changes are concerning enough to intervene. Some of these decisions are guided by protocols, but there is a fair amount of subjectivity involved—and I’m not gonna say we never fight amongst ourselves about the best course of action.16

Once Pitocin enters the picture, other interventions often follow. Partly because induced labors are often longer and more painful, moms are more likely to get an epidural. I honestly don’t have any problem with epidurals—they can be a lifesaver, but they change labor dynamics quite a bit, as I’ve written about before.

Fetal heart tracings are watched closely during induction with Pitocin because excessive uterine stimulation can stress the baby—but fetal heart rate monitoring is such an imperfect tool. Dubbed “the worst test in medicine” by the New York Times, these tracings frequently lead to C-sections despite an extremely high false-positive rate at identifying babies in distress. As a result, Pitocin inductions can create situations where clinicians are balancing competing concerns: increase the Pitocin and risk stressing the baby, or decrease it and risk stalling labor entirely.

If external monitoring becomes difficult, internal monitors are commonly recommended, especially if clinicians are trying to determine whether contractions are strong enough or whether the fetal heart rate tracing is truly concerning. That means more cervical exams, more wires, and higher risk of infection. A fetal scalp electrode (FSE) is a tiny wire screwed into the baby’s scalp to get an accurate reading of the heart tones. An intrauterine pressure catheter (IUPC) can trace the strength of contractions more accurately than an external monitor, so they are commonly used in inductions, especially if the mom has an epidural or labor is not progressing well.

Emotionally, inductions can be rough. Even the strongest, calmest, best-supported mothers can reach a point of profound desperation during a prolonged induction. I know because I have personally experienced this. At the end of my first birth, a 48-hour process with about 24 hours of Pitocin, I had not slept, eaten normally, or left my tiny L&D room for many hours. It was probably the closest to insanity I’ve ever felt—and this was in a situation where I had the utmost support from some of my favorite nurses, midwives, and my husband. I hated going through that, and I hate watching other moms go through it. When it happens, I have to dig deep and find my absolute best cheerleader self.

My Overall Takeaways About The Induction Process

I realize that what I’ve written above could feel like a threat or a worst-case scenario, so let me be clear that most inductions go quite well. I definitely don’t want to scare anyone away from an induction that they truly need. I’m just trying to paint an honest picture of what it feels like from my side of the labor room, so you can understand why I like spontaneous labor so much more.

And if I’m honest, I think part of the difference between how many midwives and physicians typically view induction comes down to proximity. Midwives often spend long stretches of time physically in the labor room, sitting with women during the process. The obstetric model of care usually has the physician coming in every 4-8 hours throughout the labor for 10-15 minutes, and then showing up to catch the baby at the end of the pushing phase.17 After enough years of watching women tethered to monitors, catheters and IV poles, unable to sleep, exhausted, discouraged, and desperately asking when it will finally be over, it becomes hard not to develop a complicated relationship with induction.

I realize that I’ve said a lot here, so let me just summarize my biggest suggestions:

• Induction is not a walk in the park. I personally wouldn’t sign up for it unless there is a legitimate medical reason, especially if you do not have a favorable cervix, but different moms want different things

• Risk factors for stillbirth can be a legitimate medical reasons. If this is why your doctor or midwife is recommending induction, ask for information on what increased risk of stillbirth you might be accepting by waiting for spontaneous labor

• If you need to be induced, and you do not have a favorable cervix, you are in for a long ride, but you will likely still have a vaginal birth if you (and the people taking care of you) are patient. My favorite cervical ripening method is Cervidil, but this is mostly just based on my experience/opinion! If you are offered an out-of-hospital cervical ripening balloon, that is something to seriously consider

• I do not think induction vastly changes your individual chances of C-section (I also do not believe it improves them—see below section!) unless you are being cared for by people less likely to follow evidence-based recommendations for C-section

• The benefits of having a doula and/or using midwifery care apply whether you are being induced or not

But What About The ARRIVE Trial?

Thus far, I’ve argued against elective induction of labor on the grounds that the process often isn’t pretty. But you may be thinking “Ok, isn’t spontaneous labor also hard? Isn’t it also unpredictable, long, and sometimes complicated? And didn’t the ARRIVE trial show that elective induction at 39 weeks actually lowers the cesarean rate for first time moms?” It has been widely cited as one of the strongest pieces of evidence we have in favor of elective induction.

First of all, let me just say that my hospital-based midwifery practice was already achieving C-section rates lower than the ARRIVE trial despite caring for a fairly high-risk population—and we were not doing this through routine elective induction.

When the results of ARRIVE first came out, I remember feeling a mix of frustration and unease that was hard to articulate without sounding like a whiny, biased midwife with a “natural birth” agenda. Obviously, we can’t just dismiss the results of a well-done study because we don’t like them. But my big concern was that people would run away with these findings even though there was little chance of them actually translating into lower C-section rates in real life.

Thus far, my concerns have been valid. Since ARRIVE was published in 2018, we have not seen a substantial reduction in the overall nulliparous, term, singleton, vertex (NTSV) cesarean rate at the population level, despite all the women being pressured into unnecessary inductions.

I have some guesses as to why. First of all, I question the supremacy of a randomized controlled trial (RCT) in assessing birth outcomes. I actually debated with about RCTs vs. retrospective data in assessing birth outcomes on her Parent Data podcast! Start listening at 21:10 if you want to hear my full explanation.

Basically, I think retrospective and observational data is more valuable, because it shows how people actually practice in the real world. The pressures on obstetricians are quite different on a random labor and delivery unit in West Virginia at 10 p.m. on a Friday night than within the confines of an RCT where physicians are being watched and protocols for evidence-based cesarean are being followed.

What stood out to me about the ARRIVE trial was that both arms of the study achieved cesarean rates substantially lower than the national average for NTSV births, which is 25–27% and varies substantially by hospital. For example, one study of California hospitals showed nearly 5-fold variation in NTSV cesarean rates across labor and delivery units (18.5% to 84.6%)!

C-section outcomes are highly institution-dependent, and sadly, most of us don’t have control over whether or not the hospital nearby is C-section happy.

So, not to drag into this, but I recently experienced some intellectual whiplash reading her Substack. First, she published a beautiful piece called To Home Birth or Not to Home Birth? that I found very helpful and accurate. My only concern was that it didn’t spend much time defining which kind of women were low-risk enough for home birth, or acknowledging that a large percentage of women—probably the majority—either would not be good candidates for home birth, would not personally want one (epidurals are a popular choice!) or simply would not have access to qualified home birth midwives. Also, about one-third of first-time mothers planning a home birth will ultimately transfer to the hospital at some point during labor anyway.

Then, in Should You Induce at 39 Weeks? she basically came to the polar opposite conclusion, glazing the ARRIVE trial and saying that for everyone else who is planning to give birth at a hospital, you might as well just get induced at 39 weeks:

If we ignore individual preferences (which we shouldn’t) and just look at the data, then it seems to me like well-integrated, midwife-attended home birth is still optimal choice for low-risk pregnancies in terms of maternal outcomes (as I reviewed in depth here), but if you are going to give birth in a hospital, and it’s your first birth, outcomes are actually slightly better if you induce at 39 weeks.

Ok, sorry, but I basically started my whole “A Moderate Midwife” Substack to present the viewpoint that there are more than two choices in birth. There is actually a lot between a zero-intervention home birth and a 39-week induction with every possible intervention. You can have a nice hospital birth.

And maybe I’m just in a bad mood because it feels like she left out the substantial number of CNMs in our country kicking butt at reducing the C-section rate. We’re active in all 50 states, and 94% of us attend births in hospitals, making us a lot more accessible to the general population than your average home birth midwife.18

Take a look at this beautiful recent study (N=7345) from the Journal of Midwifery and Women’s Health where induction was common, but not routine, and it didn’t seem to impact the C-section rate much: Outcomes for Labor Induction Compared With Expectant Management Among Women Receiving Hospital-Based, Midwifery-Led Care:

Look at the NTSV C-section rate without any kind of routine IOL policy:

The overall cesarean birth rate was 10.7%; the nulliparous, term, singleton, vertex cesarean birth rate was 18.4%. Labor induction occurred in 28.8% of births. Cesarean birth rates following induction of labor (IOL) ranged from 10.5% at 39 weeks to 31.1% at 42 weeks. No significant differences in cesarean birth rates were observed between IOL and expectant management groups across gestational ages in adjusted analyses. Secondary outcomes, including postpartum hemorrhage, Apgar scores, and neonatal intensive care unit admission showed no significant differences across groups. Time from admission to birth was significantly longer following IOL, averaging 31.5 compared with 12.6 hours for spontaneous labor at 37 weeks.

I highlighted that last bit just to remind everyone why I hate inductions. It’s not necessarily that they are more likely to end in C-section. It’s that they are longer and more unpleasant.

And this is exactly why I’m so interested in the French ARRIVE trial, now underway, which is attempting to replicate the original ARRIVE findings in a healthcare system that looks very different from ours in that 70-80% of care during birth is provided by midwives. That’s right—in France, midwives are not some fringe alternative. They are the default providers for low-risk labor care. And that matters because (surprise, surprise!) baseline cesarean rates in this country are already much lower. The expected control-group cesarean rate in the French trial is around 15%, compared with roughly 22% in the original ARRIVE trial.

If a system already achieves relatively low cesarean rates through midwifery-led, physiologic labor management, does adding more elective induction improve outcomes further? Or was ARRIVE’s apparent benefit in reducing the C-section rate actually specific to the American obstetric environment in which the trial was done?

I guess we’re about to find out. I can’t wait!

Closing—An Analogy For Induction

I know a lot of moms struggle with knowing what to do when induction is recommended, so I have written this analogy to help you wrap your head around it:

Imagine that you are the mother of a two-year-old child, and it’s a beautiful day, so you walk several blocks to the park, hand-in-hand with your child. Once you arrive, you judge the toddler playground area to be safe, so you let him explore. He can climb the small ladder and go down the slide. He may ask to be pushed in the swing. He can contentedly toddle around in the grass nearby. You are letting him lead the experience because all is well. If nothing changes, you will let him play until he’s tired, hungry, and wants to go home.

But if you start to notice storm clouds and thunder in the distance, you will tell him it’s time to go. In some circumstances, he may not want to go! He may put up a fight. But if it’s clear by looking at the sky that you cannot stay at the park, you will snatch him up, despite his protests, and begin to lead him home. If he will not walk, you will carry him, even if he struggles and kicks. With any luck, he will be in a good mood, and come willingly. Either way, you will make this decision for him because, as the adult, you judge that the situation is dangerous.

Suppose that on the walk home, you are suddenly caught in a torrential downpour, maybe even with hail or lightning. There is a 5 in 1000 chance that you will be struck by it. So you will find cover. You duck into a nearby coffee shop.

Cold and drenched to the bone, your child crying in distress, you will lean on the safety of the coffee shop and its staff. Chances are, they will take good care of you both. They may offer you a towel, some kind words, and a warm drink.

Of course, there is a chance they will not be so kind. The coffee shop owner may complain about the wet footprints you’ve left on the floor. She may say something uncharitable like: “Didn’t you read the weather forecast today? How did you not know it was going to rain?” Perhaps she will question your parenting: “What kind of mother brings her child out in a rainstorm?”

These comments may hurt you, but you should hold your head high. You have done what you needed to do. You have brought your child out of the storm.

6

This chart from ACOG is useful at describing stillbirth risk with certain factors compared to the overall stillbirth rate, which is 6.4/1000

12

Maybe you’ve heard of the Bishop Score, but it’s a system we use to determine if someone is ready for Pitocin or requires cervical ripening first. Being honest, there is a lot of subjectivity to a Bishop score: lots of variability based on your examiner.

Lo que más le entristecía —me contó— era que siempre se habían imaginado tener una familia más numerosa. Tres o cuatro hijos. Pero ahora los médicos les desaconsejaban hacerlo. «Al parecer, no es realmente seguro someterse a más de dos cesáreas. Nos dijeron que tres como máximo», dijo, haciendo con las manos un gesto de corte a través de su abdomen. «Después de eso, le ligarán las trompas». No se les presentó como una opción.

Esta no era la primera vez que oía hablar de la regla de «solo tres cesáreas». Pacientes de México y Nicaragua me han contado lo mismo; a menudo acuden a mí entre 5 y 10 años después de su cesárea de repetición y del procedimiento de esterilización, preguntando si existe alguna manera de tener otro bebé.3 En un caso, una mujer puertorriqueña de unos treinta años me explicó que fue esterilizada tras su tercera cesárea, a la edad de 17 años. Una mujer mexicana me contó que ella no deseaba la esterilización, pero que «su esposo firmó los papeles de todos modos». Él era ahora su exesposo, y ella anhelaba profundamente tener un bebé con su nueva pareja. Otra mujer mexicana, que llevaba seis años intentando concebir sin éxito, me comentó que cree que le realizaron una esterilización durante su cesárea, aunque no tiene la certeza absoluta. «¿Hay alguna forma de averiguarlo?», preguntó.4

Sentí que una rabia familiar brotaba en mi interior al escuchar a mi amigo lamentar con tristeza la pérdida de los hijos que, probablemente, nunca llegaría a tener. Sin embargo —explicó— su esposa estaba pasando por un momento muy difícil. La recuperación de aquella cesárea estaba resultando dolorosa y ardua, y él no sabía si sería seguro para ella someterse a una intervención similar de nuevo. No le falta razón al preocuparse por la salud de su esposa, y resulta comprensible que estas inquietudes modifiquen la trayectoria de sus planes reproductivos futuros.

La morbilidad y la mortalidad materna aumentan sustancialmente con cada cesárea subsiguiente.5 En las zonas de América Latina con recursos limitados, los sistemas de salud se muestran —comprensiblemente— cautelosos ante el riesgo que supone para una mujer en particular someterse a un número excesivo de cesáreas. E incluso al margen de los casos de esterilización forzosa, muchas mujeres que dan a luz mediante cesárea optan por evitar dichos riesgos decidiendo tener menos hijos.

Si la cesárea es una causa tan importante del declive de la fertilidad, ¿por qué no aparece en las noticias?

El declive de la fertilidad en América Latina es, evidentemente, multifactorial; sin embargo, cada vez que los economistas y demógrafos hablan sobre las tasas de natalidad, parecen centrarse en la ausencia de hijos. Las mujeres de hoy en día están más formadas, empoderadas y son más «feministas», lo que las lleva a renunciar al matrimonio y a la maternidad. Los costos de la vivienda y la falta de empleos de calidad dificultan la posibilidad de mantener a una familia. Los jóvenes pasan demasiado tiempo con sus teléfonos inteligentes —apostando o consumiendo pornografía— y, sencillamente, están optando por este estilo de vida hedonista en lugar de elegir el matrimonio y la familia.

Quizás estos sean los factores principales en las naciones occidentales y ricas. Pero, basándome en mis experiencias en América Latina y en la atención a pacientes inmigrantes de la región, las causas del declive de sus tasas de natalidad son bastante diferentes. Esta cultura todavía valora enormemente la maternidad: la mayoría de las mujeres desean fervientemente y tienen la intención de ser madres, y muchas madres desean tener más de dos hijos.

Una parte más significativa del declive de la natalidad en esta zona se debe a las personas que tienen «menos hijos» de los deseados, más que a aquellas que carecen de ellos por completo. Así lo demostró Tyler Cowen en un artículo reciente sobre la drástica caída de la fertilidad en toda América Latina (las partes en negrita son énfasis mío):

Demostramos que el descenso de la fecundidad de periodo entre 2000 y 2022 se debe principalmente a reducciones en las tasas de natalidad intragrupo, más que a cambios en la composición de la población; las mayores contribuciones provienen de las mujeres más jóvenes y con menor nivel educativo. Al comparar la cohorte nacida a mediados de la década de 1950 con la nacida a mediados de la de 1970, observamos que la disminución de la fecundidad completada refleja no solo un retraso en la maternidad, sino también reducciones sustanciales en el número promedio de hijos por mujer. Este fenómeno se explica fundamentalmente por una menor fecundidad entre las madres, y no por un aumento de la ausencia de hijos.

El demógrafo Lyman Stone reconoció también el efecto de las cesáreas electivas sobre la fecundidad completada, demostrando que la prevalencia de las cesáreas presentaba una de las asociaciones más sólidas con las tasas de fecundidad —superior al efecto del uso de anticonceptivos, del control de las esposas sobre su propia salud o de la tasa de mortalidad infantil del país.

Explicó el gráfico diciendo:

Como puede observarse, las tasas más elevadas de cesáreas se asocian con un mayor número de mujeres que se detienen en tan solo uno o dos hijos, y con un menor número de mujeres que tienen tres o más partos. Esto, una vez más, coincide precisamente con lo que cabría esperar si, de hecho, las cesáreas llevaran a las mujeres a evitar los partos de mayor paridad.

Sencillamente, debe ser cierto que el uso excesivo de la cesárea está moldeando la fecundidad en América Latina de una manera que muchos economistas y demógrafos no parecen reconocer ampliamente —al menos no hasta el punto de abogar por abordar la injusticia que supone imponer a las mujeres latinas cesáreas que no están médicamente indicadas.

Creo firmemente que este factor está afectando también a la tasa de natalidad en los Estados Unidos6, y existen datos obstétricos que así lo demuestran7. Pero si las actitudes paternalistas en la medicina y el uso excesivo de la cesárea constituyen un problema en los Estados Unidos, en América Latina se hallan mucho más profundamente arraigadas.

Documentando el aumento en la prevalencia de las cesáreas en América Latina

Cuando escuché a Derek Thompson y al demógrafo Jesús Fernández-Villaverde hablar sobre la fertilidad en América Latina, estuve esperando que surgiera este factor, pero no lo hizo.

Thompson: ¿Dónde se está produciendo el colapso de la fecundidad más sorprendente del mundo?

Fernández-Villaverde: En América Latina. Si me preguntas cuál es el continente que, en este preciso momento, está experimentando una asombrosa revolución demográfica —en términos de colapso de la fecundidad— que no recibe cobertura en los grandes medios de comunicación, la respuesta es América Latina.

Permíteme poner mi ejemplo favorito: Guatemala. Me encanta Guatemala; tengo muchos buenos amigos guatemaltecos. Sin embargo, Guatemala no ha sido, precisamente, un ejemplo paradigmático de desarrollo en Centroamérica. Hacia el año 2006 o 2007 —cito de memoria—, Guatemala registraba una tasa de fecundidad de 3,9; es decir, una tasa equiparable, básicamente, a la de un país del África subsahariana. El año pasado, esa cifra rondaba probablemente el 1,9 o el 1,8. El hecho de que, en tan solo 20 años, Guatemala haya reducido a la mitad su tasa total de fecundidad resulta sencillamente alucinante. De mantenerse el ritmo actual, dentro de cinco años Guatemala tendrá una tasa de fecundidad inferior a la de la población blanca no hispana.

Sin embargo, se está produciendo otro cambio importante en Guatemala: un rápido viraje hacia el parto por cesárea, cuya incidencia ha aumentado drásticamente en las últimas dos décadas. Si bien el parto por cesárea electiva ha sido común desde hace mucho tiempo en los hospitales privados de toda América Latina, esta tendencia se está extendiendo ahora también a las comunidades indígenas rurales.

A nivel nacional, la tasa de cesáreas en Guatemala era del 11,9 % en 2002 y había ascendido al 26 % para el año 2015. Resulta difícil hallar estadísticas nacionales más recientes; no obstante, estudios más recientes sugieren que la tendencia se ha propagado a algunas poblaciones rurales. Un artículo científico reciente informó que 83 de los 98 partos (85 %) registrados en un hospital que atiende a mujeres indígenas mayas se realizaron mediante cesárea. Conjuntos de datos regionales más amplios apuntan en la misma dirección. Un gráfico publicado en el artículo *Trends in the mode of delivery of pregnant women in rural Guatemala from a Quality Improvement Database* (Tendencias en el modo de parto de mujeres embarazadas en la Guatemala rural a partir de una base de datos de mejora de la calidad) muestra que, entre 2015 y 2017, la tasa de cesáreas aumentó sustancialmente, partiendo de un ya elevado 43 % para incrementarse hasta el 64 % en tan solo dos años.

Evidentemente, si estas tasas adicionales de cesárea mejoraran sustancialmente los resultados maternos o neonatales en toda la región, tal vez serían más fáciles de justificar. Sin embargo, existen pruebas sólidas que sugieren lo contrario. Un análisis de las tasas mundiales de cesárea —que abarcó a 194 países miembros de la Organización Mundial de la Salud (OMS)— no halló ninguna mejora adicional en los resultados maternos o neonatales una vez que dichas tasas superan el 19 %. Asimismo, un estudio independiente sobre la morbilidad materna grave (hemorragias, sepsis, transfusiones sanguíneas, histerectomías, etc.) en América Latina reveló que, aproximadamente, el 70 % de los casos estaban asociados a un parto por cesárea.

A pesar de esto, las tasas de cesáreas han aumentado drásticamente en toda la región durante las últimas dos décadas; varios países informan ahora que más de la mitad de todos los nacimientos se producen por cesárea. En México, la tasa nacional de cesáreas aumentó de aproximadamente un 45% en 2010 a un 55% en 2023. Brasil y la República Dominicana han reportado algunas de las tasas más altas del mundo, superando ambos el 55% a nivel nacional. En algunos sectores del sistema de salud privado, las cifras son aún más extremas: estudios realizados en Brasil han documentado tasas de cesáreas superiores al 80% en hospitales privados.

De hecho, la región ha experimentado el mayor incremento en el uso de cesáreas a nivel mundial, pasando del 22,8% al 42,2% para el año 2014. La OMS proyecta que la tasa de cesáreas en América Latina alcanzará el 54% para el año 2030.

Si bien las tasas de cesáreas siempre han sido más elevadas entre las mujeres de mayor nivel socioeconómico y educativo en América Latina —quienes, además, suelen optar por tener menos hijos—, la tendencia de las cesáreas electivas se ha extendido también a las mujeres de menores recursos. Eche un vistazo a estas estadísticas extraídas de *Cesáreas y desigualdades sociales en 305 ciudades de América Latina*.

Pero, ¿es esto realmente lo que desean las mujeres en América Latina?

Algunos podrían objetar la idea de que las cesáreas estén contribuyendo a las bajas tasas de natalidad, argumentando, por el contrario, que la relación causal opera en sentido inverso: las mujeres que ya desean tener menos hijos son más propensas a optar por una cesárea y, tal vez, por una ligadura de trompas después de su primer o segundo bebé. Hay cierta verdad en esto, y podría explicar una pequeña parte del aumento en el número de cesáreas, especialmente entre las mujeres de mayores ingresos.

Sin embargo, a través de mi labor como enfermera partera certificada (CNM) en un centro de salud comunitario (FQHC) en los Estados Unidos —donde atiendo a muchas inmigrantes provenientes de América Latina—, observo una realidad bastante distinta. La inmensa mayoría de las madres a las que asisto se muestran, sencillamente, agradecidas por la atención que reciben, tanto aquí como en sus países de origen. No se les ocurre cuestionar las recomendaciones de un médico o una partera debidamente capacitados. Sus opciones de atención médica se limitan a las clínicas y hospitales locales; y cuando estos sistemas las orientan hacia una cesárea, les resulta sumamente difícil negarse.

Y cuando estas mujeres me relatan los motivos que les esgrimieron para practicarles una cesárea —razones que, francamente, jamás se considerarían indicaciones legítimas en el entorno hospitalario donde yo asisto partos—, lo hacen con una suerte de resignación:

«Solo atienden partos los miércoles».

«En la ecografía se veía el cordón umbilical alrededor del cuello del bebé».

«Soy demasiado bajita».

«Me pasé de la fecha prevista de parto».

«Tenía poco líquido amniótico».

«Se me rompió la bolsa».

Es más, casi ninguna de estas mujeres tiene acceso a la anestesia epidural durante el trabajo de parto en sus países de origen; lo cual significa que, a menudo, debían elegir entre someterse a una cesárea o afrontar un trabajo de parto doloroso y de varias horas de duración.

¿Saben las madres que, en ocasiones, están siendo coaccionadas para someterse a cirugías innecesarias? Sospecho que algunas sí lo saben. Cuando le pregunté el motivo de su cesárea anterior, una mujer puso los ojos en blanco y me dijo: «Siempre hacen cesáreas en México. Pagan más». Otra mujer me contó que se marchó a otro hospital en pleno trabajo de parto porque el médico —que quería irse a casa— intentaba obligarla a someterse a una cesárea. Otra más me relató que cruzó la frontera de Perú a Ecuador para dar a luz, ya que se le estaba negando la oportunidad de intentar un parto vaginal después de una cesárea (PVDC).

Otra razón por la que no creo que las mujeres latinas, en términos generales, «prefieran» las cesáreas por motivos culturales es que, cuando se les ofrece la opción, la mayoría de mis pacientes que han tenido una cesárea en otro país eligen intentar un PVDC. Esta elección está estrechamente vinculada con el deseo de tener más hijos en el futuro y con el hecho de llegar a tenerlos.

Una madre que se había sometido a una cesárea en México —tras habérsele dicho que era «demasiado estrecha» para dar a luz y que su bebé era «demasiado grande»— dio a luz a un segundo bebé, de nueve libras de peso, mediante un PVDC. Al terminar, suspiró y me dijo: «Sabía que no había nada malo en mí».

¿Por qué me importa?

Nada de esto significa que las cesáreas no sean, en ocasiones, necesarias. Pero la cesárea es un asunto de gran envergadura: una cirugía mayor que puede, simultáneamente, salvar una vida y ponerla en peligro. También limita la fertilidad. Por ello, cuando los médicos, los hospitales —o incluso países enteros de América Latina— realizan un gran porcentaje de los partos mediante cesárea, surgen serias interrogantes éticas sobre la normalización de un procedimiento que no está médicamente indicado; así como sobre el impacto que esto puede tener —intencionada o inintencionadamente— en la capacidad de una familia para tener el número de hijos que desea.

Las razones del declive de la fertilidad que más deberían preocuparnos son aquellas que llevan a las personas a tener menos hijos de los que realmente quieren. A lo largo de mi carrera, he conocido a muchas mujeres que terminaron teniendo menos hijos a consecuencia de las cesáreas; y algunas de estas cesáreas ni siquiera eran médicamente necesarias. Y, francamente, aun cuando las tasas de fertilidad desciendan, me inquieta mucho menos que ello sea fruto de la libre elección que lo que observo entre mis pacientes: mujeres que se encuentran entre la espada y la pared, incapaces —o reacias— a arriesgarse a un nuevo embarazo debido a los peligros que podría entrañar otra cesárea.

Tenemos la obligación, para con las madres de todo el mundo, de preocuparnos por esta injusticia.

Gracias por leer. Traduje esta publicación de Substack del inglés porque creo que es muy importante que personas de toda América Latina la lean. Por favor, compártela con cualquier persona a la que creas que le podría interesar.

¿Tienes opiniones o experiencias relacionadas con lo que he compartido aquí? ¿Estás de acuerdo en que las tasas de cesáreas están afectando las tasas de natalidad en América Latina? ¿Por qué o por qué no?

On a recent visit to El Salvador with my ELCA church—we’ve had a partnership there for fifteen years, and I’ve visited four times—I spoke with a Salvadoran friend who had recently welcomed a second child with his wife. With their first baby, his wife was informed by doctors that she was too estrecha—too narrow—to deliver vaginally.1 A C-section would be done instead without waiting for labor. During her second pregnancy, she was told she would need another cesarean because it was unsafe to give birth vaginally after a prior C-section.2

What saddened him most, he told me, was that they had always imagined having a larger family. Three or four children. But now the doctors were warning them against it. “Apparently it’s not really safe to have more than two C-sections. They told us three máximo,” he said, making a slashing gesture across his abdomen with his hands. “After that they’ll tie her tubes.” It was not presented as a choice.

This was not the first time I’d heard of the “three cesareans only” rule. Patients from Mexico and Nicaragua have told me the same thing, often coming to me 5 to 10 years after their repeat C-section and sterilization procedure, asking if there is any way to have another baby.3 In one case, a Puerto Rican woman in her 30s explained she was sterilized after her third C-section at age 17. A Mexican woman told me she didn’t want the sterilization but “her husband signed the papers anyway.” He was now her ex-husband, and she badly wanted a baby with a new partner. Another Mexican woman, struggling to get pregnant for 6 years, told me she thinks a sterilization was done with her C-section, but she doesn’t know for sure. “Is there any way to find out?” she asked.4

I felt a familiar rage rising in me as I heard my friend sadly lament the children he’d probably never have. But his wife was having a hard go of it, he explained. Recovering from this C-section was painful and difficult, and he didn’t know if it would be safe for her to go through it again. He’s not wrong to worry about his wife’s health, and it is reasonable that these concerns will change the trajectory of their childbearing future.

Maternal morbidity and mortality rises substantially with each subsequent cesarean.5 In under-resourced areas of Latin America, healthcare systems are understandably wary of the risk of an individual woman having too many C-sections. And even without coerced sterilization, many women who give birth by C-section will choose to avoid these risks by having fewer children.

If C-section Is Such A Big Reason For Fertility Decline, Why Doesn’t It Make The News?

Fertility decline in Latin America is obviously multi-factoral, but whenever economists and demographers talk about birth rates, they seem to focus on childlessness. Women are now more educated, empowered and “feminist,” causing them to forgo marriage and childbearing. Housing costs and a lack of good jobs make it hard to afford a family. Young people spend too much time on their smartphones—gambling or watching pornography—and are simply choosing this hedonistic lifestyle rather than marriage and family.

Perhaps these are the major factors in Western, wealthy nations. But based on my experiences in Latin America, and caring for immigrant patients from the region, the causes of their birth rate decline are quite different. This culture still values motherhood quite a bit: most women strongly desire and intend to be mothers, and many mothers want more than two children.

A larger portion of birth rate decline in this area is due to “child-fewer” rather than “childless” people. This was shown by in a recent paper about the sharp decline in fertility across Latin America (bolded parts, emphasis mine):

We show that the decline in period fertility between 2000 and 2022 is driven primarily by reductions in within-group birth rates rather than by changes in population composition, with the largest contributions coming from younger and less-educated women. Comparing the cohort born in the mid 1950s and the one born in the mid 1970s, we find that the decline in completed fertility reflects not only delayed childbearing but also substantial reductions in the average number of children per woman. This is driven primarily by lower fertility among mothers rather than by rising childlessness.

Demographer acknowledged the effect of elective C-sections on completed fertility as well, showing that C-section prevalence had one of the strongest associations with fertility rates—larger than the effect of contraception use, wives’ control of their own health, or the country’s child mortality rate.

He summarized the above graph, saying:

As can be seen, higher rates of C-sections are associated with more women stopping at just 1 or 2 children, and fewer women having 3 or more births. This is, again, precisely in line with what we would expect if in fact C-sections cause women to avoid higher-parity births.

It simply must be the case that C-section overuse is shaping Latin America’s fertility in a way that many economists and demographers don’t seem to widely acknowledge—at least not to the point that they are advocating to address the injustice of non-medically indicated cesarean being forced upon Latina women.

I strongly believe this factor is affecting the birth rate in the U.S. as well6 and there is obstetric data showing it.7 But if paternalistic attitudes in medicine and cesarean overuse are a problem in the U.S., they are far more deeply entrenched in Latin America.

Documenting The Rise in C-section Prevalence in Latin America

When I listened to and demographer Jesús Fernández-Villaverde talk about fertility in Latin America, I kept waiting for this factor to come up—but it didn’t.

Thompson: Where is the most surprising fertility collapse in the world?

Fernandez-Villaverde: Latin America. If you ask which is the main continent right now undergoing an amazing demographic revolution in terms of fertility collapse that is not covered in the mainstream media, it’s Latin America.

Let me give my favorite example: Guatemala. I love Guatemala. I have many good friends from Guatemala. But Guatemala was not really a shining example of development in Central America. Around 2006 or 2007, I’m quoting from memory, Guatemala had a fertility rate of 3.9, basically the fertility rate of a Sub-Saharan African country. Last year, it was probably around 1.9, 1.8. The fact that in 20 years Guatemala has cut in half its total fertility rate is mind-blowing. At the current speed, Guatemala will have a lower fertility rate than non-Hispanic whites in five years.

But there is another major change unfolding in Guatemala: a rapid shift toward cesarean birth, which has risen dramatically over the last two decades. While elective cesarean delivery has long been common in private hospitals across Latin America, the trend is now extending into rural Indigenous communities as well.

Nationally, Guatemala’s C-section rate was 11.9% in 2002 and had risen to 26% by 2015. More recent national statistics are difficult to find, but newer studies suggest the trend has spread to some rural populations. One recent journal article reported that 83 of 98 births (85%) at a hospital serving Indigenous Maya women in occurred by C-section. Larger regional datasets point in the same direction. A graph published in the journal article Trends in the mode of delivery of pregnant women in rural Guatemala from a Quality Improvement Database shows that from 2015 to 2017, the C-section rate went up substantially, starting at an already high 43% and increasing to 64% in just two years.

Obviously, if these additional C-section rates were substantially improving maternal or neonatal outcomes across the region, they might be easier to defend. But good evidence suggests otherwise. A analysis of global C-section rates which included 194 countries that belong to the World Health Organization (WHO) found no additional improvement in maternal or neonatal outcomes once C-section rates rise above 19%. And a separate study of severe maternal morbidity (hemorrhage, sepsis, blood transfusion, hysterectomy, etc.) in Latin America found that about 70% of cases involved a cesarean birth.

In spite of this, cesarean rates have climbed dramatically throughout the region over the last two decades, with several countries now reporting that more than half of all births occur by C-section. In Mexico, the national C-section rate rose from roughly 45% in 2010 to 55% in 2023. Brazil and the Dominican Republic have reported some of the highest rates in the world, both exceeding 55% nationally. In parts of the private healthcare system, the numbers are even more extreme: studies from Brazil have documented C-section rates above 80% in private hospitals.

In fact, the region has experienced the largest increase in cesarean use worldwide, increasing from 22.8% to 42.2% as of 2014. The WHO projects Latin America’s C-section rate will be 54% by 2030.

While C-section rates have always been higher among wealthier, more educated women in Latin America, who also tend to choose to have fewer children, the trend of elective C-section has spread to poorer women as well. Take a look at these stats from Cesarean sections and social inequalities in 305 cities of Latin America

But is this just what women in Latin America want?

Some might object to the idea that C-sections are contributing to low birth rates, arguing instead that the causation runs the other way: women who already want fewer children are more likely to choose a C-section, and perhaps a tubal sterilization after their first or second baby. There is some truth to this, and it may explain a small portion of the rise in cesareans, especially among higher-income women.

But through my work as a certified nurse-midwife (CNM) at a community health center (FQHC) in the U.S. serving many immigrants from Latin America, I see something quite different. The vast majority of the mothers I care for are simply grateful for the care they receive, both here and in their home countries. It does not occur to them to question what a trained doctor or midwife recommends. Their healthcare choices are limited to the local clinics and hospitals, and when those systems are nudging them toward a C-section, it becomes very difficult to say no.

And when women tell me the reasons they were given for cesareans—reasons that, frankly, would never be considered legitimate indications in the hospital setting where I attend births—they do so with a kind of acceptance:

“They only do births on Wednesdays.”
“The cord was around the baby’s neck on ultrasound.”
“I am too short.”
“I went past my due date.”
“My water was low.”
“My water broke.”

Furthermore, almost none of these women have access to epidural anesthesia while in labor in their home countries, meaning that they were often choosing between a C-section and an hours long, painful labor.

Do mothers know that they are sometimes being coerced into unnecessary surgeries? I suspect that some do. When asked the reason for her prior C-section, one woman rolled her eyes and told me, “Siempre hacen cesáreas en México. Pagan más.” (They always do C-sections in Mexico. They pay more.) Another women told me about leaving for a different hospital in the middle of her labor because the doctor, who wanted to go home, was trying to force her into a C-section. Another told me she crossed the border from Peru into Ecuador to give birth because she was being denied a chance at a vaginal birth after cesarean (VBAC).

Another reason I do not believe Latina women broadly “prefer” C-sections for cultural reasons is that, when offered the option, the majority of my patients who have had a C-section in another country choose to attempt a VBAC. This choice is highly associated with wanting future children, and with having them.8

One mother who had undergone a C-section in Mexico after being told she was “too narrow” to give birth, and her baby “too big,” gave birth to a second, 9-pound baby by VBAC. Afterward, she sighed and said to me, “I knew there was nothing wrong with me.”

Why Do I Care?

None of this means cesareans aren’t sometimes necessary. But C-section is a big deal—major surgery that can be both life-saving and life-threatening. It is also fertility-limiting. So when doctors, hospitals, or entire Latin American countries perform a large percentage of births by cesarean, it raises serious ethical questions about the normalization of a non-medically indicated procedure—and the impact that may have, intentionally or unintentionally, on a family’s ability to have the number of children they want.

The reasons for fertility decline that should concern us most are the ones causing people to have fewer children than they want. Over my career, I have known many women who ended up having fewer children because of cesareans, and some of these cesareans weren’t medically necessary. And frankly, even if fertility rates fall, I am far less troubled when that comes from free choice than from what I see among my patients: women whose backs are against the wall, unable or unwilling to risk another pregnancy because of the dangers another cesarean may pose.

We owe it to moms all over the world to care about this problem.

She’d had a few prenatal appointments with us but was new to the area and didn’t know where the hospital was. My medical assistant called 911 in an attempt to get her there, but the ambulance took too long. So she paced around an exam room until finally announcing “I have to push!” Then, she climbed up on the exam table and gave birth. It was really peaceful and uncomplicated—that is until the firefighters showed up in full gear and started excitedly throwing clamps and scissors at me and trying to separate the baby from the mom.

Apparently their one-hour training about how to attend births did not emphasize the importance of delayed cord clamping and skin-to-skin contact! From my perspective it was a perfect birth—she was very calm and intuitive about pushing, the baby came out breathing and crying, and the placenta delivered easily with no excess bleeding. It was funny to see that even a textbook normal birth can feel like a big, scary emergency to people who don’t see birth very often.

So, Are Humans Bad At Birth?

Well, clearly, the human described above was not. In fact, if everyone were as good at birth as her, I probably wouldn’t have a job.

But it would be disingenuous of me as a midwife to try to present this case as typical. I’ve watched humans give birth for twenty years, and over that time I’ve seen a mix of births, from “Whoops, I sneezed and gave birth in the toilet” to “It’s been three days of contractions! How can I only be 1 centimeter dilated?” There are really easy, uncomplicated births and really difficult, traumatic births—with most falling somewhere in between.

And over the years, I’ve asked myself questions like “Why is birth really easy for some people and really hard for other people?” and “Why did this person who I predicted would have a hard birth have an easy one?” and, alternatively, “Why did this person who should have had a really easy birth have a difficult one?”

On my worst shifts—when it’s 3 a.m., we’ve been pushing for 3 hours in every position other than standing on her head, and all I see is a tiny tuft of baby hair—I have even found myself asking “How could a birth canal this bad have been selected for over several thousand years of human evolution?”

Don’t worry—I never say these things out loud. That would be super discouraging.

The mystery of it all is honestly what I love about my job: it’s never boring and always keeps you on your toes. You try to recognize patterns, consider data, keep your biases in check, consider an individual mom’s priorities, and make the best recommendation possible with the information you have—while knowing full well that the person in front of you may surprise you and completely defy the statistics.

I may never have the answers I seek about why birth is so variable—but I do have a lot of guesses! I’ve been meaning to write a post exploring the evolution of human birth for a while, but it was going to require far more biological anthropology research than I realistically had time or brain power for given that I have a full-time job and am armed only with a BA in anthropology. Fortunately, did me a huge solid by researching and writing about it herself!

MOTHERHOOD UNTIL YESTERDAY

Your Body Didn't Evolve To Give Birth Easily

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4 months ago · 149 likes · 75 comments · Elena Bridgers

To summarize Elena’s article very briefly: she explores the evolutionary theories for why human birth is often difficult, painful, and dangerous. Of great interest to me, she critiques the famous “Obstetrical Dilemma” hypothesis—the idea that humans evolved a narrow pelvis for efficient upright walking while simultaneously evolving giant baby brains, leaving modern women tragically trying to squeeze enormous infants through inadequately sized holes.

This theory has absolutely permeated popular culture. I remember learning it in college anthropology classes, and it made its way into the obstetric textbooks we read in midwifery school as well. I’ve heard it mentioned in podcasts and science writing aimed at the general public, and a lot of people accept it as fact. As Elena points out, the field of medicine “seized on it with considerable enthusiasm.” In her words:

If the human birth canal is a structural compromise baked into our evolutionary architecture, the logic goes, then obstetric intervention is not an intrusion on a natural process but a brilliant correction to an evolutionary design flaw. The Obstetric Dilemma (OD) became, in other words, a justification — for inductions, for C-sections, for the entire apparatus of managed, medicalized birth.

Personally, the OD is one of my least favorite hypotheses because I see how badly it has hurt women. You have no idea how many moms I’ve met who had unnecessary C-sections because some doctor looked at them, decided they were too estrecho (narrow) to give birth vaginally, and coerced them into a C-section without even waiting for labor. This practice is absolutely common throughout Latin America, and I’ve known doctors in the U.S. who do it as well.

Women are told they are too short to give birth, too small, too old, too fat, too narrow. Their bodies are treated as inadequate before labor has even begun. Let me just say once and for all: this is BS. Before labor, you cannot reliably predict who is going to struggle to give birth.

Let me tell a story to try to bring this point home. I recently had a first-time mom ask me to check her cervix at a 40-wk prenatal visit. As I was doing it, I noticed something weird about her pelvis. The pubic symphysis felt like it was encroaching on the vaginal opening. The sitz bones seemed to jut inward, blocking the path of my fingers. It felt super crowded and narrow—alarmingly so. Not knowing what to say, I finished the exam, told her she was 1 centimeter dilated, and kept my mouth shut. But privately I was thinking: “Oh boy. How in the world is this person going to give birth vaginally?”

A week later I followed up and saw that one of my midwife coworkers had caught her baby: eight pounds, uncomplicated birth, pushed for one hour. I was shocked—and incredibly glad I’d kept my concerns to myself instead of saying something hurtful or discouraging about her ability to give birth.

Because despite twenty years of watching births, I cannot reliably predict who will give birth easily based on pelvic exams, body type, or height. So my guiding principle as a midwife is pretty simple: I assume that all moms are capable of giving birth vaginally. I cannot predict ahead of time what clinical circumstances may arise during labor, or whether a vaginal birth will ultimately be the safest option for her or her baby. But I do not assume there is some inherent flaw in her body before labor has even begun.

That doesn’t mean there aren’t trends! For example, tall women supposedly have an easier time giving birth than short women. But I have cared for tiny people who effortlessly delivered large babies, and tall, athletic people who still struggled through days of labor. Birth surprises me time and time again, and I’ve learned it doesn’t pay to stereotype moms or count them out.

This is why I’ve always had trouble accepting the Obstetrical Dilemma hypothesis. It relies heavily on skeletal measurements and interpretation of ancient fossils (sometimes not even accurately identifying male vs. female skeletons!)—as though birth outcomes can be predicted primarily by pelvic dimensions.

Obstetrics spent a long time thinking this way too. For decades, physicians performed pelvimetry: measuring women’s pelvises in an attempt to predict whether they could give birth vaginally. They even used to X-ray women in the middle of difficult labors! The problem is that it doesn’t work! The practice was abandoned because evidence suggests pelvimetry poorly predicts labor outcomes and may mostly increase cesarean rates without improving outcomes for babies.

Birth turns out to be far more dynamic and adaptable than a static set of bone measurements suggests. Pelvic diameters change with movement and position. The fetal head descends. Hormones loosen connective tissue late in pregnancy. The cervix softens, ripens, thins out, dilates over time (sometimes, a lot of time). The fetal skull molds during labor. Factors like psychological support in labor (aka “the doula effect”) also make a huge difference in the end outcome.

And then there’s the underappreciated factor that, in my experience, matters most of all: whether someone has given birth before. Human birth is often dramatically harder the first time, and I honestly do not think this fact gets enough attention.

I also think this has serious evolutionary implications. Let’s talk about that!

Human birth is harder the first time

I love birth stories, and because I’m a midwife, I’ve found that even complete strangers like to share them with me!

When it comes to describing their births, I hear a lot of people tell some version of this story: “My first birth was awful—long, painful, traumatic—because of X (hospital birth, epidural, bad nurse, not moving enough, etc.). Then my second birth was magical—short, uncomplicated, empowering—because of Y (birth center, midwife, doula, different positions, no epidural, etc.).”

And I’m not saying those factors didn’t matter! Environment, support, labor management, and birth setting can absolutely influence both the psychological experience of birth and the end outcome.

But (forgive me for being Captain Obvious): your second birth was also easier because it was your second birth!

These facts are well established. Labor is longer the first time and C-section rates are markedly higher for those who’ve never given birth vaginally before compared to those who have. Vacuum or forceps assisted birth is about 3 times more common and the chance of a 3rd or 4th degree perineal laceration is about 10 times higher for first time moms. Epidural use is more common because—duh—labor is a lot longer. Another fun fact: first time moms have longer gestations on average than women who have given birth before (40w5d vs. 40w0d) and are therefore more likely to have a postterm pregnancy and be induced.

Unsurprisingly then, serious complications for both moms and babies are also more common in first births. First-time moms are more likely to experience things like severe tearing, infection, hemorrhage, blood clots, or emergency interventions, and their babies are more likely to struggle during or immediately after birth. First babies have worse Apgar scores, are more likely to need resuscitation, to have a seizure, to suffer neurological or respiratory problems, and to experience birth injury or death.

Why am I telling you all this? It’s not to scare you into never having a first baby. It’s to reinforce my previous point: birth difficulty cannot simply be explained by the size or shape of the bony pelvis. If it could, second and third births would not so consistently become easier. Clearly, something profound changes after the body has already given birth once: it’s the elasticity and tone of the pelvic floor muscles and the soft connective tissue of the cervix and vaginal canal. And this is great news!

So the caveat I would add to Elena’s title—”Your Body Didn’t Evolve To Give Birth Easily” is your body didn’t evolve to give birth easily the first time.

In my experience, almost every “easy” birth I’ve seen—the person who accidentally gives birth at home on the way to the hospital, the one who arrives in triage complete and ready to push, and yes, the mom from the opening story who gave birth at my clinic—has been a multip (someone who has given birth before).

This is so commonly understood in my field that we have a joking phrase for it when the board fills up with first-time moms: “death by primip.” It’s not that we don’t love these moms just as much, but we know their labors are going to last longer, and there’s a higher chance they’ll end up needing interventions (like Pitocin, epidurals, C-sections, vacuum or forceps). And before you accuse us hospital birth attendants of unnecessary intervention, I want to point out that this is true even for first-time moms who are committed to non-interventive births. Transfer rates to the hospital during home or birth center birth are markedly higher (30% vs 4%!) for first time moms, as shown by this study.

First births are harder, and this is a fact of nature that we just can’t wish or birth plan our way out of. Take it from me—I really wanted a nice, low intervention birth for my first. Here’s what I got instead:

Water broke at 40w2d. Labor didn’t start. “Natural” methods of inducing labor—pumping, castor oil—didn’t work (Zero stars. Do not recommend). Finally consented to Pitocin after 24 hours. Then had another 24 hours of contractions. Got stuck at 6 cm for 12 hours. Finally got an unplanned epidural. Dilated to 10 cm. Pushed for 3 hours. Begged for a vacuum. Had a vacuum assisted vaginal birth (40w4d, 48 h later). Got a 3rd-degree laceration. Baby weighed 9 lb 6 oz.

But don’t worry, it got easier!

Second birth: went into labor on my own at 41w1d. Woke up at 1 a.m. Went to the hospital at 6:30 a.m. Gave birth at 8 a.m. Did not use an epidural. Did not tear. Baby weighed 9 lb 6 oz.

Third birth: 41w2d, woke up with mild contractions at 5:30 a.m. Walked around my house for a while. Worst labor pain of my life at 11:50 a.m.. Had my husband drive me to the hospital. Begged him to run red lights. He said “but I don’t want to hit the pedestrians.” Begged him to run red lights anyway. Arrived at hospital. Told my midwife I needed to push. Had baby 16 minutes after arrival at 12:52 p.m. Baby weighed 10 lb 14 oz. Did not tear.

Do you see the point I’m trying to make? It’s not that the human female pelvis is somehow inherently “bad at birth.” If there were something fundamentally wrong with my anatomy, why would my second and third births have been so dramatically easier—even with a baby that was 1.5 lb bigger than my first?

Some people talk about difficult human births as if we’re the only species dealing with an evolutionary compromise. But humans aren’t alone: throughout the animal kingdom, many mammals experience higher rates of difficulty, stillbirth, or neonatal loss with first offspring—including cattle, horses, and some marine mammals such as dolphins.

When I was a high school student in rural Iowa, our anatomy teacher (who was also a farmer’s wife) took us out to watch one of their cows give birth. We stood there gawking at the poor animal for what felt like forever, only to see a small orb protruding the entire time. (In retrospect, maybe a crowd of awkward teenagers staring at her crotch was not especially conducive to physiologic labor.) We eventually gave up and left, only to learn the next day that the calf had been stillborn after a 24 hr labor.

And honestly, that memory stuck with me because it raises an uncomfortable possibility: maybe evolution never particularly cared whether first births were easy, as long as they worked often enough to allow future reproductive success.

From an evolutionary perspective, a human female’s first birth did not necessarily need to be smooth, fast, or empowering. It just needed to work often enough that most women survived to reproduce again, even if their first babies died or were injured during the process. For most of human history, losing a significant portion of your children was simply a fact of life. In many premodern populations, 30–50% of children died before age five. Maternal death was tragic but far less common by comparison; even estimates as high as a 1-in-150 lifetime risk mean the vast majority of women survived childbirth long enough to conceive again.

Maybe this theory is already out there, but if not, I hope some PhD student picks it up, figures out a way to test it, and names it after me.

Here’s the encouraging part: once someone has given birth vaginally, future births are much more likely to succeed. And that, more than pelvic measurements or fossilized hip bones, may tell us something important about how human reproduction actually evolved.

What We Misunderstand About Human Evolution

I am not an evolutionary biologist, and I don’t want to overstate my expertise here. But one thing I appreciated about Elena Bridgers’s essay is that she pushes back against the common tendency to think about evolution as some kind of refining process that has our best interest at heart, gradually producing perfectly optimized organisms.

Um, no—it produces a species that survives and reproduces well enough in a given environment, while giving little care about collateral damage. And because environments constantly change, what worked reasonably well for Homo sapiens thousands of years ago may not be perfectly suited to modern life.

So when people ask whether humans are “bad at birth,” I think they are often imagining that evolution should have produced a system where labor is always safe, efficient, and uncomplicated. In the promoters of physiologic labor camp (of which I consider myself part!) you’ll often hear statements like:

“You’ll never grow a baby too big for your body.”

“Your body won’t give you pain you can’t handle.”

“Your body is not a lemon.”

That last quote, famously said by the midwife Ina May Gaskin, is one I mostly agree with. As I stated above, women have been deeply harmed (and coerced into unnecessary interventions) by being told their bodies are defective, inadequate, or incapable of giving birth.

But I also think people sometimes swing too far in the opposite direction and start imagining that nature—or God, depending on your worldview—must have created a perfectly functioning birth process for mothers and babies where nothing ever goes wrong naturally—and anything bad that happens is somehow the “fault” of too much medical intervention. I already explored this, so I won’t go into it too much:

But, in fact, I have seen a baby grow too big for someone’s body. It’s called gestational diabetes, and it happens all the time. Turns out this much sugar was not available in our ancestral environment, is not particularly good for us, and increased rates of obesity and infant macrosomia are making childbirth harder. As the mother of three macrosomic infants (no, I did not have GDM), I can attest that it’s not the best way to get yourself an easy first birth.

Here’s another example. In a recent Substack note I said the following:

I was not trying to poke the bear, but many of the comments pushed back on this recommendation on the grounds that if vitamin K were really so important, surely babies would naturally have enough of it. After all, why would evolution—or God—design imperfect babies?

But newborn vitamin K deficiency is actually a pretty good example of how evolution works. Without vitamin K prophylaxis, a small percentage of babies will experience serious bleeding, including intracranial hemorrhage (about 1 in 59). Some of those babies will die or suffer permanent neurological injury. And yet apparently this problem was never severe or consistent enough to create strong evolutionary pressure for dramatically improved placental vitamin K transfer to the baby. There may even have been tradeoffs that selected against higher fetal vitamin K levels. Pregnancy is already a relatively hypercoagulable state, and vitamin K plays a central role in clotting. Perhaps substantially increasing transfer raised the risk of dangerous clots for the mother, fetus, or placenta. We do not really know.

What we do know is that natural selection has never meant “optimized for zero risk,” and evolution tolerates far more suffering, dysfunction, infant loss, and maternal injury than modern people are comfortable with. And when there’s a simple intervention to prevent suffering or death, most people are pretty comfortable saying “screw evolution.” They will give their baby the vitamin K shot, the vaccines, the antibiotics. They will accept the C-section, the blood transfusion, the magnesium sulfate. Very few people will willingly sign up to be the victim of natural selection when the bad outcome is staring them in the face.

But some of these bad outcomes—like intracranial bleeding due to inborn vitamin K deficiency—are relatively rare. Which means most people will never personally witness them. You can make the “wrong” decision and get away with it nearly all the time. And as humans, we are notoriously bad at intuitively weighing low-probability, high-consequence risks. We tend to reason from anecdotes, personal experience, ideology, or what feels emotionally salient to us—not from population-level probabilities.

As I see it, the challenge for modern humans is not deciding whether to trust nature or reject it. It is figuring out which aspects of our biology we can use to our advantage, which risks we are willing to tolerate, and which interventions meaningfully improve health and survival without creating larger harms in return. That requires humility about the strengths and weaknesses of our bodies, and the value of medical intervention.

What is my takeaway?

Long, difficult, exhausting (and usually first) labors may have always been part of normal human reproduction, but that doesn’t mean that women are “flawed.” Even difficult first births likely resulted in maternal survival and future reproduction, and that was enough for selection. Women are, afterall, tough. 💪

Human birth has always been a system shaped by tradeoffs rather than optimization, which is honestly what we’re left with today. Some risks are avoidable, some are rare, and some are newly relevant in modern (sugar-filled!) environments.

We have evolved highly sophisticated immune systems and reproductive systems. But we also live in a world where we can amplify those systems (think: vaccines), correct for their blind spots (think: vitamin K), and sometimes bypass their limits entirely (think: safe cesarean). Personally, I don’t see any conflict in appreciating that design while also choosing reasonable interventions. If anything, it feels like using what evolution—and God, if you’re a person of faith—gave us at its highest level. As humans we can use our ingenuity and prosocial nature to improve the world for ourselves, our children and our neighbors.

So the question isn’t whether we should accept or reject “the natural” but rather, how to make decisions in a system where neither nature nor intervention is perfectly safe, and where the best outcomes usually come from knowing how and when to take advantage of both.

I am curious how others navigate this question. How do you decide when to trust your body and when to trust intervention in making decisions for yourself or your children?

But the funny thing about birth that no one really emphasizes is—there is a lot that comes after it. Like, they expect you to take that child home with you and actually raise him. This requires making very hard decisions. If you decide wrong you could ruin his life, or at least that’s what a lot of people will tell you in various corners of Parenting Substack. But none of this was covered in childbirth classes. WTH!

So in this essay, I want to talk about one hard decision that certain parents face: whether or not to “redshirt” a child — that is, delay kindergarten by a year so they aren’t placed in the class their birth date would normally dictate. Cutoff dates vary by district, but in mine, a child has to turn four by September 1st to join our district’s half day K-4 program, or five by September 1st to start full day K-5, meaning that a child born in mid to late August like my son will be the youngest in the class, and a child born in early September will be the oldest in the class.

Redshirting is most common for kids born in the summer months—let’s say June through August (though I have also seen May!)— and more common for boys than girls. The thinking goes that boys are less developmentally ready for school, and struggle more with things like sitting still, concentrating and staying organized. So holding them back a year presumably has academic and social-emotional advantages. As it turns out, it also has huge athletic advantages for kids who plan to participate in sports (we’ll talk about that later!)

This topic has gotten a lot of attention lately, in part due to publicity by people like . In his advocacy for boys and men, he mentions redshirting as a system-level policy idea to help close the achievement gap between boys and girls in school. While acknowledging that there are significant trade-offs and uncertainties, this proposal is one among many that might help counter some of the problems boys face throughout their school years. While I found his points thought-provoking and especially loved this podcast he did with Emily Oster, there was just one problem: all this came out long after my husband and I had already made a decision for our son.

What follows is a reflection on how we made that decision and how it’s going. So yeah, basically, it’s “me-search.” And as some very wise people (eg. ) have pointed out, “me-search” isn’t necessarily scientifically rigorous. So don’t worry—I’m not here to give you advice on this topic. And, respectfully, I’m not really looking for any either. No need to tell me that I made a huge mistake, that I should have quit my job and homeschooled, or sent my kid to a multi-age Montessori instead. Maybe there are downsides to my decision that will reveal themselves in fifteen years when my son is living in a van down by the river. Stay tuned for that essay if Substack is still a thing in 2041.

But for now, I just want to explore the pros and cons of this issue in a way that hopefully makes this decision slightly easier—or at least, lighter—for other parents. As you might have guessed from my moderate handle, my overall takeaway is that, like so many things in parenting, there’s no single “right way.” There are just a lot of factors: your child, your family, and your schooling options. And even after you weigh all that, there will still be some uncertainty and lack of control over the outcome that you just have to accept.

I promise, if I hint even once that my way is the right way, you have permission to immediately unsubscribe.

How did we decide?

Like any educated, data-driven parent, when I realized I’d have to decide whether or not to redshirt my child, I did my homework: extensively researching the topic and carefully reading articles that supported the decision I already wanted to make.

It’s been a while, so I’m struggling to find the articles I read back then, but they basically said that, yes, children who are the oldest in their class tend to perform better in school than those who are the youngest. These advantages were strong in early elementary but faded by high school—basically gone by 10th grade. In addition, the kids who started school earlier were further ahead in their careers and making more money in their mid-20s, basically because they started their education sooner. Not rocket science.

Education and academic achievement are pretty important to both me and my husband, and we didn’t want to put our son in a situation where he would struggle or be at a permanent disadvantage. But he had already shown himself to be a bright and gregarious child. Besides, when it came to academics, we of course knew that our son was going to be a genius. I mean, his genes came from us. 😉

Another consideration was maturity and social-emotional ability. A lot of people decide to redshirt because they’re worried their child might not fit in well with older kids, might get bullied, or might struggle to make friends. But by some miracle, this child of ours had inherited a recessive gene that made him incredibly engaging, outgoing and well-liked by people of all ages, very much unlike his shy, quiet parents. I wrote about his unique sales acumen here—he had a talent for charming neighbors into buying tons of overpriced popcorn for his Boy Scout fundraiser.

The next consideration for us was money. Our August boy was the middle child, with a big sister three grades ahead of him and a little brother three grades behind. By the time he was eligible for full-day K-5, my husband and I had been paying up the wazoo for childcare for about eight years, often for multiple kids at once. For most of my kids’ early childhood, our childcare costs exceeded our mortgage by a lot.

Though I only worked part-time (three days a week), my schedule was all over the place: night shifts that wiped me out the next day, random weekends and therefore weekdays off—exactly the kind of schedule daycares are not designed for. We had a nanny for a while, and she was great, but we couldn’t give her enough consistent hours to make it worth her while, and she eventually left for a family who could offer full-time work. After that, it was back to daycare, where we were often forced to pay for care we weren’t even using (five days a week) to reserve a spot.

During the year our son was eligible for K-4, we still had a nanny on the days I worked, which made the half-day schedule manageable. But by the time he reached K-5 and was eligible for full-day school, she was gone and we hadn’t been able to find a replacement. And with only one child at home full-time, a nanny no longer made financial sense anyway. So we enrolled our youngest in full-time daycare and sent our middle son to full day K-5.

That’s when it really hit me: if our middle son had been born just a few weeks later, we would have been paying for another full year of daycare at the same time. So the fact that he was born in August and not September saved us a huge chunk of change. At the time, we paid about $250 a week for childcare—close to $12,000 for the year.

Ok, I know what you are thinking. How can you put a price on your child like that? But I’m not the only one considering this, and this is where the redshirting conversation gets messy. As points out in that podcast I referenced earlier, redshirting is more common among higher-income families than lower-income ones, which is probably the opposite of how it should work, since kids from higher-income families already tend to arrive at school with more advantages. In theory, the developmental benefits of being older in a class might matter even more for lower-income children, but those are often the kids least likely to access them.

The broader context is that childcare itself is really expensive! The national average for preschool-aged children runs roughly $10,000–$19,500 per year, with high-cost cities like San Francisco, New York City, and Washington, D.C. often closer to $18,000–$25,000. So you really can’t blame parents for factoring that into their decision about redshirting.

For me personally, public school is the only financial benefit I’ve ever received for my kids. We are the quintessential example of parenting with a minimal village: both sides of our family live far away. So after years of expensive childcare bills—and then paying thousands each year in property taxes, much of it going to school referendums (I’m not complaining! I voted for them every time!)—I don’t feel especially conflicted or guilty about sending my son to public school when he was eligible.

That being said, I want to acknowledge just how messed up it is that family finances probably have a significant impact on the decision about whether or not to redshirt. I also want to point out that people like my sister, who was a stay-at-home mom and didn’t consider childcare expenses in the equation, chose to redshirt her two October born boys (the New Jersey public schools had an ever later cutoff, meaning she could have sent them to kindergarten before they were officially five) in part because the financial calculus was a lot different to her.

How did it go in the early years?

At different points in my son’s childhood, I have felt we made the right decision, and at other times the wrong one. One example of the latter was an infamous parent-teacher conference. Keep in mind that when my son entered K-4, he had just turned four two weeks earlier—the oldest kids in his class had been alive 25% longer than him. This meant they were pretty much better at everything: coloring inside the lines, drawing, cutting, and sharing. In spite of that, he kept up with the class (or so we thought).

When we met with his teacher for a conference in March of his K-4 year, she showed us some squiggly lines on a paper.

“This is your son writing his name in September,” she pointed out. “This is in December. And this is in March.”

The results were clear: somehow, our son’s penmanship had gotten worse over six months!

This K-4 teacher had also taught my daughter, consistently calling her “bright.” She is May-born, so also not the oldest, but not the youngest—and, well, a girl. It was very clear to us that the teacher was hinting at something very different about our son. She also showed us some shapes she had asked the kids to cut out. Turns out, my son was also very bad at cutting.

She didn’t say it outright, but you could tell from the “some parents decide to have their kids repeat K-4” undertones that she didn’t necessarily think he was ready to move on to K-5. This was hard for us to hear. And as we’ve realized now, if cutting or neat handwriting were important for advancement, certain members of our family (including my husband and brothers) might still be in kindergarten.

At that point, we hesitated a bit. We talked to our son, who resolutely swore he was ready for K-5, and that he would work hard. When we considered our family situation—my husband working out of town a lot, me trying to balance part-time work with a one-year-old at home and an older child who was not without her own needs—we realized we hadn’t been giving our middle son much individual attention. So basically, we chose to ignore her hints, spend some more time working on our son’s (obviously lacking) hand-eye coordination, and move him up to K-5 with the rest of his class.

Other than those first few years—maybe kindergarten and first grade—he’s felt at grade level, if not above. Then the Covid pandemic came along and our public school district went fully virtual for the 2020–2021 school year, a decision we just couldn’t abide for our son, who was a third grader at the time. In addition to both being essential workers who had to go to work in person or quit, we did not feel competent to homeschool (tried that March through May 2020 and it did NOT go well). So we sent our boys to a private Catholic school for that year, which turned out to be a really good decision.

By the time my middle son returned to his public school class in fourth grade, any differences from his classmates had largely disappeared. I’m still not sure if this was just due to increased maturity, or if a year of in-person school while his peers had done everything at home on an iPad basically leveled the playing field. Either way, he had caught up, and in some subjects (like math, where he skipped a grade) was performing above grade level.

How’s it going now?

My son is going to graduate 8th grade this year, and he is very excited. When I talk to him about the redshirting decision, he tells me he is very glad we didn’t do it because he is so sick of middle school and ready to move on to high school. I’m happy for him, and it’s great.

But one area where this has been less great is athletics. While he’s a good athlete, he has almost always been at an age disadvantage relative to his peers. And this is something no one really spelled out to me when we were making this decision: unlike academic differences, which tend to even out over time, age differences in sports don’t fully disappear, especially for males, who apparently do not reach peak strength until their late 20s or early 30s. And these athletic differences become more pronounced as kids go through puberty!

Even when he eventually becomes one of the oldest students—a senior in high school—he will still be competing against athletes who are a year older than him, either because they are the oldest in their cohort, or because they were redshirted. In other words, he may never actually experience the advantage of being one of the oldest in his cohort in the same way some of his competitors will.

A great example is Bo Bassett, a Pennsylvania wrestler who is widely considered one of the best high school wrestlers in the country. He won a state title in 8th grade, has already beaten college national champions, and will graduate high school at 19—meaning he was essentially one of the oldest kids in his class for his entire high school career. It doesn’t take anything away from how good he is, but it does put things in perspective. When he won a high school state championship in 8th grade, he was the same age my son will be as a sophomore. And even as he’s beating NCAA college athletes while still in high school, it’s worth remembering that he is doing it at 19—an age when many athletes are in college wrestling programs already.

That being said, my kids were probably never going to be Division I athletes, and I’m not sure I would have done anything differently. It’s just something worth noting: many of the top athletes tend to be among the oldest in their age groups. Athletics, after all, is where the word “redshirting” even comes from.

popularized this idea in Outliers, pointing out the “relative age effect” in youth hockey: in elite Canadian leagues, a disproportionate number of players are born in the early months of the year (January through March). The idea is that those kids are the oldest in their cohort—bigger, stronger, more coordinated—so they get more attention, better coaching, and more opportunities. Over time, those small early advantages compound, making it more likely that they will reach the highest levels.

And honestly, this has absolutely matched my experience.

In Wisconsin, the state wrestling tournament uses two-year age brackets. In his older year, my son qualifies for state; in his younger year, he sometimes doesn’t (this year: woo hoo, he did). And when you look at the kids who make the podium (top 6 out of 24 state qualifiers), they are almost always on the older side of the bracket.

For example, this past year in his 2011–2012 bracket, four of the six medalists were born in 2011 and only two in 2012. That’s striking, because that age group spans roughly 16 months of birth dates for 8th graders—only four of those months fall in 2011, while twelve fall in 2012 (not counting the redshirted 8th graders!) You might expect a more even distribution, but instead, the winners are clustered among the oldest athletes in that window. In other words, a relatively small slice of the oldest kids is overrepresented on the podium.

And this makes perfect sense when you consider puberty. A year or even several months can translate into meaningful differences in strength—especially in a sport like wrestling.

Here’s another example: our middle school wrestling team includes 6th through 8th graders, and matchups are based on weight. My son is on the bigger side for his age and pretty athletic. But in 6th grade, even though he made the varsity lineup at 117 lbs, he was often wrestling 8th graders of the same weight—sometimes two, or even three years older if they had been redshirted.

I remember watching in quiet horror as he wrestled an 8th grade state qualifier and podium finisher who could pick him up and throw him around like it was nothing. My husband later said it was “like watching a boy wrestle a man,” and he wasn’t wrong. When your prepubescent 6th grade son—the youngest in his class—is going up against an 8th grader with a mustache who’s already placed at state, the odds are not exactly in your favor.

One of our proudest moments was watching him not get pinned by a really good state-qualifying older wrestler. He still lost—by tech fall—meaning the opposing team picked up five points, not six. It felt like an accomplishment at the time.

Given that I’m sharing all this, you might think we regret not redshirting our son. But the truth is, nah, we don’t. We care about sports because we think they are good for him, but we know they’re not the most important thing.

And in a weird way, I think him always being the underdog has worked in his favor. He’s used to throwing himself into the ring, losing and then picking himself up off the ground. He’s developed a certain immunity to it, and it makes his wins even sweeter. If one of the benefits of redshirting is giving your kid the confidence that comes from always being at the top of the class—or the top of the podium—then one of the benefits of not redshirting is raising a humble kid who can maintain some sense of self-esteem in spite of all the losses. Cue the music: 🎶I get knocked down, but I get up again. No you’re never gonna keep me down.

Did not redshirting our son make it less likely that he will be recruited into a D1 wrestling program? Quite possibly! But even if that’s the case, we think he’s gained other things that might matter more.

Conclusions

If I’m honest, I have to admit that I sometimes judge redshirters—mostly because I worry they made the right decision and I made the wrong one, and that my kid’s life has been irreparably harmed because of it. But when I step back, I see there are very good reasons for redshirting, and also some downsides. So either choice can make a lot of sense depending on your circumstances.

Having already made this decision, I can’t go back—and of course there’s a fair amount of confirmation bias at play. I want to believe we made the right call, so I’m probably more alert than I should be to evidence that supports our choice. When I look ahead, I do see some advantages for him, like being able to potentially take a gap year after high school or college without feeling behind, or starting his adult life and career a little earlier than some of his peers.

On the other hand, while I was very ready—possibly too ready—for the early years to be over and for the free (or at least, paid for by my taxes) help of public school to kick in, now that I think about him turning 18 and then immediately leaving home to go to college, I feel a certain pang of sadness. I would have actually liked to have him around one more year! He’s kind of a cool kid.

I assume anyone who has made the decision to redshirt also has plenty of valid reasons, research, and anecdotes to justify their choice. And honestly, good for them. What about you? Have you experienced redshirting or not redshirting? Any pros or cons I missed? Feel free to share them in the comments.

These requests put me in a difficult position. I want moms to like me! I also want them to feel reassured, confident, and excited about their pregnancies. I completely understand the appeal of ultrasounds—seeing your baby on the big screen is fun. The pictures and videos are cool. They can be put on the refrigerator, shared on social media, and given to partners and grandparents to help them bond and make the pregnancy feel real. I feel like such a giant killjoy when I have to say no to these requests!

And sometimes I have lingering doubts about my decision. What if I reassure her that everything is fine, something goes wrong, and then she blames me for a bad outcome because I did not order an extra ultrasound? Intellectually, I know an additional scan would not prevent most complications, but many people have an inflated sense of how important ultrasounds really are, believing that they ensure the safety of a pregnancy.

They are viewed as perhaps the most important part of prenatal care, even though strong evidence that routine or repeated ultrasounds improve outcomes is lacking.

So I don’t say “no” to extra ultrasounds because I want to be dismissive of a patient’s concerns or take away a meaningful experience. I am mostly just trying to provide responsible maternity care in a system where many people seem unaware of the costs and downstream consequences of unnecessary medical testing.

This essay is my attempt to explain those consequences.

I wish more pregnant people understood what ultrasounds do well and when they are helpful—but also where they fall short and why more isn’t always better. I also want to give some information that may help moms advocate for themselves if they have concerns about the number or frequency of ultrasounds that are being recommended for them. Read on if this topic is of interest to you!

Why Are So Many Ultrasounds Being Ordered These Days?

I had three kids between 2009 and 2015, and had a total of four ultrasounds, which now seems like a drop in the bucket. Recent research suggests that women have an average of 4-5 ultrasounds per pregnancy, and that this number has increased substantially in recent years.

I’ve definitely noticed inflationary ultrasound use in my 20 years as a midwife. When I first started, our patients were getting one ultrasound in pregnancy. Now it’s at least two, with many patients having five or more. Many times, I will send a mom for her anatomy ultrasound at 20-24 weeks, and she will come back with several additional ultrasounds recommended by the maternal-fetal medicine physicians with whom I work. Personally, I think some of these scans are a good idea and warranted…and some are not.

So my critique here isn’t just of patients who want extra ultrasounds. It’s also of a medical system that prioritizes generating revenue and overvalues technology even when it hasn’t been shown to improve outcomes. This system frequently leaves moms in the dark about why additional ultrasounds are being ordered, presenting them as essential care instead of optional. The message moms receive, implicit or explicit, is that declining these ultrasounds could put their baby at serious risk. And what mom can say “no” when she believes her baby’s health is on the line?

What is rarely shared with patients is that many recommendations around additional or repeat ultrasounds are based on Level C evidence—meaning expert opinion rather than strong evidence that additional scans improve maternal or infant outcomes. This includes many recommendations around the frequency and follow-up use of ultrasounds, and the use of ultrasound for a biophysical profile test (BPP).

In practice, increased ultrasound surveillance is often applied to patients labeled “high risk,” such as those with obesity or advanced maternal age. But there is actually limited evidence that specific protocols—like weekly BPPs rather than nonstress tests (NSTs)—improve outcomes. While certain patients may have a higher baseline risk of stillbirth, it does not necessarily follow that more frequent testing reduces that risk.

I don’t want to completely devalue expert opinion here—we don’t always have perfect data to go on, and in these cases, physicians and scientists who have spent years caring for pregnant moms definitely have valuable opinions to offer. But these experts also carry their own biases.

First, they are strongly motivated by “CYA” (cover your a#$) medicine and worry about being sued if they fail to uncover a health problem, and a stillbirth occurs or a very disabled baby is born. These fears aren’t unreasonable: a study of malpractice suits showed that missing an anomaly on an ultrasound is a common reason to sue, and there have been lawsuits for “wrongful life” of a baby with a congenital abnormality. I’m going to be honest: I find this incredibly frustrating and unfair, and I wish there were laws protecting health care providers from this kind of legal action.

Another reason for ordering a lot of ultrasounds is that, in my experience, physicians tend to come from a school of thought that prioritizes tracking every detail with scientific precision and uncovering every possible abnormality, however minor or unlikely it is to affect the end outcome. Sometimes there is an unwillingness to accept uncertainty which can bias caregivers toward making firm recommendations based on imperfect data rather than simply admitting that they don’t know, for example, the severity of an abnormality or the prognosis for a baby. Instead, it becomes, “Let’s do one more ultrasound,” even when another ultrasound is very unlikely to yield useful, actionable information.

While trials have shown that routine ultrasound improves detection of anomalies and multiple pregnancies (moderate-quality evidence), they have not demonstrated improvements in perinatal mortality or other hard clinical outcomes. Yet clinicians don’t always take the time to explain this to a mom, ask what her priorities are, or give her the option of deferring another ultrasound versus following up with one.

Meanwhile, a mom may have a very different perspective. She may want to accept things as they are, and avoid the inconvenience of missed work and difficulty finding childcare to attend additional appointments. She may want to avoid bills piling up for several additional ultrasounds. She may find that the information gleaned from the ultrasound isn’t all that helpful to her, and that the process of attending multiple follow up appointments is anxiety-provoking rather than reassuring.

Sometimes it’s just a matter of miscommunication: the clinician assumes the mom wants all possible knowledge and data (that is, after all, often their personal bias as a scientist, and probably what they would want as a patient!), whereas the mom just wants reassurance, or to know if the family should start preparing for a catastrophic or life-changing diagnosis.

In my experience based on conversations with patients, ultrasound findings are not always communicated by physicians in a way that clearly distinguishes between clinically significant abnormalities and incidental findings. Over the years, I’ve talked with many moms who were frightened by ultrasound findings that were actually quite benign.

To be fair, I work with a lot of Spanish-speaking patients, so things can get lost in translation. But even well-intentioned providers can sometimes amplify anxiety by blowing minor findings out of proportion and ordering unnecessary follow-up ultrasounds ad nauseum. I’ve spent countless hours in my office talking moms off the ledge because minor or insignificant ultrasound findings were not explained well and triggered a cascade of questions, usually prompted by the “need” to return for another ultrasound. I hate to see someone’s otherwise normal pregnancy derailed by an obsession over some minor ultrasound finding.

I’m going to pause here and try to put into words why this bothers me.

Pregnancy should be a special, exciting time where a mom feels confident and supported in her ability to birth a healthy baby. When we rely too much on technology in a way that doesn’t meaningfully improve outcomes, we risk shifting that trust away from the mother and onto machines. Over time, I think that has a real psychological effect on moms, decreasing belief in their innate ability to give birth and care for a newborn.

And while we pour money into this expensive intervention, other things that could potentially improve maternal and infant outcomes a great deal more—like doulas, midwives, birth centers, mental health care, and nutrition support—are under resourced or cast aside. That really bugs me.

How Much Does An Ultrasound Cost?

There’s an uncomfortable reality that rarely gets discussed: ultrasounds cost money. A lot of money.

Sometimes patients don’t see the financial impact of ultrasounds directly, which is honestly part of the problem. I care for many women on Medicaid, which means ultrasounds are ultimately paid for by taxpayers.

For patients with private insurance, the costs are spread across the insurance pool and show up later in premiums and overall healthcare spending. And because care during pregnancy and birth are expensive, many privately insured moms will meet their deductible or out-of-pocket maximum during the year anyway, so an additional ultrasound may not feel like it changes their personal financial situation very much.

And obviously, when you’re pregnant, it is normal to want reassurance. Moms might justify extra ultrasounds and feel like their expense is secondary to the peace of mind they bring, especially if a trusted midwife or doctor is recommending them.

But even when a patient doesn’t personally feel the financial impact of too many ultrasounds, the system does. Every ultrasound requires equipment, technicians, physicians to interpret the images, and administrative infrastructure. Multiply that by millions of pregnancies each year, and the costs add up quickly!

How much does an ultrasound actually cost? The answer is complicated. It depends on where the ultrasound is done (hospital versus outpatient clinic), what type of ultrasound is performed, what region of the country you live in, and what rate your insurance company negotiates.

Some patients pay very little out of pocket, while others receive bills for hundreds or even thousands of dollars for a single scan. In some settings, ultrasounds are covered entirely by insurance or Medicaid, while in others they are offered at low or no cost through pregnancy resource centers. The wide variation makes it easy for both patients and providers to lose sight of the true financial impact—but regardless of who pays, the cost is real and it adds up across the healthcare system.

Is all of this medical spending resulting in better outcomes for moms and babies?
Well, not always.

This is why I take the responsibility of ordering ultrasounds seriously. Before I recommend one, I want there to be a plausible medical benefit—something that will meaningfully change how we care for the pregnancy or improve outcomes for mother or baby. And ultrasound does have benefits! When used appropriately, it is an incredibly valuable tool—one that has improved pregnancy care in important and meaningful ways. Let’s talk about that!

What I Love About Ultrasounds

At the beginning of my career, I worked at a clinic that cared for many low-income moms with no insurance or Medicaid. The delivery hospital and clinic had a deal: for a mere $500, moms would get all necessary prenatal visits, birth at the hospital, and one ultrasound only. What a steal!

But this presented a challenge for me as a clinician. If I thought the dating was off—which was common—an early ultrasound could help clarify. Yet to screen the baby for anatomical abnormalities, the ideal ultrasound is around 22 weeks. I often tried to compromise by ordering a scan in the 15-20 week range: early enough to get a good estimate of the due date, but late enough that major fetal anomalies would likely be visible. Sometimes it worked out, and sometimes it didn’t.

The radiologist would often report “anatomy incompletely visualized,” meaning it wasn’t really possible to see every structure they were supposed to identify and assure it was normal. Moms didn’t always love this either! Sometimes it was too early to determine the baby’s sex, so they’d have to wait and find out the old-fashioned way on the day of birth (obviously, this was also prior to the advent of genetic tests that can reveal a baby’s sex as early as 6 weeks).

Other times, the dating might seem a little off, but the ultrasound wasn’t done early enough to confirm it. We use a strict protocol to decide when to adjust the due date. So at 18 weeks, a 10-day difference between the last menstrual period (LMP) and ultrasound due date still wasn’t enough to officially make a change (it needed to be 11 days!)—but it left me doubting the “real” due date and wishing we had more clarity.

So when do I love ultrasounds? I love ultrasounds when they help me date the pregnancy! Early ultrasounds reduce uncertainty about dating and help avoid unnecessary inductions for pregnancies that aren’t truly overdue.

For example, a Cochrane review found that early ultrasounds were associated with a 41% reduction in inductions for post-term pregnancies. Another smaller study showed that 41% of women who had a dating ultrasound in the first trimester had their due date adjusted, compared with only 11% of women who had a dating and anatomy scan in the second trimester. These adjustments mattered: women who didn’t have an early ultrasound were more likely to undergo postdates inductions than those who did.

The truth is, due dates based on the last menstrual period (LMP) assume that everyone has a 28-day cycle and conceived on day 14—but nothing could be further from the truth.

Menstrual cycle variability is the norm, not the exception. Large modern cohort studies like this and this use digital tracking data show that cycle length varies widely between individuals and within the same individual over time, with only a minority of cycles clustering around a 28 day cycle. Ovulation timing is particularly variable, making last menstrual period (LMP) based dating inherently imprecise even in women who consider their cycles “regular.” So even moms who keep careful track of their LMP don’t necessarily give us an accurate gestational age of their pregnancy! I suggest the book Period: The Real Story of Menstruation by Kate Clancy if you want to know more about this!

For better or worse, ultrasound technology gives us a tool to see just how often LMP-based due dates are off. Some moms may feel confident about the day they conceived and want to date based on that. I personally was one of these moms: without an ultrasound, I convinced my midwives to change my due date based on my knowledge of the conception date. My daughter was born at 40 weeks 4 days, but by LMP she would have been 42 weeks 2 days—a gestation that would have freaked most people out! And, my 20-week anatomy ultrasound actually aligned perfectly with my conception dating, which reinforced that I was right.

Some moms might bristle at the idea of “needing” technology to know when you’re due. Why can’t we just trust our bodies and wait for labor? Well, as a midwife, I basically agree, and if moms are sure of their date of conception, I will go with that.

But that kind of certainty among my patients is extremely rare. And we also have to be honest about the risks of going too far past term. The stillbirth rate rises substantially after 41 weeks, so having an accurate idea of gestational age is pretty important. The same applies if a mom goes into preterm labor: the recommended interventions vary based on the weeks gestation, and if that is unknown or inaccurate, it can have consequences.

Another time I really appreciate ultrasounds is when they allow us to diagnose a serious fetal anomaly and help parents come to terms with it. Over my career, I’ve cared for patients whose babies had diagnoses such as serious heart defects, gastroschisis (when intestines are outside the body rather than inside), or, in the most tragic cases, conditions where the baby was clearly not viable, such as anencephaly. But thankfully, serious congenital anomalies are rare—occurring in only 2-3% of births.

While obviously heartbreaking, identifying these anomalies during the anatomy scan gives parents and care teams critical time to plan. Sometimes it means delivering in a hospital with a higher level of neonatal care, such as a Level III or IV NICU, because the baby may require immediate interventions or surgery after birth. Other times, it allows parents to consider palliative care options, organize support for siblings, and emotionally prepare for a baby who may not survive long outside the womb.

This experience is highly individualized. Some moms don’t want extensive information or follow-up ultrasounds after the first diagnosis—they prefer to focus on each day as it comes. Others feel empowered by the knowledge, finding reassurance in having all the details and knowing what to expect.

Finally, I’d be remiss not to mention another clinical situation where an ultrasound can be incredibly helpful—identifying breech or transverse lie babies. I’m pretty good at identifying this through Leopolds (the maneuvers where you feel a mom’s belly to determine position), but on occasion, I’m just not sure. In these cases, ultrasound is invaluable—it helps us identify the malposition in time to offer external cephalic version, or discuss the risks/benefits of breech vaginal birth versus planned C-section ahead of time rather than in a moment of chaos with a late diagnosis of breech during labor!

Also, in some of my higher-risk moms, particularly those with hypertensive disorders or gestational diabetes, having a maternal-fetal medicine specialist evaluate through ultrasound can be critical in determining whether the baby is compromised. Interventions based on that information have undoubtedly saved some babies’ lives over the years! In fact, this study showed that specialized ultrasounds in the case of certain high-risk pregnancies—fetal growth restriction, hypertension, and placental insufficiency—lowered the risk of perinatal death.

Ultrasound can also catch placenta previa, a condition that can lead to life-threatening hemorrhage during childbirth, allowing us to plan a safer delivery (C-section, in that case!)

And obviously, there are many other situations where ultrasound can be helpful—this is not an exhaustive list! There are definitely things to love about ultrasounds.

What I Hate About Ultrasounds

Now that I’ve tried to honestly present the good things about ultrasound, let me tell you what I don’t like.

Not infrequently, I’ll be seeing a mom for prenatal care. We listen to the baby’s heartbeat, measure her belly, talk about symptoms and concerns, and everything looks reassuring. Then she’ll say something like, “But how do we know the baby is okay without an ultrasound?”

And the honest answer is: how do we know the baby is okay with an ultrasound? Ultrasound can tell us some things, but it can’t tell us everything. If the baby is moving, has a strong heartbeat, is clearly growing, and an earlier ultrasound showed normal anatomy, there often just isn’t much additional information another ultrasound will provide.

But I sometimes have a hard time communicating this in a way that feels reassuring. Many moms have been taught—by the medical system, friends, or other clinicians—that more ultrasounds equal better care. So when I don’t automatically offer one at every visit, it can feel to them like I’m being negligent. In reality, I’m trying to provide evidence-based care and avoid expensive, unnecessary testing that is not shown to improve outcomes.

I also hear a lot of comparisons: “My friend had five ultrasounds,” or “My friend’s doctor does an ultrasound at every visit.” Sometimes, it’s because their friend had a higher risk pregnancy than them, and what they’re not understanding is that they’re the lucky one—with no major risk factors or known congenital anomalies!

But in other circumstances, even low-risk pregnant women are getting tons of ultrasounds. I once worked as a L&D nurse with a physician who routinely performed ultrasounds at every prenatal visit. Even though he frequently missed important things that were essential to prenatal care, did a ton of unnecessary C-sections, and cut giant episiotomies for every vaginal birth he attended (basically, not a physician who practiced evidence-based medicine) some women in the community gravitated toward him because they associated more imaging—and more intervention—with higher quality care.

Other moms have the opposite experience: they come in extremely anxious because something was flagged on ultrasound and they were told to follow up without much explanation. For example, a worried mom once told me, “They said something is wrong with my baby’s spine and I need to come back in four weeks!” When I reviewed the report, it simply said the spine was poorly visualized—meaning the baby was in a position that made it hard to get a clear image.

During an anatomy scan, there is a checklist of over 20 structures that need to be seen, and if any one is not perfectly visualized, patients are often asked to return for another scan, sometimes without a clear explanation that this is largely precautionary. As I explained earlier in the essay, I spend a lot of time doing damage control—helping moms understand incidental findings that are clinically insignificant but still cause a great deal of worry.

Another issue is how minor anatomical “soft markers” are sometimes followed ad nauseum. Common examples include fetal pyelectasis, intracardiac echogenic focus, echogenic bowel, and choroid plexus cysts. These are usually benign variants that do not affect outcomes, and there is often nothing that can be done during pregnancy anyway.

In addition, many follow-up ultrasounds are triggered not by true abnormalities, but by borderline or technically limited findings—such as “suboptimally visualized” anatomy, borderline amniotic fluid levels, or fetal size measurements that fall slightly outside the expected range. Even findings like low-lying placenta or marginal cord insertion often prompt serial imaging despite a high likelihood of normal resolution or minimal clinical significance.

Yet these findings are frequently tracked with repeat scans, creating a cascade of appointments, anxiety, and sometimes additional “findings” that were never clinically meaningful to begin with.

And then there is fetal size, which is my absolute worst pet peeve. A perfectly healthy pregnancy can be reframed as high risk simply because the baby is estimated to be “too big.” Yet according to ACOG guidelines, elective C-section for suspected macrosomia is generally not recommended unless estimated fetal weight exceeds 5000 grams in non-diabetic patients. Despite this, parents are often scared or subtly pressured into a C-section based on estimates that can be off by a pound or more.

I once cared for a patient who was extensively counseled about the risk of shoulder dystocia if she attempted a vaginal birth. She was frightened, but ultimately chose to proceed with a vaginal birth. Her “huge baby” weighed 8 pounds and literally slid out. It was a reminder of how imprecise these estimates can be—and how often decisions are made based on projections that may never have been accurate in the first place. The truth is, shoulder dystocia occurrence and severity is largely unpredictable, and the majority of cases occur in babies with normal weights.

So what I hate about ultrasounds is that they can create both a false sense of security and reassurance, and a false sense of alarm.

Final Thoughts

A few times in my career (a very few times), I’ve had a mom decline all ultrasounds during pregnancy. This honestly didn’t bother me much at all. If a mom is confident in her dates, not experiencing unexplained bleeding, baby’s head is clearly down at the end of pregnancy, and she accepts the possibility that a serious defect might not be discovered until birth, I am generally supportive of that decision. Think back forty years—people like my mom had four pregnancies in the late 70s and early 80s with zero ultrasounds, and babies like me were still born healthy every day. My mom swears she carried both of my brothers to 44 weeks, but that’s another story!

Ultrasound is a diagnostic tool, not a treatment. Most of the time, it helps us identify potential problems, but it rarely fixes them. So given that, here are my overall takeaways.

Dating ultrasounds: 👍👍Helpful if last period is unknown, cycle lengths are typically more than 28 days, is worried about miscarriage and wants to confirm a viable pregnancy, or there is any doubt about when conception occurred. Best done at 8-12 weeks! Too early (4-6 wk) can be inconclusive and cause unnecessary worry if no heart rate is identified. Too late and they’re not as accurate for dating. Helpful at preventing unnecessary post-dates inductions!

Anatomy ultrasounds:👍👎They have a benefit if the goal is to identify anatomical abnormalities in the fetus, but with very few exceptions, these abnormalities cannot be treated during the pregnancy anyway and will likely lead to several follow up ultrasounds to “monitor” the abnormality, which may or may not be helpful to the mom. Advantages are being able to plan for care and high level intervention if a serious anomaly is found, but disadvantages are the additional time, money and stress of follow up ultrasounds that likely won’t affect the end outcome anyway. Moms should think about whether these ultrasounds bring them peace of mind versus stress, and communicate that clearly with their providers.

Growth ultrasounds:👍👎Helpful if we’re worried about growth restriction, but sometimes the opposite of helpful if baby is large, causing self doubt and worry among moms, and unnecessary intervention by healthcare providers (like C-section or induction of labor).

Biophysical profiles (BPPs): 👍👎They are known to reduce fetal death rates in certain high risk patients (those with high blood pressure, known growth restriction) but for many “high-risk” moms (people with obesity, advanced maternal age), they are not that much better than an NST, which is a cheaper and less time-consuming intervention.

Recreational ultrasounds: 👍👎This is my first time mentioning it, but there are companies that offer ultrasounds for parents who simply want to see their baby. The difference between a medical/diagnostic ultrasound and an elective/recreational ultrasound is explained here (note I am NOT endorsing this company or elective ultrasound in general, just thought this website did a pretty good job explaining the difference).

The FDA recommends against these services, largely due to concerns about safety and lack of medical oversight.

I’ll admit—I see this a little differently.

If what a parent really wants is connection or just to see their baby, I actually think there’s something to be said for separating that desire from medical care. A recreational ultrasound, paid for out of pocket (usually around $80–100), may be a more honest and appropriate way to meet that need than asking a clinician to order an ultrasound that isn’t medically indicated.

In some ways, it could even reduce unnecessary medical imaging and the cascade that sometimes follows. At the very least, it acknowledges an important truth: moms tend to like ultrasounds in part because it is fun and meaningful to see the baby!

What are your experiences with ultrasounds?

Now that I’ve word vomited all my deepest thoughts and opinions about ultrasounds, I would love to hear about your experiences. Did you like getting ultrasounds? Do you think you had too many? Too few? Did you understand why ultrasounds were being ordered? Did you get a “choice” to have more or were you simply told it was necessary? How did ultrasounds affect your relationship to the pregnancy?

Women in line at the public bathroom gestured for me to go ahead of them. Elderly strangers nodded, wished me a nice day, and stepped aside to let me pass. People smiled at me as if I were a celebrity they recognized from their favorite TV show. What was going on? Why were these randos being so nice?

Well, it turns out I had forgotten that I was wearing my six-month-old baby. Plastered on his face was a perma-grin showing off his new bottom teeth. He was in that smiley, interactive phase that many babies go through—intent on making eye contact with everyone who crossed his path and NOT GIVING UP until they smiled back at him. And as it turned out, most people were happy to oblige. They thought he was kind of cute. Per my friend , that’s a thing with babies!

I’ve used my Substack to catalogue some of my many frustrations as a parent, mostly complaining that:

My kids never slept much

My kids don’t care about looking nice

My kids are hard to keep alive

People have occasionally been mean to us in public

But in keeping with my moderate branding and desire to present balanced takes, I now want to share another side of the story: Actually, people really like kids. And not just babies. I have proof.

How do I know? Because for six years in a row, my boys milked over $3,000 in Cub Scout popcorn sales out of our community. And trust me, our neighbors weren’t buying this popcorn because it was a really good deal, or because it’s tasty (I would highly recommend avoiding the Peanut Butter Cup flavor—it looks good, but is so sickeningly sweet that it makes you want to vomit!)

Before you make any assumptions, let me assure you—I am not that mom. I take no joy in planning, organizing, or executing fundraisers. I actually hate them with the fire of a thousand suns. When my kids come home from school with a handout about a fundraiser in their backpack, it usually goes immediately in the trash. I purposely skip meetings where I think I may be asked to volunteer for the fall festival or the spring dance fundraiser. I’d rather just write a check to the PTO, the soccer club or the robotics team for the bare minimum needed assuage my parental guilt, and then use my spare time to do…basically anything else. Yard work. Laundry. Taxes.

And no, I did not just force overpriced popcorn on unsuspecting coworkers and friends. I am not that popular and don’t have $3,000 dollars worth of friends! I swear to you, my sons were literally the driving force behind these popcorn profits.

Here’s the story of how it all began. I reluctantly became involved in Cub Scouts of America when my oldest son (pictured below) was in second grade. At the time, I didn’t know much about the organization, other than hearing wind of the sexual abuse scandal and noticing how they showed up with flags at every sporting event, seeming really patriotic. But my son was adamant that he wanted to participate. A couple of his friends were doing it, and the activities seemed so fun. Camping! Biking! Building cars! Shooting arrows! I could not dissuade him even though it didn’t really feel like my jam (guess it wasn’t really about me anyway lol).

Right away, he became determined to help his troop by selling popcorn for the annual fundraiser. As per usual, I told him I would buy 200 dollars of popcorn to shut him up and meet the bare minimum requirement of the fundraiser, but he did not seem happy with that. He got it in his head that he was going to join the “Winner’s Circle”—aka, the top tier Cub Scout sellers who manage to sell at least $3,000 of popcorn.

Seven-years-old at the time, he excitedly told me about all the amazing prices he might win. A telescope! A tablet! A TV! I knew the prizes were low-quality junk, and I told him that. But he was obsessed and wouldn’t let it go.

So I did what any reasonable mom would do. I told him he was about as likely to sell $3,000 of popcorn as he was to play basketball for the Bucks NBA franchise, his other big dream at the time. Basically, I did my best to crush his spirit with the end goal of saving myself a lot of time, misery and awkward conversations with neighbors and co-workers who would undoubtedly feel pressured to buy from him.

But no matter how hard I tried, my son was insistent, so eventually I told him I’d pick up $1,000 of popcorn for him to sell in the neighborhood, and we could go and get more if he actually sold it. I assumed we’d be returning the unsold popcorn in shame to the Pack’s “Popcorn Colonel” (haha, get it?) a few weeks later, but instead my son surprised me. He went to work, filling up our old jogging stroller with popcorn, and pushing the cart around the neighborhood with me following sheepishly behind.

As luck would have it, in the fall of 2020, the peak of the Covid pandemic, almost everyone was home. When we’d ring the doorbell, clad in masks, it was like we were angels sent from heaven—literally the best thing they’d seen all day.

Socially isolated people, starved for any human interaction but especially charmed by my cute little boy in his Cub Scout uniform, opened the door and were delighted to see us. Some of these people we knew, as they were neighbors we saw walking their dogs around, but many were unknown to us. My husband and I are shy people, so we’re not exactly planning the neighborhood block party. Mostly, these neighbors didn’t know us and didn’t owe us anything.

Completely expecting to have the door slammed in our faces, I was shocked at just how nice people were. The good people of our neighborhood bought this overpriced popcorn in droves! My son did his sales pitch, often convincing them to buy the most expensive items, like the $60 chocolate lover’s tin. If he saw they had up a Packers flag, he’d try to sell them the caramel sea salt Packers tin for $25 (it’s $28 now—inflation!) If someone “didn’t like popcorn” he’d remind them that “we also sell trail mix, chocolate pretzels, coffee, and accept donations.” That kid rarely left a house without a fat wad of cash. Sometimes, it felt like we’d never leave a house at all.

Neighbors reminisced with my son about their own time in Scouts. They let him pet their dogs. They laughed about the fact that he wasn’t wearing shoes (don’t tell Cub Scouts—I’m pretty sure shoes are supposed to be part of the uniform). On occasion, an old man would insist that he recite the Scout Law and the Scout Oath before purchasing. My son obliged to the best of his ability.

I was in awe of my son’s sales acumen. It was starting to make me think he’d been switched at birth. Who was this smooth-talking, eye-contact making person? We easily sold $1,000 of popcorn, so we went back for $1,000 more. After that, we went back for $1,000 more. And pretty soon my son was in the “winner’s circle.” I convinced him to pick the $200 Amazon gift card as his prize, and he was in heaven, that being the largest sum of money he’d ever had control of in his life.

After that first year, with his initial success, the boy knew what to do to milk the neighborhood. He also took his products to cross country meets, grocery stores, and tailgates at the Brewers stadium parking lot. That is, until they kicked us out—turns out the Brewers want to sell their own overpriced food and don’t tolerate outside groups coming in to make money off their customers!

A few years later, my younger son, who is more like me—quiet and shy—also had the goal of following in his brother’s footsteps and selling $3000 of popcorn, but times were different. The Covid pandemic was behind us and people weren’t as flush with cash, having no where else to spend it. Also, we found that a lot of people had installed Nest cameras, so they could more easily avoid talking to us when we’d ring the doorbell. Had neighborliness left us? We were worried.

So this time, we had to take a different approach: we camped out at the local Pick n’ Save supermarket for several hours every Sunday, preferably right before or after the Packers game, when we could expect an influx of customers. Unlike the Brewers, this grocery store chain was very accommodating of our little popcorn shop. We’d set up our table, sit back, and wait for the kindness of strangers to fund our Cub Scout Pack.

Sometimes it was hard. Sometimes it was borning. Ten, fifteen minutes would pass without a hit, but then we’d get an influx of customers. Maybe they felt sorry for us, sitting all alone, my son making this sad face (pictured above).

Eventually someone would buy, because you see, it’s pretty hard to say no to a kid who camps out in front of a grocery store and makes you feel like his Troop’s summer camping trip might not happen unless you pony up 28 dollars for that tiny tin of caramel sea salt popcorn.

The other thing that surprised me was the donations! Some people didn’t want popcorn, but would randomly hand us a 20, 50 or even 100 dollar bill. It was shocking how generous our community members were.

Sometimes, people would make small talk. My son’s favorite thing was when older men would tell us about their Eagle Scout projects. One guy organized a large-scale voter registration operation. Another built a mountain biking trail at one of the state parks. Someone else built a bridge over a muddy creek. It was fascinating to hear the well-remembered details of these projects decades later!

My favorite thing was the old ladies who would say things to my son like “Boy, you got a good mama. She’s out here with you selling popcorn when she could be at home. You better be thankful for your mama” or “It’s so refreshing to see a young man out here doing something for his community, selling popcorn to raise money for his troop. You sure are raising a good kid ma’am.” Why, thank you 🥹 because we moms don’t hear that kind of thing enough!

Anyway, it took some work, but my younger son also managed to get to his goal of $3000 in popcorn sales.

So there you have it, my proof that people like kids. If it were not so, how could my sons have been eligible to earn all these amazing prizes?

While making people mad is not my intention, I understand that this post may offend people on both sides of the political spectrum—the religious and the non-religious. Sorry! I know that some hold deeply rooted religious beliefs that artificial contraception is morally wrong, and I completely support them in living their lives accordingly. But from this crowd, I often get the impression that they think a woman not wanting to spend a couple decades pregnant, breastfeeding, and stay-at-home momming is a betrayal of femininity.

On the other side, majorities of people seem to view birth control as a tool of liberation and assume its benefits to women are obvious and universal. They have trouble understanding the crazy people who don’t want to be on birth control constantly, especially if it means risking—gasp!—pregnancy. Such was the tenor of this New York Times article, “Who Am I Without Birth Control?” which blames right-wing anti-birth control influencers for a rash of unwanted pregnancies.

I found it condescending, painting women as dupes rather than adults capable of making their own decisions. It tells horrible stories of women who decided to go off birth control and had babies. They are now miserable, depressed and overwhelmed all because TikTok influencers led them astray. There is no control group (are mothers with planned pregnancies also overwhelmed sometimes?) and no check back in two years to see if these moms regret their pregnancies (odds are, they don’t!)

The thing is, after twenty years caring for women across their reproductive lives, I think the truth about birth control is incredibly nuanced. Contraception can be really helpful, really harmful, and everything in between.

My job requires me to help people navigating these decisions at every stage of life—from teenagers in their first relationships to perimenopausal women hoping to avoid the “oops” baby. Many of the patients I counsel are already mothers trying to decide how many children to have and how much space to put between them. These are tough decisions that have a huge impact on the trajectory of their lives and their children’s lives.

Over the years I’ve educated myself about the full range of options. But beyond that, I’ve had a lot of intimate conversations with the people making these decisions and experiencing the risks and benefits of different methods. This essay is mostly trying to speak from that perspective. Birth control can be really beneficial. It can also be pretty disruptive to a woman’s health, moods, and relationships.

I honestly have no agenda here. My greatest wish for families is that they have the children they want, when they want them. I don’t want women pressured into pregnancies they aren’t ready for. But I also feel a deep sadness for women who are unable to conceive the babies they desperately want. Sometimes delayed childbearing—often made possible by contraception—plays a role in that story too. We should be honest about that.

But First, What Do I Even Mean By “Birth Control?”

I want to be clear that when I talk about birth control in this essay, what I really mean is any method intended to avoid conception.

There are hormonal methods and non-hormonal methods. There are methods with high efficacy and low efficacy. There are permanent sterilization methods and reversible ones. There are fertility awareness approaches like natural family planning (NFP) and lactational amenorrhea (LAM). But for the purposes of this essay, anyone who is having penis-in-vagina sex and doing something to avoid pregnancy is using a birth control method.

Granted, depending on the method chosen, the risk/benefit profile is very different. I’ll try to distinguish between the methods I’m talking about along the way, but I am not going to be able to cover every birth control method in detail. Use the section subheadings to navigate to the sections that interest you most!

Now, A Nod to The Oldest Birth Control Method

When I was a midwifery student, I remember being sent into a postpartum room alone without my preceptor to talk to a patient. She had just given birth to her fourth or fifth child. She was an older, confident, buxom, Spanish-speaking woman—the kind of seasoned mom who probably did not need advice from the likes of me. At the time, I was a naïve, pollyannaish type who had grown up Catholic and had still never had a serious boyfriend in my early twenties. On my checklist of required questions was: “Do you want anything for birth control?”

So I asked her, in Spanish.

Her response: “Él me cuida.” He takes care of me.

I was confused. He takes care of her? Was my Spanish failing me? So I asked again whether she wanted us to prescribe a birth control method.

“No,” she said firmly. “Él me cuida.”

Same answer, and now she’s seeming a little annoyed. Oh well, I’ll ask one more time.

“Ya te lo dije. Él me cuida.” I already told you. He takes care of me.

Sensing her growing frustration, I finally gave up and left the room to talk to my preceptor about the interaction. She was an experienced midwife who had worked with this immigrant population for years.

Completely unfazed, she explained:

“He pulls out.”

“What?” I asked.

“Withdrawal,” she said. “It’s very common in this population.”

Seeing the blank expression on my face, she rolled her eyes and practically shouted:

“HE DOES NOT COME INSIDE OF HER. HE EJACULATES OUTSIDE HER BODY.”

Well, gosh golly. That was embarrassing! This mom’s birth control method was literally the oldest trick in the book, and somehow I did not see it coming.

Since that interaction, I’ve talked to many more women who use this method successfully. Sometimes I share a few statistics with them about its effectiveness as a caution—it’s relatively low. About 1 in 5 couples relying on withdrawal will experience a pregnancy each year. Yet, I’ve had women tell me they’ve used it their whole lives and only gotten pregnant when they wanted to. And indeed, I have known patients who used this method with committed partners (who must have really good self-control, by the way!) to space pregnancies four or five years apart, all the while avoiding the side effects of hormonal birth control. So before we move on, let’s acknowledge what was probably the most commonly used birth control method for all of human history: withdrawal.

Next Up—The Method Approved by the Vatican: Natural Family Planning (NFP)

While we’re on the topic of “natural”—that is, non-hormonal, non-surgical, non-device-based—methods, I want to talk about another one we hear a lot about: Natural Family Planning (NFP). Or maybe it’s just me and the Substackers I engage with—I’m not sure!

As a former Catholic (I’m Lutheran now, but still respectful of the tradition) and someone who attended Catholic universities for both undergrad and graduate school, I had plenty of opportunities to learn about NFP. I understand that some people don’t like describing NFP as “birth control,” but anyway, I googled it and the world wide web agrees with me:

An important difference with NFP, of course, is that it also helps couples understand fertility in a way that can help them achieve pregnancy, not just avoid it. While I don’t consider myself an expert on NFP, I’ve read books and articles on the topic and attended conferences where it was taught.

I once even dragged my unsuspecting Protestant fiancé to an NFP workshop during a pre-marriage retreat. The class was taught by two men: one a father of five, and the other a scientist living a celibate religious life. In retrospect, they may not have been the world’s foremost experts on avoiding pregnancy and I’m not going to lie—it was a little cringy listening to them mansplain the different kinds of cervical mucus I should watch for that signal fertility: “raw egg whites” rather than “tacky,” etc.

Still, I don’t want to jest too much. Many people—including people I love and respect—have deeply held religious beliefs that artificial contraception is morally problematic. I don’t share that belief. But I also think there is something worth taking seriously in the broader ethos that often accompanies NFP: the idea that sex is actually a big deal. It’s an act with real psychological, social, and physical consequences (partner bonding! babies! STDs!) and one that I believe is best undertaken within a relationship where two people are genuinely committed to each other. And there are certainly benefits to avoiding the risks and side effects of hormonal contraception—which I’ll talk about later.

Why Some People Aren’t Great Candidates for “Natural” Approaches

So what’s my overall take? Honestly: everyone should learn the basics of fertility awareness. Understanding when you’re fertile can be incredibly helpful, and I’ve taught those fundamentals to many patients trying to conceive. As a birth control method, though, NFP is less reliable than other methods—about 76-88% effective with typical use. In practice, it also limits “safe” sex to just a handful of days each month. That can be a real drag for couples who actually like each other—especially women, whose libido peaks right around ovulation (not to overlook men, whose libido is pretty high whenever!) It’s also hard to use during times of irregular, unpredictable ovulation, like lactation and perimenopause.

So I get a little annoyed when NFP is presented as a one-size-fits-all solution, or when its effectiveness is portrayed as higher than it realistically is for most people. Over the years I’ve cared for women living in all kinds of difficult circumstances, and many of those circumstances make NFP a poor fit. I’ve had mothers drag their teenage daughters in for birth control because they didn’t want them to repeat their own experience of teen motherhood. I’ve met women who genuinely feared rape, and who did not have much say in when or whether sex happened in their relationships. I’ve had patients ask me to secretly place IUDs and cut the strings very short so their partner wouldn’t notice because they were being pressured to have more kids than they wanted.

Beyond these difficult social circumstances, I’ve also helped women choose a birth control method because pregnancy itself posed serious health risks. Some had uncontrolled hypertension, diabetes, kidney disease, autoimmune disorders, severe depression, or opioid use disorder—all conditions that can make pregnancy far more dangerous for both mother and baby. I serve on my state’s Maternal Mortality Review Team, and we regularly review cases where women entered pregnancy with complex medical or psychological conditions like these, and, tragically, did not survive the experience.

A birth control method that requires careful tracking, predictable cycles, and a partner willing to cooperate with periods of abstinence assumes a level of health, stability and autonomy that many women simply don’t have. For a lot of patients, the question isn’t “Which birth control method will most lead to human flourishing?” but “Which method will actually protect me from becoming pregnant in my current circumstances?”

I’ll share one example from early in my career. I cared for a patient during pregnancy who went on to have her fifth child—and her third C-section. She shared with me that she wanted it to be her last, but she delivered at a Catholic hospital, which meant she did not have access to tubal sterilization at the time of surgery.

Afterwards she developed a horrible flesh eating bacteria at the incision site, requiring repeat surgery to remove giant chunks of infected flesh and save her life. She survived the ordeal by the skin of her teeth, and even her Catholic OB/GYN surgeon did not think it would be safe for her to become pregnant again. But when I read the discharge plan, the recommendation was that she be counseled on NFP for birth control.

Now, to be fair, I have worked with Catholic physicians over the years who were deeply committed to pro-life principles and opposed to contraception. Many of them were extraordinarily generous people. These were the doctors volunteering at my community health center, donating diapers and baby supplies to pregnancy resource centers, and performing procedures for uninsured patients through charity care.

However, I just have to say that even if you think birth control is sinful, advising a woman who does not necessarily share your religious beliefs and almost died giving birth that the best method of birth control for her is NFP feels disingenuous. It’s is a fine method for people who are basically willing and able to accept a somewhat ill-timed or unplanned pregnancy. It’s not a great birth control method for someone who could literally die if she becomes pregnant again.

Moving on to Hormonal Birth Control

If I sound annoyed with the “NFP is the only acceptable method; everything else is sinful” crowd, don’t worry—I’m also annoyed with people who gloss over the downsides of hormonal contraception. I’m talking about progesterone IUDs and implants, Depo-Provera, and combined estrogen-progesterone methods like oral contraceptive pills, the vaginal ring, and the patch.

If anything, the “Birth control: what could go wrong?” perspective is even more prominent in the broader cultural conversation. In modern Western societies there’s a strong assumption that women of childbearing age should be on some form of hormonal birth control more or less continuously unless they are actively seeking pregnancy.

This is what led my friend’s boyfriend to say “I thought all girls were on the pill,” when she told him she did not want to have sex due to fear of pregnancy. 🙄

The cultural narrative goes something like this: a woman starts birth control in her late teens and stays on it throughout her twenties and early thirties. During those years she enjoys great, consequence-free sex and experiences minimal side effects. Then, the moment she decides she wants a baby, she simply stops her chosen method and promptly gets pregnant. Voilà!

I’m not saying this plan never works out, but I do want to point out that inside this story are a few big assumptions:

• Hormonal birth control has minimal risks or side effects.

• It doesn’t affect mood, libido, or relationship quality.

• Pregnancy is easy to achieve, and we have control over when it occurs

Let’s unpack some of those.

Hormonal Birth Control is Essentially “Faux Pregnancy”

Let’s start with the first assumption: that hormonal birth control has minimal side effects or risks. In reality, these medications work by significantly altering the body’s hormonal environment. One way I explain it to patients is that hormonal birth control creates a kind of controlled, reversible imitation of pregnancy.

Most hormonal contraceptives supply synthetic progesterone, sometimes combined with estrogen. High progesterone levels suppress ovulation and change the uterine lining so pregnancy cannot occur. In other words, the body receives the signal that ovulation is unnecessary because a pregnancy is already underway.

During pregnancy, high progesterone levels prevent you from ovulating (obviously—what would be the point?!) After birth, progesterone drops so milk can come in, but frequent breastfeeding keeps prolactin levels high. This high prolactin acts as a natural 'off switch' for the hormones that trigger ovulation, which is why many exclusively breastfeeding women don't have a period for months. This is known as lactational amenorrhea (LAM) which is another “natural” birth control method. It creates a high-prolactin, low-estrogen state—physiologically similar to menopause. This is the culprit behind the low libido during breastfeeding, a little-discussed downside to lactation—or upside, from the perspective of the baby who is not yet ready for a younger sibling!

Anyway, to summarize, hormonal contraception places the body in a pregnancy-like hormonal state for months or years at a time. This isn’t necessarily bad: after all, it may have been the normal state for many women for most of our human history!

Historically, Women Spent Far Less of Their Lives Cycling

For most of human history, women spent much more of their reproductive years pregnant or breastfeeding. Today a woman may experience around 400 menstrual cycles in her lifetime, whereas women in traditional high-fertility societies may have experienced closer to 100–150, largely because pregnancy and prolonged breastfeeding suppressed ovulation for much of their reproductive years.

This difference may help explain some of the health effects associated with both pregnancy and hormonal contraception. Fewer ovulatory cycles appear to reduce the risk of ovarian and endometrial cancers.

I thought it was interesting when compared the benefits of lactation to the benefits of the pill, saying in a note:

I think it’s true that breastfeeding has health benefits, but I disagree that they are significant enough to make breastfeeding obligatory or even a normative choice. There are lots of decisions in life that can positively impact health that people can reasonably forego if they have an otherwise healthy life and have other reasons for not wanting to engage with them.

Oral contraceptives (“the pill”) reduce ovarian and endometrial cancer risk by around 30-50%, and may reduce overall risk of cancer from 3-12%. If you like being on the pill, you should feel good about that too! But similarly, I just don’t think these benefits are significant enough that women should feel obligated to get on the pill at some point in their lives.

She’s not wrong to point out that OCPs have some benefits—but I would also point out that OCPs are linked to higher breast cancer rates, whereas breastfeeding is linked to lower ones. Anyway, it’s interesting to think about how birth control methods have become a way to imitate our ancestral hormonal history.

Probably for this reason, hormonal birth control can have important medical uses. It can treat heavy or painful periods, acne, irregular cycles, and conditions like endometriosis. But precisely because they change the body’s hormonal environment in significant ways that imitate pregnancy, it shouldn’t be surprising that they also come with serious downsides.

Hormonal Contraceptives Have Real Risks

Combined hormonal contraceptives (estrogen and progesterone) are associated with an increased risk of venous thromboembolism—blood clots that in severe cases can lead to pulmonary embolism—compared to non-use. They are also associated with small increases in stroke and heart attack risk, particularly in women with other risk factors. They can raise blood pressure as well—on average about 8 mm Hg systolic and 6 mm Hg diastolic compared with women using non-hormonal methods like the copper IUD. This may not seem like a big increase, but in a world where so many people are already struggling with stress, obesity, diabetes, alcohol and tobacco dependence, we don’t need one more thing raising our blood pressure. This is why I often find myself dissuading women in their 40s and those with any kind of comorbid conditions from using these methods.

For most healthy young women these risks remain small. But they are not imaginary, and must be balanced against the risks that pregnancy poses (both physically and psychologically) for that individual woman. Interestingly, women are also at increased risk of venous thromboembolism while pregnant or postpartum.

And even if combined estrogen/progesterone methods aren’t an option for some women, that still leaves behind some important progesterone-only options, right?

Which brings us to another assumption in the cultural narrative: Hormonal birth control has minimal effects on libido, moods, or relationships.

How Good Is The Sex on Hormonal Birth Control?

For some women, hormonal birth control makes very little difference in sexual desire or satisfaction. Some even report improvements—especially if contraception reduces anxiety about pregnancy or improves painful menstrual symptoms.

But for others, the change is noticeable. I meet these women in my office all the time. They describe feeling more prone to depression, less interested in sex, or somehow “not quite themselves.” Granted, I am seeing the women who come back to clinic because they are unhappy with their methods quite a bit more than the ones who are satisfied. But I have conversations with women who notice weight gain, mood changes, and decreased libido all the time. Because I have access to their records, I can look at their weight on the date the birth control method was started and compare it to their current weight. I often see a 5, 10, or 15 lb weight gain even in just a few months, especially with methods like Nexplanon (progesterone implant) or the Depo-Provera injection, so I don’t think this is just a matter of perception.

Yet when I try to confirm these findings in the literature, the evidence is mixed. There is, however, a pretty good study linking Depo-Provera use over five years to greater weight gain (13.7 lb) than other methods or non-use. After seeing everything from weight loss to excessive weight gain, I conclude that hormonal birth control side effects vary among women the same way pregnancy does. Some women love pregnancy and feel great; others hate it and feel miserable and more prone to depression. Some gain a lot of weight while others do not. While it’s hard to make generalizations, it seems unlikely that our hormonal milieu has no effect on mood, libido, or relationships.

Research on libido shows a similar pattern. The evidence is mixed, but some studies suggest hormonal contraceptive methods can reduce sexual desire for a subset of women, particularly progesterone-dominant methods. For example, users of Depo-Provera and Nexplanon (implant) have reported lower sexual interest compared with women using non-hormonal methods like the copper IUD.

As we discussed earlier, hormonal birth control creates a hormonal environment resembling pregnancy or breastfeeding—states in which libido is often naturally lower and ovulation (a woman’s horniest time of the month!) is not occurring. From an evolutionary perspective that makes sense: a woman who is already pregnant or breastfeeding a newborn infant does not benefit biologically from becoming pregnant again. Reduced sexual interest during a high-progesterone state may therefore be part of the body’s normal design.

Does Hormonal Birth Control Affect Mate Choice?

There’s another wrinkle that researchers have explored which I find fascinating: hormonal contraception may subtly influence attraction and partner preference. Some studies suggest that women on hormonal birth control may show different patterns of attraction than women cycling naturally—for instance, OCP users showed a decreased preference for more masculine features and a decreased sense of sexually relevant odors. Naturally cycling women in the periovulatory phase are significantly more sensitive to androstenone, androsterone, and musk than women taking oral contraceptives.

The research here is still evolving and has been disputed, but personally, I find it plausible that altering our chemical makeup through exogenous hormones could shape who we’re drawn to. Hormones influence many aspects of behavior across the animal kingdom, including mating preferences. For many mammals, scent plays a powerful role in attraction and partner selection. While we like to think humans have evolved beyond that kind of instinct, we may still be more influenced by subtle sensory cues than we realize.

I’ve always had a very developed sense of smell. I can’t really explain it, but I’m certain I could sniff any member of my family out of a crowd even if I were blindfolded. Experiences like that make me suspect that scent may play a larger role in human relationships than we usually acknowledge.

This idea reminds me of a story one of my anthropology professors told in college. He had spent time living among a hunter-gatherer society on a Pacific island. When he mentioned that women in his culture often shave their armpits, the people he was speaking with were shocked and appalled. One of them asked, “But then, how do you smell the woman?” For them, scent was obviously part of how people recognized and evaluated potential partners.

None of this means hormonal birth control is “bad” or that women shouldn’t use it. For many couples, the benefits—especially reliable pregnancy prevention—far outweigh any drawbacks. But the idea that these medications are completely neutral with respect to sexuality and relationships probably isn’t quite right either.

How Easy Is It To Turn Fertility Back On?

The last part of the cultural narrative I want to examine is the assumption that pregnancy is easy to achieve and that we can control when it happens.

Imagine a woman who spends her twenties carefully avoiding pregnancy using hormonal contraception. Then, sometime in her early thirties, she stops birth control and expects things to happen quickly.

As describes it:

I get it. We all want ‘NO FERTILITY! NO FERTILITY! NO FERTILITY!’ until the point where we want ‘ALL FERTILITY! ALL FERTILITY! ALL FERTILITY!.’ ‘No fertility!’ we’re getting pretty good at.

She’s right about that. We’ve become extremely good at preventing pregnancy. Hormonal options like Nexplanon (the implant) are so effective that in my entire career, the only person I’ve seen get pregnant on it left it in for thirteen years (it’s designed to last five!) IUDs are also about 99% effective, and many women are choosing these long-acting reversible contraceptives (LARCs) because they work so reliably. In other words, we’ve gotten very good at turning fertility off.

Turning it back on, however, is less predictable.

People often assume that getting pregnant is easy, but even at a very fertile age—around twenty-five—the chance of conceiving in any given month is only about 25%, and that’s if intercourse happens during the fertile window. As women age, the odds each month gradually decline.

Over time, of course, the cumulative odds of pregnancy are high if couples consistently have unprotected sex. And to be clear, reversible contraceptive methods are indeed reversible. I’m not blaming contraception for the difficulties some women experience when they try to conceive later. While certain methods (Depo-Provera, for example) can take some time for fertility to return, the effects are temporary.

What isn’t reversible is age-related fertility decline. As women are encouraged to spend their most fertile years avoiding pregnancy, many reach their thirties and discover that conception is not as easy as they expected. In clinic, I sometimes hear comments that reveal how much control people think they have over the timing of pregnancy. For example:

“I want my baby to be born in October, so I’m going off birth control this month. If I don’t get pregnant right away, I’ll just go back on birth control and try again next year.”

Or:

“I want another baby, but I think I’ll wait five years before trying again.” (said by someone who was 35!)

These plans sound reasonable—but they assume that fertility behaves like a switch that can be turned on and off exactly when we want it to. Unfortunately, biology doesn’t really work that way, especially as we age.

See the post below for more on that topic!⬇️⬇️⬇️

Final Thoughts

I hope you have found this essay thought-provoking, whether or not you agree with it! Personally, I don’t feel that contraception is the best or the worst thing to happen to womankind. That doesn’t mean it’s not life-changingly wonderful for some women, or extremely detrimental for others. Most people will experience a mix of risks and benefits—and it’s up to each woman to weigh those for herself.

One last thought I want to leave you with: no one should feel obliged to use birth control because of a societal expectation to have sex. I’ve had this conversation with many women over the years: if the idea of having a baby with your partner horrifies you, that’s a pretty strong signal they might not be the right one—birth control or no birth control! And there are plenty of fun things you can do that don’t risk STIs or an unplanned pregnancy while feeling out the situation—like making out! Loved ’s take on this (see below).

If you’ve made it this far, thank you! I hope you enjoyed my take. Now I’m more than happy to hear yours! Any pros or cons I forgot to mention?

But it’s no wonder there are whole websites full of fanfic where amateur writers publish their imaginings about the next chapter in the couple’s life once the love story ends (not that I’ve ever done this personally, of course😉).

My point is, there is something profoundly romantic about having a baby with someone you love, and it’s like…we don’t really talk about that very much! As reported on by , in Scott Galloway is wrong about dads and childbirth, apparently some weirdos actually find birth—get this—”disgusting and unnatural" and think dads are a “waste of space” in the early days! Can you believe it?

As you may guess, I feel differently. In fact, when I was interviewed by Emily Oster on the ParentData podcast, we had the following conversation:

Emily: So before you go, let me ask you…you attend a lot of births. What is your favorite moment in a birth?

Me: Oh, I love this question. Nothing compares to passing the baby to the mom for the first time. There’s usually just so much relief in that moment. I also think, one really beautiful thing I get to witness all the time is like, I don’t know, I’ll call it the “postpartum kiss.” Usually if a partner has been with his partner for this labor and he’s seen this really hard thing take place, his respect for his partner has gone up a ton, and there’s usually this moment where they just…kiss…it’s like two minutes after the birth, once we’re totally sure that everything’s fine and the baby is breathing and crying and on the mom’s chest. That’s a really beautiful moment and I feel really, you know, blessed that I get to witness that all the time.

So there you have it: one of the reasons I most love being a midwife is that I get to see the end of the story, or at least the “next chapter.” And I’ve always felt babies are a pretty great epilogue.

When it comes to dads in the delivery room, it’s pretty clear to me that they make everything better. I see a ton of strength and resilience in dads that rubs off on their partners. When a mom choses labor without an epidural, the dad’s support is crucial. I see them holding their partners up, swaying with them, reassuring them and telling them they’re strong. In one case, early in my career, I even had a dad with lightning fast reflexes reach in to catch the baby as his partner returned from the bathroom pushing. I was right behind her but somehow he saw it coming and I didn’t. He was like "Dad of five here. Step aside.” Then he acted all nonchalant, shrugging when I thanked him, like it was no big deal that he prevented his baby from hitting the floor!

When a mom decides on an epidural, the dad doesn’t become a “waste of space” but an important supporter of both his partner and the staff, as we often need their help with repositioning, leg holding during pushing, etc. On a few occasions, I’ve been the one to sit with the dad while they were prepping his partner for a C-section, and then watched when they were reunited in the operating room. The dad’s presence is such a balm to the mom in these stressful moments.

Have I ever met dads that weren’t great support people? Yeah, of course. Sometimes they just need a little guidance, “Hey, could you massage her back like this?” “Can you help us turn her in the bed?” “Can you offer her a sip of water about every ten minutes?” In my experience, dads love to have something to do. Waiting for someone to give birth can feel very helpless, especially if you see that they are suffering.

Other times, dads are really not into the carnal experience that is birth: the amniotic fluid, blood, squishy organs, etc. That can make the experience a bit scary and get in the way of them being present. But usually if you help them reposition in a chair by the mom’s face, they can still play an active support role. I’ve had plenty of dads too grossed out to cut the cord. No shame. It’s not for everyone. All that Wharton’s jelly turns some people off.

On the other hand, I’ve encountered some real “science nerd” dads. Some of them were farm boys who’d watched other mammals give birth (cows, pigs, goats) and wanted to discuss the differences in birth mechanisms. These dads didn’t just want to cut the cord: they wanted to help catch the baby, inspect the afterbirth and play around with it. That’s fine too—but you might want to put gloves on first!

I loved ’s account of her lab’s research on birth and completely agree that we need more studies on this! I was particularly interested by this:

In one study, we found that when men described their partner’s childbirth as more stressful, they had worse symptoms of postpartum depression six months later, even when we controlled for their prenatal depression. In another study, pregnant couples who argued more negatively during a conflict task in our lab subsequently had more difficult childbirth experiences several months later, suggesting that the tenor of the couple relationship may have shaped how they navigated labor.

And, come to think about it, when I think about the nicest births I’ve attended recently, they all had wonderful dads present. And when I think about the hardest, least pleasant labors and births…they did not. This is probably at least part correlation, not causation but, it’s completely plausible that there is at least some causal effect. , maybe someday we can do a study together :-)

I’m going to end with this photo from a birth I attended recently. I got in touch with the couple yesterday and they agreed that I could share. This dad’s level of love and support for his partner was off the charts. When I see stuff like this, I can’t help but want to double as a birth photographer. I’m like “give me your phone and let me snap a pic.”

If there’s anyone out there who doesn’t find this super beautiful and romantic, something is wrong with them. Because if a couple can get through a birth together like this, they can get through anything!

At a recent birth, the nurses and I called for NICU staff to be present due to meconium fluid, as is our policy. It’s not an uncommon occurrence for a baby to poop prior to being born—it happens in about 1 in 7 births and is more common with longer gestations (>40 weeks pregnancy). However, in rare cases (~5% of infants with meconium fluid) it can be very dangerous, leading to meconium aspiration syndrome (MAS), which is life-threatening. I’ve seen it two or three times in my career, and it was scary enough to be fully on board with the plan to have extra personnel present to resuscitate and intubate a newborn baby if necessary.

But in the vast majority of cases, babies born with meconium fluid are just fine. They come out breathing, crying, and reaching for their mothers like any other baby—which is exactly what happens in this birth:

As soon as I see that this baby is vigorous and transitioning well, I glance at the NICU team waiting by the warmer.

“Can we do a few minutes of delayed cord clamping?” I ask.

Delayed cord clamping improves newborn iron stores, lowers rates of infant anemia, and supports smoother cardiovascular transition. It should be an easy yes. Instead, I see eye rolls and impatient shifting. In their defense, they probably have a million other things to do right now, and my insistence on delayed cord clamping is putting them behind schedule.

“Ok fine. One minute,” someone says.

I place the baby on mom’s chest, skin-to-skin, and she immediately wraps her arms around him. This is my favorite moment in a birth. She needs this moment to process—to explore her baby’s tiny body and gorgeous face, to see the fruits of her labor.

“A MINUTE HAS PASSED,” someone calls out, interrupting the tranquil moment.

I sigh, clamp the cord, and hand the scissors to dad, who cuts. I explain to mom that the team wants to check the baby’s breathing just in case. Even though this assessment could almost always be done with the baby on her chest, that’s not how our NICU team works. And this mom, like 99% of moms, would agree to anything that medical staff presents as necessary for the good of her baby.

So she agrees and I pick up baby—totally fine-looking, pink, breathing and now crying because he’s been separated from his mom—and bring him to the warmer, where the NICU staff swoops in, and three sets of hands start poking and prodding.

I return to my tasks: delivering the placenta, making sure the bleeding is controlled, checking for tears. Ten minutes pass, and I noticed mom craning her neck, looking over at her baby longingly.

“Are you guys done?” I ask.

No response.

“Do you think she could get her baby back now?” I say louder.

“In a minute — we just want to weigh him,” someone replies.

I watch the nurses quickly trying to take care of their tasks—and they have many. In the 90–120 minutes between birth and transfer to the postpartum unit, they’re responsible for a long checklist: repeated vitals, measurements, medications, documentation. With so many tasks and limited time, the temptation to keep the baby at the warmer and finish everything at once is enormous.

In this case, I get frustrated when I see one nurse pull out a measuring tape to check the baby’s head circumference — a completely non-urgent activity — so I loudly interrupt, “HEY, CAN SHE PLEASE HAVE HER BABY BACK NOW!?” The nurse shoots me an annoyed look, sets the tape measure down, and reluctantly returns the baby to his mom.

Welcome to an American hospital birth, where even though the benefits of skin-to-skin and breastfeeding within the first hour of life are well known, systems are designed to make it difficult.

Why I’m Writing This Essay

Despite how bossy I sound in that story, confrontation doesn’t come naturally to me. I’m a people-pleaser by nature, and there are other times I stay quiet and go along with routines that I know make early breastfeeding less likely simply to keep the peace. But that’s the problem. A baby getting to spend the first hour(s) of life in his mother’s arms shouldn’t depend on me choosing to pick a fight.

Recently I read ’s practically fairytale account of giving birth in Germany, where she described “the systems that made breastfeeding an easy and soft choice.” In contrast, I want to walk you through the systems that make initiating and sustaining breastfeeding genuinely difficult in the setting of American maternity care!

I’ve been reading a lot of breastfeeding discourse lately, with takes from , , , and that I found fascinating and well-argued. And while I find points of agreement and disagreement across the spectrum, this essay isn’t about convincing anyone that breastfeeding is the “right” choice. Despite being a big fan of breastfeeding and a breastfeeder myself, I can accept without judgment a woman’s decision not to breastfeed for any number of reasons.

What I cannot stand is how often American maternity care undermines the efforts of women who really want to breastfeed.

So going along with ’s recommendation in a recent post…

After twenty years working in four different hospitals — as a postpartum RN, labor and delivery RN, and now a midwife — I still see systems that separate mothers and babies without clear medical need, prioritize low-value tasks over breastfeeding support, lack meaningful lactation infrastructure and staff education, and promote policies that are not aligned with physiologic breastfeeding or the best available evidence.

Worst of all, when moms struggle with breastfeeding in part because of these policies, we frame their bottle feeding as a personal choice rather than the result of policies and procedures that actively undermine breastfeeding. Too many moms who really wanted to breastfeed leave the hospital already on the wrong path—without breastfeeding well established—and are therefore less likely to meet their breastfeeding goals.

So the purpose of this essay is to name the things I see getting in the way of early breastfeeding, but also to help parents understand the way hospital systems work, and what they can do to advocate for a better breastfeeding experience. In this essay, I will:

1. Name a common maternity care practice that makes breastfeeding difficult

2. Explain how and why it influences breastfeeding success, and what the alternatives are

3. Offer moms practical ideas to avoid letting these practices derail their breastfeeding experience

Let’s get started!

Common hospital practice: Maternal/infant separation at birth

I opened with this story because incidents like this are incredibly common. In an ideal world, a baby is born and placed directly on the mother’s chest for skin-to-skin contact. This should last at least the first hour of life, preferably two hours. I’ve worked at hospitals that were excellent at respecting this “golden hour” and others that were not.

Even in the case of cesarean birth, immediate skin-to-skin contact can sometimes be facilitated, though it does not appear to be routine practice in many settings. One online convenience sample—composed largely of white respondents—reported that 29.7% experienced skin-to-skin contact during cesarean, a figure I found surprisingly high. Because convenience samples often reflect the experiences of patients who feel more empowered to seek information, advocate for their preferences, or share their stories online, these findings probably don’t represent the broader population.

In my career, I recall one physician who was very on board with skin-to-skin during C-section. He ordered a special drape with a little window that allowed for easy passage of the baby between the surgical field and the mother. It was such a big deal that it made the news!

Given that lactogenesis II—when a woman’s body shifts from producing colostrum to larger volumes of mature milk—happens about 12-24 hours later on average when a baby is born by C-section, options like this seem really important!

Why does this matter? Right after birth, babies are biologically alert and highly responsive. They instinctively root, crawl toward the breast, and are often very good at latching on their own. But this alert period is fleeting — babies quickly become sleepy in the hours after birth. They go into a deep sleep about 2-3 hours of life and sometimes do not feed well until around 24 hours later. If separation occurs during the first two hours of life, the chance to establish a strong latch and robust early milk supply can be significantly reduced.

A recent Cochrane review called “Strong evidence supports skin-to-skin contact after birth as standard care” confirms this:

The findings show that mothers who have skin-to-skin contact with their babies in the first hour after birth are more likely to exclusively breastfeed for the first six months of the baby’s life. Exclusive breastfeeding brings many health benefits for mothers, babies and health systems.

The review found that about 75% of babies receiving early skin-to-skin contact were breast feeding exclusively at 1 month compared with 55% of babies in the groups that did not receive skin-to-skin contact. Newborns also benefit from more optimal sugar levels, body temperature, breathing and heart rate.

Despite guideline recommendations to initiate immediate, uninterrupted skin-to-skin contact until after the first breastfeeding, many health systems still separate mothers and infants during this period.

Sometimes babies do need special care or advanced resuscitation. Approximately 5% to 10% of newborn infants need help to begin breathing at birth, and of those, 1% need advanced resuscitative measures (like intubation). Babies that are born prematurely or low birth weight are the most likely to need extra help. But for the vast majority of babies that don’t fall into these categories, staying with mom is nearly always the best choice. Given this strong evidence, why are babies being separated?

The reasons are often complex. Hospital routines, staffing patterns, training traditions, and concerns about safety or liability can all shape how care is delivered in the first hour after birth. Assessments are frequently performed at a warmer because that is the longstanding workflow, even when many evaluations could safely be done on the mother’s chest during skin-to-skin and delayed cord clamping. While there are times when separation is medically necessary, for many healthy newborns it may happen more out of habit and system design than true clinical need.

What moms can do

If you want immediate skin-to-skin contact and delayed cord clamping, make your wishes clear early and often. While these practices are increasingly recognized as best standard of care for healthy newborns, stating that they matter to you helps your team understand your priorities and opens the door for shared decision-making if concerns arise.

If you are the birth plan writing type, make sure your desire for skin-to-skin and delayed cord clamping is well-documented. If you don’t have a birth plan, tell your nurse that this is important to you when you are first admitted to L&D. If you are told at any point in the labor or birth that complications have arisen (such as meconium fluid or concerning heart tones) tell your nurse that skin to skin is still important to you, and that you would like your baby to be evaluated on your abdomen for the first minute of life before a decision is made to take the baby to the warmer. This is reasonable in 90% of cases, and if staff feels strongly that it’s not a good idea, ask them to explain why.

Many newborn evaluations — listening to the heart and lungs, drying, stimulation, and observing tone and color — can be done while your baby remains with you.

In my experience, many babies who are taken to the warmer are healthy and don’t actually need separation. Being firm about your wishes — especially in borderline cases — can make a real difference. Having a doula or birth advocate present, such as a partner who understands your wishes, can help, too. Unfortunately, moms without advocates or with limited hospital knowledge are much more likely to be separated from their babies by default. I do my best to advocate for these families, but even experienced staff can struggle against systemic routines.

Common hospital practice: NICU admission

In the United States, about 1 in 10 newborns is admitted to the NICU. This care is often life-saving, allowing premature or critically ill infants to survive and later thrive — don’t get me wrong. But some of the statistics give me pause. For instance, admission rates for full-term infants vary five-fold depending on the hospital, according to the Dartmouth Atlas of Neonatal Intensive Care. Two babies with very similar health profiles might receive dramatically different levels of care solely based on where they are born. NICU admission rates, imaging practices, and intensive treatments differ widely across hospitals, and much of this variation cannot be explained by differences in newborn illness.

Nearly half of NICU admissions are for babies of normal birth weight, highlighting how expanded NICU capacity and hospital practices have shifted care patterns. While the NICU is critical for babies who truly need it, these statistics suggest that use of intensive care is not always driven by medical necessity. Hospitals now have more NICU beds and more low-risk babies are likely to be admitted, meaning that many otherwise healthy newborns experience separation from their mothers, exposure to highly medicalized routines, and, as research shows, a greater risk of interrupted breastfeeding.

In the case of premature or low birth weight infants, while necessary NICU care can be life-saving, unnecessary or prolonged NICU stays can be disruptive to the breastfeeding relationship. These are often the babies who could most benefit from breast milk, yet separation from the mother interferes with early breastfeeding establishment and the hormonal signals that drive milk production.

Research supports this concern. For example, a study in Colorado looked at late-preterm infants (34–36 weeks) and adjusted for maternal and infant characteristics to compare those who went to NICU versus stayed with their mothers. The researchers found that breastfeeding initiation was roughly the same between groups, but continuation at 10 weeks was significantly lower for the NICU group. Specifically, infants admitted to the NICU were 14% less likely to still be breastfeeding. This suggests that even when medical need is similar, the experience of being in the NICU can directly impact breastfeeding duration.

I find these results really unsurprising. While technically parents have 24-hour access to their babies in the NICU, I’ve seen firsthand that the rooms are small, not very private, and don’t have a bed for a parent to stay in overnight. In many cases, a mom is literally forced to be separated from her baby unless she chooses to spend the night in a chair, away from her partner or other children. After a difficult birth — or especially a C-section — this is not a real choice. I don’t mean to diminish the dedication of NICU staff, many of whom are compassionate and supportive, but it is clear that the medical team largely controls the decisions surrounding the baby, leaving parents with limited agency over early feeding and bonding.

These findings align with broader evidence showing that breastfeeding success is closely tied to early, frequent, and direct contact with the mother. When babies are separated or receive care that prioritizes medical routine over feeding cues, the breastfeeding relationship can be disrupted. In other words, the decision to admit a baby to the NICU has ripple effects on feeding, bonding, and long-term health outcomes.

Unfortunately some of this may come down to money. I don’t consider myself an expert on this topic, but I would encourage you to read ’s post called “Stuck in the NICU.“ To quote:

The NICU is among the most profitable units in the hospital. In contrast to labor and delivery, which is often treated as a loss leader, the NICU is widely regarded as a money machine. A single day can cost more than a weeklong stay at a luxury hotel, and it is not uncommon for premature infants to remain hospitalized for months, accruing medical bills that reach into the millions of dollars. Since 1995, the number of NICU beds in the United States has surged by more than 65 percent, even as birth rates have fallen and the share of premature births declined. Today, more babies are admitted to the NICU than ever before…Admission rates to the NICU for full term infants vary five-fold, and the criteria for getting to leave the NICU is highly subjective…

What moms can do

This is a tough one, and I want to be very clear: I am not advocating for ignoring medical recommendations. NICU care can be absolutely necessary, and sometimes hospitalization is critical for a baby’s safety. But in borderline cases, advocating for yourself and asking questions can make a meaningful difference.

In my own experience, my first child was born with a vacuum assist, so NICU staff were present. Years later, I learned that my L&D nurse—a friend and coworker—actually prevented my daughter from being taken to the NICU! They were concerned about a bruise on her head from the vacuum and recommended “observation.” But my friend firmly told them, “No, you cannot take Ann’s baby.”

I find this story funny now, but it illustrates how subjective some NICU decisions can be. There are plenty of borderline cases, and the more parents and their advocates ask for explanations, alternatives, and reasoning, the less likely they are to be pulled into unnecessary separation simply because of routine or convenience. In my daughter’s case, it was medically important to watch for any signs of intracranial hemorrhage due to the vacuum delivery, but she showed no signs of illness, and postpartum nurses were fully capable of monitoring her safely.

Beyond individual stories, there are proactive steps parents can take to maximize contact and support breastfeeding:

• Rooming-in or kangaroo care (skin-to-skin) whenever medically feasible helps stabilize the baby and supports early milk production.

• Ask early and often about feeding options, such as direct breastfeeding or expressing milk, instead of defaulting to formula.

• Work with a lactation consultant — they can help set routines, monitor supply, and coach parents on overcoming challenges.

• Communicate proactively with the care team about discharge goals. You may be told, “We don’t know yet,” but asking frequently signals that you are paying attention and motivated to reduce unnecessary separation.

In short, while NICU care is sometimes essential, knowledge, advocacy, and presence give parents more control over borderline situations and increase the chances of bonding and successful breastfeeding.

Oops: Once again, I have written a way longer post than I intended to

My New Year’s resolution was to keep my posts at ~1000 words to make them more reader friendly. HA! I am failing miserably. Even though I wanted to cover the additional practices below, I’m going to leave them for another day. Please comment on which of these you’d like to hear more about!

• Common hospital practice: Strict warnings against co-sleeping and lack of accommodation to co-sleeping on hospital units (TBH I’ve already written about this here)

• Common hospital practice: Under-resourced nursing and lactation departments, particularly understaffed on nights and weekends

• Common hospital practice: Routine formula supplementation without medical need

• Common hospital practice: Encouraging scheduled feedings rather than cue-based feeding

Or, if you have other questions or ideas about how healthcare professionals and parents can work to make maternity care better, please share in the comments!

“In our current system of care, the baby is the candy and the mother is the wrapper. Once the candy is out of the wrapper, the wrapper is cast aside.” -Alison Stuebe

A Scary Moment Last Week

A few days ago, I was in clinic when a 39-week pregnant woman who I had been seeing regularly—pregnant with her first kiddo and just one week from her due date—came in for routine prenatal care. We chatted for a bit about the usual stuff (baby’s movement, discomforts of late pregnancy, signs of labor to watch for), and then started the exam.

I felt the baby’s position (head down—good). I measured her abdomen (normal growth). Then I took out my Doppler to listen for the heartbeat, and… it wasn’t there.

I’m an experienced midwife, so I know where to look. I angled the Doppler one way, then another. I waited. As the seconds passed, I started to worry. It is never this hard for me to find heart tones, especially late in pregnancy. I tried another spot, then another. I frantically searched for the baby.

About thirty seconds passed, maybe a minute. “Is everything ok?” she asked, probably noticing the terrified look on my face.

“Well, I usually find it much more easily than this…” I stammered, trying to buy time. I kept looking, moving the Doppler this way and that. Then suddenly I heard it, very faintly: tick tick tick—140 bpm. The baby was alive.

I’m not going to lie—during those moments, which felt like an eternity despite probably lasting no more than a minute—I was freaking out. I was mentally reviewing her risk factors, wondering if I had missed something along the way. I was hoping and praying that the heartbeat would reveal itself to me, something that felt less likely with each passing moment.

Most of all, I was dreading the moment when I’d have to do the hardest thing I’ve ever had to do in my career: look a mother in the eye and tell her that her baby has died.

Why You Cannot Be Pronatalist Without Being Pro-Mom

Experiences like this clarify something for me. Of course I care about babies—they are profoundly important to their mothers. But babies do not exist in isolation; from the very beginning, their lives are inseparable from the person carrying them. Decades of medical and social science research confirm that a child’s health, survival, and long-term outcomes are inextricably linked to the physical and emotional well-being of the woman who gives birth to them and, usually, raises them.

Day after day, I see moms fight through morning sickness and extreme exhaustion, give up vices, count carbs, miss out on paid work to attend appointments, poke themselves several times a day to stay on top of blood sugars, accept vaccines for their baby’s benefit, carefully consider birth plans, and endure painful labor contractions or surgeries. In some cases, moms risk serious injury or even death to bring new life into the world. They do these things because they want babies, and hope to give them the best start to life possible.

Pronatalists also want more babies. But there is currently only one way to get a baby: through a mom. So in a very important sense, you cannot be pronatalist or pro-baby without being pro-mom. You cannot choose “births” in some abstract sense without choosing the person who is giving birth. The opposite is also true. To look away from the things that threaten a mother’s physical or psychological health during pregnancy, childbirth or early parenting is to make an anti-natalist choice.

What Holds Me Back From Accepting the “Pronatalist” Label

Recently I was able to put a finger on my reluctance toward the pronatalist movement, helped in part by reading takes by and in favor, and , and against. Pronatalism literally means “in favor of births.” It doesn’t even specify that the mother and baby remain alive. As a midwife, it is hard for me to accept a label that centers “births” while seeming to minimize or overlook the experience of women who give birth, and the outcomes of their babies. I am told some pronatalists care about such things, but their advocacy for mothers seems quiet to nonexistent.Here are some examples:

Having babies less than two years apart? What could go wrong? No big deal, you can handle it!

Concerning trends in maternal mortality? Exaggerated! Pregnancy and birth are very safe!

You don’t think you can handle a large family? Why not? Your grandma did it, and she never complained! You won’t even notice the difference when you get past three kids!

I’m exaggerating (a little), but this is the vibe I get from the pronatalist movement. It sometimes gestures toward concerns like tokophobia—the severe, pathological fear of pregnancy and childbirth that involves extreme, irrational dread. But is this fear always irrational?

What is largely missing from the conversation is how profoundly the experiences of pregnancy, childbirth and early parenting shape future fertility. During my career, I’ve found that one of the strongest deterrents to pursuing another pregnancy is a woman’s fear—often grounded in past experience—that she will not be able to do right by her child. When birth or early parenting has been medically complicated, traumatic, or inadequately supported, women reassess their preferences and decide to have fewer children.

To make this concrete, here are just a few examples I have encountered in the last month:

• A mother asked me whether she could give birth at a different hospital this time, because every time she sets foot in the hospital where she delivered her first child, she experiences panic attacks triggered by memories of that birth.

• I was asked by my obstetric colleagues to ensure that a 22-year-old mother—who had just undergone her second cesarean section—fully understands that she should never become pregnant again, given the severe uterine scarring and blood loss she experienced, and the very real risk that a future pregnancy could be fatal.

• I read an essay by describing three births to four children marked by substandard obstetric care, including several life-threatening failures—such as not being treated in a timely manner for preeclampsia.

• My professional organization, the American College of Nurse-Midwives (ACNM), has resorted to suing the state of Mississippi, where discriminatory laws make it effectively impossible for midwives to practice—despite a severe shortage of maternity care providers and some of the highest cesarean, infant mortality, and maternal mortality rates in the country.

• A fellow certified nurse-midwife in Nebraska, Heather Swanson, filed a federal lawsuit asking the Supreme Court to strike down a state law making it a felony for herself and other trained, licensed midwives to attend home births.

I wish people understood how often women tell me that a traumatic or dangerous birth—or one in which their choices were ignored—played a decisive role in their decision to avoid another pregnancy. Those of us who want to improve maternity care face an uphill battle and, most of the time, it doesn’t seem like the pronatalist movement cares.

Or, Things the Pronatalist Movement Should Care More About

I sometimes encounter pronatalist arguments—most often made by men—that offer confident projections about ideal fertility rates while paying little attention to the physical and institutional realities required to make those numbers possible.

This is from in I Am A Pro-natalist:

What is the ideal fertility rate for a society? I don’t know, but would guess somewhere between 4 and 8 per woman. I think 15 is definitely too many, and 2 is too few. Perhaps a fertility rate of 6.5 is ideal from a utilitarian perspective.

I have no objection to large families—they keep me in business. My sister has seven children, all of whom I adore, though it is admittedly, much easier to be an auntie to seven than a mother of seven! And a noticeable portion of my Substack audience consists of mothers of many children, who tend to love midwives (we love you back!)

But I thought the goal of the pronatalist movement was to recover from a total fertility rate of roughly 1.6 to replacement level at 2.1, or maybe to get back to the desired family size of 2.7—not to propose an “ideal” of six or seven children per woman!

There are plenty of practical reasons most women don’t want six or seven kids, but I’d like to hone in on one of them—the state of maternity care.

C-section overuse

Start with the fact that roughly one in three births occurs by cesarean section in the U.S. I’ve already argued that C-section Overuse Is Suppressing the Birth Rate, but suffice it to say that cesareans are major abdominal surgeries with cumulative risks that limit the number of babies a woman can safely have. Yet the dangers of repeat cesareans are almost never acknowledged in pronatalist discussions, which focus entirely on more babies, more babies, more babies.

Meanwhile, women give birth within a medical system where access to vaginal birth after cesarean (VBAC) is hard to come by because it is banned or severely restricted by many hospitals. A recent survey showed that only 16% of U.S. counties offer pregnant people the opportunity to attempt VBAC. But Does Access to VBAC Affect Family Size? Based on my research and clinical experience, the answer is a resounding YES! Yet I see no pronatalists fighting for the women who are required by doctors and hospitals to have major abdominal surgery to give birth, or any attempts to count the babies that are perhaps not being born because of these policies.

Can we acknowledge that a fertility target of six or seven children translates directly into several major surgeries, with sharply rising risks of hemorrhage, placenta accreta, hysterectomy, and death with each one? Unsurprisingly, a lot of women say “no thanks!” and request a tubal sterilization procedure with their repeat C-section.

If my anecdotes are unconvincing, consider new research by Haley Wilbert, who used Army health claims and medical records to study subsequent fertility in people who had a C-section. Her study is called After the Cut: Cesarean Delivery and Subsequent Fertility and here is from the abstract (sections in bold, emphasis is mine):

Among women undergoing C-sections that were likely unplanned, we observe a reduced probability of subsequent childbirth within four years by 28% to 34%…. These results suggest that the birth experience surrounding C-section delivery plays a critical role in shaping future fertility decisions. To explore mechanisms, we examine short-term maternal outcomes and find that unplanned procedures are associated with increased hospital readmission and mental health visits, consistent with the influence on reproductive behavior running through physical and psychological pathways. Because childbirth in the military setting is nearly costless and insulated from financial incentives, our estimates likely represent a lower bound on the effects in the broader population, among whom repeat C-section carry higher financial and logistical burdens.

Which brings me to my next point…

The sacrifices of men and women who have children are not the same

Later on in his pronatalism essay, Hanania names his sacrifices as a father:

In my own life, I’ve sacrificed a lot to have children. I don’t get enough sleep. I live on the West Coast when I should be out East. I should travel a lot more, write about my experiences, and do more in-person interviews. But I had kids, and have lost some status as a result given our current value system. It should be adjusted to reward me for creating new life.

Look—I appreciate the sacrifices of fathers, which can be significant. But it is difficult to read something like this without noticing how starkly different those sacrifices are from what I see women going through every day. In just the last week, I have cared for a patient who lost nearly two liters of blood during a repeat C-section, and another who asked for a “return to work” letter at four weeks postpartum. The sacrifices I witness women making to have children are orders of magnitude greater, and any conversation about pronatalism that does not acknowledge this feels incomplete.

When pronatalist arguments focus on the personal sacrifices of fathers while calling for dramatically higher fertility rates—four, six, or even eight children per woman—they obscure the fact that these costs scale very differently by sex. For women, each additional child compounds physical risk, career interruption, and long-term economic loss. Against this backdrop, appeals to social “rewards” for men who have children ring hollow when women are not even guaranteed the basics: paid maternity leave, breastfeeding support, economic security during periods of unpaid caregiving, and the ability to give birth without incurring large medical bills. When it comes to having kids, women make the deepest and most enduring sacrifices, and are so often taken for granted.

Since I’m just a regular, non-homeschooling mom with a meager 3 kids, I’ll leave this to from Why I am still not a pro-natalist:

I have four children myself, and it is a huge job. I absolutely do not want my elected officials weighing in on whether it would be ideal for me or any other woman to have more (or fewer). Each additional pregnancy is serious, significant work. Unlike what some people online will tell you, I find that there is an enormous difference between having three kids and four kids, and I am sure that should we add a fifth child to our family one day, that would also be a huge shift.

On that note…

You actually need buy in from women to fix the low birth rate

There is a basic biological reality at play here: a single man can father many children, but a single woman’s reproductive capacity is limited by gestation, recovery, and a finite window of fertility. The total number of children a society can produce is therefore capped not by the number of willing men, but by the number of women who are able—and willing—to bear children. This fact is so obvious it feels strange to state it outright, yet it is routinely ignored in pronatalist discourse.

Which brings us to Elon Musk.

Yes, an extremely wealthy man can usually find willing women with whom to have children. But from a population-level perspective, this does not increase the birth rate. It merely pulls women who might otherwise have partnered with other men into the orbit of one very powerful one. The number of wombs does not change. The bottleneck for fertility remains the same.

Musk feels himself to be a kind of pronatalist exemplar: a man “doing his part” by having many children. But a closer look at his behavior reveals how thin that claim really is. With his first wife, he conceived five children—a set of twins and a set of triplets, via IVF, all male. According to his trans daughter (with whom he no longer has a relationship) and his first wife, Musk uses IVF to select boys. From a pronatalist standpoint, this is not just morally fraught but bizarrely counterproductive. If women are the limiting factor in future fertility, engineering a legion of sons shrinks, rather than expands, the reproductive base of the next generation, and if a lot of people did this, we’d be in big trouble!

We have already seen where systematic son preference leads: distorted sex ratios, social instability and long-term demographic problems in countries like India and China.

I appreciate naming it here:

If you cannot condemn Elon Musk’s modern-day harem, using surrogates and NDAs producing his “legion” of genetic heirs, your version of pro-natalism is different than mine.

Just as importantly, Musk-style fathering turns a lot of women off. Again, :

A worst case scenario, in my mind, is that having babies suddenly becomes politically polarized, and thus liberal women are shifted further away from having babies in reaction to their disgust at people like Elon Musk trying to raise the birth rate. Here, in my mind, is where the pro-natalist movement may end up being ironically counterproductive.

wasn’t too concerned about that:

The real problem is… conservatives having too many babies! We wouldn’t want liberal women to be disgusted; won’t someone please think of the liberal women? We’ve got to stop being in favor of babies until we can figure this thing out.

But here is the inconvenient truth. You cannot be “in favor of babies” while dismissing women’s reactions, values, or experiences. Whether you respect them or not, agree with them or not, the fact remains: raising the birth rate requires women’s participation. Until artificial wombs take over—which hopefully won’t happen anytime soon—any serious attempt to increase births depends on women willingly choosing pregnancy, childbirth, and motherhood. Any movement that alienates women while claiming to care about births is working against its own stated goal.

So there is basically no way around it: we need these women to choose to have babies with these men. So what’s the plan? (graph source):

My Optimistic Conclusion: Actually, Women Really Want Babies Too

I think low birth rates are a solvable problem because, it turns out, women want babies too. Feeling a pull—or at least a curiosity—toward having children is part of the human condition, and for good reason. Babies are cute, but even better, they grow into funny, sarcastic, opinionated people who secretly troll you online and buy you “#1 Mom” mugs for Christmas. They become travel companions, co-conspirators, and eventually, members of your adult support system. In a world that is increasingly lonely, having kids is an antidote.

The problem isn’t that women don’t want children. It’s that they conclude that the cost—to their bodies, their mental health, their work, and their sense of self—are too high or too poorly supported. If those experiences are safer, more respectful, and better supported, many women are happy to have children. So if we want more babies, a good place to start would be caring about the experience of the women who have them.

Just kidding. Mostly.

If you’re short on time, the TL;DR really is: whenever you want, whenever you can—but ideally somewhere around 25-31. But since you took the time to click, I’m going to reward you with a brilliant, comprehensive post to explain why I think this window makes the most sense. It will involve some data, and also my own meandering experience as a midwife and parent.

This conversation isn’t just for women. While much of what follows—particularly the discussion of biological constraints around fertility—applies more directly to women, many of the broader lifetime tradeoffs apply to men as well, maybe even more so. On average, men live about 5.3 years less than women, which means there is even less time to spend with your children and get to know your grandchildren if you choose to procreate later in life. That being said, guys can probably add a year or five to the range, but if they want to be fathers in their lifetimes, they too should put some serious thought into the following question:

At what age will I reach the intersection of being young and healthy enough to be an energetic parent to young children (and undergo a pregnancy if female), and also be secure enough in my relationships and financial situation to provide for a family?

First, I want to acknowledge that “At what age should you have your first kid?” is an oversimplified question built on a false premise: that we have full control over our reproductive lives, and that the answer is the same for everyone. We don’t, and it isn’t.

Even floating the idea of this post drew comments that made it clear it would strike a nerve. Many of us don’t get to have children when—or with whom—we hoped to, and suggesting that that this reflects some kind of misjudgment or personal failure on an individual’s part understandably lands badly. While infertility varies by age and other factors, about 1 in 6 people worldwide will experience it at some point in their lives—that’s roughly 17.5% of adults.

And lately, I’ve started to worry that many in Gen Z may be taking their fertility for granted. As a certified nurse-midwife (CNM), my work extends well beyond attending births; I also provide general women’s healthcare like contraception, preconception and fertility counseling. In that role, I’ve had some concerning conversations that suggest many young women don’t have a realistic understanding of their fertility.

I don’t normally like to agree with , nor do I love the term “pronatalist,” but I couldn’t help hitting the “heart” button when I saw this:

It’s not that we all have to identify as “pronatalists” but if you are pro-“I would like to have kids in my lifetime” then it is worth pondering the question of when to start your family.

A few weeks ago, shared this fascinating graph from the British Fertility Society which, for me, doubled down on the idea that young adults need to start asking themselves some questions like...is having kids really important to me? If I make it to the end of my life and haven’t had them, or don’t have as many as I want, how sad will that make me? In comparison to other goals I have for my life, where does this one sit?

If the answer is a resounding “Having kids is really important to me!” then it’s worth taking a closer look at this graph:

Suppose you really, really want at least two kids—so much so that it would be deeply upsetting not to have them. In that case, it makes sense to shape your life choices around having, say, a 90% chance of that outcome. As this graph shows, even with access to IVF, achieving a very high probability of having the family you want typically means starting to try around age 31.

From that perspective, delaying serious relationships until your 30s and childbearing until your 40s—because you’re writing a novel, pursuing a PhD and a tenure-track position, or hiking Mount Everest—represents a clear prioritization of one goal over another. And that can be completely reasonable. I’m not judging people who pursue ambitions beyond childbearing. But we should be honest that devoting substantial time and energy to one goal often means accepting increased risk or reduced odds for another.

My point here is that when it comes to having children, those of us who truly want them shouldn’t leave it up to chance. If building a family is a lifelong dream, it’s reasonable to make choices that maximize the likelihood of that dream becoming reality. The same way you wouldn’t wait until your 50s if your goal were to compete in the Olympics, you probably shouldn’t wait until your 40s (IVF or no IVF) to try to have a baby.

All of that said, it’s just as important to acknowledge the other side of the timing equation: many people delay childbearing for very good reasons, and one of them is that young parenting is not a walk in the park. So, let’s talk more about childbearing at the early ages.

The Pros And Cons of Having Kids Young

As a midwife working at a community health center that serves people with significant socioeconomic disadvantages, I take care of a lot of moms with unplanned pregnancies.. While rates of unintended pregnancy have been declining, they still account for 41.6% of pregnancies in the U.S. These moms tend to be poorer and younger.

I recently became what you might call a “grandma midwife.” I cared for a 17-year-old patient whose mother recognized me and said, “I think you delivered her.” Dang—nothing makes you feel old like realizing you’re caring for babies whose births you attended who are now pregnant themselves!

There is a lot of judgment of young mothers. But accepting a pregnancy that comes at an inconvenient or imperfect moment often makes sense when you zoom out far enough. I have a friend and former student who became pregnant in high school (oops). She later told me that the kindness she received during pregnancy and childbirth—especially from midwives—was what motivated her to finish high school, go to college, and eventually become a midwife herself. Many of us can relate to the idea that unexpected, sometimes even tragic events shaped our lives in ways that ultimately made them more meaningful.

When it comes to giving birth, young moms are among my favorite patients to care for because they’re so good at it! In my experience, they come at it with a “can do” attitude and seem to have shorter, less complicated labors with shorter pushing phases. I just checked in with Open Evidence AI to see if my anecdotal impression was correct, and it was! (nulliparous=never given birth before)

Labor progresses more quickly in younger women. Nulliparous adolescents had significantly shorter first and second stages of labor compared to women aged 25-30 years (384 vs 524 minutes for first stage, 47 vs 63 minutes for second stage). Analysis from the Consortium on Safe Labor showed that for nulliparous women, time to progress from 4-10 cm decreased from 8.5 hours in those <20 years to 7.4 hours in those 30-39 years. The second stage was up to 97 minutes shorter in younger nulliparous women (<20 years) compared to older women (>39 years).

In a U.S. study of over 43,000 nulliparous women, younger adolescents (≤15.9 years) had half the cesarean delivery rate compared to young adults aged 20-24.9 years (aOR 0.49; 95% CI 0.42-0.59), and older adolescents (16-19.9 years) also showed reduced rates (aOR 0.75; 95% CI 0.71-0.79). A Swedish national study found teenagers were more likely to deliver vaginally (aOR 1.70; 95% CI 1.64-1.75) and less likely to have cesarean sections (aOR 0.61; 95% CI 0.58-0.64).

So great, birth is easier if you’re young! But none of this is meant to sugarcoat reality. Teen and very young mothers also face higher risks of preterm birth, anemia, preeclampsia—largely driven by socioeconomic factors in my opinion.

And the costs of early parenthood are rarely about the pregnancy or birth itself. They’re about everything that comes after: economic instability, reduced ability to remain in school or the workforce, and relationship strain. This (and increased access to more reliable birth control) is probably why births to teenage moms are at an all time low (source).

If there were a way to separate out the socioeconomic factors that make young pregnancy and parenting difficult—poverty, lower levels of education, and higher rates of abuse in relationships—the children of young mothers might do just as well, or even better, than those of older parents. But the fact is, the children of younger mothers (defined as <25 yo) experience more adverse childhood events (ACEs), which can impact them for a lifetime. They are more likely to have:

• experienced economic hardship (food or housing insecurity)

• experienced parent or guardian divorce or separation

• experienced the death of a parent or guardian

• had a parent or guardian who served time in jail

• witnessed domestic violence

• witnessed violence in their neighborhood

• lived with someone who was mentally ill, suicidal, or severely depressed

• experienced discrimination (based on race, disability, sexual orientation, etc.)

Having children at a very young age doesn’t have to be a disaster—I’ve seen many young parents do a wonderful job—but it’s also understandable why most people aren’t eager to have kids before 25. Very few of us in our late teens or early twenties have the stable relationships, financial stability and emotional maturity that would help make a child’s life safe and nurturing.

From an evolutionary perspective, human biology evolved in contexts where people often started families earlier—but they did so within close-knit groups, surrounded by extended family members who shared the work of raising children. Among my younger patients, I sometimes see relatives step up in exactly this way, particularly in Black and Latino communities. But I’ve also seen situations where that support wasn’t available, much to the detriment of both the parent and the child.

Taken together, this suggests not that young parenthood is doomed to fail, but that starting too early often comes with real structural challenges that can make life harder for parents and increase the risks children face.

Now let’s talk about the other side of things…

The Upsides—And Risks—of Waiting to Have Kids

The average age at first birth has risen steadily for decades, and beginning motherhood in your 30s is now common—especially among highly educated women. This delay often reflects real advantages: people who start families later tend to have had more time to complete education and establish careers, which can make them more financially secure and better able to afford stable housing, health insurance, and other resources that support child-rearing. In addition, recent data show that first-time mothers with a bachelor’s degree are much more likely to be married or living with a partner at the time of their first birth compared with previous generations, suggesting increased relationship stability among older parents.

So it’s understandable why many people postpone childbearing. But I also think we need to be honest that waiting has disadvantages. Biology is not offended by our ambition to do other things; it just doesn’t care about them. When I see for older first-time moms as patients, I don’t judge them at all. I am genuinely happy for them, as these are usually very wanted pregnancies! Whether the guys they dated in their 20s were losers or they were considering life in the covent, it’s really none of my business what took them so long to have a baby. Far be it from me to judge anyone’s childbearing choices.

But I do usually end up working harder and worrying more.

I don’t want to beat a dead horse, because everyone already knows this, and in my experience women are really sick of the threats and fear-mongering. But there is solid evidence that childbearing at older ages comes with additional risks. None of this is to say women shouldn’t pursue motherhood in their late 30s and early 40s if it’s what they really want. But here is a brief summary of the risks associated with “advanced maternal age” (AMA)—also historically called “elderly multigravida”—everyone’s least favorite medical term (feel free to skip this section if you’re sick of hearing about it!):

Advanced maternal age (≥35 years) is associated with significantly increased risks for both maternal and fetal complications compared to younger women. According to the American College of Obstetricians and Gynecologists, women aged 35 years and older face higher risks of gestational diabetes, preeclampsia, labor dystocia, and cesarean delivery. These risks increase progressively with advancing age, particularly beyond 40 years.ACOG

Maternal morbidity and mortality risks escalate substantially with age. A large U.S. cohort analysis found that compared to women aged 25-29 years, those aged 35-39 years had a 1.36-fold increased risk of pregnancy-related morbidity, those aged 40-44 years had a 1.83-fold increase, and those aged 45-54 years had a 3.33-fold increase. Maternal mortality risk ratios are particularly striking: 3.18 for women over 40, 11.60 for those over 45, and 42.76 for women over 50 years.

Fetal and neonatal risks are also elevated. Women of advanced maternal age face increased risks of chromosomal abnormalities (particularly trisomies), miscarriage, stillbirth, preterm birth before 34 weeks, fetal growth restriction, and neonatal intensive care unit admission. The stillbirth risk is approximately 1.75 times higher in women ≥35 years compared to younger women, with a population attributable risk of 4.7%. For women aged 40 and older, stillbirth risk increases to 2.16-fold, and chromosomal abnormality risk increases 7.44-fold compared to women aged 20-34 years.

Chronic medical conditions are more prevalent in pregnant women of advanced maternal age, including obesity, chronic hypertension, and type 2 diabetes, which further compound pregnancy risks. Even after controlling for these baseline conditions, older women remain at significant risk for developing preeclampsia and gestational diabetes.

Also, there’s this sad reality: miscarriage is a lot more common at an older age:

This doesn’t even consider older age during parenting, which is its own marathon. More on that later!

Will Technology Save Us From Biology?

Egg freezing and assisted reproductive technologies (like IVF) are often presented as ways to pause or bypass the biological clock. But I’m skeptical that they can truly substitute for the higher fertility, lower complication rates, and healthier pregnancies (and therefore—healthier babies) that most women experience in their 20s and early 30s. Most of my concerns about IVF come from the standpoint of someone who has seen how much higher-risk these pregnancies are. For that reason, I’m biased toward the idea that a more reliable path is working with our biology—that is, attempting to find a partner and start a family in the roughly 25–31 year-old window, when fertility is still relatively high and risks are lower.

I made this argument in “Why I Don’t Fear An IVF Takeover” and similar thoughts were shared recently by who went through IVF and basically confirmed that it sucks. Or in her words:

Having done IVF a few times—three retrievals and three transfers, to be specific, culminating in two live births—I find it very hard to believe that a sizable amount of people would voluntarily choose this hard road for a spurious promise of a 130 IQ baby when they could simply take some backshots for three minutes instead and risk the outcome of a midwit baby.

On a lighter note, I am sympathetic to the argument made by in a recent NYTimes article about making IVF more available to women.

Although cultural commentary often suggests otherwise, many Gen Z women, including myself, deeply want children. We’re simply trying to navigate a world where the timelines of our bodies and the timelines of our ambitions rarely align. As a result, childbearing drifts later, and many of us feel a sharp anxiety as each year passes, widening the distance between our hopes and reality. Meanwhile, technologies to preserve and support fertility exist, but they remain prohibitively expensive and inconsistently effective.

But I think that, even when technology is used optimally, it’s a bit of a false promise to depend on IVF to have children in your 40s—or even 50s. Using younger eggs can improve the odds of conception, but pregnancy still occurs in an older body, with all the physical risks that come with age. For these reasons, I don’t see IVF, egg freezing, or genetic screening as a substitute for planning with biological realities in mind.

Is It Really So Bad to be Female? And, A Few Thoughts on Older Fatherhood

One thing I sometimes hear during the fertility conversation is: “Life is so unfair! Men can ruthlessly pursue their careers, put off relationships and childbearing, and still have kids late in life.”

Yeah, they can, but…why would they want to? Men are not immune to the challenges of older parenting: the sleep deprivation, the way your kids want to run around, go on roller coasters, or wrestle you before bedtime (ouch). In some ways, I think women are better off because our biology nudges us to have children earlier, which means we tend to be younger when our kids grow up.

Having a kid at 60 doesn’t sound great if there’s a 50% chance you’re going to die before they graduate high school! I don’t mean to be rude here; it just depends on what your goal is. If your goal is purely to push your DNA into the next generation, sure, having a kid later is fine. If your goal is to actually be in their lives—to have relationships with your children and grandchildren—well, waiting too long can backfire. Even on the DNA front, having children younger means more descendants by the time you die, as was pointed out to me by in back and forth notes where, I stupidly didn’t understand her point and she kindly clarified by saying:

At the population level the demographic effect is very different if everyone has two children starting at 39 or two children starting at 19.

Sticking to this caricatural example, in the first case, at age 40 you have 2 descendants, at 60 still 2, and at 80 you have 6 (when your 2 children had their own 2 children each around age 40). In the second case, at 40 you have 6 descendants (your 20ish year old children had their own 2 children each), at 60 you have 14 (2 children, 4 grandchildren, and 8 great-grandchildren), and at 80 you have 30. That’s a lot more children around, and more population growth, simply by having generations closer together.

Personally, I have never envied men, wished to be one, or felt that male bodies are superior. Yeah, they’re stronger, but women can literally create new life! And we live, on average, five to six years longer. I feel like those extra years more than make up for the fact that we may spend several years in pregnancy and intense parenting. Granted, the total depends on how many kids we have and our parenting choices (breastfeeding, working vs SAH motherhood, homeschooling, etc.). But for the average woman who wants two kids, she might spend about 18 months pregnant and maybe two years breastfeeding, adding up to roughly five years of intense parenting…followed by decades of life to concentrate on other things.

And then there’s the emotional piece: research consistently finds that mothers tend to have closer and more sustained relationships with their children than fathers do. Adults are more likely to report being closer to their mother than their father growing up and children and parents alike report stronger emotional bonds with mothers. Mothers also spend significantly more time on day-to-day childcare and emotional support, which deepens attachment over the long term. (Sadly, this is unlikely to apply to me. My kids all prefer my husband, probably because I spend too much time writing Substack essays.)

Interestingly, evolutionary biology offers a neat explanation for why women’s long-term involvement with their children and grandchildren might matter. The Grandmother Hypothesis suggests that menopause—and the long post-reproductive lifespan that comes with it—may have evolved so that women can invest in their children and grandchildren. By helping the next generation survive and thrive, grandmothers indirectly increase the likelihood that their genes are passed on.

So when it comes to older parenting, men may have more flexibility on paper, but in practice they also face challenges. Shorter life expectancy, less guaranteed emotional closeness, and the physical demands of parenting mean that postponing children has consequences for them too. IMHO…women are the lucky ones: biology and longevity align to give us a better chance at meaningful, long-term relationships with our kids.

My Conclusion: Have Your First Kid Between 25-31 If You Can

I realize that by writing this post, I have probably pissed off people of all ages, family situations, political and religious beliefs. Sorry! Young parents might feel judged, older parents might feel judged, and honestly, some people will just be mad because I suggest there’s a “sweet spot” that I can’t really prove and is just based on my own opinion and experience.

To review, the reason I argue for this age range is that: younger parenting is a lot harder—admittedly, often due to socioeconomic disadvantages rather than biology—and waiting too long risks infertility, increased pregnancy complications, and more challenging parenting realities. But keeping with my moderate branding, I will also admit that I can’t possibly understand your situation enough to give you advice! I just wanted to get the conversation moving. Feel free to comment telling me why I’m stupid and wrong.

And no matter what, I hope you get the number of kids you want, when you want them. ✌️

To the woman who became upset when my two-year-old son accidentally bumped into her while trying to get a better view of the airplane outside the window: I am so sorry. You’re right—it was unreasonable to expect you to share a five-foot-wide window with a toddler experiencing pure, unfiltered aviation joy. Obviously, only one person is entitled to gaze at the Boeing 787 on the tarmac, and you were there first. Never mind that you are in your sixties and have probably encountered an airplane or two in your lifetime. Of course— no problem. I will immediately drag my small son, kicking and screaming, away from the window, so that you can have an unencumbered view. I wouldn’t want his enthusiasm for commercial aviation to continue to disturb you.

To the man who glared and hissed “SHHH!” at me and my eighteen-month-old daughter when she began a tantrum in the middle of church—I am exceedingly sorry. But you see, she has a disability. It’s called “being eighteen months old.” But, you’re right: church is no place for a small child. We will see ourselves out immediately. Please don’t worry; we won’t burden you with our presence again. We must have misunderstood all that talk about Jesus loving the little children and saying, “Let the little children come to me.” Clearly, what He meant was as long as they do so quietly and without expressing any emotions. I did notice that your pews and collection plates look a little empty. But no matter, we can find another church to belong to, since children clearly aren’t welcome here.

To the librarians enforcing “65+ library hours,” I am so sorry for bringing my sixth-grade daughter to pick out a few books. No, I didn’t see the sign. I foolishly assumed that a child who hadn’t attended public school in person for an entire year due to COVID lockdowns might benefit from choosing something new to read. That’s on me. Never mind that everyone over sixty-five had access to vaccines months ago, or that by now it is common knowledge that children are among the least likely to contract or spread COVID—we will see ourselves out immediately. No, unfortunately, I can’t just come back later. I need to go pick up my sons from their private school, the one I began paying for when public school shut down and my kindergartener was asked to attend class via an iPad. But, my apologies for the inconvenience caused by this potentially germ-ridden child. Don’t worry too much—she has barely left the house in a year.

To the woman reading a book in the shallow end of the pool at Grandma’s condo association, who asked that my seven-year-old niece and eight-year-old nephew please not make any splashes: I am so sorry. A library book, you say? My goodness. The horror. The potential fine. How cruel of my nephew to consider a cannonball in the general vicinity of someone who chooses to read paper literature while partially submerged in communal water. You’re absolutely right—it is wildly unreasonable to expect to get wet at a pool, especially one where children play all the time. I will, of course, let my brother know that he needs to invest immediately in private diving lessons so his kids can learn to enter the water in a splashless, dignified way. Our sincerest apologies for this shocking failure to anticipate that going to a pool with children risks getting other people wet.

Gosh, I have so many more stories about the times my inconsiderate, poorly disciplined children have inconvenienced others in public, but there is simply no way to catalog them all here. So please, to anyone who has been wronged by my children’s existence, accept my sincerest apologies. When they are—who knows—designing the bridge that doesn’t collapse beneath you, treating your various ailments as a healthcare provider, and paying a solid thirty percent of their income to fund your Medicare and Social Security, I hope that will make it up to you.

But my favorite take came from , who makes an important point that too many people overlook: caring for young children who seem to be on a mission to kill themselves five times a day is really, really exhausting. And sometimes screens can help.

She called her essay Screen free parenting is risky: Or, in defense of everyone’s least favorite parent: the helicopter mom.

But I am definitely NOT a helicopter mom, nor am I a typically anxious or neurotic person, and I could still completely relate to this:

In order to raise kids without screens and avoid the headache of 24/7 anxious supervision, some of these tradeoffs will need to happen. Either you have to become much more tolerant of various accidents, property damage and ER visits (or worse!) or your kids have to be too scared of you to do anything risky. I’m sure some parent will come in to inform me that they’ve never had to punish their eight perfect screen-free kids, who spend all day peacefully and silently playing with corn husk dolls, but for the other 99.9% of people living in reality, screens exist to keep children safe and in one location during times when parents can’t be directly supervising them (while cooking dinner or breastfeeding a baby, for example.)

While my kids’ young childhoods did not involve a ton of screen time, I did sometimes use it strategically to avoid horrible accidents or big messes when I was, for example, putting the baby down for a nap or cleaning up the kitchen after lunch. And each child ended up with more screen time than the one before because my hands were increasingly tied each time another small human was added to the mix.

My oldest daughter barely used screens, and when she did, the content was almost 100% educational and supervised. By contrast, I once walked in on my third child watching a wildly inappropriate YouTube video of Caillou being spanked for “being a bad boy,” which autoplayed immediately after a different Caillou video. Oops.

I often hear the argument that…no need to occupy your little one with a screen! Toddlers and young children should simply shadow you throughout the day, absorbing important life skills through observation and imitation. But in my experience, they mostly just unfold your piles of folded laundry and slam their fingers in the washing machine. Don’t get me wrong—I’m sure this parenting hack works great for some people—especially those who: A) have one child, or B) have very compliant children (and, usually, girls—but we’ll circle back to that later).

At the risk of piling on, I would like to add something to the discourse. We tend to assume that parents use screens because they are lazy. But is it possible they just have harder kids? Furthermore, my children have all reached adolescence and are still alive. And I guess I just want some credit for that, because….

Some Kids Really Are Harder To Keep Alive Than Others

When I wrote Ok, But My Kids Are Harder Than Yours, it was mostly to vent about my youngest son’s “poor sleep”—which I later came to understand was really just a biological difference in his sleep needs compared to other children his age. At every stage of development, he slept about an hour less than any chart said he should. This meant that my husband and I got 2-4 fewer hours of freedom from the kind of hyper-vigilance necessary to avoid toddler accidents and destruction of property.

One of the most interesting comments on the piece came from , who works in the infant/toddler sleep space, and said the following:

There’s no evidence of any difference in developmental outcomes between low and high sleep needs kids - the low sleep needs babies just have more sleep deprived parents. And anecdotally, I feel like I tend to see them hit milestones early simply because they often have several additional hours a day to practice!

This was another moment of epiphany for me! All three of my kids walked early—at 10 months, 9 months, and 10 months, respectively. So apparently, while they weren’t sleeping, they were busy learning to be extremely mobile. As you can imagine, a baby who walks at nine months has even less sense than one who starts at twelve or fifteen. And once they were mobile, an attentive adult had to be within arm’s reach during every waking moment.

With my kids spaced two and a half to three years apart, that meant nearly nine consecutive years in which vigilance was constant and breaks were few and far between. Also, we live far from family, so no one helped us with our kids who wasn’t being paid.

What does this have to do with screens? Leaving the room to say, change a load of laundry, wipe another kid’s butt, or clean up a spill could have major consequences in terms of accidents or messes. And when I had overlapping babies, toddlers and preschoolers…well, you can guess what one of my hacks was. It starts with WILD and ends with KRATTS.

Even with all this vigilance, my kids basically had a perma-bruise on their foreheads from age 10-18 months. This generated a lot of comments from strangers and friends who made subtle accusations of poor supervision, yet never offered to come over and babysit. The irony is that for every bruise you saw, there were probably 20 to 30 prevented. During this stage, we were saving our kids’ lives several times a day. We had baby gates, cabinet locks, padded corners, etc. But it was never enough.

I feel that other parents were given a three to six month longer honeymoon period with their minimally mobile munchkin that I didn’t get. And the stats back me up: most children start walking at twelve to fifteen months. As you can see, my children were harder to keep alive from a very young age.

Maybe you think this is some kind of subtle mom brag. Um, no. My kids are older now, and I have way better material than early walking (did I mention my son made podium at the Wisconsin State Wrestling Tournament???)

Places We Could Not Live, Places We Could Not Go

When my husband and I looked at houses, we only had one child, and she was one. Even then, when our realtor showed us a house that backed up to a huge river, it was a non-starter. I can’t imagine the level of vigilance (or excessive screen use!) that would have been required with a river in the backyard. I also never would have considered a house with a pool. Beyond the fact that pools are money pits and we live in a state where an outdoor pool is usable maybe two months a year, I would have certainly lost a kid to a drowning incident.

Childhood drowning is the leading cause of unintentional death for children aged 1-4, and my kids were not cautious, “let’s stay close to Mom so we avoid getting hurt” types. I never would have trusted any gate or lock I could have built or bought. My kids climbed out of cribs at 18 months and scaled fences up to eight feet high starting at age four. Maybe I should care more that I couldn’t trust my kids to sit quietly where I put them, but mostly I just tried to avoid situations where their lives depended on obedience to me. Even a house on a busy road would have been a terrible idea, given the number of times I had to prevent them from running into the street on our not-that-busy block. One mistake, and…yikes. I don’t even want to think about it.

It was the same in parking lots. I loathed taking my kids to the grocery store for this reason. This is another example of when I feel frustrated by advice like, “Take your kids with you when doing adult chores—they’ll learn by watching!” That all sounds fine and dandy, but if your toddler doesn’t make it to adulthood because they darted in front of a Chevy Suburban in a grocery store parking lot, imitation didn’t help much, did it? There was simply no safe way to unload all three kids at once, locate a cart, and make it into the store. It might seem obvious to anyone with multiple children, but research actually backs it up: the presence of an older sibling is associated with an increased risk of childhood injury, particularly when the children are very closely spaced.

In my case, if my hands were full with the baby, the toddler could bolt at any second, and the six-year-old was prone to wandering off if she saw a cool pigeon. And don’t even get me started on returning the shopping cart—I did it, but it was NOT easy. So when the debate broke out over a viral video of a mom refusing to return her shopping cart due to the logistical gymnastics required, I personally found it very validating. Her frustration in the video was palpable, and I couldn’t help but cheer her on even while others judged her.

She was naming what many of us parents experience: an expectation to participate in polite society and “do your part,” with no acknowledgment that we are already doing our part—by caring for little humans with developing brains, who will one day become functioning adults funding other people’s Social Security checks. So, if those same people wanted to, I don’t know, actually help those children stay alive instead of judging their parents in a scary public place with zero margin for error, that would be super helpful. Thanks!

“Child-Friendly” Spaces That Weren’t Child Friendly Enough

While trying to keep my kids alive and off screens, I would frequently take them to places like zoos, playgrounds, and children’s museums. Perfect spaces for children, right? Well—not always. At the local zoo there were these two animal statues: a cow and an elephant. Great size for climbing! The elephant even had a slide for an ear. My kids could have entertained themselves for hours!

Except, they couldn’t. Because next to the statues was this sign:

So, parents: Don’t be confused. These attractive, fun play structures are NOT playground equipment. Why is this so hard for your toddlers to understand?? Why have you not trained them better??

When it came to REAL playgrounds, I was a big fan. Finally, a space specifically designed for physical, rambunctious children like mine! But they had to be in the right neighborhood. By that I mean, far away from judgy upper-middle class parents who constantly hover and give you the side-eye when you let your kids take reasonable risks. I just wanted to sit on the bench and enjoy my coffee, not tail my kids and reprimand them for going up the slide while sweet little Suzy is trying to go down—or scaling the roof of the playground equipment. Like I said, they were climbers! I learned to visit playgrounds at odd hours—like 7:00 am, when everyone else’s kids were still asleep even though mine had been awake for two hours—or to seek out parks in more humble parts of the city, where parents had bigger things to worry about than my kids climbing too high.

At the same time, there were moments when other parents’ concern was completely justified. On one occasion, my son (probably around eight at the time) climbed a tree next to the playground—and not just a little way up—we’re talking maybe thirty feet. The other parents started panicking, especially as their own kids tried to follow his lead. I was scared too. I believed he was capable, but I also knew that if he fell, it would not be a small accident. I tried to coax him down, but for a solid five to ten minutes, he pretended he couldn’t hear me—taking in the view from the top, calmly ignoring the crowd of anxious adults below. Eventually, he came down on his own, unharmed and very impressed with himself. What a little #$%@!

Here’s one last example: Several years ago, we took a road trip to Colorado with our kids—three, six, and nine at the time—and our twelve-year-old niece. We rented a two-bedroom Airbnb near the mountains that advertised itself as “child-friendly.”

It wasn’t.

Tiny glass and ceramic knick-knacks were everywhere—coffee tables, benches, low shelves. Not just breakable, but sharp. To protect the owner’s belongings—and to keep our children from getting cut by shards of glass—we moved the items to the tops of the kitchen cabinets, fully intending to put everything back exactly as we found it before we left.

But the night before checkout, my youngest was up all night with a bad cough, which ended with a 4 a.m. trip to the ER for croup. My husband was left behind to manage the other three kids, pack up the minivan, and clean the condo by himself. By the time my son and I returned from the hospital around 9 a.m., it was time to check out and we were both sleep-deprived and completely overwhelmed—and we forgot to put the nick-nacks back where we found them.

Much to our embarrassment, the Airbnb owners gave us a one star review, complaining that we’d “hidden their collectibles.” We wrote them back apologizing and explaining the situation, but they didn’t respond. Their complaints were warranted, but their condo was definitely NOT child-friendly and I have no clue what made them think that it was! In shame, we ended up deleting our Airbnb account and haven’t used it since.

I Don’t Want To Go There But…Girl Moms Don’t Always Understand

Sometimes I see takes from moms who are certain that other parents must be doing something wrong. After all, their child doesn’t make a mess everywhere. Their child can sit quietly in the corner coloring for an hour. Their child likes to sit and look at books. Their child doesn’t endanger themselves constantly. Their child is compliant when redirected.

Not always, but often—their child is a girl.

Sorry, not sorry, but there are often real behavioral differences between boys and girls. And I love boys! This is not a dig at boys. After attending my goddaughter’s Nutcracker rehearsal (yawn), I felt deeply relieved that I get to watch wrestling meets, soccer matches and robotics competitions on the regular rather than ballet.

I say this as someone who also has a daughter who is not at all girly (she’s the one busy with robotics): the two boys who followed were orders of magnitude harder to keep alive. Here are some examples of things my boys have done:

• gotten out of a booster seat before the car came to a complete stop

• skateboarded down an incredibly steep hill

• tried a black diamond the day after a first snowboarding lesson

• rode scooters and bikes barefoot and helmetless

And this is not an exhaustive list! Even my daughter recognizes their (occasional) idiocy. One afternoon, we were watching the boys play in the backyard. They were being ridiculous—tackling each other in the mud and throwing handfuls of dirt and sticks in each other’s faces. My daughter turned to my husband and said, “Dad, thank you so much for giving me an X chromosome.”

So here’s what a screen-light summer looks like for teenagers. This summer, my daughter mostly practiced piano, studied for the ACT, and read novels off her AP Lit/Lang summer reading list. In contrast, my son:

• ding dong ditched the neighbors, leading to a visit from an irate elderly man (it’s always good to meet the neighbors!)

• rode his bike to a town 15 miles away, then texted me from a friend’s phone to ask for a ride home

• snuck in the middle school when a door was left open “to get a drink of water,” leading to a call from the principal

• sliced open his foot during a scooter accident, requiring nine stitches, the day before his 13th birthday

• chased down a criminal who stole his friend’s bike on his own bike, only giving up the pursuit when the thief (who was probably 5 years older than him) turned around and threatened to “beat his ass”

I am sure the comments will be loaded with examples of little boys who are extremely tranquil and compliant. Probably people will come after my parenting too: “Well, if you were just stricter, your son would both stay off screens and stay out of trouble!” Maybe their kids are easier? I’m not trying to stereotype, but I don’t think I’m alone in my experience. There is evidence showing that, at all ages of childhood, boys are more prone to accidents and injuries — a pattern seen across many countries. According to global child injury data, boys tend to have both more frequent and more severe injuries than girls, with injury death rates for boys under 15 roughly 24 % higher than girls.

Look—I’m proud of my boys. They are strong and brave and wonderful. I could see them being wonderful firefighters, paramedics or ER physicians. I could also see them falling victim to a sports betting addiction, trying some “Free Solo” adventure that ends poorly, or spending a night in the slammer because they felt the rules only applied to other people. While I don’t want to squash their rambunctious spirits, in all honesty, it has made them extremely hard to keep alive.

Actually, My Kids Are Awesome

Since I’ve now written three essays about how hard my kids are, I worry a bit that I’ve given the wrong impression. Actually, my kids are awesome. Remember that 1-star Airbnb rating? Well, on that same trip, my children tackled three grueling hikes—putting in around 15-20 miles of hiking on very difficult terrain even though they were only 3, 6, and 9 at the time. My youngest spent some time in the hiking backpack (my husband is awesome too!) but for the most part he did it on his own. Best of all, no one fell off a cliff. I guess what I’m saying is, my kids may be hard to keep alive but I wouldn’t have it any other way.

It’s all good, though—now I have a Substack, so I can publish whatever I want and leave it un-paywalled just for you! If you want to thank me, please subscribe to A Moderate Midwife:

I’m a little sad about all the rejections, though—because IMHO birth is a really important topic! It has been around through all presidential administrations, and even if media outlets need to prioritize other healthcare-related stories right now (as one editor told me), birth is not going away anytime soon. It affects a lot of people. We were all born. A good portion of the half of us who are female will give birth at some point. And nearly all of us care about someone who has, or will have a baby. Also, those babies matter, and the circumstances of their births have implications for the rest of their lives.

And for better or worse, 98% of births in the U.S. occur in the hospital. Let’s talk about that.

Hospital Birth Isn’t Perfect, But It Saves a Lot of Lives

As a birth junkie who follows a lot of home birth and birth center content, I think those settings can be wonderful for the right people, and I wish they were available to more families. At the same time, I’ve attended hundreds of beautiful births in the hospital, given birth to my own three kids there, and witnessed many moments when skilled teams literally saved the lives of moms and babies. I think some people are too quick to dismiss the value of hospital birth, wanting to throw the proverbial baby out with the bath water.

Natural birth advocates may also overestimate the percent of women who are truly good candidates for out-of-hospital birth—more on that later!

A common counter-argument to the idea that hospital birth saves lives is that hospitals themselves create the medical problems they claim to treat—that unnecessary interventions pile up, triggering what is often called the “cascade of interventions.” I don’t always disagree with that critique; I’ve made it myself more times than I can count, and there are plenty of things about hospital birth that frustrate me and absolutely need to change. Given some of my prior posts, you might think me an unlikely defender of hospital birth. Afterall, I’ve written that The C-section Rate Doesn’t Have To Be This High and suggested that You May Want To Give Birth Without An Epidural.

But I strongly believe that, when it comes to birth, there is something in between intervening too much and intervening too little. It is called: intervening the right amount.

That doesn’t mean it is always easy. There is gray area in maternity care decision making. Did inducing a 41 week pregnant mom prevent a stillbirth and save a baby’s life? Or did trying to force birth before the body was ready lead to prolonged labor, chorioamnionitis, compromised fetal heart tones, and an unnecessary C-section? We can never know for certain how any action—or inaction—would have changed the outcome. Birth isn’t a “choose your own adventure” book where we can go back and try again. None of us has a crystal ball; we’re all working with imperfect data and doing the best we can.

Still, the assumption held by some natural birth advocates—that any intervention in childbirth is inherently harmful, and that left to nature all would be fine except for in rare cases—is obviously wrong. Pregnancy and birth carry real, inherent risks, many of which can be mitigated through skilled midwifery and modern medicine. Helping one another through childbirth is a practice as old as humanity itself, and is probably one of the reasons our species has been so reproductively successful. In fact, UNESCO recognized midwifery on the Representative List of the Intangible Cultural Heritage of Humanity, noting that it is a global, universal tradition, present in every society throughout human history.

And medical advances during the 20th century, like antibiotics to treat infection, blood transfusion to treat hemorrhage, magnesium sulfate for preeclampsia (before it turns into seizures and strokes, aka eclampsia), and safer cesarean section have caused death rates for moms and babies to plummet even further. For proof, see below:

Let’s Talk About Medical Over-Intervention

Looking at Figure 2, are you wondering why maternal mortality went up instead of down in the 1920’s? The increase during that time was primarily due to inappropriate and excessive medical interventions as physicians moved childbirth out of the home and into the hospital. The problem wasn’t hospitals in themselves, but practices that were adopted by obstetricians without proper evidence—twilight sleep (scopolamine and morphine), routine use of episiotomy and forceps, manipulating the cervix, uterus or fetus during labor and poor hygiene. Doctors weren’t washing their hands and were going directly from dissecting cadavers during autopsy to attending births, causing high rates of sepsis.

At the same time, traditional midwives of the era were put out of business due to lobbying from physicians. Wanting to do away with the competition, these doctors argued to remove midwifery training programs and advocated for laws that took away midwives’ licenses to practice. This marks a big difference between U.S. medical culture—where midwives were shunned—and other places like the U.K. where they were embraced and integrated, a la “Call the Midwife.” To me, this is an important point: the best maternity care systems in the world have an intimate, respectful collaboration between midwives and physicians. Even in the U.S., states with the best outcomes have higher levels of midwifery integration.

While some births require a high level of intervention, most don’t—and being experts on normal birth, skilled midwives are well-equipped to recognize the difference.

Let’s Talk About Free Birth

In case you need further proof that intervention in childbirth isn’t always bad, recent reporting on free birth—childbirth without trained attendants—makes this painfully clear. An investigation by The Guardian looked at the Free Birth Society, a network that made millions of dollars promoting unassisted home birth, reporting on numerous cases in which women experienced stillbirths, neonatal deaths and severe maternal injuries.

For me, the most heartbreaking part of the article was the account of a 17-minute shoulder dystocia that left the baby with permanent brain damage. Three friends the mother had met through the Free Birth Society were present at the birth, but repeatedly told her, ‘the baby is safe,’ even as she asked for help, knowing her baby was stuck.

As a midwife, I’ve managed several shoulder dystocias and my longest was around 3 minutes, so the idea of watching one unfold for 17 minutes without acting is almost incomprehensible. Shoulder dystocia is a terrifying emergency that occurs in 1.4% of births and needs to be addressed immediately. Even with the best management possible, babies can sometimes be injured—broken clavicles, brachial plexus injuries—but the worst risk is brain damage from prolonged oxygen deprivation. That’s exactly what happened to the little boy in the article, who is now severely disabled, fed through a tube, and cannot walk at age 3.

Reading that part of the story made me physically ill, especially as I recalled the shoulder dystocia I experienced with my own third birth, which my midwife skillfully resolved in less than a minute. I feel awful for that mother. She asked for help and was ignored; the people present weren’t trained in anything other than an ideology of “baby is safe” even when the exact opposite was true.

Just yesterday, the Huffington Post shared more tragic news. A 30-year-old wellness influencer in Australia died of a postpartum hemorrhage after a free birth with only her husband and a doula present. By the time she was taken to the hospital, her blood supply was completely exhausted. When her husband announced the death on Instagram, he told his wife’s followers that she died of “unforeseen and extremely rare” complications. My heart goes out to this man for this terrible loss.

This tragedy also highlights an important fact: postpartum hemorrhage isn’t as rare as some people believe. It affects 3-4% of births and is the leading cause of death in childbirth worldwide. It is also very treatable with medications, hemorrhage control devices (Bakri balloon, Jada), blood transfusions and, in a worst case scenario, surgery such as hysterectomy.

Over my career, I’ve helped countless families give birth, and I can count on one hand the people who would truly reject medical intervention if it meant preventing avoidable tragedy for themselves or their babies. Every day, incidents like the ones mentioned above are prevented during hospital birth, and also during home birth or birth center birth with a skilled attendant.

Why Does Hospital Birth Get a Bad Rap?

Now that I’ve waxed poetic about hospital birth, let’s take a step back. Because there is some pretty good evidence that people are not happy with the state of hospital birth. For this essay, I’m mostly going to focus on the U.S., but I’m well aware that medical hierarchies, dehumanizing practices, and non-evidence-based maternity care exists all over the world.

A recent CDC report found that 1 in 5 mothers reports mistreatment during childbirth, a number that rises to 1 in 3 for people of color. Their most common complaints were:

• Receiving no response to requests for help.

• Being shouted at or scolded.

• Not having their physical privacy protected.

• Being threatened with withholding treatment or made to accept unwanted treatment.

Black mothers, in particular, face bleak statistics: they are more likely to be subjected to unnecessary cesareans, and many report racism within the medical system. It’s no surprise that Black moms are increasingly turning to midwifery care and out-of-hospital birth in search of more respect and better outcomes.

The idea that hospital birth is disempowering and traumatic is so widespread that it even became the punchline of a comedy sketch. On The Daily Show, after joking that she chose home birth because “I wanted to ruin my couch,” unpacks what women hate about hospital birth, stating “Whenever I talk to a woman who has given birth in a hospital, it’s almost always a horror story.”

She goes on to highlight the most common complaints about hospital birth: the loss of autonomy, profit-driven hospital policies, the prioritization of physician convenience over patient wishes, and the unjustifiably high C-section rates of many hospitals. Then she concludes that integrating midwifery care would be a great solution. Obviously, I agree! In fact, I wrote about it in You May Want To Give Birth With A Midwife!

But many medical professionals dismiss mothers’ dissatisfaction as naïve or unrealistic. On platforms like X, doctors mock birth plans, widening the gap between the care people want and what they receive. This dismissive attitude can contribute to situations of obstetric violence, where women’s autonomy is violated and their experiences become traumatic.

What some healthcare professionals fail to see is that the most essential intervention in pregnancy and childbirth isn’t a technology or procedure, but rather the presence of attentive, supportive caregivers. When this basic support is missing, it’s no wonder that mothers start looking for out-of-hospital alternatives. Modern medicine has introduced valuable interventions, but its reliance on technology, often at the expense of human connection, may be its biggest blind spot.

Faced with hospital bans on options like vaginal birth after cesarean (VBAC) and vaginal breech birth, which were once widely available in American hospitals, some people attempt these births at home despite the elevated risks, driven by a desire to avoid major surgery. Pregnant people wanting to avoid cesarean correctly assume that their chances are much better with home birth. Despite wide recognition that the C-section rate is too high, very little is done to hold the healthcare system accountable for unnecessary cesarean.

Even in our modern day, the evidence in favor of continuous labor support for improving birth outcomes is overwhelming. Yet this kind of support is shockingly rare during hospital birth.

Midwives, offering a lower-tech, higher-touch version of care, face barriers in U.S. hospitals due to discriminatory laws and policies. While midwives attend the majority of births in other countries, they assist in only 12% of U.S. births. Doulas, whose presence improves numerous birth outcomes, are used in only 6% of labors, mostly by those who can afford them. In some hospitals, staff view doulas as adversaries, undermining their support or even kicking them out of delivery rooms.

In theory, labor and delivery nurses are the ones providing support during hospital birth. In practice, hospital culture and policies prioritize unproven technology and efficiency over one-on-one care, as shown by recent New York Times reporting. The technologies involved with birth seem designed to help staff be anywhere but the patient’s room. Continuous electronic fetal monitors broadcast heart tones to the nurses’ station, and blood pressure cuffs can be programmed to go off automatically. Epidural anesthesia, while an incredibly useful tool for some laboring moms, can be pushed by overworked staff who know that people laboring with anesthesia require less in person support.

When I worked as a labor and delivery nurse, I often felt buried under tasks like tracking fetal heart tones, completing documentation, and making phone calls to doctors who were not present on the unit but expected to be called at exactly the right moment to attend the birth. These demands distracted from the person who mattered most—the laboring mother—and forced me to be less present to her.

In short, you do not have to work very hard to convince me that our current system of hospital birth is flawed. The question is, what should we do about it?

Is Home Birth a Way Out of the Horribleness of Hospital Birth?

The connection between dissatisfaction with hospital birth and the rise in home birth is rarely discussed, but it’s undeniable. For example, a Washington Post article profiling the deaths of several infants under the care of a certified professional midwife showed evidence that many mothers who were not good candidates for home birth chose it anyway due to their distrust of the medical system, or religious beliefs that kept them from accessing care. Similarly, Court TV’s coverage of the “Midwife Delivery Death Trial” revealed that a couple whose baby died of asphyxiation during a home birth chose this option with a non-credentialed midwife after being denied the option of a vaginal birth after cesarean (VBAC) at their local hospital.

If we want to reduce the risks of unsafe home births, we need to address the real problems driving people away from hospitals in the first place.

First off: I am not opposed to people who are good candidates choosing home birth or freestanding birth center birth (this is a facility apart from a hospital designed for low-risk birth, usually run by midwives). I hear a lot of great things! My sister-in-law had a very nice home birth, as did one of my best friends. Despite some of the horror stories published in the media, the home birth stories I hear are overwhelmingly positive. Beyond this, data shows that planned out-of-hospital birth with a skilled attendant is actually pretty safe. In fact, one could argue it’s safer for the mom by way of lower intervention rates, and perhaps a little bit less safe for the baby (depending what studies you chose to look at).

One of my favorite researchers, Elizabeth Nethery, did a fairly large study of home and birth center birth in Washington, a midwifery-friendly state where, in her words “midwifery practice and integration mirrors international settings.” Here were their outcomes:

Results: The study population included 10,609 births: 40.9% planned home and 59.1% planned birth center births. Intrapartum transfers to hospital were more frequent among nulliparous individuals (30.5%; 95% CI 29.2-31.9) than multiparous individuals (4.2%; 95% CI 3.6-4.6). The cesarean delivery rate was 11.4% (95% CI 10.2-12.3) in nulliparous individuals and 0.87% (95% CI 0.7-1.1) in multiparous individuals. The perinatal mortality rate after the onset of labor (intrapartum and neonatal deaths through 7 days) was 0.57 (95% CI 0.19-1.04) per 1,000 births. Rates for other adverse outcomes were also low. Compared with planned birth center births, planned home births had similar risks in crude and adjusted analyses.

Emphasis on C-section rates is mine. Can you believe how low they are? But when you look at who was included in the study, it kind of makes sense.

They excluded the following risk factors from their analysis. For reference, I researched the frequency of each thing in the general maternal population:

• Pre-pregnancy diabetes (frequency: 0.5-2%)

• Pre-pregnancy hypertension (frequency: 3-5%)

• Twins (frequency: 3%)

• Amniotic fluid abnormality—too much or too little (frequency: 10-15%)

• Previous cesarean (frequency: 14.7%)

• Gestational hypertension or preeclampsia (frequency: 8-16%)

• Breech (frequency: 3-4%)

• Labor at <37 wk (frequency: 10.5%)

• Labor at >42 wk (frequency: 5-10% *higher rate found with older data, as routine induction at or before 41 wk has reduced the incidence of >42 week pregnancy)

I guess my point is, there are plenty of people who just aren’t great candidates for out-of-hospital birth! It’s also worth noting the transfer rate—30.5% of first-time mothers planning an out-of-hospital birth were transferred to the hospital. Some might see this as a ‘failed’ home birth, but I see it as evidence that the midwives involved were making safe, appropriate decisions—recognizing risk, staying within their scope, and transferring when necessary. Kudos to them. ✌️

While I support expanding options like home and birth-center births, we also need to be realistic about how many people they can safely serve. When you consider the risk-factor data, the high transfer rates for first time moms, and the fact that most laboring mothers choose epidural anesthesia (71%), it becomes clear that only about 20–30% of pregnant people are truly candidates for out-of-hospital birth.

Why Don’t Women Have More Options During Hospital Birth?

When my sister was pregnant with her first child, she specifically chose a hospital-based midwifery practice that offered water birth. At 38 weeks, her midwife gave her the disappointing news that the hospital had a new head obstetrician who had unilaterally banned water birth, going so far as to lock the portable tubs away in his office.

At the time I was a midwifery student, and it was one of my first glimpses into how power and policy—rather than evidence or patient preferences—often shape hospital birth. Since then, I’ve seen many more examples, such as an anesthesiologist blocking our unit’s efforts to introduce nitrous oxide, and patients who were decent candidates for breech vaginal birth or a VBAC being required to have a C-section.

The deeper issue is that healthcare is built on hierarchy, liability fears, and profit-driven motives. Many physicians practice the way they were taught, even when evidence shifts. Hospitals often adopt policies based on risk management rather than patient autonomy. And because physicians sit at the top of the hierarchy, their preferences—sometimes even personal biases—can override the options available to patients. Hospitals rely on physicians to generate revenue, and replacing a doctor is not always feasible—especially in areas already struggling with provider shortages. All of this makes meaningful change slow, even when everyone agrees patients deserve better options.

To complete the story, my sister went on to have two hospital water births later on with a group of certified nurse-midwives (CNMs) at a New Jersey hospital. I was there for the second one, and it was the first water birth I’ve ever witnessed. It was calm, intimate, and nothing like the impersonal experiences that drive some people away from the hospital. Two years later I was present in the same hospital when a medically necessary induction of labor probably saved my nephew’s life. During both births, my sister’s midwives and nurses never left her side, and obstetricians stood ready to intervene if needed.

At its best, this is what hospital birth can be: an experience that honors the incredible power of mothers while giving them access to life-saving modern medical care when needed.

Is Low Intervention Birth Possible in the Hospital?

The other day I was on call when a low-risk mom came into the hospital in labor. She didn’t have an IV, didn’t get an epidural, and I only checked her cervix once. Her water broke spontaneously, and she paced around the room until it was time to push. She pushed standing up, leaning over the bed. Once the baby was born, I passed her to the mom for immediate skin-to-skin contact and breastfeeding, and we waited several minutes before dad cut the cord. I recommended 10 milliunits of Pitocin injection to help prevent postpartum hemorrhage, and she agreed. The placenta delivered normally, and she did not tear or bleed heavily. Other than that single dose of Pitocin, she experienced no medications or interventions during her birth.

So, yes! This is possible. Why is it so rare? As discussed above, it’s complicated: it has to do with hospital policies, provider training and culture, patient preferences (like epidural), and legal/liability concerns.

How To Have The Most Beautiful Hospital Birth Possible

No one becomes a nurse, midwife, or doctor because they want to ruin your birth. The vast majority of maternity care workers are good people who want the best for moms and babies, but we’re still working within a flawed system.

I know everything I’ve written here might feel like whiplash: “So is this midwife saying hospital birth is good or bad?” Well, yes, I am! To make up for being totally confusing, I’m going to leave you with some ideas for how to work with the system to make your (hospital) birth as good as possible.

• Research your hospital ahead of time: Not everyone can choose where they give birth, but if you can, it’s worth looking into which hospitals follow evidence-based practices. Hospitals are required to report their NTSV (nulliparous, term, singleton, vertex) C-section rates. Rates above 23.6% exceed the national benchmark, which may indicate higher-than-average intervention rates. Use this website to research your hospital

• Birth plans vs. birth wishes: Please communicate what matters most to you during birth. Some providers may roll their eyes at a detailed birth plan—after all, birth is unpredictable, and you can’t control everything. That’s why I prefer thinking in terms of birth wishes. Share your priorities with your healthcare team: a calm atmosphere with dim lighting, minimal cervical checks, freedom to move during labor, and the ability to eat and drink are all reasonable in most circumstances. Honestly, I wish more parents would speak up, so I wouldn’t be alone in advocating for these preferences to the nurses!

• Consider midwifery care, or at least giving birth in a hospital that has midwives: Midwives often focus on low-intervention, patient-centered care so having a midwife on your team can help you access evidence-based practices and advocate for your birth wishes. Even if you’re too high risk for midwifery care, studies show midwives influence the culture of a hospital, so giving birth at a hospital open to midwifery can still positively influence your birth.

• Hire a doula: A trained labor support person can provide continuous emotional and physical support, help you communicate your preferences, and act as an extra advocate with hospital staff. Research shows doula support is associated with lower rates of interventions and higher satisfaction with the birth experience.

Thank you so much for sticking with me this far! I know this topic brings up a lot of strong opinions, and I’m happy to hear your thoughts and answer any questions in the comments.✌️💌👶