Maternal and Child Health Leadership Conference (Chicago: April 27-29, 2003)    

Dr. Jose Peralta:  Thank you, Michelle, and good afternoon to all of you.  Thank you for being here.  I’m very proud and honored to have been invited.  Like Michelle said, I’m director of the MCH program at our School of Public Health.  She forgot to mention, my biggest claim to fame is I father all these kids, and they’re mostly girls, as you can see.  What I want to do today is, I want to share with you some of the work that we are doing at the MCH program in Puerto Rico in dealing with the problems of obstetrical practices and their, many times, negative impact on the health of our mothers and our children, and, really, and of society in general.  I’ve collected a few enemies on the way.  Some of my colleagues in the obstetrical field hate me for the things I say and some of the things I’m going to say here today.  So like somebody once said, if your enemy hates you, you must be doing something right.  My colleague and mother of my children, Anna Paralta, is very sorry that she couldn’t be here.  She got a little delicate of health in the last week or so.  So she’s back home, getting better and doing a little mothering for the kids.  But I called her up last night, and I spoke to--what we did last night in the Puerto Rican community, and I think she couldn’t sleep because she thought she wanted to be here.  But this work that I’m going to present here belongs to both of us, and like Michelle said, it’s part of our--one of our major community service and research interests at the school, and the topic of a book which we have--should be finished by now, it’s just that the day insists on having only 24 hours, and sometimes we have a hard time getting everything in there.  So we’re going to talk a little bit about the medicalization of birth in Puerto Rico.  All the fancy visuals are my wife’s deed, huh?  I can hardly get this thing on.  Puerto Rico, as most third world countries, has gone through demographic transitions during the 20^th century.  Our typical society by the end of the 19^th century was an agrarian society with limited and decentralized healthcare services, and reproduction was mostly handled by the midwife, which was usually a traditional midwife with very little formal training, with a lot of wisdom just acquired, hand-to-hand and mouth-to-mouth, from previous midwifes.  The labor and delivery were a family affair, and the physician, if there was one available, was called only for critical situations.  At the beginning of the 20^th century, when we started constructing some sort of system of health statistics, our fetal, neonatal infant, and maternal mortalities were very high.  It could probably be described as a percent instead of per-thousand.  I won’t go into many details, because the figures are probably very inexact, anyway.  Beginning in the post-World War II period, as Puerto Rico entered its first major healthcare reform process, the medical model was applied to handle most of our causes of illness and death.  It’s done many wonderful things for the Puerto Rican society, the medical model has; and in reproduction, it did provide some needed benefits.  For the last 30 or 40 years, however, the thing has sort of gone out of hand.  The paradigm has changed.  The role of the mother in the process of reproduction has been completely taken away from her.  She has become a surgical patient, and the process of having a baby has changed for the minds of the Puerto Rican mothers, families, and doctors from a family affair, which is mostly and usually a normal process, to a view of labor and delivery as a disaster waiting to happen, and thank God that there is an obstetrician standing there to prevent it with some intervention, which he can hardly, or she, keeps his hands away before doing something.  And this, I’m sure, is familiar to you.  It’s probably similar to what’s happened in this country in many ways, but as you will see in our statistics, we do have certain specifics.  Puerto Rican mothers, at the present time, have access to limited prenatal education, and the prenatal education that is offered is many times very much domesticated.  Many of the labor educators, childbirth educators in Puerto Rico, facing a very powerful medical establishment, have watered down their message from one of empowerment and of giving back to the woman the protagonic role of being the star of the show to sort of prepare the woman and the mother to let the physician do whatever the physician thinks he has to do, and they even have conferences on C-sections and the importance of the electronic fetal monitor, and why they should have their pudendum shaved, and so forth, and so on.  And this is a way that many childbirth educators have been able to get around the medical establishment and preserve some kind of acceptability in hospitals to help mothers.  We don’t have birthing centers, and 99 percent-plus of our deliveries occur in hospitals.  We don’t have access to professional midwives with legal recognition.  We have very limited labor support personnel.  The only hospital in Puerto Rico which has a certificate of intent to become a baby-friendly hospital, we don’t have any baby-friendly hospitals yet, and the only one that has a certificate of intent, and which we are helping with technical assistance to train their personnel in the breastfeeding field, recently met their obstetrical department, and they unanimously rejected a proposal to bring doulas into the delivery suite, so this is the situation.  Access to birth companions of the mother’s choice is very restricted and only under very stringent and limited circumstances.  Contrary to what is happening in this country, where certified nurse midwives are gaining an important foothold in the delivery of obstetrical or delivery care in this country, already close to 10 percent of all vaginal deliveries in the US are being done by CNMs, and in certain localities, like New Mexico, almost a third of the vaginal deliveries are handled by midwives, nurse midwives.  In Illinois, I looked it up, 4.42 percent of all deliveries are done by CNMs, and 5.5 percent of spontaneous vaginal deliveries, which is a little below the national average.  In the United States, as far as the Hispanics who are being attended by nurse midwives, the Hispanic population is--9.4 percent are being attended the deliveries by nurse midwives.  We have, in Puerto Rico, going back to the island, a very limited and insufficient and inadequate description and information regarding obstetrical practices of hospitals to the community, and very few people do not even dare to ask, “What is your C-section rate?”  Hospitals do not say what their C-section rates are.  They don’t say what their epidural rates are, and they sort of, “If you want to come here, take it or leave it.  We are not going to give you a lot of information.”  There is a rampant lack of sensitivity towards the mother’s preferences.  My secretary couldn’t find a physician who would allow her the opportunity of a trial of labor after a Caesarean section two months ago.  I’m not in practice right now, so I don’t have insurance, so I couldn’t take care of her.  Restriction of movement during labor is practically universal in hospitals, and the lithotomic position is routinely used for mothers.  This crazy position described about 300 years ago by a French *accuisure, who described it as “very convenient for the *accuisure.”  He never said it was good for the mother.  There was very little information on that time regarding the dangers of this position for placental profusion, but even though we’ve had that knowledge now for close to 50 years, obstetricians feel that this is the position they want to use, and the one they do use in Puerto Rico, unless we have a very aggressive, crazy mother who says, “I am not going to lie there and put my legs up for you, no?”  Anyway, there is very much noncompliance with evidence-based obstetrics.  The philosophy is:  My mind is made up; don’t confuse me with facts.  Everybody knows that shaving is unnecessary.  It’s humiliating, it’s uncomfortable, but they do it.  Everybody knows that enemas are absolutely unnecessary, but they do it, some people say to protect the olfactory sense of obstetricians.  IV fluids are routinely applied to mothers, which has a lot of problems, and when these things are brought out in obstetrical meetings, either they walk out or they sort of sneer at you and say, “What are you talking about?” when you tell them that one of the reasons why they claim to have to give babies sugar water after they are born is because the mother has received an IV fluid with dextrose, which has created a production of insulin on the baby’s part, then they say that they need to have IV fluids because, “Suppose I have to do an emergency C-section,” which although it is a very large risk in Puerto Rico, as you will see, it is absolutely unnecessary and it just comes out of a surgical frame of mind towards labor and delivery.  Women are routinely forbidden to eat or drink anything during labor and delivery, and the artificial rupture of the membranes is carried on with a (inaudible) registration of the statistic, but over and over, 60 percent of the cases.  Induction of labor is a way that obstetricians find to organize their work, so they don’t get called at night or over the weekends.  We’re going to be talking a little bit about that later.  The electronic fetal monitor is hooked up to every mother at some time, and the statistics report 78 percent of full use of the monitor during the entire process.  The episiotomy is done indiscriminately.  It’s not even reported as an obstetrical intervention in the birth certificate.  Sometimes, it’s not even reported in the hospital front sheet, but two studies that we have done from the Maternal and Child Health program, one in a very large, private hospital in San Juan, and one at San Juan City Hospital, tells us that we’re doing it anywhere from 79 to 88 percent of the cases.  We’re going to be talking about a frame of reference for that in a little while.  This is a famous electronic fetal monitor.  It hasn’t lived up to its expectations.  Cerebral palsy rates in this country are no different today than they were 30 years ago, and yet, physicians insist on using this.  There is no, absolutely no scientific evidence to sustain the routine use of the electronic fetal monitor.  The only statistic that changes between acoustical stethoscope monitoring of the fetal heart rate during labor and the routine use of the electronic fetal monitor is in the Caesarean section.  It doubles and triples in cases which are monitored routinely by means of the monitor.  It’s a moneymaking proposition for hospitals, and it’s a time saving situation for physicians.  They feel that if the mother is hooked up to the monitor, then nobody has to take a look at her.  Nobody has to be--“She’s with a monitor, she has a monitor.”  Okay?  The episiotomy, which we are going to discuss in a little while, this is a picture from the Williams obstetrics textbook, we like to call it “genital mutilation,” absolutely unnecessary when done on a routine basis in Puerto Rico, and we’re give you a little statistics on that.  I congratulate the United States.  It has reduced its episiotomy rate by 50 percent in the last 20 years, from 64 percent down to 32.7 percent.  I think I should congratulate mothers in the United States, or somebody’s fighting obstetricians and taking away their systems from them.  It may even be that obstetricians do read more than our obstetricians do.  But anyway, this is a significant improvement.  The United Nations and the World Health Organization states that no jurisdiction should have an episiotomy rate over 15 percent, and the goal should be 5 percent.  So this is a great improvement.  Remember, I said Puerto Rico from the two studies we have, we’re running around 80 to 88 percent.  We are using pharmacological methods of pain relief like they’re going out of style.  We have excessive rates of Caesarean section, and very low VBAC rates.  The mother is routinely separated from her child once they’re born.  I was remembering this this morning, that Dr. Hogue was talking about how we set our capacity for stress coping in the first year, from conception to the first year after birth.  Dr. Marshall Klaus, who you probably heard about, says that the experiment of the newborn nursery, has been an experiment after the second World War, makes the Nazi experiments pale compared to what taking the mother and the baby and separating them to take the baby to a nursery, routinely does to the psyche of a mother and to her newborn child.  We have inadequate support for breastfeeding, and our dismal breastfeeding statistics are there to show for it.  This is why our biggest research push right now is on identifying the barriers to breastfeeding among our population.  We still don’t have an 80 percent epidural rate, like they do in this country, because most insurance coverage does not cover it.  Otherwise we probably--we would have it.  A look at our Caesarean section rates:  as you can see, there are very large differences between the rates in the US, represented by this line, and the rates in Puerto Rico.  We are running a 42.7 percent Caesarean section rate in 2001, as compared to a 24.4 percent C-section rate in the US.  The Healthy People 2010 Objectives call for 15 percent primary Caesarean section rates, and this is worrisome to the people who are doing work in this field in this country.  Ours is worse.  We have a saying in Puerto Rico that says that whenever somebody sneezes in Washington, we get pneumonia in San Juan.  The only thing that these two curves are similar in is that you can see dips around 1995, 1996, in both jurisdictions.  There was a reduction in the Caesarean section rate, which came to (inaudible) at about 20.7 in 1996, and we dipped to 29.7 in 1995, coming up to 31.5.  This was basically produced by an increase in VBACs, vaginal birth after caesareans.  When the American College of Ob/Gyn produced around the late ‘80s and early ‘90s an official position paper on not doing routine repeat Caesarean sections because of all the available evidence that showed that is was a worthwhile recommendation, a lot of people, both in the US and in Puerto Rico, started doing more VBACs, and you will see another slide that demonstrates that.  Of course, the pendulum has taken another swing.  The forces of evil are very active, and now they are talking about prophylactic C-sections for everybody, okay, and the former head, or president of ACOG, and the present head of Ob/Gyn of the UPR School of Medicine are on record, stating that every woman should deliver abdominally, that vaginal birth is outmoded; we are better than God.  Okay?  So this is basically what’s happening, the horror stories that women are told in Puerto Rico about the dangers of a VBAC, or the outright denial of the opportunity, in absolute violation of all the principles of informed consent, are carrying this rate to what should be close to--we have hospitals that have 60 percent C-section rates.  Now, this is the VBAC rates in Puerto Rico and the USA.  As you can see, ’96 was the golden era in the States.  We were reaching 30 percent VBAC rate.  The Healthy People 2010 Objective for VBACs calls for 37 percent, and in 1996, it looked like the US was on a good track to achieve that goal.  Now, see what’s happened, thanks to people like *Favor, and *Adamses, and all the guys who are talking about prophylactic C-Sections, and are selling all the horror stories about VBACs.  In Puerto Rico, there are no data for these years, but you can see that we are running below 5 percent right now, and most OBs on the island are flatly stating to their patients that they will not allow them the trial of labor with a previous C-section.  Then, they wonder why they are getting sued out of their ears, because they are not allowing informed consent, they are not doing good obstetrics, they are not observing ACOG’s standards, okay?  There is plenty of evidence-based research, which we will just mention here in your handouts.  I tried to include as many bibliographical references as I could to sustain all of the evidence that I am presenting here.  The supine position, having the mother lay on her back for labor and delivery, has been proven for over 40, 50 years, produces maternal hypertension from compression on the vena cava and the aorta, reduction of placental profusion, and placental insuffiency.  But other, more recent studies have shown that there is an increase in the amount of pain perceived by the mother when she is lying on her back.  There is more compression on the pelvic ganglia and the pelvic nerves.  Labor is prolonged, because you’re working against Mother Nature, and against the law of gravity.  Nobody would think of emptying his or her bowels laying on her back with his legs standing up.  Yet, we have women do that for something which is a lot more difficult that moving bowels.  We got more depressed neonates, not only because we have more decreased placental profusion, but because we have more need for pharmacological anesthesia and analgesia, because there is more pain in labor with the woman laying on her back.  Many studies have shown, and there are several cited in your references, that allowing mothers to ambulate and to assume the position of her choice during labor and delivery produces analgesic effects.  Just being able to walk has an analgesic effect, therefore reducing the need for drugs, shortening the duration of labor, and we get better babies, because mothers deliver faster, better, with fewer drugs.  Shaving and enema not supported, like I said, uncomfortable, humiliating, and unnecessary, and so are IV fluids.  IV fluids bear the additional problem of immobilizing the woman.  The woman wants to walk, and the labor room nurses say, “No, don’t get up out of bed.  I’m going to lose my vein.”  Well, it’s not her vein; it’s mother’s vein, anyway, and she didn’t need that thing sticking in her vein to start with.  See, one of the big things about modern day obstetrics is we ignore physiology.  What’s physiology, you know?  We don’t accept the fact that Mother Nature made woman increase her circulating blood volume by 50 percent, just because she’s pregnant, because she is going to come to a period of delivery where she is going to lose blood.  So she has a 50 percent increase in her circulating blood volume.  So if we need to get a vein for a true emergency, I mean the veins are like this, because she has 50 percent more circulating blood volume.  See, when we started thinking that we knew more than God, we forget these little things, you know?  IV fluids are for, and besides the glucose problem that I talked to you about, which is a very big barrier towards initiation of breastfeeding.  I first heard Dr. Roberto *Galdedo *Varcia, from Uruguay, in the decade of the ‘70s, stating about how artificial rupture of the membranes should not be done routinely, and if God wanted babies to be surrounded by a bag full of water, why should we break the bag of waters?  It has a hydrostatic protection against pressures on the fetal head, and it is a barrier against infection.  I’m going to show you a picture in a little while of a baby born in (inaudible), like we say in Spanish, born surrounded by the membranes, which is perfectly fine.  Eventually, you have to break the membranes so they can breathe, but they can be born with the intact membranes.  They don’t have to be broken.  How am I going to use the internal fetal monitor if I don’t rupture the membranes?  Who says you need the internal fetal monitor routinely, okay?  You may need it in a few cases.  You may even need to have your appendix out, someday, but you don’t take the appendix out on everybody, do you?  Induction of labor in Puerto Rico:  when I tell my labor room nurses in San Juan that the Department of Health reports 6.6 percent, they unanimously stand up and say, “I think you have a typo there.  It must be 66 percent,” because nurses anecdotally know that, you know, physicians are all inducing all their patients.  They are not forcing them to, technically, but they will say something like, “You know, honey, you’re just about ready, and this weekend, I’ll be in *Dorado, playing golf, so Dr. Kelly is going to cover for me.”  And the patient will say, “I don’t know Dr. Kelly.  I want to deliver with you.”  “Oh, well in that case, I’ll do it for you, and I’ll induce you tomorrow.”  So many obstetricians are doing all their deliveries on Tuesdays, Wednesdays, and Thursdays, between seven in the morning and four in the afternoon, and those are the ones that have 70, 80 percent C-Section rates.  Labor inductions are underreported.  We are having all sorts of difficulties getting access to records to study this and to able to prove that this is a gross underreporting, but suffice it to say that there are very large risks of hyperbilirubinemia, which may be or may not be a big problem, but it turns into a big problem, because as soon as the baby turns yellow, the first thing the pediatrician says back home is, “You cannot breastfeed.”  Our pediatricians don’t know physiology, either.  Okay?  Jack Newman, in Toronto, says that hyperbilirubinemia is a healthy thing for babies to have when they are born.  But in Puerto Rico, a pediatrician sees a baby with yellow sclera, the first thing he always does is, “Stop breastfeeding,” and of course, gives them a styli, blood cultures, urine, because he’s septic, okay?  Induction increases the need for drugs.  It has been shown to increase maternal stress.  Maternal stress shows to hinder the effective function of oxytocin, so you have to give them more pit.  It increases the risk of Caesarean section, and in Puerto Rico, another thing that we are looking into is that our neonatal mortality rate is increasing, and one of our hypotheses is that since our low birth weight rate is also increasing as our Caesarean section rate is increasing, we are thinking of antigenic prematurity.  Is the word antigenic used in this country?

Unidentified Speaker:  Yes. 

Dr. Jose Peralta:  Okay.  I’m sorry, these are crazy Greek words that, you know, I was--the World Health Organization states that no jurisdiction should have an induction rate over 10 percent, and our anecdotal evidence in Puerto Rico right now is it’s probably closer to 50, 60 percent.  We have to quantify that.  We have to get that study done.  Electronic fetal monitoring is not routinely recommended, either by AAP or ACOG.  Its promises from the ‘60s and ‘70s have not come true.   The cerebral palsy rates are identical to what they were 30 years ago, but our C-section rates started coming up as soon as they started using the monitor.  We’re getting more prolonged labor, because one of the things the monitor does, except in those places where they have telemetry, they can always make a more expensive machine for you to buy, but if you don’t have telemetry, that condemns the woman to be in bed, hooked up to cables.  So it decreases maternal mobility, usually in the supine position, because the nurse will scream if the mother turns on her side, because “You’re going to lose the focus.”  Okay?  “I’m going to lose my fetal heart rate focus, all right?”  You know, patients have to cooperate.  After all, these things are done for the benefit of the providers, not the benefit of the mother, okay?  There’s more pain, because she’s lying on her back.  There’s more exhaustion, and it has a negative effect on breastfeeding because of all these conditions that I said.  Pharmacological analgesia:  the obstetrical and neonatal negative effects have been known for years.  I’ve cited some of the studies in my bibliography.  But the epidural, in particular, will cause a higher incidence of maternal postpartum fever.  We’re not sure why.  Several studies have presented different hypotheses, but the fact is that as soon as a mother has fever, what does a pediatrician do?  Take away the breastfeeding, put the baby in ICU, and work him up for *sepsis.  Okay?  That ruins the entire mother-infant bonding process, just because somebody stuck a needle on her epidural space for something that was probably unnecessary.  And of course, separation of the mother-infant diet, because the baby has to be on IV antibiotics for seven days.  All right?  Caesarean section rate, like I said, 15.5 percent primary, 37 percent VBAC.  I was just--came back from a meeting of ACOG, where they revisited the VBAC issue, and Ben Saks, from Harvard, said that, “we’ll never make it.”  You know, it’s coming down, like you said, like you saw.  It’s down to 16 percent, and there’s no sign that it will improve.  Obstetricians think they’re against the wall, and for some reason, they insist that to keep from getting sued, what you have to do is do things the wrong way.  I would think that one would say, “Why don’t we do things right, and then, maybe at least we would lose the lawsuits.”  Okay?  Okay.  What do we do with all this mess?  Well, there’s one recommendation that I didn’t put in my visual, but which is really the one I prefer.  We have 630 obstetricians in my country, and they deliver 55,000 babies a year.  That’s less than a hundred babies per OB.  That’s not enough.  You don’t pay your malpractice with that kind of a volume.  Okay?  So I think we have like 400 obstetricians that we don’t need.  Would you like some?

Unidentified Speaker:  No, thank you. 

Dr. Jose *Gording:  I’ll take up a collection and send them all to you.  So that’s my main recommendation, but that’s not really feasible at this moment.  But we do have to work on empowerment of the pregnant couple, and this is not just, as you well know, this is not just providing information.  This is empowering people.  I tell my fathers, when we do--we have a lot of community support groups and talks on childbirth education, and I tell my fathers, “It used to be that the man would stand in front of the cave with a big thing on his shoulder to prevent the mammoths and the tigers from coming in and eating up his wife and his kids.  Well, you have to stand up now, and this is the knowledge that you’re going to acquire, and the empowerment that you’re going to acquire, to protect your wife and your kid from the obstetrician, from the pediatrician, and from the labor room and pediatric nursery nurse.”  And you have to give them information, but you have to break paradigms, and in Puerto Rico, lack of empowerment is, of course, accompanied by a very paternalistic view of what medicine is all about.  Usted son doctoros *decel que sabe.  You are the doctor; you are the one who knows.  What should I do?  Okay?  Breaking that, as you well know, health behavior is very difficult to achieve, and it takes a lot of empowering.  We are working with the legislature, legislators.  We have three political parties, and we are working with all of them, we try to identify every four years one or two people from either gender, because we get some machistas who are xx, that are even worse than some of our xy’s, you know.  But you know, you have to work with whatever you get, and that’s what the people elected, so we work with what they have, and we are trying to work in many different areas, and one of the areas is to get a legislation approved to authorize professional midwives to work as independent providers.  We do have a nurse midwifery program at our school.  I was a medical director of it for a few years.  But then, they decided, the nurse midwives who run the program, that they would be licensed under the Nursing Act in Puerto Rico, which is what happens in most states.  But, there’s one big difference:  we don’t have nursing practice in Puerto Rico.  We don’t have advanced nursing practice, and the nursing law in Puerto Rico is so backwards, so retrograde, that it expressly forbids nurses from performing any diagnosis or treatment, so you can’t deliver babies.  Okay?  So what we are really training in that nurse midwifery program is obstetrical nurses, okay, which is a shame, because they have some very fine students.  My recommendation was, you know, that we should fight for a midwifery practice act.  If we tried to get a midwifery practice act going, we would probably get four or five hundred obstetricians against us.  But trying to get a nursing practice act going puts 12,000 physicians against you.  Puerto Rico is going through a very complex healthcare reform process, which I can’t discuss in detail, but it’s something, like, not even Garcia Marcas would write about, because nobody would believe him, but physicians feel under fire.  We have too many physicians.  We have, like, 10,000 practicing physicians in the island, and there’s just not enough Indians for everybody.  So they are not about to give up one patient if they can avoid it.  So nursing practice in my country, unfortunately, is not a viable perspective, as much as I would like it to happen.  We are trying to get the Department of Health to put some teeth in their regulations, and to demand that hospitals update and publish their statistics, and that let’s put them to compete with each other on their C-section rates.  I’ve seen that in the papers in Massachusetts, you know, and you can--you are offered either--I don’t know whether it happens in Illinois, but, you know, you can choose between an OB or a midwife, our C-section rates, and so forth, and so on.  It’s taking a while.  Even the Department of Health, who is run by a fine physician who I know, he told the press that I was guilty for getting him into that mess (inaudible) health, because I met him in Atlanta when he finished his training at CDC some years ago.  He was a young kid then, and he said, “I don’t know what to do.”  And I said, “What do you mean, you don’t know what to do?  With all this training and all these credentials, you have to back home and help.”  So he did.  Now he’s Secretary of Health, so he says I’m to blame for that.  Anyway, we’re trying to get the Department of Health to work along those lines, and to get the legislature to approve some of these issues, also, and we are trying to work on the Mother-friendly Childbirth Initiative, and this is what I want to dedicate a few minutes to.  My wife and I just became council members of KIMS.  How many of you are familiar with KIMS?  Okay, well don’t feel bad if the rest of you aren’t.  I was lucky enough to meet *Marza Wagner, who is another one of these crazy physicians who swims against the current, like the salmon, huh?  And I met him in Washington one day, and his lovely wife and he had us for lunch at his house, and he gave me the papers on KIMS, and we just got aboard, and at the last meeting in Arlington, we got into the council.  So we are trying to--because we feel that KIMS is a very important solution.  This was an organization founded in 1996 in Chicago at a La Maze meeting.  Six organizations got together:  La Maze, the American Academy of Husband Co-childbirth, the Bradley Method, the International Childbirth Education Association, Birthworks, La Leche League, and Informed Homebirth, Informed Birth and Parenting.  These are the organizations that got together.  They had coffee, and they said, “We’ve got to do something.  I mean alone, each one of us is not enough.  Let’s coalesce.”  So they build this coalition, which, right now, has over 90,000 members in the United States.  The KIMS mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs.  This evidence-based mother, baby, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis and treatment programs.  Since current maternity and newborn practices are contribute to high costs and inferior outcomes, include the appropriate application, in appropriate application of technology and routine procedures that are not based on scientific evidence.  This is one of the basic postulates of KIMS.  Increased dependence on technology has diminished confidence in women’s innate ability to give birth without interventions.  It’s the doctor’s job; it’s not the mother’s job anymore.  The integrity of the mother-child relationship, which begins in pregnancy, is compromised by the obstetrical treatment of mother and baby as if they were separate units with conflicting needs.  This only one of the factors which make midwifery a better model.  The midwife takes care of the mother and the baby, and midwife will even provide postpartum care for both.  Back home, it happens all the time; we have artificially divided this dyad between obstetricians and pediatricians, and then the obstetrician will treat the mother’s condydiasis, breast condydiasis, but won’t treat the baby, and the pediatrician will treat the baby’s *monylyiasis or *condydiasis, but won’t treat the mother.  And many pediatricians back home, I don’t know whether it happens in this country, will not even look at a mother’s breasts.  And I ask them, “Well, do you look at the bottle, if they’re bottle feeding?  Well, why don’t you look at the mother’s breasts?”  You know, because we have sexualized the breasts, and only male obstetricians--the only males that are allowed to look at a woman’s breasts are obstetricians, unless she has cancer, and then it can be a surgeon, right?  And of course, the husband, for other reasons.  So this mother is there.  She’s sitting in a labor room.  Somebody hooked her up to a monitor, and now, all they do is look at the monitor.  They don’t look at the mother anymore.  Since the nurse is overworked, and she has to go far away to get other works done, she will turn on the volume of the monitor, “boom, boom, boom, boom, boom,” as loud as possible, make sure that the mother produces a lot of cortisone and adrenaline, which effects negatively the function of oxytocin.  So but nobody is paying attention to the mother.  They pay attention to the fetal monitor.  Although breastfeeding has been shown to provide optimal health, nutritional and developmental benefits to newborns and mothers, only a fraction of US and Puerto Rican mothers are fully breastfeeding their babies by the age of six weeks.  In Puerto Rico, it’s three percent at three weeks.  But if we ask mothers, and this is a study done by the Division of Maternal and Child and Adolescent Health of the Department of Health, they ask mothers, before discharge from the hospital, “Are you presently breastfeeding your baby?”  In 2000, 42 percent said yes; in the year 2002, 54 percent, I’m sorry--yeah, 54 percent said yes, they were breastfeeding.  That doesn’t mean they were exclusively breastfeeding, but at some point, they had breastfed in the hospital.  Now, let’s ask them the second question:  “Do you plan to breastfeed once discharged?”  And look at that, it went up to 91 percent in 2002.  In 2000, it was 42 percent and 83 percent.  So twice as many mothers in Puerto Rico plan to breastfeed, but they are not breastfeeding in the hospital.  So we must not blame the victim, at least in Puerto Rico.  Mothers do want to breastfeed, so the solution is not like the Secretary of Health said, “We have to make every obstetrician tell mothers about the benefits of breastfeeding.”  They know that.  They want to breastfeed.  Then why are they not breastfeeding?  We have to look at the barriers in the hospital.  Anecdotally, we know, and we have made studies with some of our students in certain hospitals that show that the biggest barriers are the health professionals and the hospital rules.  Hospital rules, as you know, are sculpted in marble.  Okay?  They can never be changed.  Okay?  The baby must be taken to the nursery as soon as he’s born.  “And when will I see my baby?”  “When the pediatrician says it’s okay.”  “When is the pediatrician coming?”  “I don’t know.”  Has that happened in your place?  So mothers want to breastfeed.  Now, they don’t know that if they haven’t breastfed in the first three or four days, and they’re there for four days if they have a C-section, and half of them have a C-section, and they haven’t breastfed, how is the milk going to come down, okay?  That’s another part of physiology that obstetricians have forgot.  They don’t think that breasts are important.  They are important to sell Budweiser.  Perfect balance, are (inaudible) in Puerto Rico.  They sell beer, they sell sports cars and other things, but they’re not for breastfeeding.  You know Cathy Gunweiler, from Houston?  She’s an anthropologist.  I love her.  She’s great, and she says that in her neighborhood, when the daughter graduates from high school--when the son graduates from high school, he gets a sports car.  When the girl graduates from high school, she gets cosmetic breast surgery.  And then we talk about the Chinese, who used to bind the girls’ feet some years ago.  The current maternity care system in the US, this is what KIMS says, does not provide equal access to healthcare resources for women from disadvantaged population groups, women without insurance, and women whose insurance dictates caregivers or places of birth.  So based on these whereases, or these principles, KIMS anticipates and suggests that these principles be offered to correct the above-mentioned problems.  First of all, birth is a normal, natural, and healthy process.  We shouldn’t have to say this, but it has to be said.  Women and babies have the inherent wisdom necessary for birth.  They had it for thousands and thousands of years, and babies are aware, sensitive human beings at the time of birth, and should be acknowledged and treated as such.  Breastfeeding provides the optimum nourishment for newborns and infants.  Birth can take place safely in hospitals, birth centers, and homes.  That’s blasphemy back home.  You can get kicked out of the medical college--I wish they would, so I wouldn’t have to pay my dues--for saying these things.  It doesn’t matter that the evidence is out there, you know, that you can have as safe a delivery at home as you can--my wife and I had Anna Sophia at our house, our baby, and we even got in the press, and some doctors said that we had violated the law.  We were delinquents.  It’s a wonder they didn’t send social services to our house and take the baby away, yeah.  It’s the only reason I could think of I would have used my gun.  And the midwifery model of care, which supports and protects the normal birth process, is the most appropriate for the majority of women during pregnancy and birth.  You have to empower women, and women’s confidence and ability to give birth and to care for her baby, and this is very important, are enhanced or diminished by every person who gives her care, and by the environment in which she labors and delivers.  If you start telling a woman that she has absolutely dependent on you, and that what she wants to do is crazy, and she’s going to kill her baby if she does that, is that free choice?  And then, they give them a consent form to sign, and they call that “informed consent.”  That’s ridiculous.  Who can labor at ease in a situation like this?  It’s probably good to have your appendix out, or your gall bladder, but not to have a baby.  A mother and baby are distinct, yet interdependent during pregnancy, birth, and infancy.  Their interconnectedness is vital and must be respected.  Taking a baby away from his mother right after he’s born--we realize babies come in two sexes, but I use the word, “his” just to simplify things--just because somebody wrote a hospital rule that says it must be done, and nobody understands why nurseries came to be in the first place, and why they are still maintained, and why they get so many gifts from the formula companies, if not the entire nursery, okay?  And then again, when mother goes home and gets a urinary infection, and we give them sulpha, or ampicillin, the pediatrician will say, “You’re taking antibiotics.  You can’t breastfeed.”  And I ask the pediatrician, “If you were asked to leave your wife because you were going to take ampicillin, would you do that?”  Well, some would say, “yes,” but basically, nobody would like to get a divorce just because they’re going to be using antibiotics.  And yet, the effective bond between a mother and her breastfeeding child is stronger than a husband and wife’s, and yet we say it like, you know, “It’s raining.  I’m going to give you Demerol,” you know, they need Demerol.  Some mothers in Puerto Rico, they want to breastfeed so badly that they won’t take Demerol after a C-section, which is inhuman treatment.  I mean you have your belly cut up in half; you need Demerol for 24 hours, at least.  So why you have to tell them that, “You can’t breastfeed if you take Demerol”?  Most of them don’t breastfeed, but some heroines will breastfeed and don’t take any analgesia, which is bad.  Pregnancy, birth, and the postpartum period are milestone events in the continuum of life.  These experiences profoundly affect women, babies, fathers, and families, and have important and long-lasting effects on society.  Are you people familiar with Michel Odent?  Nobody read Michel Odent, “Primal Health”?  It’s a beautiful book.  It’s an old book.  It was recently re-edited, and I recommend it to everyone.  This is a baby, or a sibling, watching his mother labor with a birthing ball, which is a very effective analgesic tool.  Every woman should have the opportunity to have a healthy and joyous birth, experience the birth experience for herself and her family, regardless of age or circumstances.  She should give birth as she wishes, in an environment in which she feels nurtured and secure, and her emotional well being, privacy, and personal preferences respected.  She should have access to the full range of options for pregnancy, birth, and nurturing her baby, and to accurate information on all available birthing sites, caregivers, and practices, and she should receive accurate and

up-to-date information about the benefits and risks of all these procedures, drugs, tests, suggested for use during pregnancy, birth, and the postpartum period, with the right to informed consent and informed refusal.  And if you read the Supreme Court decisions on informed consent, and the policy statements by ACOG, the consent form that my secretary signed for her repeat Caesarean section is invalid, because she did not have a free choice.  It was either that, or deliver in the gutter in the street.  See, so they don’t want to get sued, but they insist on doing things, so they get sued.  And she should receive support for making informed choices about what is best for her and for her baby.  This is a couple in labor.  Remember Gaylan?  He said (inaudible), at first, do no harm.  Intervention should not be applied routinely during pregnancy, birth, or the postpartum period.  Many of these things carry risks to the mother and the baby, and should be avoided in the absence of specific indications for the use.  If complications arise during pregnancy, birth, or the postpartum period, medical treatments should be evidence-based.  Sonograms:  in our environment, sonograms are a problem, not only because they cost money, not only because they’re unnecessary routinely, but somebody will see something, doesn’t like the circumference of the baby’s head, couldn’t see the fetal bladder, or whatever, or measures it wrong and says it’s interuterine growth restriction, and mother winds up with an unnecessary Caesarean, and a premature baby that was not supposed to be born yet.  So we do have to control sonograms, not only because they’re an unnecessary waste of money, but because they can mislead people to undo interventions.  The forceps, well, they really belong in museums, don’t they?  There is no reason why forceps should be applied.  When I came up for my internship some years ago, they were talking about prophylactic forceps.  So I learned, I put more forceps on than I care to remember.  I also did more circumcisions than I care to remember.  So these are all interventions.  Some people forget that the original forceps, made by Chamberlin in the 17^th century, were originally meant to crush the baby’s head, like a nutcracker; take him out, dead.  Some still do.  You can prevent most forceps applications if you just let the mother get up and walk.  Help her.  Help her with some non-pharmacologic pain intervention that will allow her to accommodate this baby.  The birthing ball, say the doulas and the midwives, I personally have no training with them, I’ve just seen them, the birthing ball will even get a *oxyputposterior turn around, if you know how to use it.  I know a midwife that says, “I don’t have to do pelvic exams.  All I have to do is, I have to look at the low back of the mother, and there are some de-colorations that she can identify that puts her within one centimeter of the actual cervical dilatation.  Why don’t we listen to these things?  I mean they can’t--they don’t do any harm, you know?  It’s better than sticking your fingers, 20,000 times during a delivery, during a labor.  Okay?  Maternity care practice should be based on the needs of the mother, not on the needs of the caregiver.  If you don’t want to get up at night, go into dermatology, you know?  Or, go into public health, like I did.  Each hospital should be responsible for the periodic review and evaluation, according to current scientific evidence, of the effectiveness, risks, and use of its medical procedures for mothers and babies.  But then again, society, both through government and the public health establishment, is responsible for ensuring access to maternity services for every woman, and for monitoring the quality of these.  And of course, when you talk about responsibility, it’s a two-way street.  Individuals are ultimately responsible for making informed choices about the healthcare they and their babies receive.  When I tell my students that formula companies are worse than tobacco companies, they say, “Why?”  I says, “Well, at least, whoever puts a cigarette in his mouth is old enough to light it; but a baby who gets a formula bottle stuck in his mouth can’t say anything.”  He can’t object.  So KIMS has devised what they call the Mother-Friendly Initiative with 10 steps.  You are familiar with the 10 steps of the Baby-Friendly Hospital Initiative.  Well, the 10 steps of *Kims, the 10^th step of KIMS is the 10 steps of the Baby-Friendly.  So KIMS is sort of a getting (inaudible), and this was a big discussion in the last KIMS meeting, because if we are going to certify a mother-friendly hospital, we have to get it certified as baby-friendly first, and that puts another organization, which is Baby-Friendly USA, ahead of us, in the sense that if they veto a hospital, we can’t do anything, and that’s a conceptual problem that has to be worked out.  But you can’t be mother-friendly if you’re not baby-friendly; that was my position during the entire meeting.  I was one of two males in that meeting, so I was fortunate.  I’m always surrounded by women; that’s why I’m surrounded by people smarter than me.  It’s the first step:  offer all birthing mothers unrestricted access to the birth companions of her choice, including fathers, partners, grandmother, children, family members, and friends.  Michel Odent doesn’t believe in this.  He even has reservations about fathers being in there.  He says, “This is a woman’s thing.”  Well, I’ve been present in the birth of all my children, and I’m glad I was there.  I realize I’m not the most important person there, and I sort of stand in the background, but I want to be there. 

Dr. Bradley, from the Bradley Method, used to say, “A father should be man enough to finish what he started.”  So he should be there, and they usually do pretty well.  They can’t afford to look weaker than their wives, so they gather strength from whatever.  Offer all birthing mothers unrestricted access to continuous emotional and physical support from a skilled woman, for example, a doula.  Doulas can help a mother during labor.  Doulas can help a mother present her plan of labor to the obstetrician during the prenatal period, serve as a translator, advocate, somebody who explains things in plain English to mothers.  So a doula is a great resource, and a 1993 study by Ken (inaudible) Klas has showed that the presence of a trained doula during labors provokes, or shows, a 25 percent reduction in the duration of labor, 50 percent reduction in the Caesarean section rate, 40 percent reduction in the uses of forceps, 60 percent reduction in the need for epidurals, 30 percent reduction in the need for pharmacological analgesia, 40 percent reduction in the use of oxytocin, and less episiotomies and tears.  And yet, the brilliant OBs in (inaudible) Hospital in San Juan reject the doulas unanimously.  Why?  I invited them to a meeting.  Let’s bring the doulas, and you present your evidence base, the evidence for your conclusions, and I’ll present mine.  Of course, they don’t have any evidence-based conclusions.  Don’t confuse me with facts.  By the way, this is our doula, Marisol, and this is my wife in there, laboring Anna Sophia.  Offer all birthing mothers access to professional midwifery care, like I already mentioned.  Step two:  provide accurate descriptive and statistical information to the public about its practices and procedures for birth care, including measures of intervention and outcomes.  This is something that in Puerto Rico just doesn’t exist.  A mother will ask her obstetrician--I have a chapter in a book written by my wife, which is called “16 questions to ask your OB.”  I got about 10 enemies per question.  As a matter of fact, we haven’t been able to market the book through OB’s offices, because of that chapter.  They don’t mind a book on breastfeeding.  After all, by the time you get to breastfeeding, I’ll be over with you.  But that book, and they’ve said it, “If you would only take out *Goring’s chapter, we would have the book in the front desk there for the patients to buy,” and one of the questions is, “Doctor, what is your C-section rate?”  Isn’t that infamous?  How does a patient dare ask that question?  “Doctor, what is your VBAC rate?  Doctor, do you perform episiotomies routinely?”  Basically, what we’ve talked about here.  So they don’t want the book because of that.  Step three:  provide culturally competent care.  This is something that I have learned a lot in this country.  I used to think that in Puerto Rico we didn’t need cultural competency, because we’re all Puerto Ricans.  No.  No.  We have social classes, and our differences are not as much based on skin color as in this country, because we’re all mixed.  See?  We are a subtle race.  We are all a mixture.  This is why our women our so pretty.  But I have found out that, yes, we do need to be culturally competent, and that not everybody is the same in the way they feel and the way they think, and this is something I learned in this country.  I’ve learned many things in this country.  Step four:  provide the birthing woman with the freedom to move, walk about, and assume the position of her choice during labor and birth, except the *lithotomy position.  This is the only position where no woman should have a baby in.  This is how we birthed Anna Sophia.  That’s not my wife, but she delivered in the squatting position.  This is a water birth.  This is a, we say, “en cuatro partas.”  How do you call this position, where the woman is kneeling on the four legs?  All fours?  And this one scares the wits out of OBs.  She’s delivering in the toilet.  “What about *asepcia?”  Well, whoever saw--did anybody ever see a sterile vaginal delivery?  That’s what obstetricians call them.  No dentist would be stupid enough to say that he pulled a tooth under sterile conditions, because they’re working in the mouth, so how can you do a sterile vaginal delivery?  But that’s what we do, and if the mother should be undisciplined enough to have her baby before we can scrub and gown, then we put her on antibiotics and send the baby to the ICU, because she had an unsterile delivery in bed.  Don’t confuse me with facts.  Step five:  you should have clearly defined policies and procedures for collaborating and consulting with other maternity services.  This is very important, especially when we’re going to talk about home deliveries.  Home deliveries need to be discussed with the couple.  In Holland, they do about 36, 37 percent of the deliveries at home, and one of the criteria is, where do you live?  How far is it from your house to a hospital?  In Puerto Rico, we’re always told that our biggest problem is we’re too small.  Well, I think that for healthcare services, that’s probably the biggest virtue.  I mean if I were living in North Dakota, it’d probably be a problem; but in Puerto Rico, you’re never more than 20 minutes away from a hospital, a hospital qualified for a C-section, because every hospital wants to do C-sections, because everybody delivers in hospitals, okay?  So we do have to maintain linkages, and link the baby and the mother to appropriate community resources, including breastfeeding support.  Step six:  do away with all these procedures that are not evidence-based:  shaving, enemas, IV fluids, withholding nourishment.  Nobody would think of having an Olympic athlete train without drinking Gatorade, right?  And yet, we have a mother in labor, she’s using the strongest muscle that the human being has.  It’s not us men that have strong muscles.  The uterus is stronger than any muscle we can ever develop, and yet, we don’t let her drink anything.  Isn’t that stupid?  It’s a surgical frame of mind.  And of course, artificial rupture of membranes, and electronic fetal monitoring.  This is baby being born on all fours--her mother is on all fours, and if you look here, it’s being born in its (inaudible).  Still, the membranes are intact.  See?  See the amniotic fluid in there?  It’s just beautiful.  It’s like a water birth.  I’ve seen water births where--I’ve seen movies on water births, where I have been tempted to say, “Take him out.  Take him out of the water.”  You know?  There’s no hurry.  There’s no hurry.  I mean they’ve been in a liquid environment for nine months.  Eventually, you have to take them out of the water.  We don’t have gills anymore.  This is Anita, my wife, and this is Anna Sophia’s daddy, listening to mother’s--to the baby’s fetal heart rate, just to show that, you know, you don’t need--we had a little Doppler there, just to be fancy, but--and then, I threw it away and went back to my old fetalscope, which I had to dig up from some--and these are interventions that are recommended by KIMS.  No more than 10 percent induction rate.  No more than 20 percent episiotomy rates, with a goal of five.  In Holland, they do 8 percent, and I have not seen one study that shows that Dutch women have more pelvic relaxation, crystal seels, rectal seels, or tears.  The only thing that increases a little bit when you don’t do episiotomies is anterior tears, which are usually very benign.  Many of them don’t even need stitching, and many times--and they don’t do permanent harm.  Episiotomies are associated with fecal incontinence, even if you don’t get a sphincter tear, a (inaudible) source of tragedies that happened when they are used indiscriminately.  KIMS strives for a total C-section rate of 10 percent or less, allowing for 15 percent in tertiary care hospitals, and a VBAC rate of 60 or more, with a goal of 75.  Even ACOG, which is not the paradigm of liberalism, accepts that 60 to 80 percent of women with a previous C-section can delivery vaginally the next baby.  So these are standards.  Okay, just in case some of you haven’t seen episiotomies lately, this is what we do to women’s perineums, because of course, everybody knows you need an episiotomy.  “What’s Gording talking about?”  That’s what they say back home.  Nobody has come up with any evidence to the contrary, but they insist that I’m wrong.  This is absolutely unnecessary most times.  The median episiotomy, as you know, is defended by its defenders in the fact that it’s supposed to provide a

more--an easier repair, and better cosmetic and functional results, has one disadvantage:  it has a higher risk of going into sphincter and the rectum.  The medial-lateral does not have that problem.  It just goes into the *iscial rectal *fossa, and it’s a mess that you don’t want to talk about.  So they’re both unnatural.  If God wanted women to have an episiotomy, they would probably have a zipper, you know, that you could open and close, you know.  Now, if you put a woman in the *lithotomy position, and you haven’t given her any prenatal education, and one leg is pointing to California and the other is pointing towards Boston, and she’s scared to death, and you’ve shot her full of drugs, and then you tell her not to push until you scrub and gown, and then you do all sorts of things.  She’s going to tear, because she’s delivering in the wrong position to start with, and she’s delivering in very unfavorable circumstances.  There are some women which should probably not choose the squatting position.  Women with very short perineums, or women who have had previous tears, the squatting position will exert some tension, sideways tension, on the perineum.  But I said, “Should not.”  If she decides to squat, go ahead.  It’s your perineum.  There was a Dutch physician in the Arlington meeting, and when we talked about the 8 percent episiotomy rates in Holland, and that there were no more lacerations or pelvic extensions, he stood up and says, “Dutch women have concrete perineums.”  So this is what they do-- well, in some selected nations, just to put you around.  The US is pretty good.  It’s come down from 64 to 32.  Hungary, I don’t know what they do over there.  But see, Puerto Rico:  this is terrible.  This is terrible.  This is why I wanted to call this talk, “The Management of Delivery in Puerto Rico:  Violence Against Women.”  This is genital mutilation, unnecessary genital mutilation.  It’s a ritual.  You’ve got to do it.  Why?  Because everybody knows you have to do it.  Why?  You know, it’s genital mutilation.  It’s not even for religious reasons.  And now, here we go to the favorite sport of obstetricians in my country:  the Caesarean (inaudible) section.  Five to seven times more maternal mortality:  with all these complications, how can somebody say that everybody should deliver this way, in the face of this evidence, goes beyond me.  I don’t know.  The first cause of maternal mortality in Puerto Rico right now is pulmonary emboli, and pulmonary emboli are a phenomenon of the C-section.  Nobody who delivers vaginally gets a pulmonary embolus, ever since we started walking them right after delivery, you know.  So this is amazing.  But then again, there are several morbidities that are not even recorded in any book.  They record the infection rate, the hemorrhage rate, this and that, but they don’t talk about the quality of life.  Ten percent of these women will have difficulty performing their normal activities, and 25 percent report pain, and some of these as much as 12, 15 percent, six, eight months to a year after the Caesarean.  There is a two times greater risk of hospitalization, and this is very important.  If we should only respect the emotions of the woman, especially the woman that has an emergency C-section.  She didn’t have time to prepare an “emergency,” quote/unquote.  Or, even a real emergency C-section, especially if you’re prepared for a normal, natural delivery, there is a sense of failure, a sense of loss, a sense of “I couldn’t have my baby.  They had to take it out,” and this, when done out of necessity, is bad enough.  When done because you induced her so she wouldn’t call you at three o’clock in the morning, and then she wound up with a C-section, it’s terrible.  It’s terrible, and it has been studied that the probability of a woman deciding to have another baby is lower if she’s had a C-section.  Long-term risks?  Pelvic pain, *disparuvia, painful coitus, bowel problems, which could even lead to an intestinal obstruction from adhesions, increased risk of infertility, miscarriage, placenta *previum, ruptured placenta, premature births, and the risk of uterine rupture.  You leave a woman with a scarred uterus.  So even if you do a planned repeat C-section, the risk of rupture is greater.  So the solution is not, “No VBACs, everybody gets a repeat C-section.”  Even if you do that, you get a higher risk, statistically demonstrated, of a rupture of the uterus.  It’s not an intact uterus anymore.  An intact uterus you can hit with a bat, and it won’t break.  But once you scar it, that’s another story.  But babies are not saved by this.  Fifty percent more likelihood of a low Apgar score, and some OB in the audience might say, “Oh, yeah, but that’s why we did the C-section, because the baby needed a C-section.  He was ill.  He was in fetal distress.”  No, I’m talking about 50 percent more likelihood of low Apgar scores, even if the C-section was not done for fetal indications.  So there’s something about not being born naturally that will affect a baby, and elective C-sections, the ones they do because they don’t want to do VBACs, are at a greater risk of a problem with a low Apgar score and respiratory difficulties.  And now, it has been shown, and you have your reference there, that before a woman goes into labor, and on the first three or four hours when she is laboring, the hormonal changes and the activity in the uterus will dry out the baby’s lungs.  We used to talk about the wet lung syndrome from Caesareans, and we thought that it was only due to the fact that babies born by Caesareans don’t get their chests milked out by vaginal pressure as they’re coming out.  So we started doing smaller uterine incisions so we would milk out the chest of the baby through the uterine incision.  All we achieved with that is lacerating uteri, because we had to pull the baby through to a too small a hole, and then it just lacerates.  But it’s not that; it’s just going into labor.  So this is why the author of this study recommends that even if a woman is not going to have a VBAC trial, she should be allowed to go into labor.  And then, you know, she gets to the hospital, and does her paperwork, and calls her mother-in-law, and two or three hours go by, and that will have a beneficiary effect on the baby’s lungs.  These babies are four times more likely to be admitted to an NICU, and this--I’ve seen this happen.  You know, they will be cut from the surgeon’s knife, and the iotogenic prematurity problem that we talked about, and persistent pulmonary hypertension, which is the wet lung thing, and problems with the closure of the *ductis arteriosis, and this is a life-threatening situation.  But these babies will have more difficulty attaching to her mother, because her mother has major surgery now.  So probably, he won’t be allowed rooming in, even if the hospital allows rooming in, which is not always the case in Puerto Rico, because mother has a C-section.  But then again, the nurse will say, “You’re taking Demerol.  You can’t breastfeed,” or, “You’re using antibiotics, so you can’t breastfeed.”  So all these things work negatively against breastfeeding.  So let’s talk about the elective repeat, which is the panacea for avoiding VBACs, according to many OBs.  There is still a two times greater risk of maternal death, likelihood of surgical injury, and these women will have a greater risk of ectopic pregnancy, and CDC reports ectopic pregnancy is the first cause of maternal mortality in this country.  If you’ve had one C-section, you have a four times greater risk of placenta previa, which goes up to 45 times greater risk if you had four or more C-sections.  Abruptia placenta and placenta *accreta:  placenta *accreta has increased.  Everybody knows what a placenta *accreta is?  The placenta goes into the muscle layer of the uterus, and it just won’t separate from the uterus after the baby is out.  It has gone up 10 times in the last 20 years.  Could it have something to do with our increased rate of Caesareans?  Yes.  It has been shown that previous Caesarean will leave a scar in the area where the endomitrium many times does not regrow adequately, and when the placenta implants in an inadequate endomitrium, it goes into the miomitrium, and that’s an *accreta.  It can kill people.  Step seven--we’ll be done in a few minutes--educate staff in non-drug method of pain relief, does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication.  This is an analgesic strategy.  I mean fathers; we can do something.  You know?  The birthing ball is a great instrument, like I already said.  These are just a few.  There are other strategies:  kinesiology, aromatherapy, music therapy, hydrotherapy, getting in the bathtub, whatever works.  Michel Odent has studied the hydro--the birth water, water birth thing, and apparently, there are some changes in some electric waves in the brain, and maybe that’s why we like to be close to the sea.  I go to the sea; I don’t even go into the water.  I just want to see it and hear it.  Okay?  It has a relaxing effect, watching water fall.  You have a little Jacuzzi that drops a thing of water in your house?  A little fountain, they sell them at Walgreen’s, you know?  Just have water falling relaxes you.  So whatever works.  You don’t need Demerol.  And none of those things have any risk for the baby.  Step eight, this is very important:  encourage all mothers and families, including mothers with sick babies, or premature babies, or babies with congenital anomalies, to touch them, and hold them, and breastfeed them to the extent that the baby’s condition allows.  You’ve heard of the kangaroo baby thing, the thing that people in Bogotá, Columbia have devised.  These babies thrive faster, better.  They control the temperatures better.  God, maybe mothers are better incubators than incubators, huh?  Isn’t that something?  I love this picture, because that man is crying, so I wasn’t the only one to cry when I had my baby born.  Men do cry, and we should.  Immediate breastfeeding, within an hour after birth, is something that all babies and mothers should be allowed.  Oh, (inaudible) here.  This is Anna Sophia, you can tell from the receding chin and her double chin that she’s my daughter.  This is Christina, and this is when I used to have a beard, (inaudible) Sophia doesn’t want me to grow a beard again, so I’m not growing a beard.  This is a premature, should be with his mother and father.  The next best thing to a mother is a father.  It’s not an intensive care nurse; it’s a father.  And then, we discourage non-religious circumcision of the newborn, and with all due respect, I think that even people who do it for religious reasons should revisit the issue.  I don’t want offend anybody, but, you know, I feel strong enough against circumcision.  Are there risks?  Yes.  There are risks.  I’m trying to pay off my karma for this, because when I did my internship, it used to be the OBs that did the circumcisions, not the pediatricians, in the University of Maryland.  So I used to get there in the mornings and check my laboring mothers, and then I would go to the nursery, “Let me have all the males,” and I would bring my little train with three or four incubators, and take them into the labor room, because I was overseeing patients who were in labor, and then I would just go, “Ding, ding, ding, ding.”  And, of course, I would say, “It looks like it hurts,” and my attending physician, “Nah, they don’t feel anything.”  Well he’s screaming, I mean he must feel something.  “No, they don’t feel pain.”  Now, we know that they feel pain, and it’s probably worse than what we would feel, because they haven’t been *miolonized yet.  Their nerve fibers are not *miolonized, so the transmission and the perception is probably even worse.  Many men will have problems, long-term problems with circumcision, and one thing that we must tell parents when we talk against circumcision is that many pediatricians will tell them, “Well, if you’re crazy enough not to want to circumcise your baby, at least I’ll have to teach you how to peel the *prepuce back, and you’re not supposed to do that, either.  The *prepuce is not supposed to be able to be pulled back until early adolescence.  It’s not supposed to peel, and many men will eventually need a circumcision because their foreskins were retracted forcibly, and that creates adhesions, and that creates strictures.  So then again, if God didn’t want males to have foreskin, we wouldn’t have a foreskin.  If it’s there, it must have--my pediatrician loves to show fathers a study he has, which shows the thousands of nerve endings, which every male loses once he’s circumcised.  And of course, the last argument is, “Well, if his father is circumcised, then why shouldn’t he be circumcised?  They’re going to be different.”  Well, you know, it’s like, instead of brushing your teeth, you pull your teeth?  Or, you could tell them, “You know, it used to be that Black people couldn’t sit at the front of the bus.  Does that mean that you’re going to teach your son to sit in the back of the bus, because you couldn’t sit in the front of the bus when you were a kid?”  I mean things change.  I mean society does evolve.  So we feel that the circumcision is something that, other than for religious reasons, should be discouraged.  It’s not a medical or a social issue; it’s a human rights principal, unless for religious indications.  And then, just as we come back and we agree totally with our friends, the feminists, who attack female genital mutilation, I think we should be attacking male genital mutilation, as well.  There’s no reason to do it routinely.  It does hurt the baby.  It does potentially create problems, and unquestionably, it affects initiation of breastfeeding.  You can’t have a baby who’s hurting and half asleep because he was anesthetized with drugs for a circumcision, he can’t very well get those breasts going on the first or the second day.  And the step ten is the strive to achieve the ten steps of the Baby-Friendly Hospital Initiative to promote successful breastfeeding.  So far in the US, as far as I know, there are only three or four mother-friendly baby hospitals, and a couple more are working at it.  Just to sum up, World Health Organization recommends that midwives, as well as KIMS, should be the primary birth attendant.  In the USA, 91.4 percent, in Puerto Rico, except a few crazies, like my wife and myself, who got away from one, everybody else delivers with a physician, and in Puerto Rico, it has to be an obstetrician.  Even family physicians are not granted obstetrical privileges in our hospitals.  It’s a very tightly knit thing.  Place of hospital, who recommends (inaudible) hospital KIMS or a mother prefers, Puerto Rico and the States hospitals.  Electronic fetal monitoring:  not routine by both organizations, the States, 84; Puerto Rico, 78.  Drugs and labor:  in the States, 80 percent.  In Puerto Rico, we don’t even know.  It’s not even registered.  Induction of labor:  this is what I said that is obviously anecdotally a under-registration of some registration.  In the US, 20.5 percent are reported.  The suggestion by the United Nations and by KIMS is 10 percent or less.  Stimulation of labor:  10 percent or less, 16.6, 17.5.  Episiotomies:  20 percent or less.  In the US, that’s not as bad, but look at us.  Caesarean sections:  10 to 15 percent.  US, 24, 42 percent.  Breastfeeding after birth, in Puerto Rico, 54 percent during hospital stay, not necessarily immediately or exclusively, and after three weeks, our latest data shows that only three percent are breastfeeding, and not even that is being done exclusively.  I saw this many years ago when I first came up to college, and first visited the Jefferson Memorial.  I still think it’s a beautiful thought, and I thought I’d close off with that, written by Thomas Jefferson, the author of your Declaration of Independence:  “I don’t think that we should require a man who wears still the coat which fitted him when a boy, as civilized society, to remain ever under the regimen of their barbarous ancestors.”  Some OBs back home will say that I called them barbarous.  Sorry for that.  Any questions?  I think I overdid my--thank you. 

Unidentified Speaker:  Thank you so much, Jose.  Now, we did have a late start, So we can take some questions (inaudible). 

Dr. Jose Peralta:  Well, I’m not in a hurry, so if you guys don’t have to catch a plane or anything, no problem.  I have to go see the Puerto *Riquenos later, but they’re always late, too, anyway, so. 

Unidentified Speaker:  (inaudible).  You’ve been telling me for a long time, it’s barbaric--

Dr. Jose Peralta:  It’s barbaric, yes.  It’s barbaric. 

Unidentified Speaker:  -- just to lay it out was terrific.  I’m wondering, it’s getting late.  (inaudible) wrap up (inaudible) questions, or (inaudible) what will you be talking about tonight. 

Dr. Jose Peralta:  We’re going to be talking about community wellness.  I’m going to address maternity care--

Unidentified Speaker:  Okay. 

Dr. Jose Peralta:  --and several slides are repeated from this conference.  I’m going to give it a little more (inaudible) atmosphere. 

Unidentified Speaker:  Will you be speaking in Spanish tonight? 

Dr. Jose Peralta:  No, I’m speaking in English.  I asked the community leaders, and I didn’t want to be culturally incompetent. 

Unidentified Speaker:  Right. 

Dr. Jose Peralta:  So they said that I should speak in English.  There are Puerto Ricans, like Andrew, here, who says he’s not.  He probably is, but he said he’s not totally fluent in Spanish, and I’m sure they are expecting some Americans in the audience tonight, too, so.  I think there’s a couple of questions.  She was--yeah, you were first. 

Unidentified Speaker:  I just had a question about that WHO recommendation. 

Dr. Jose Peralta:  Which one? 

Unidentified Speaker:  The one that was preference for out of hospital births.  Is that because in so many developing countries, a hospital is a very unsafe place to be?  In other words, what’s the reason behind it. 

Dr. Jose Peralta:  Hospital births are, first of all, unavailable in many countries, and second, it’s a hazardous place for your health, yes.  You know, like cigarette packs, hospitals should have that in bronze out there, especially in Puerto Rico.  No, WHO, you know they have to do these wide scope recommendations, and of course, two-thirds of the people in the world are born, right now, without any kind of technically competent help.  So but, a normal birth and delivery, a normal labor and delivery, really shouldn’t be in a hospital.  I think that paradigm has to--. 

Unidentified Speaker:  And I got a second question. 

Dr. Jose Peralta:  Yeah. 

Unidentified Speaker:  What do you think about, in places in the world where there’s very high rates of HIV, what do you think about circumcision?

Dr. Jose Peralta:  I don’t think circumcision should be done except for religious reasons, and I say that because I think I need to say that.  I know there is, maybe Arden can elaborate on that; I know there is some people in the Jewish faith that are Jews against circumcision.  I don’t know whether that has really flown or not.  I’ve heard that it--but then again, when it’s done, as far as I know, and excuse my ignorance, it’s not done as in a barbaric way, like we do in hospitals. 

Unidentified Speaker:  We give a lot of wine to the baby. 

Dr. Jose Peralta:  You give wine, and you don’t do it until breastfeeding is well established. 

Unidentified Speaker:  Yeah, seven days. 

Dr. Jose Peralta:  Seven days. 

Unidentified Speaker:  Right. 

Dr. Jose Peralta:  So I don’t want to underestimate the importance of a religious or cultural or whatever persuasion, you know, but, of course, that would have to be decided by the people.  I thought you were going to ask about HIV and breastfeeding?

Unidentified Speaker:  Yeah, I did.  No, I didn’t, but that’s another question. 

Dr. Jose Peralta:  Because that’s a big field where I want you guys to keep your ears to the ground, because the present recommendation in the US is per CDC, and therefore in Puerto Rico, is that HIV-Positive women don’t breastfeed, but that’s not sculpted in marble, either. 

And there are several studies, in third world countries especially, that have shown that if a mother has (inaudible) a baby and the baby is breastfed exclusively, first of all, (inaudible) artificial feeding because someone is going to have (inaudible) water, but even if you have drinkable water the (inaudible) of births of HIV positive apparently are very few if they are breastfed exclusively.  The greatest danger is in partial breastfeeding.  So, if I had (inaudible)that would probably involved, other people are talking about (inaudible) and these babies are going to have an immune deficiency problem and (inaudible).

Unidentified Speaker:  These are stunning statistics.  I mean it was really incredible.  I was wondering, I mean given the need to have standards and guidelines that will help change this, as well as *sort of legislative mandates, what do you think is the potential for changing curriculums in medical schools. 

Dr. Jose Peralta:  Well, I heard that the present chief of OB has retired, so that could help.

Unidentified Speaker:  In Puerto Rico?

Dr. Jose Peralta:  But there are two big problems, and they are both inter-related.  We have a very under-empowered population, both men and women, and we have an absolutely omnipotent medical practice.  Not even family physicians are allowed to deliver babies.  I’m considered a traitor by many of my colleagues.  I wrote a piece for the “Puerto Rico Health Science Journal,” which is our type of “New England Journal,” this is our (inaudible), on the management of labor and delivery, and its impact on breastfeeding, and I was really just geared, looking towards the impact of episiotomies and C-sections and everything else that we’ve been discussing, and the editor, you know, we submit it to peer reviewing and everything, and it was published, and we had requests for reprints from Spain and several countries, and then, the Deputy Chief of OB called the editor of the journal, and said, “I knew you were half-crazy, but now I know you’re crazy.  Why did you publish that piece of junk?”  And the editor said, “Well, it was peer reviewed, and it had 84 references, but I’ll tell you what, send me your rebuttal.  I’ll guarantee I’ll publish it, (inaudible).  This was two and a half years ago, and they haven’t submitted anything.  So (inaudible). 

Unidentified Speaker:  Good, good, good, good.  So they haven’t done anything? 

Dr. Jose Peralta:  Yeah, I went to an ACOG meeting recently, and I met with 40, 50 OBs from the US, and I was (inaudible).  I mean these people are genuinely trying to work with a very difficult scenario, medical-legal scenario, and everything else, (inaudible) trying to say (inaudible) today.  (inaudible) the keynote speaker of the (inaudible) Sunshine Seminar.  Now, I think I’ll have the seminar in San Juan in January, call it the Sunshine Seminar for marketing purposes, obviously, (inaudible) January, and the keynote speaker was a guy that promotes elective universal C-sections.  (inaudible) School of Medicine and School of Public Health are very much divorced.  I love this last IOM publication, you know, “Who Will Keep the Public Healthy,” because we’re trying to read--this divorce has to end, you know.  Medicine and Public Health cannot walk separate paths anymore.  They should never have.  So I was happy when that came out, because (inaudible), somebody might start paying attention to these issues (inaudible).  I’m glad I have tenure. 

Arden Handler:  And unfortunately, (inaudible) a long time.  I mean I want to talk about prenatal care and that relationship between, *you *know, *care and *office.  That’s a whole another issue I’d love to discuss at some point, the woman’s satisfaction with*care, and all those issues.  So we have more time, those of you who are interested can come tonight at 4:30, about?

Unidentified Speaker:  Yeah, I can *give the details, if anyone’s interested.  (inaudible) having a little reception buffet with home cooking, and (inaudible) home cooking, and then (inaudible) will present again at 5:30. 

Unidentified Speaker:  Great, and--

Unidentified Speaker:  (inaudible). 

Unidentified Speaker:  (inaudible) survey.  Right. 

Unidentified Speaker:  (inaudible) Spanish, and not in English. 

Arden Handler:  Right.  Right.  Well, (inaudible) thanked everybody for coming.  It’s the very end of the conference.  We just have a few departing people left, and I wanted--

Unidentified Speaker:  The diehards, the diehards. 

Unidentified Speaker:  The diehards, and I, of course, want to thank the planning committee, and the planning committee for the event last night, and we’ve come up with some great ideas for next year and the future of (inaudible) conference, against all odds, to keep on going.  And, of course, we want to thank Chris *Gupta, and we have a little something for Chris (inaudible) we’ll just hand it to her, since she’s too tired to get up and come to the front (inaudible). 

Chris *Gupta:  Thank you. 

Unidentified Speaker:  Please fill out your evaluation forms, and remember, there’s a conference list serve, we’ll be sending you updates during the course of the year, and also, if you want to be part of our regular MCHE serve, which is, you know, that is constant.  You’ll get stuff from us (inaudible) seminars and things we’re doing etcetera, etcetera.  So, everything, all the main sessions, and will be on the left side, if you want to get to the PowerPoint slides, that will all be available to you, and anything that you don’t find there, bug Chris, we’ll find a way to get that stuff to you.  And so thank you for a fabulous presentation.