Hank Green: Hello, welcome to How to Adult. Today, we are talking to a person who is more of an expert than I am on how babies.... happen... and the whole process. This is Amy Romano of Baby and Company.

(0:22) Hank (continued): You are a midwife, and I have witnessed sort of, beginning to end, one single pregnancy. So you may be a bit more of an expert than I. So can you tell me a little bit about what Baby and Company does?

Amy Romano: So we have a network of birth centers that are staffed by midwives and nurses and are partnered with different hospitals. We're in North Carolina, Tennessee, and Colorado so far, and plan to be in more States before long. We provide kind of a home base for pregnancy, a very engaging, family-centered model of care, where the woman who's receiving prenatal care as well as her partner, her kids, and everyone who's involved can be sort of part of the prenatal care experience and the educations that needs to happen as you prepare both for giving birth and also for parenthood.

Amy (continued): And then we actually have birthing suites in our facilities, where people who are interested in natural childbirth and who are low-risk from a medical standpoint can have their babies in the center, but we're also partnered with hospitals so that if we need to change location or if somebody just prefers to be in a hospital setting for their birth, we can accommodate that.

Amy (continued): And then we also provide, as midwives, a full scope of services for women's healthcare. We do well-woman care, family planning, and we're building out a whole preconception, pre-pregnancy program now to really zero in on the opportunities to start getting prepared even before you start your prenatal care.

(1:51) Hank: So theres's this weird shift that occurs between working very hard to not have a baby, which is, can be a fairly long period of someone's life, into a, like, that mental shift to like, "I am doing this on purpose." Like is is okay to sort of be up in the air? Because that's what I hear over and over again is people are like, "How do you know whether or not I'm ready to take this sort of adult, like ultimate responsibility on?"

Amy: For people who are, you know, still in the "I'm not trying" stage and are thinking of sort of transitioning to "I'm trying," or maybe, you know, some couples go through the, like "Well, let's not not try for a while," it's a good time to actually pause and ask yourself questions about, "Am I ready, am I physically ready? Am I, like if I became pregnant today, would this likely be be a healthy pregnancy?" It's so much easier to correct health issues that can have implications for pregnancy before you actually get pregnant.

Hank: Mm-hm.

Amy: But then there's all the rest of it, too, like is my life ready, am I at the right point in my career, is my relationship ready, do I have the money -- that's a huge one for a lot of people, and all of it, so yes, of course, it is very common, in fact, I would say universal even, to not know for sure that this is the right thing to do or this is the right moment to do it. It's a huge leap of faith and kind of requires some degree of craziness to even consider it. But at the same time, it's how we end up with a population of people, so we need people to decide it sometimes.

Hank: (laughs) I do like people.

Amy: We need friends. Everyone needs friends.

Hank: (laughs) "So, I just need need somebody to hang out with, so have a baby please."

Amy: (laughs)

Hank: I do like hanging out with my baby. He's super chill.

(3:38) Hank: So interestingly, disappointingly, there's actually been an increase in maternal mortality in the U.S. over the last few years. I wonder if you have any thoughts on that situation and how we're dealing with it.

Amy: Yeah. I'm really, probably pleased is the wrong word, but I'm pleased to see some of the attention that we're starting to see in the news to the increasing rate of maternal mortality in the United States. And maternal mortality, even though the data seem to show that it's increasing, is still, thankfully, an extremely uncommon event.

Amy (continued): But right behind maternal mortality is this much larger and harder-to-define-using-data group of people who come closer than they should in this day and age, in this country, with the amount of resources we throw at healthcare service delivery. There's a lot of factors at play. I think the primary factor, what we know to be true in the numbers, is that it's very much an issue of racial disparities, and economic disparities as well, but particularly Black women, and... in certain part parts of the country face rates of maternal mortality that are, frankly, as high as they are in developing countries.

Amy (continued): And the United States is one of just a couple of countries where we're seeing an increase. The rest of the world is successfully reducing the rate of these complications. So a lot of it has to do with just how we organize, frankly, the political choices that we make around access to care and consideration of prenatal care, in general women's healthcare, as essential benefits or as critical to the health of a population, it's really, I would say, we treat them a little more as, kind of political bargaining chips, particularly these days.

Amy (continued): So we see not enough access, but there's also just a quality problem in our healthcare system in general, and maternity care is not immune to that. So we see both under-use of things that should be used, things that we know from evidence are treatments that should be applied when complications happen, and for whatever reason, they they don't happen in time.

Amy (continued): But we also have the other side of it, and kind of an epidemic of overuse where we see a lot of excess use of surgical intervention in particular, particularly c-sections. And an initial c-section early a very safe procedure -- where we start to see a lot of potential harm is in women who have multiple c-sections. It kind of transforms the pregnancy into a high-risk pregnancy after you keep, kind of, operating on the uterine muscle, which is so important for growing the baby, not just for delivering the baby one time.

Amy (continued): You know, we take -- Baby and Company, we take care of generally very healthy women. It's not something we see often at all, where women get very sick in our care, but we have a really heavy focus and partner very closely with our hospital systems on just, continuous quality improvement, and really, kind of, using the data to guide how we deliver care, getting a lot of input from women themselves and families to understand what their experience is, and just trying all around to make it safe, high-quality, family-centered, all of that.

Amy (continued): But we have a lot of work to do as a country to kind of, make childbirth safer. Ultimate adulting is when you figure out how to navigate the American healthcare system.

Hank: (laughs)

Amy: (sarcastically) And the best time to do it is when you're pregnant, because now you have to, kind of, understand all the pieces of it. (laughs)

(7:10) Hank: We had a midwife, and I, like, just... so nice. So nice. We had a hospital delivery, but, so, she was technically a doula, but she was there, and she was very much, like, just calm, and knew what was going on, and always there for a second opinion, and...

Amy: Yeah.

Hank: ...just great, to feel like it was all normal, and sort of a sense of, like, the staff of a hospital, they're there for emergencies. And, like, they are prepped for that, and they look like that, and they're dressed like that. So they sort of have, doctors and nurses can pretty easily bring anxiety into the room, whereas a midwife or a doula, like, their job is kind of to bring serenity and calmness into the room, which is...

Amy: Do you know the difference between a midwife and a doula?

Hank: Uhh, I mean, the woman that we were working with was both, but I don't.

Amy. Yeah. Um, I'll tell you--

Hank: Sure.

Amy: --because I think it's a good distinction to make. Midwives are clinical providers who specialize in a wellness-oriented approach and in, generally, in sort of normal and healthy women, so we, our scope of practice includes managing a broad range of complications, but it does not include surgery.

Amy (continued): So we collaborate with doctors and other providers -- anesthesiologists and so on -- to incorporate what they have to offer, but it's really a complementary relationship where the physicians are specialized in, sort of, the medical aspects of pregnancy, and treatments and stuff that can be provided for different kinds of issues and complications, and then the midwives are, sort of, managing it sort of as the whole woman approach, really like understanding her family and her motivations

Hank: Mm-hm.

Amy (continued): and her interests and that kind of stuff and helping her kind of get the birth she wants. A doula often works with the midwives and has some things that overlap, but they're really non-medical. They don't come come from a clinical training standpoint, they come from sort of supporting and advocating for the woman, and so it's really the person who is going to be there to rub your back, which midwives do too occasionally, like doctors and nurses... well you know anybody can rub on your back but...

Hank and Amy: (both laugh)

Amy (continued): ...you know, the doula is there... is someone who has seen birth, has been around birth, can tell you "you're doing great, this is normal,"

Hank: Mm-hm, yeah.

Amy (continued): "...here's a cool cloth for your forehead, here's -- I'm gonna press on your back like this," but they don't get involved in sort of, diagnosing or managing anything. They leave that to the midwives or doctors.

Hank: Interesting.

Amy: But I wanted to touch on stress in the room, because we actually know that stress can interfere with the normal function of the body, in many realms, but childbirth is definitely one of them. So the actual, you know, being in an unfamiliar environment, being around strangers, kind of just being scared because in the hospital is -- can be a scary -- can, you know, trigger, kind of, all kinds of fear-based reactions, can actually have a physiologic effect that you can overcome with good support and with kind of reframing the experience for yourself or to, you know, have supportive people helping you do that, but it's easier to labor in a calm and familiar environment. And your body just works better a lot of the time.

(10:32) Hank: I have a question from a member of the audience, which is, I'm sure, a question that many people have, I have heard it: Is it possible to give birth naturally if I am petite?

Amy: Um... yes is the short answer--

Hank: (laughs)

Amy (continued): --and the other answer is that there are so many other ways I've heard that question. I think a lot of women internalize the notion that they can't give birth naturally or in whatever manner they are hoping to give birth. Maybe for this person it's because they're petite, and maybe their bones aren't big enough to let a baby through, but women who are overweight or obese are told this as well. Women who are older are -- literally used to be called "elderly pregnant" with primagravidas -- "elderly person giving birth" even if you were just above, like, 35.

Amy (continued): So there's a whole host of reasons women can be told or can feel like "I can't actually do this, my body's not designed for this." And what I will say is that I, just, I've personally seen it -- babies come out of all shapes and sizes of women. I've seen petite women with these monstrously tall, you know, husbands, and still, yet, she grows a baby that seems to be just the right size. And then I've also seen, you know big-boned women, or women who are super fit, just get hung up in the various things that can happen in labor that--

Hank: Mm-hm.

Amy (continued): --create the need for a c-section or for other kinds of interventions to help it happen.

Amy (continued): And so, I think there are just pragmatic ways that every woman, whether you're petite, whatever your body size or whatever your reason is, to think about, like, if natural childbirth is your goal, the biggest thing I would say is... shop around, find a hospital or a birthing center -- as well as a doctor or midwife -- who has a low c-section rate. Increasingly--

Hank: Mm-hm.

Amy (continued): --we're able to actually track that consumer reports and some other, some consumer-oriented information sources have the c-section rates of different hospitals, and generally lower is better. At least in this country, lower c-section rates are what you're looking for.

Amy (continued): Generally speaking, of course we're speaking in generalizations here, if you're working with a midwife as part of your birthing team, you're probably at a lower risk of c-section. But there's just, there's interesting research that's been coming out, that the biggest risk factor for a c-section is the door you walk into when you're in labor. And if it's the hospital with a 50% c-section rate--

Hank: Mmm.

Amy (continued): --which, believe it or not, those exist -- you're probably, you know, (laughs) you probably have a 50% likelihood of a c-section too. And really, any individual woman's c-section likelihood should be much more in the realm with, you know, 10 to 15 percent depending on what's going on with her.

Amy (continued): And then the other piece, I would say, is just, getting prepared, but mentally is a huge piece of it. There's interesting research coming out now about the role of mindfulness, and there's a lot of, kind of, birthing preparation techniques that incorporate mindfulness, or self-hypnosis, or just deep relaxation. Those are hugely beneficial. Having a doula, there is -- there are decades of research that show having a doula actually reduces your likelihood of a c-section. And then, just having patience with labor and really, like, getting familiar with what it's going to be like, because it's an intense physical feat you're gonna do and you do have to train for it a little bit.

Hank: Mm-hm.

Amy (continued): Again, it's largely mind over matter. People who aren't, you know, physically fit in every way can still totally have a natural childbirth. I had two, and I was not peak form when--

Hank: (laughs)

Amy (continued): --when I was having babies. And my labors went quickly, so it's really like, you know, at the end of the day, it's kind of being a good consumer about it -- really educating yourself and building out a really great support network for when you're actually in labor -- and then, at the end of the day, accepting that there's an element of chance and just kind of...

(14:20) Hank: Right.

Amy (continued): ...risk.

Hank (continued): I've had friends who have gone into the process saying, like, "The last thing I want to do is have a c-section." And a certain amount of, like, when it happens, feeling a bit like a failure, feeling like, "I did it wrong, I did it badly."

Amy: Yeah.

Hank (continued): There's so much that we ask of mothers already that I do want to, like, you know, obviously, like, the c-section should not be the goal...

Amy: ...but it shouldn't be...

Hank (continued): ...yeah...

Amy (continued): ...you know...

Hank (continued): It shouldn't, it shouldn't feel like a tremendous failure.

Amy: Shouldn't feel like a failure. And it's definitely true, that a lot of women perceive it as a failure. It's... I think we need to talk about the overuse of c-sections, because it's true that we overuse them--

Hank: Mm-hm.

Amy: --and also totally support women who have c-sections, and including supporting women who have c-sections where you could kind of look at it and say, "Well maybe that one was--wasn't necessary."

Hank: Mm-hm.

Amy (continued): At--at the time when a c-section is done, it's usually necessary, and the opportunity to prevent it may have been, you know, way before, or maybe it wasn't there at all, and it's certainly not on the woman. We should be pointing our, sort of, efforts at the system and the, kind of, providers that need to build, frankly, some skills that have withered away over the, kind of, medicalized period of time that we've gone through.

Amy (continued): So some of those, just the art of taking care of women in labor isn't there, but I think, you know, women who do have everything up to and including post-traumatic type symptoms after negative birth experiences, and not every c-section is a negative birth experience. A lot of them are incredibly positive experiences.

Amy (continued): But the little, kind of, nugget that I like to talk to women about is that it's okay to feel complexly, it's okay to have complex feelings about your birth experience--

Hank: 

Amy (continued): --and to be, feel let down about parts of it, while at the same time feeling in love, or--with your new baby, or feeling grateful for the, you know intervention that did help you greet your baby safely. You  know, and then just providing all kinds of, just, loving on those families, because they've been through a lot. 

Hank: Yeah.

Amy (continued): And they need a lot of support postpartum too, because it's the only operation that they send you home, from the hospital, with a baby that you have to take care of now.

Hank and Amy: (both laugh)

Amy (continued): They don't do that when you have heart surgery.

Hank: Yeah, glad that doesn't happen with most surgeries.

(16:40) Hank: This is more nuts-and-bolts-y, and maybe not a question that feels okay to ask, but I think we should be asking it. How do I save money on my baby? How do I not spend an arm and a leg getting this thing out of me/my partner?

Amy: Yeah, I think we do need to just get real about that. And part of it is that, you know, babies have always cost a lot of money. In our current healthcare environment, we know that families are just bearing a larger percentage of the cost. A lot more people have these high deductible health plans, or just have insurance that doesn't cut it, and then--but--it's not just the cost of the pregnancy and birth itself, it's all of this... everything that comes -- there's the income hit that one or both parents is likely to--

Hank: Mm-hm.

Amy (continued): --have to deal with, given that we don't have good parental leave policies in our country. And then, of course, there's things like daycare, which is a huge piece of it, and then just the long view of all of the costs, sending the kids to college and so on.

Hank: (laughs)

Amy (continued): I think, if we start with just, like, the childbearing gear, let's say, the big things I would say is, make sure you're actually aware of what your benefits are. There are a lot of ways to accidentally spend a few extra thousand dollars. So some of those are, you know, if you do have an opportunity to shop around for different health insurance, if you know "I'm thinking of getting pregnant in the next year," and maybe there's an open enrollment time--

Hank: Mm-hm.

Amy (continued): --or maybe you're married and your spouse has, you know, one option and you have another, or maybe you're shopping on the state exchanges, or something like that. So you might have an opportunity to change your insurance to one where the out-of-pocket costs are going to be more favorable to you. And so for a time when you know you're likely looking at a hospitalization, or just, at least a high cost thing, paying a little more each month into a premium so that you can have...

Hank: Mm-hm.

Amy (continued): ...lower deductible which is that out of pocket, like, lump sum that you've gotta hit is one good thing. There's also some employers... if you're working for an employer that has short term disability insurance -- pregnancy and giving birth are not disabilities -- but that's the bucket that they fall into--

Hank: Mm-hm.

Amy (continued): --when you think about what the potential maternity leave or paternity leave benefits are. And the standard for--the government standard is that employers that have 50 or more employees have to offer unpaid family medical leave at... but some employers do have... will pay for either you know, a portion, or even all of your salary during this time, but it might be something you have to opt into.

Hank: Mm-hm.

Amy (continued): So make sure, if you have an opt-in short term disability insurance option, that you're opting into it. You could easily be just, you know, paying a couple hundred bucks for that extra insurance and then get 60% or some percent of your income when it's time to take some time off for the baby. So those are just some, like, kind of, managing you benefits and navigating it. There's also, the biggest part, I will say, of the total bill that you're going to pay at the-- for the birth and pregnancy is the amount of money you're going to pay directly to the hospital for something called the hospital facility fee. Birth centers also have facility fees -- they do tend to be lower -- so overall, a birth center or, for that matter, a home birth, is generally a lower cost, but like, you shouldn't be choosing that for cost reasons.

Hank: Mm-hm.

Amy (continued): But the hospital facility fee is, um, is the big, kind of, uh...

Hank: The big--

Amy (continued): ...chunk of the pie.

Hank: Yeah, just your... just your room rental.

Amy (continued): It's... it's hard to... it is not easy to get the information from the hospitals, but there's increasingly some information to help understand what the--

Hank: Mm-hm.

Amy (continued): --lower cost hospitables are. And then, the other thing, I would say, is just take some time to clarify what you, what's important to you, and invest in, sort of, the things that matter, and you don't need everything that's on the list. So--to--as far as baby gear and that, there's so much you can get secondhand or from consignment.

Amy (continued): And then I think the other thing people should be thinking about is just building their social networks, building their communities, recognizing that, truly, the only way that any of us can afford this is to help each other out. And so, taking the time during pregnancy to make some new friends, whether that's in like your birthing class or just, you know, like, making it a goal for yourself to just start to strengthen some of your social networks,

Hank: Mm-hm.

Amy (continued): or to make some new friends that are going to be parents around the same time as you, can help you get creative with things like childcare, whether it's your actual childcare solution or just to fill the gaps when things fall apart, to have another 
parent that can look--

Hank: Mm-hm.

Amy (continued): --after your kid to just, you know, barter services... There's all kinds of ways, if you have a good, creative network of friends and family, that you can just sort of spread the cost around and everybody wants to help.

Hank: Yeah, I mean, from my own experience, a huge tip is to be the last person in your friend group to a baby,

Amy: Definitely!

Hank (continued): because then, you're just like--

Amy: You get all their stuff! (?)

Hank (continued): --your basement is full of clothes from, you know, newborn to six years old. So, I will never have to buy baby clothes. I have bough, like, three pieces of baby clothes, and it was entirely because they were cute.

Amy: Totally.

Hank: And in fact a little bit regretted it because I was like "Whumph, I'm- I- I- now I'm never going to use this thing." So that's my suggestion.

Amy: Yeah, and they grow out of that stuff so quickly, you know. And then there's things like cloth diapers. And there are certain things that you can spend a lot now to reduce the cost overall. Breast feeding is, over the course of all of it, definitely less expensive than buying formula. Not everybody can or wants to breastfeed exclusively but a little bit of investment in the front end to just be prepared for breastfeeding or get some help from a lactation counselor or lactation consultant to just get over the initial hump so you can reach whatever your breastfeeding goal is, also has an economic benefit. So there's just there's all of it.

I think it starts with understanding what your expenses are, looking at your lifestyle. Some of that stuff is just going to fall away when you have kids anyway like if you're going out to eat for all of your meals you're probably not going to (laughs) for awhile.

Hank: (laughs) Yeah.

Amy: So there's some natural ways to save money that don't hurt that hard and then you got to think about the part, the ways that it's going to hurt or be more of a trade off. But people successfully incorporate babies into all kinds of households at every income level and it isn't easy for the majority of us but it's doable.

Hank: My last question here came in in a lot of different forms from our viewers.

Amy: Okay.

Hank: Tell me about the grossest thing that people don't talk about slash how much am I going to poop slash how much am I going to puke.

Amy: (laughs) Alright

Hank: (laughs)

Amy: Puking, lets- (laughs)

Hank: (laughs)

Amy: Let's start with puking because it happens in the beginning, generally. There's usually some puking and if there's not there's everything smells bad or tastes bad or you just feel queasy. It really ranges but I will say for people who are vomiting more than a couple times a day in those early weeks there are medications and there are sort of modifications to diet and so on that you can do to ease that.

But the biggest thing is that for the vast majority of women it is time limited and those symptoms start to resolve as you get into the second trimester which is 13 to 15 weeks. But it can be pretty brutal couple of months and that's the time to just take care of yourself and also talk to your provider and tell them this is how much I'm puking and this is how often I'm feeling queasy because if you can tell them in objective terms they can either normalize it for you if its within the range of normal or help you tweak things. A lot of women that have enough puking that they should be considering medication think that it's a normal amount and they should just suck it up and deal. So, open communication and then just trusting that eventually it will get better. If it doesn't by the second trimester then it will (laughs) by the time the baby's out.

Hank: (laughs)

Amy: And if there is one thing that parenting teaches you its like new concept of time and what you can cope with and how long. And then puking, sorry, puking makes another (pauses) appearance...

Hank: (laughs)

Amy: ...in labor and I don't think a lot of people (laughs) know this. That puking is a very common part of labor, your body is just in this intensity, there's just incredible power happening in your body and people often respond to that as well as the pain sensations with vomiting. And it typically happens right as when you're in transitional times of labor, so when you're transitional from early labor to a more active labor pattern or when you're getting closer to pushing. So the pearl I would say for puking and labor is that it's usually a sign of progress. Like as a midwife, I'm like "Oh good she's puking, yay! (laughs)

Hank: (laughs)

Amy: Good, something's happening."  That is also true of pooping. When I see poop as a midwife I'm excited. My job is almost going to be done here because its usually means the baby is coming out. So people do poop in labor.

It's actually really normal to be constipated in pregnancy and that is, not normal, but it's common to be constipated in pregnancy. Your digestion slows down because your body is trying to absorb all these extra nutrients for the baby, right?

Hank: Mmm-hmm

Amy: That often presents as constipation and you can kind of do the normal things you would do for constipation in pregnancy: fluids, high fiber foods, cleaning up your diet, Squatty Potty. Do you know about that?

Hank: Yeah

Amy: There's ways you can adjust your position when you're trying to go that make it easier. And then also there some safe stool softeners and things that people can use. But then when it's like your body is ready to have a baby, usually people will poop a lot in the days leading up to that. That again, so it's like "Yay, something's changing, something's happening" you can be excited about it. And also maybe it's a little bit of relief because you've been constipated for all those months.

Hank: (laughs)

Amy: But then I would say it's not all that typical for women to be pooping a lot during labor but when the baby is actually coming out of the vagina and it's pushing everything else out in front of it. And so when women are pooping it's in the throes of pushing a baby out. So the women herself usually is completely oblivious that it's happening and those of us who work around it are very adept at getting it out of the way and it's no big thing for us. And if anything it's a happy we're about to have a baby yay.

Hank: (laughs)

Amy: What else gross happens? Oh there's all kinds of skin changes and hairs grow in places and, you know, it's a full body experience I would say, pregnancy is.

Hank: (laughs) Yeah, it is a carnival of hormones and endorphins and just the endocrine system is having a brand new day.

Amy: Pregnancy gas is stinkier than...

Hank: Oh

Amy: ..non-pregnant gas.

Hank: That's weird.

Amy: It's the same fuel you're just digesting more mindfully.

Hank: Amy Romano thank you so much for spending so time with use. You can find more about Baby and Company at babyandcompany.com.

Amy: Absolutely, thank you so much Hank.

Hank: Yeah, it was a pleasure talking to you.

Amy: Likewise.

Hank: And thank all of you for watching and thinking about how to continue populating the earth. This has been How to Adult.

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