Open Letter To Jillian Michaels

Hi Jillian,

I recently read your book Yeah Baby.  You maintained a calm and collected approach in discussing what are typically emotionally charged topics, and it is in that same spirit that I hope you will receive this letter.  Some of the book’s content troubled me, and I’d like to offer some alternative perspectives that you may not have considered.

As a background, my education in childbirth largely parallels your own: I’ve been at my wife’s side through pregnancy and birth on two occasions, and I’ve done extensive research into an assortment of birth related areas via peer-reviewed studies, professional texts, books, lectures, films, and many hours of personal discussion with experienced childbirth practitioners.  Both of my children were planned home births, the first resulting in a hospital transfer 30 hours into active labor and culminating in a pharmaceutically-assisted vaginal delivery, and the second resulting in an unmedicated vaginal delivery in our house.  So it is the confluence of first-hand subjective experience with academic and interpersonal research that ultimately informs both of our perspectives.

To be clear, I think much of the book is excellent.  It wonderfully highlights the importance of being optimally healthy prior to conceiving, along with the link between the health of the mother and baby (even into adulthood).  It stresses the importance of nutrition and legitimate exercise, dispelling the myth of pregnant women being fragile and helpless.  It draws attention to the myriad toxins people regularly encounter and/or ingest unknowingly, and outlines ways to avoid them.  It has very good commentary on the effects of smoking and drinking alcohol while pregnant and trying to conceive.  It dismisses the notion that family bed sharing is controversial or dangerous in the context of sober parents.  And it illuminates the shortcomings and limitations of what doctors actually know.  

With that being said, I find some of the book’s other points of discussion disconcerting.  

After Heidi gave birth to your son, you write: “I was wondering if we were ever going to have a romantic relationship again.  I was being a selfish ass, I know.  However, I guarantee your significant other is wondering this, too.”  

I can guarantee you that not all significant others share your sentiment - I certainly didn’t after the birth of my children.  Yes, some partners do feel ignored and/or left out in the aftermath of a birth.  It's fine to acknowledge this possibility, but it’s not the responsibility of new moms to remedy this, as the book suggests - it’s the responsibility of the partner to sort their issues out and to temporarily put their needs aside.  As a partner, one should be genuinely invested in doing whatever is best for mom and her needs.  It’s not about the partner right now; it’s about the family they’ve (theoretically) chosen to build.

The book stresses the importance of sex in maintaining a connection between partners, encouraging new moms to make a conscious effort to work around all the emotional, hormonal, sleep, and practical impediments that get in the way.  You state that while “sex for some can seem low on the totem pole, I can’t stress enough how critical it is to your overall long-term relationship.”  

Yes, connection between partners is crucial - but if sex is the only means by which partners can maintain connection, then the relationship may have a bigger problem.  

You then offer an analogy: exercising even when you’re not in the mood results in feeling great post-workout, and so it will be with sex.  Thus, the book’s final instructions with respect to intercourse and other forms of sexual relations: “Do them.  When you aren’t in the mood, do them anyway.”

For those new moms who are in the mood (or who wish to do it despite feeling otherwise), they should.  But for those who are disinclined, they shouldn't feel guilty about it, and they definitely don’t need outside pressure to do something about it.  I’m not disputing the benefits of sex - I'm disputing the force with which you appear to advocate it, as it comes across like a mandate.

You decry at length what you perceive as judgement from those who support natural childbirth toward those who choose alternative means of delivery.  I agree that people shouldn’t judge others.  However, let’s not pretend that all modes of delivery are equal.  They simply aren’t.  Stating this fact doesn’t mean medical interventions shouldn’t be utilized as and when necessary, and it doesn’t mean babies born under such circumstances are doomed.  Nor does it mean mothers who elect to receive pharmaceutical and/or surgical assistance are horrible people.  But it also isn't necessary to diminish the virtues of natural childbirth in order to make others feel better about their birth experience, which is what you seem to be doing.

You take issue with the term “natural childbirth” which you feel implies that anything other than an unmedicated vaginal birth is “unnatural.”  As I understand it, “natural" refers to maintaining the integrity of the birth process inherent in our biology - yes, that translates to unmedicated vaginal birth, but there’s no need to turn this into an insult.  

Nevertheless, you write: “Um, pretty sure the birth of any human being who’s been made inside of another body…is “natural,” no matter how the child comes into this world - thank you very much.”  

There is nothing natural about having a baby pulled out of your stomach.  Is it common?  Yes.  Sometimes medically necessary?  Yes.  Natural?  No.  Importantly, cesarean birth not being natural has no bearing on its applicable merit.  C-sections save many babies and/or mothers who would not have otherwise survived childbirth - this should be celebrated - but we don’t need to deceive ourselves that somehow it’s a natural process.  It’s anything but natural, and that’s perfectly ok.

The book attacks The Business Of Being Born and similar documentaries for laying on guilt trips and judging women who choose anything other than natural childbirth, claiming that it’s unfair to put that kind of pressure on women.  Having seen these documentaries, I’m puzzled by your critique.  How is it judgmental to suggest that women have the capacity to give birth naturally?  How is it unfair to inform women of the implications of medicated and/or surgical childbirth?  

Imagine if someone levied a charge that your book’s detailing the importance of eating organic unfairly places pressure on women, guilting those who fail to adhere to the book’s advice; or someone who accused your outlining of the consequences of smoking during pregnancy as being unfairly judgmental to those women that do smoke during pregnancy…surely you would call such characterizations of your work unfounded, misguided, and inaccurate (and rightly so).  And yet, the flawed reasoning displayed by this imaginary critic seems to be reflected in your commentary on natural childbirth films.

Documentaries that educate about unmedicated vaginal birth, midwifery, home birth, etc are also correcting for the cultural narrative in which women are told a) childbirth is nothing but pain and agony, b) they should be afraid of birth, c) they will certainly need medicine to get through the experience because they aren't strong enough, d) even if they are strong enough, there’s no value to be gained, and e) they should just do whatever their doctor tells them.  Thus, the documentaries which you appear to disparage serve to educate and empower women, even those who ultimately choose to birth in hospitals with medical assistance.

In discussing newborn GBS disease, the book summarizes the matter in a paragraph, essentially advising adherence to the CDC guidelines.  While an in-depth analysis of this topic is beyond the scope of this letter, suffice it to say I believe the issue is far less straightforward than the book represents…I invite you to give this a read, at your leisure.

The book goes into detail about the birth of your son and Heidi’s birth story.  The reader learns it was important to Heidi to have a natural childbirth.  Not wanting to discourage Heidi outright, you tried to keep her open minded to alternative potential outcomes.  You state: “All I had to do was look at Heidi to see the size of her belly in comparison to her tiny hips, and I knew (or at least had a very strong feeling) that “natural childbirth” was not going to be in the cards for her.”  

The notion that one can determine the chances of a vaginal birth based on a visual assessment of a woman’s hips and belly has no medical basis, and it naively discounts labor’s physiology, along with how such is affected by maternal position.^1-4 

You write: “the big day came, and big surprise, our baby did not come ‘naturally.’”  Heidi was a week past her due date, so the doctor “deemed it best to induce labor.”  Detail as to what prompted the need for induction is absent.  Heidi gets admitted and induced via Pitocin, after which “there is no more food, just liquids.”  

Unfortunately, the book doesn’t clarify that hospitals banning food is an outdated guideline stemming from a risk of vomiting during general anesthesia that is not applicable today, and the continued ban on food during labors with low risk is not supported by evidence.^5-7 

8 hours later, Heidi dilates from 1 to 2 cm.  The doctor performs a manual rupture of membranes, followed by more Pitocin.  13 hours in, she’s at 3 cm.  Heidi is in a lot of pain, and you beg her to let them give her an epidural.  Heidi consents.  27 hours in, 4 cm.  Heidi still had not eaten since being admitted to the hospital.  Heidi begins running a fever and the baby’s heartbeat goes irregular.  So you take control of the situation:

“The whole “I am woman hear me roar” thing had gone far enough.  I called our ob-gyn at 3 a.m. and said, “Get over here and cut this kid out of her now, or I’m going to MacGyver this myself with an X-Acto knife and some Xanax!””

The ob-gyn came right away and “Heidi was so depleted at this point that she had no strength to fight me.”  I find this statement extremely telling.  Here you have a pregnant woman with a very clear set of intentions, wanting natural childbirth, but having to “fight” those around her, with her partner appearing to doubt her capacity from pregnancy through labor.

Natural childbirth is every bit mental as it is physical,^8-11 and it can derail when the mother is stressed, anxious, scared, disempowered, inhibited, self-doubting, etc.  Even in the best of circumstances it can take 100% of a woman’s focus to successfully navigate labor unmedicated, which is why anything short of complete support and unity in the birthing environment is so toxic to the process.  Moreover, research shows the body’s hormonal system is crucially important in preparing and facilitating labor (among other birth-related effects), and that such hormones can be fostered or disrupted in response to both the psychological state of laboring women and medical interventions that transpire.¹² 

Thus, consider the stripping of Heidi’s membranes, an induced labor at 41 weeks, manual breaking of her water, administration of analgesic and synthetic hormones, presumably high levels of stress and anxiety for Heidi throughout the entire ordeal, not to mention fatigue (exacerbated by lack of food and sleep), and then ask, is it really surprising that labor didn’t “progress”?  For those familiar with natural childbirth, no one is surprised at this outcome.  However, you drew a different conclusion:

“The lesson here?  Our son was 9 pounds!  His shoulders were simply too broad to get past Heidi’s hips, rendering him unable to “drop” and therefore Heidi unable to dilate.”

Or is the lesson here that subverting the innate biological processes of birth, by way of interventions, restrictions, or limitations (whether medically necessary or otherwise), has corresponding physical and mental side effects from which surgical outcomes can result?  This is not an indictment of the medical model - it’s simply to say all actions have consequences.  It’s also important to acknowledge that vaginal births of 9 pound babies (and heavier) do happen¹³…it’s not science fiction; it’s human physiology.

The book proceeds to discuss birthing environment.  While you respect everyone’s choice of birthing environment, you strongly advocate hospital birth.  I take no issue with this, in and of itself, however your characterization of home birth fails to grasp its primary motivation - that of maximizing one’s chances of having an unmedicated vaginal childbirth - and how the home environment relates to that objective.

You include an excerpt from a doctor who argues that contrary to popular belief, medical interventions in labor are not profit driven.  Fine, but those seeking unmedicated vaginal birth are not concerned about profiteering…they're concerned with what they perceive as unnecessary interventions that routinely take place at hospitals for a variety of reasons (arbitrary timelines, impatience, liability concerns, poor judgement, etc), and which can result in a cascade of further interventions,^12,14-18 increasing the chances of undesirable outcomes.^12,17-25 

Surprisingly, the high cesarean rate in this country does not seem to be of significance to you, as you state: “30 percent of babies nowadays are delivered through C-section…most happen due to medical necessity…”  The actual rate is 32% and it’s patently obvious that a significant portion are not medically necessary.^26-28  Just compare US cesarean rates in hospitals to those of planned home births, the latter having C-section rates in the low single digits.^29-31  Granted, most women who plan to birth at home are considered low-risk, which does create an asymmetry in this comparison.  However, according to the CDC, national cesarean rates specifically for low-risk pregnancies are still 26%,³² revealing a tremendous disparity.  And this disparity persists even when looking at birthing centers, whose cesarean rates also average to single percentages,^33-35 similar to planned home births.  The reality is that something is artificially inflating cesarean outcomes among hospital births - failing to give credence to this is misleading in my view.

The book’s argument for hospital birth essentially amounts to “better safe than sorry.”  While you don’t want the reader to feel pressured, you argue that if something goes wrong it is better to have instant access to lifesaving technology.  I understand and respect this perspective, although it should be weighed against a person’s individual pregnancy risk and the risks that hospitals potentially introduce (medically unnecessary intervention / cesarean, lack of food, reduced mobility, environment-induced stress response, hospital acquired infections, etc).  “Better safe than sorry” can work both ways.

You continue: “with the birth of our son, we experienced fairly atypical complications that ultimately required pain medicine and a C-section.”  Except they weren’t atypical complications.  In fact, they are quite common in response to the medical interventions that transpired (which was made clear in those documentaries you were criticizing).  Nonetheless, you conclude: 

“Heidi was considered “low risk” throughout her entire pregnancy.  Yet, when the day came for our son to be born, he was simply too big to be pushed out vaginally.  She ended up requiring all the lifesaving benefits of modern medicine that we have come to take for granted over the last century.  Shit happens - why not be prepared?” 

See the above points.

In discussing induction of labor, the book references ACOG’s guidelines that you can wait up to 42 weeks to induce.  This begs the question, why wasn’t Heidi allowed to wait until 42 weeks?  

You also list scenarios in which induction will be medically required, which includes being “Past term or ‘late.’”  I respectfully disagree.  Being “late" in and of itself does not constitute a medical emergency, particularly given that estimated due dates are notoriously inaccurate anyway.³⁶

Finally, the book outlines the various methods of induction, none of which worked for Heidi because “our son was incapable of “dropping” in order to open the cervix effectively.”  There are many variables that influence the rate at which labor progresses and how a baby “drops” (e.g. fetal presentation, labor position, etc), but I am unaware of any medical diagnosis called “incapable of dropping.”  It seems that you are conflating the fact that your son didn’t drop in that series of events with the notion that he was inherently incapable of dropping.  These are not the same things.  And it’s important to parse that out, as otherwise you instill in the reader an unfounded fear that big babies (or large bellies) pose some insurmountable obstacle to vaginal delivery.  They don’t.

Overall, I find that the book’s commentary on labor exemplifies much of what is missing from birth in modern society.  It diminishes the capacity of women to withstand and navigate labor, has little to no regard for the merits of the biological forces that underpin natural childbirth, and no appreciation for how influential and important the psychology of laboring women is to the entire experience.  It is also remarkable that within the entire 300+ pages of text, there is no discussion of the biomechanics of birth, alignment, or labor technique - knowledge and skills which are of direct importance and applicability to laboring women.^37-53  If the reader is to be armed with the information necessary to successfully navigate pregnancy and birth, as the book purports, then this information would seem to be relevant.

What’s additionally saddening is the book’s recounting of how Heidi went on to struggle with breastfeeding, something that was also really important to her.  The initial pediatrician told her to "pump every hour to increase my milk supply, which only made me want to cry.”  After the baby lost 2 pounds, the choice was made to supplement breast milk with formula.  Heidi writes, “Eventually, I became okay with the fact that my body just wasn’t going to produce enough milk for this enormous child.”  

It seems Heidi is left with the impression that she is a failure on account of her body simply not being good enough to both deliver and breastfeed her baby.  She writes, “I barely spoke for 3 months" and was “unable to snap back into life or be myself again after what felt to me like a somewhat traumatic birth experience.”  

My heart breaks for her.  Her choice of wording is interesting, in that she qualifies the experience as being “somewhat” traumatic.  My sense is that she feels conflicted speaking honestly about the matter, given the upbeat positive context of her partner’s pregnancy book.

Well, Heidi if you’re reading this - as traumatic as your birthing experience may have been, you found the light at the end of the tunnel.  You encountered obstacles you could not have anticipated, and some which had no business being there.  But you found a way through them, and that requires its own degree of strength.  Never make the mistake of thinking you are inferior or incapable…you are quite the contrary.

Lastly, it’s imperative that we recognize a woman is not weak for choosing to receive pain management.  But a society that teaches women they don’t have the ability to endure natural childbirth does create weakness.  Not believing in women does create weakness.  Scaring women without practical cause does create weakness.  Moreover, championing natural childbirth does not intrinsically entail disdain for pharmaceutical or medical assistance.  That Heidi (or anyone else) had a C-section is not a tragedy.  But it would indeed be tragic if a woman wasn’t genuinely supported and given the best chances of having the birth that was important to her, regardless of what the outcome would have been.  Mothers are always going to have strong bonds with their babies, regardless of the mode of delivery.  And birth is always capable of being positive and transformative, regardless of the methods and means utilized.  

I have great respect for what you set out to achieve in writing your book.  It is informative and truly helpful in many respects.  And I know you honestly want to assist readers in grappling with the overwhelming mountain that is pregnancy and birth, and help guide them to optimal outcomes.  You have a tremendous influence - what you say matters.  As a kindred spirit who shares your aims, this is why I felt compelled to write the above words.  May you do with them as you wish.

Sincerely,

Zack Hemsey

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1. André Michel SC, Marincek B, et al. The effect of maternal posture on pelvic outlet MR measurements. Proc. Intl. Soc. Mag. Reson. Med 9 (2001).

2. Michel SC, et al. MR obstetric pelvimetry: effect of birthing position on pelvic bony dimensions. AJR Am J Roentgenol. 2002 Oct;179(4):1063-7. 

3. Golay J, et al. The squatting position for the second stage of labor: effects on labor and on maternal and fetal well-being. Birth. 1993 Jun;20(2):73-8. 

4. Pyanov M. Small Pelvis? Big Baby? Here’s The Truth About CPD. BellyBelly June 2018. 

5.  Singata M, et al. Restricting oral fluid and food intake during labor. Cochrane Database Syst Rev. 2013 Aug 22;(8):CD003930. 

6.  American Society of Anethesiologists. Most healthy women would benefit from light meal during labor. November 6, 2015. 

7.  Medscape. Researchers Question Ban on Solid Food During Labor. October 30, 2015. 

8.  Gaskin IM. Going backwards: the concept of ‘pasmo’. Practicing Midwife, 2013 Sep;6(8):34-7. 

9.  Whitburn LY, et al. Women's experiences of labour pain and the role of the mind: an exploratory study. Midwifery. 2014 Sep;30(9):1029-35. 

10.  Whitburn LY, et al. The meaning of labour pain: how the social environment and other contextual factors shape women's experiences. BMC Pregnancy Childbirth. 2017 May 30;17(1):157. 

11.  Whitburn LY, et al. The nature of labour pain: An updated review of the literature. Women Birth. 2018 Apr 20. pii: S1871-5192(17)30629-7. 

12.  Buckley SJ. Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care. Childbirth Connection, January 2015. 

13. Hard statistics on birth weight by method of delivery are elusive, however any experienced midwife will tell you vaginal birth of babies weighing 9+ pounds is not an exceedingly rare occurrence, and there are an abundance of anecdotal cases reported in a variety of literature that illustrate the point (for example, see Part 1 of Ina May’s Guide To Childbirth, pg 208 of Katy Bowman’s Alignment Matters, the comments section here, etc).

14.  Tracy SK, et al. Birth outcomes associated with interventions in labour amongst low risk women: a population-based study. Women Birth. 2007 Jun;20(2):41-8. 

15.  Rossigno M, et al. Interrelations between four antepartum obstetric interventions and cesarean delivery in women at low risk: a systematic review and modeling of the cascade of interventions. Birth. 2014 Mar;41(1):70-8. 

16.  National Institute for Health and Care Excellence. Intrapartum care for healthy women and babies. Clinical guideline [CG190].  Section 1.1 Place of birth. December 2014, updated February 2017. 

17.  Jansen L, et al. First do no harm: interventions during childbirth. J Perinat Educ. 2013 Spring;22(2):83-92. 

18.  Lothian JA. Healthy birth practice #4: avoid interventions unless they are medically necessary. J Perinat Educ. 2014 Fall;23(4):198-206. 

19.  Anim-Somuah M, et al. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev. 2011 Dec 7;(12):CD000331. 

20.  Adams J, et al. Use of pharmacological and non-pharmacological labour pain management techniques and their relationship to maternal and infant birth outcomes: examination of a nationally representative sample of 1835 pregnant women. Midwifery. 2015 Apr;31(4):458-63. 

21.  Alfirevic Z, et al. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev. 2017 Feb 3;2:CD006066. 

22.  Segal S. Labor epidural analgesia and maternal fever. Anesth Analg. 2010 Dec;111(6):1467-75. 

23.  Klein MC. Does epidural analgesia increase rate of cesarean section? Can Fam Physician. 2006 Apr 10; 52(4): 419–421. 

24.  Chantry, CJ, et al. Excess weight loss in first-born breastfed newborns relates to maternal intrapartum fluid balance. Pediatrics. 2011 Jan;127(1):e171-9. 

25.  Lindholm A, Hildingsson I. Women's preferences and received pain relief in childbirth - A prospective longitudinal study in a northern region of Sweden. Sex Reprod Healthc. 2015 Jun;6(2):74-81. 

26.  Ye J, et al. Searching for the optimal rate of medically necessary cesarean delivery. Birth. 2014 Sep;41(3):237-44. 

27.  Pallasmaa N, et al.  Variation in cesarean section rates is not related to maternal and neonatal outcomes. Acta Obstet Gynecol Scand. 2013 Oct:92(10):1168-74. 

28.  Glantz JC. Obstetric variation, intervention, and outcomes: doing more but accomplishing less. Birth. 2012 Dec;39(4):286-90. 

29.  Johnson KC, Davids BA. Outcomes of planned home births with certified professional midwives: large prospective study in North America. BMJ. 2005 Jun 18;330(7505):1416. 

30.  Cheyney M, et al. Outcomes Of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery & Women’s Health. 2014 Jan-Feb;59(1):17-27. 

31.  The Farm Midwifery Center.  Statistics 1970-2010. 

32.  National Vital Statistics Reports. Births: Final Data for 2015. Vol 66, No 1, January 5, 2017.  Table C. 

33.  Rooks JP, Weatherby NL, et al.  Outcomes of care in birth centers.  The National Birth Center Study.  N Engl J Med.  1989 Dec 28;321(26):1804-11. 

34.  Stapleton SR, et al. Outcomes Of Care in Birth Centers: Demonstration of a Durable Model. J Midwifery Women’s Health. 2013 Jan-Feb;58(1):3-14. 

35.  Thornton P, et al. Cesarean Outcomes in US Birth Centers and Collaborating Hospitals: A Cohort Comparison. J Midwifery Women’s Health. 2017 Jan;62(1):40-48. 

36.  Jukic AM, et al. Length of human pregnancy and contributors to its natural variation. Hum Reproduc. 2013 Oct;28(10):2848-55. 

37.  Bowman K. The Hunting And Gathering Mama. Nutritious Movement. March 2010. 

38.  Bowman K. Natural Pregnancy, Natural Birth. Nutritious Movement. July 2010. 

39.  Bowman K. When Push Comes To Shove. Nutritious Movement. March 2011. 

40.  Bowman K. Aligning Or Relaxin Before Pregnancy? Nutritious Movement. March 2011. 

41.  Bowman K. Pregnancy And Pain. Nutritious Movement. December 2011. 

42.  Bowman K. Natural Mama. Nutritious Movement. January 2012. 

43.  Gaskin IM. (2003). Ina May’s Guide to Childbirth. New York: Bantam Dell.

44.  Lawrence  A, et al. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev. 2013 Oct 9;(10):CD003934. 

45.  Simkin P, Bolding A. Update on nonpharmacologic approaches to relieve labor pain and prevent suffering. J Midwifery Womens Health. 2004 Nov-Dec;49(6):489-504. 

46.  Simkin PP, O’hara M. Nonpharmacologic relief of pain during labor: systematic reviews of five methods. Am J Obstet Gynecol. 2002 May;186(5 Suppl Nature):S131-59. 

47.  Field T, et al. Labor pain is reduced by massage therapy. J Psychosom Obstet Gynaecol. 1997 Dec;18(4):286-91. 

48.  Chaillet N, et al. Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth. 2014 Jun;41(2):122-37. 

49.  Levett KM, et al. Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour. BMJ Open. 2016 Jul 12;6(7):e010691. 

50.  Shirvani MA, Ganji Z. The influence of cold pack on labour pain relief and birth outcomes: a randomised controlled trial. J Clin Nurs. 2014 Sep;23(17-18):2473-9. 

51.  Ganji Z, et al. The effect of intermittent local heat and cold on labor pain and child birth outcome. Iran J Nurs Midwifery Res. 2013 Jul;18(4):298-303. 

52.  Taavoni S, et al. Birth ball or heat therapy? A randomized controlled trial to compare the effectiveness of birth ball usage with sacrum-perineal heat therapy in labor pain management. Complement Ther Clin Pract. 2016 Aug;24:99-102. 

53.  Taavnoi S, et al. Effect of birth ball usage on pain in the active phase of labor: a randomized controlled trial. J Midwifery Womens Health. 2011 Mar-Apr;56(2):137-40.