TIME Family

This Dove Commercial Will Make You Cry Happy Tears

The spot is made from real-life footage of men getting happy news

To mark this Father’s Day on June 21, Dove is releasing an ad that wouldn’t have been possible without the foresight of some clever females.

The company cobbled together footage of men finding out that they were going to become fathers, news that their baby mamas (and one baby daddy) surprised them with in gift boxes and cards—with the camera rolling. All the footage was posted on public sites that Dove employees trawled through, contacting the parents to ask them to be part of the campaign.

Dove, whose “real beauty” campaign turned 10 years old in 2014, brought a similar approach to their men’s line, attempting to reflect dads as they are rather than as unrealistic archetypes. Jen Bremner, U.S. marketing director for Dove Men+Care, a line the company has been aligning with dads since it debuted in 2010, said that when the company was researching how to position the brand, they found that fathers felt falsely depicted in advertising, as either bumbling dolts or super-hot supermen.

“Actually becoming a dad is a very significant and transformative experience,” Bremner said. “It redefines their masculinity.” It also makes for some very good television.

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MONEY Careers

Is Work-Life Balance Even Possible?

We asked people on the streets of New York City how they manage to keep their home lives and work lives separate, if at all.

Balancing your time and energy between work and home is difficult; you’ve got that report due on Wednesday and your kids need help with their homework. We went to Times Square to ask people how they prioritize between their careers and their family. Some people said they clock out right at 5p.m. every day while some said they take work home with them every night. How do you manage your work-life balance?

TIME Family

Why My Sister Allowed Her Death to Be Filmed for TV

Renee Heidtman wanted to leave her mark on the world—which includes what her dying taught me

At 32 years old, my older sister, Renee, had to choose how she wanted to die from terminal cancer. While her choice didn’t make financial sense, and it made life harder for her family members, it was the only choice she could live with. She chose to die at home in San Francisco. I am forever grateful for her choice.

My sister was given two options when she was put on hospice. With no guarantee of how long she would live, she knew that she wanted the most comfortable death possible. She could choose to die in a facility, with strangers caring for her, or she could choose to die in a familiar setting, surrounded by people who loved her.

It was a difficult decision. Financial burdens loomed over us like dark clouds that just wouldn’t go away. And I was carrying a lot of the weight. But with a lot of luck and a network of amazing friends, we were able to make it happen. We made GoFundMe accounts and reached out to close friends to help us. Organizations like The Shanti Project helped us with experienced and compassionate volunteers. Her friends gave everything they could to make sure she had a peaceful death.

In the midst of it all, we were contacted about being the subject for National Geographic’s I Am Dying. My sister was immediately interested. She knew that she wanted to tell her story and leave her mark on the world. She accomplished so much in her life, even after her diagnosis. She wanted people to know about the positive impact she had on the world. I was more hesitant about the filming. I had to be able to trust the filmmakers to make sure that they wouldn’t sensationalize her illness.

So I met with filmmakers Dan Lindsay and TJ Martin, who told me about the piece they wanted to make. They assured me that it would be a portrait of Renee’s life and her final days, and that it wouldn’t be provocative. After seeing how compassionate both of them were, we both agreed to be filmed.

As her death grew near, and as I was forced to leave my job to take care of her full-time, they followed our journey. Everything was uncertain, but I knew that being by her side was far more important than making money.

During those final weeks, I was able to feed her, clothe her, bathe her, administer her medication and change her diapers. We were able to laugh, share memories and eat pancakes every day for breakfast. I was able to reach out to her closest friends to make sure they could spend as much time as they wanted with her.

I slowly learned her language and read her facial expressions. She would squeeze my hand if the answer was yes, nothing if it was no. Her dedicated nurses talked with me late at night as I tried to change her soiled sheets while she was still lying in the hospital bed. I was able to master it and found great satisfaction in caring for her the way a nurse would.

Together, we faced our fears of using the walker and the wheelchair – two elephants in the room that I only knew for a short time. I learned how to give her methadone after she was unresponsive, how to make sure her mouth was moist when she couldn’t swallow, and ultimately, how to say goodbye.

By being able to take care of her in her apartment, I learned a patience that I had never known before. As she slowly lost her mind, I let her take her time with simple tasks and tried to give her as much freedom as possible. Other caregivers could never give the same amount of love and affection.

When I found her breathless on April 11, 2013, I knew there would be no more reaching out to her close friends. There would be no more late-night calls to Sutter Care. And worst of all, there would be no more memories to share with her.

After the hospital bed was taken away, my mind and body were still in caregiver mode. I desperately wanted the care to continue. I ached for that special bond. As my grief took over me in a profound way, I knew that my education should continue.

Now, I strive to be the best hospice volunteer I can be. My goal is to touch the lives of others the way I was able to touch my sister’s. Whether I am able to work as a caregiver every day or not, I know that inside, a caregiver is who I am. I simply want the compassion to continue.

Before your death, you’ll be given choices. No matter what you choose, it will be difficult for your family members. My sister made the right choice for her. You can make the right choice for you, because your death should be the most beautiful experience of your life. I Am Dying shows just one example of how beautiful life and death can be. While there is sadness within its contents, there is a lust for life that lives on.


I Am Dying, directed by Dan Lindsay and T.J. Martin and produced by Casey Affleck and Joaquin Phoenix, premieres Saturday, June 13.

TIME Parenting

How I Explained Caitlyn Jenner’s Transition to My 7-Year-Old Daughter

“A man can become a woman?”

Last evening after dinner, my husband and I were comparing notes from our social-media news streams while our 7-year-old daughter was doodling. My husband was reading aloud from a statement that a personality (who shall remain nameless) we follow had posted on Facebook about Caitlyn Jenner. A conservative with deeply rooted religious beliefs — very different from our own — this person expressed that in his mind it would never be acceptable for a man to choose to become a woman.

Suddenly, our daughter’s ears perked up. “A man can become a woman?” “Yes,” I replied, “if he wants to.” My husband’s eyes widen and he lightly shook head his to signal “let’s not go there.”

“How can a person do that?” she asked, clearly intrigued. I looked at my husband, gave him my “we’re going there” smile and continued.

“Sometimes, when people are born, they may look like boys and girls on the outside, but on the inside, they know something is not right. For example, there are people who may look like boys, but know that they are really girls, and would be much happier if they could look like the way they feel on the inside. And, there are people who look like girls, but feel like they are boys on the inside. They would be much happier if the world saw them as boys. We are lucky enough to live at time where doctors and science can help people like that be who they are really meant to be.”

She got up from her seat and walked over to me and crawled onto my lap. She knew this was something serious. My husband, watching the exchange, laughed as if to say, “I warned you.”

“Mom,” she asked softly in my ear, “do the boys that become girls still have, you know, their things?” She nodded her head toward her own lap. “If they want to keep them, yes,” I replied. “They can decide.”

She gave me a kiss, walked back to her seat, picked up her colored pencil, and started doodling again. That was enough … for now.

Our girl has not yet encountered the Vanity Fair images of Caitlyn Jenner that were released last week. If she did, we’d have talked a bit about Caitlyn’s journey, and also about ideas of beauty and how magazine cover images get made. Luckily, she’s still in a childhood phase that is not affected by pop culture and media. I am hoping we can stay there a bit longer.

Want to know more about talking to your children about transgender issues? Here are a few sources you may find useful.

Angela Matusik is the executive digital editor at InStyle, and she is not afraid to talk to kids about the tough stuff. You can follow her on Twitter @angelamatusik

Read next: Watch Kids Share Eloquent, Empathetic Reactions to Caitlyn Jenner

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TIME Family

Meet the Father of Paternity Leave

Gary Ackerman
Bassem Tellawi—AP Congressman Gary Ackerman, D-NY, on Nov. 9, 2004.

Before Richard Branson, there was Gary Ackerman

Correction appended, June 11, 2015

This week, the man most celebrated for his impact on paternity leave policies is Richard Branson: the Virgin founder made news by announcing that some employees at Virgin Management would be eligible for a full year of paid new-dad time off.

Almost exactly 45 years ago, a very different man—a teacher, not an executive—was the one making strides for paternity leave. His name was Gary Ackerman, and he was a teacher in New York City who had a daughter in late 1969. When his daughter was about 10 months old, he applied for a leave (without pay) for childcare purposes. As a resulting lawsuit laid out, the principal did not recommend to the district that Ackerman’s application be approved; unsurprisingly, the superintendent followed suit by not approving the leave. Ackerman tried to appeal the decision several ways, and was told by many people that the childcare leave policies of the Board of Education only applied to female teachers.

As TIME later reported, “[t]urned down, he went AWOL from his job, [and] with his wife Rita filed a complaint of discrimination with the Federal Equal Employment Opportunity Commission and sued the board in U.S. district court. Their argument: granting child-care leaves only to women is an invasion of privacy because it forces mothers to be housekeepers and child rearers and prevents husbands and wives from dividing up family responsibilities as they see fit.”

In 1973, the EEOC, TIME continued, “found that the mothers-only rule ‘discriminates against male teachers as a class.’ As a result, the board says it will reword its bylaws to ensure equal rights for fathers.” That autumn, the relevant section of the Board of Ed bylaws was amended so that it no longer referred to an affected teacher as “her” or relied on the timing of the teacher’s pregnancy, thus expanding its relevancy to fathers and to adoptive parents. The determination is widely regarded as the groundbreaking first step toward paternity leave’s existence.

Just how groundbreaking was it? Ackerman’s motion to have a lawsuit he filed against the Board of Ed (separate from the EEOC case) considered as a class-action suit was denied because, though 40% of the Board of Ed’s teachers were men, he was the first male teacher ever—and one of two in total—to apply for childcare leave before that 1973 change. According to a New York Times article about the EEOC’s decision, at the time about 2,000 to 3,000 female teachers took a maternity leave in the city each year.

Ackerman was eventually denied compensation in his suit, because he had already stopped teaching and the relevant bylaw had already been changed, but that doesn’t mean his story came to an end. Though his first job after leaving teaching was at a local newspaper, he soon transitioned to a life in politics. Elected to the state senate in 1979, he went on to serve in Congress for three decades, until January of 2013.

Correction: The original version of this article misstated how long Gary Ackerman served in Congress. He served for three decades.

TIME Family

This 92-Year-Old Just Adopted a 76-Year-Old Daughter

"I have worked jigsaw puzzles, and my life had been a beautiful picture. But one piece was missing"

A 92-year-old Dallas woman adopted her 76-year-old cousin after a relationship that has spanned more than six decades, WFAA in Dallas reported.

Muriel Clayton began to care for Mary Smith, her younger cousin, after Smith’s father died decades ago. Smith’s mother was still living, but illness prevented her from caring for her daughter. Though Clayton wanted to ask Smith to formalize their relationship earlier, she waited until her biological mother had died.

On Tuesday, the pair went to Dallas County Court and legally became mother and daughter.

“I have worked jigsaw puzzles, and my life had been a beautiful picture. But one piece was missing, and that was Mary,” Clayton said. “And now I’ve got that piece in place. Officially!”


Read next: What I Learned About Family from Organizing the World’s Biggest Family Reunion

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TIME women

Why I Don’t Want to Have Children

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I’ve spent years carefully crafting the most amazing life I can

What I want is to be happy.

I’m often told that I’d make a good mother. Depending on my relationship with the person making this wildly incorrect statement, I have one of two reactions: either a small, insincere smile and a “mmmm” response that does not invite further discussion or a hearty laugh followed by a firm “No.”

Don’t get me wrong: I love kids. They’re hilarious, they’re adorable, and I (mostly) enjoy spending time with them. But without a doubt, I do not want them. And here’s why.

I don’t want to worry about diaper rash and “tummy time” and I don’t want to know what colic is.

I don’t want to put a kid on a kindergarten waiting list and I don’t want to decide between public and private education. I don’t want to coordinate basketball practice drop-off with ballet lessons pick-up, I don’t want to help with trigonometry and darling, I will not deal with your teenage angst because you best believe I invented that. I’d rather have bamboo shoots shoved under my fingernails than try to figure out how to pay for my child’s college while I still owe roughly twelve kajillion dollars for my own degree. I’ve more than once done something “just to tell the grandkids about it,” but I never actually planned on there being any grandkids.

It amuses me to tell people I don’t want children because no one ever quite knows how to respond. I’ve gotten “Well, when you meet the right guy, you’ll change your mind,” which is basically suggesting I’m incapable of making decisions regarding my own life without consulting a nameless, faceless FutureMan and is, by the way, astonishingly offensive. Others immediately ask what I do for a living, as though my employer holds the key to my womb and has locked it up until I retire. I don’t really consider myself a career-minded kind of girl; I’ve always worked to live, not lived to work.

Two mothers have actually said to me, “I didn’t know what love was before having a baby. You should reconsider.” I’m happy they’re happy now but “not knowing love before kids” is one of the most acutely sad things I’ve ever heard. Occasionally, I get a hearty “yeah!” from like-minded women, some of whom will eventually become mothers and some of whom will not. I appreciate the support.

But at this point, it doesn’t matter how much anyone tries to change my mind because the decision’s been made — permanently.

Last October, I spent a wonderful morning with my doctor, during which he performed a tubal ligation on me.

Yep, I got my tubes tied at 28.

I admit that once my doctor agreed to perform the surgery, I had a moment of panic. It immediately crossed my mind that maybe everyone was right and I was wrong and I would wake up at 30 and want a baby more than anything in the world or that maybe my “hard pass” on kids was a rebellion against expectations simply for the sake of a rebellion.

Maybe I would love the complete upheaval of my priorities and schedule and life in general. Shortly after these hysterical thoughts raced through my mind, though, I regained my sanity. I picked a date for the surgery. Done. Tubes tied.

Here’s the thing: I’ve spent years carefully crafting the most amazing life I can.

I’m surrounded by people I love very much, who love me in return. I’m well-educated and well-traveled. I have endless time to learn about things that interest me and to see wonderful things and to meet the greatest people on earth. I leave piles of library books all over my bedroom and plan fabulous trips all over the world. I stay up until 6 a.m. watching Sons of Anarchy because I know no small person is relying on me to feed them in a few short hours. I occasionally eat chips and salsa for breakfast and drink beer for dinner and feel no guilt that I’m teaching anyone horrific eating habits. I spend my days finding my bliss, like all the inspirational posters beg of me.

All this being said, I can’t wait to be an auntie. Whenever my friends start popping out kids, I’ll be there with inappropriately loud and expensive presents. I’ll be the aunt who slips them a vodka martini on their 16th birthday and I’ll rant and rail with the best of them whenever they feel slighted by other kids.

And when I’m off for six months teaching scuba in Venezuela, I promise to send lovely postcards.

I get the reasons people want kids. I do. I’m not such a heartless, selfish monster that I’m incapable of understanding the appeal of a small person who loves you unconditionally and relies on you to guide them safely through a scary world. Parents are brave and strong and incredible people. But so are astronauts and brain surgeons and I don’t want to be those things, either.

What I want is to be happy.

And I’m doing that. I’m there, I’m living that dream. I’m happiest not being a mom, but hey… Call me if you need a babysitter. I’m great in a pinch.

This article originally appeared on YourTango.

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Read next: What I Learned Living in a Tiny House With Two Children

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TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

MONEY Sports

5 Sports Struggling to Reach Kids

It goes without saying, but if you ever have to launch a campaign to convince people that something is cool, it's probably not.

Kids today! They’re overscheduled with activities, and they’ve got no attention spans thanks to social media, video games, smartphones, and assorted other screens. That’s the gist of how today’s younger generations have been routinely portrayed. And these factors are among the reasons cited for waning interest and participation in sports that once captured the attention—and dollars—of the masses, but are now considered too old-fashioned, too time-consuming, too unexciting, or just too uncool by kids today.

These struggling sports aren’t simply conceding defeat, however. They’re introducing marketing initiatives and new business models to win over younger consumers as if the future of these sports depends on them—which is pretty much the case.

  • Bowling

    Bowling alley with neon lights

    The number of bowling alleys in America has been on a steady decline for years, dropping roughly 25% from 1998 (5,400 alleys) to 2013 (just under 4,000). Bowling alleys once thrived thanks to active bowling leagues around the country, but participation has dwindled, perhaps as part of the broader trend of Americans detaching from society and their local communities, as explained in the groundbreaking 2000 book Bowling Alone.

    That might not be the only reason interest in bowling has faded. “People’s social tastes change, too,” Wayne State University assistant sociology professor David Merolla told the Detroit Free Press. “It’s also possible bowling isn’t what people do anymore.”

    In recent years, emerging entertainment brands like Pinstack and Latitude 360 have aimed to reinvent the faded old bowling alley concept and attract more young people by adding all sorts of bells and whistles—or rather, ropes courses, laser tag, rock climbing walls, bumper cars, restaurants, and concert and comedy venues, all under one roof. Latitude 360, which plans on opening a location in lower Manhattan in late 2015, bills itself as a “cruise ship on land.” An ongoing Kids Bowl Free summertime promotion encourages children (and their families) to bowl too.

  • Golf

    Jordan Spieth of the U.S. grins as he wears his Champion's green jacket on the putting green after winning the Masters golf tournament at the Augusta National Golf Course in Augusta, Georgia April 12, 2015.
    Brian Snyder—Reuters Jordan Spieth of the U.S. grins as he wears his Champion's green jacket on the putting green after winning the Masters golf tournament at the Augusta National Golf Course in Augusta, Georgia April 12, 2015.

    Jordan Speith and Rory McIlroy are among the young golf champions who have been heralded as the sport’s potential saviors. And why might the sport need saving? The reasons include that it’s too snobby, too hard, too expensive, or just not cool or too time-consuming for our fast-moving culture.

    Perhaps the most obvious sign of golf’s struggles is that the number of courses in America is expected to plummet for years to come. To boost participation and interest in the sport, golf associations and country clubs have tried everything from pushing the idea of playing nine holes rather than the full 18, to using oversized holes on courses to make the game less frustrating—and perhaps even fun.

  • Boxing

    Boxing: Mayweather vs Pacquiao
    Mark J. Rebilas—USA TODAY Sports/Reuters Floyd Mayweather and Manny Pacquiao box during their world welterweight championship bout at MGM Grand Garden Arena, May 2, 2015.

    The big Floyd Mayweather-Manny Pacquiao match in Las Vegas was a huge money maker, but it didn’t help endear the sport to casual fans. Dozens of lawsuits have been filed by spectators who want their money back because the match was so boring (and because Pacquiao didn’t disclose an injury to prior to the fight).

    The heightened attention given to boxing with the “Fight of the Century” was also an anomaly. Interest in boxing among fans has been described as struggling, dead, or “undead” at least since the rise of mixed martial arts into the mainstream. Prior to the most recent “Fight of the Century,” many boxing pay-per-view events have drawn disappointing viewer numbers, and some have argued that PPV format is to blame as the reason so many casual fans stopped keeping up with the sport.

    “What’s hurting boxing is they’re not putting it on free television,” boxing great Evander Holyfield theorized in 2011. In March, boxing returned to prime time network television for the first time in three decades, with Saturday broadcasts of Premier Boxing Champions on NBC. Thus far, boxing on network TV has proved to be the equal of UFC in terms of viewer numbers.

    Interestingly, while the consensus is that fan interest in boxing has dwindled, participation in boxing has been on the upswing over the past decade, as it’s become a trendy fitness activity among men and women alike. Still, the American Association of Pediatricians vigorously opposes youths being involved in amateur boxing because of the serious risk of brain injury. On a related note, fewer kids are playing football across the U.S., though the trend may come as a result of children increasingly specializing in one sport for most of the year, rather than just concerns about head injuries.

  • Fishing

    Alex Wong—Getty Images Local students of Septima Clark Public Charter School participate during a fishing event at the Constitution Gardens Pond of the National Mall in Washington, DC.

    According to a 2014 report, there was a net loss of 1.2 million fishing participants in the previous year: Overall, 9.9 million people gave up fishing, while only 8.7 participants picked up the sport, representing a decrease of 21%. The poll shows that households with kids are more likely to fish: 17.5%, versus 12% of households without young children. But teenagers are the group least likely to be interested in fishing: Only 6.6% of people ages 13 to 17 who don’t fish said they were considering taking up the sport, compared to 43% of those 45 or over.

    Unsurprisingly, the outdoors seems to be deemed less cool the older a child gets. Among kids ages 6 to 12, 44% say outdoor recreation is “cool,” compared to 34% of 13- to 17-year-olds. Nearly half (47%) of first-time adult fishing participants said they perceived the sport as “exciting,” but significant numbers also described the sport as “time consuming” (25%), uninteresting (16.5%), and “not for someone like me” (12%). The poll doesn’t reveal such perceptions with regard to children or teenagers specifically, but presumably an above-average portion of easily distracted, smartphone-addicted teens think fishing is too boring.

    The insights of an outdoors recreation analyst quoted in 2007—when a study showed the number of fishing participants had dropped 16% over the previous 10 years—seems to hold up well: “Thirty years ago, people would get up and go fishing,” he said. “Now you get up and you have a soccer game at 9, a baseball game at 11, a team picnic at 1 — it’s much more structured time. Video games also are part of it.”

    It’s understandable why the fishing industry is so eager to encourage kids to give the sport a try: 84% of adult participants say they were introduced to fishing by the time they turned 12. Of course, it helps if you actually catch a fish: 40% of men said the most enjoyable thing about fishing was (what else?) catching a fish, and 37% said the worse thing about fishing was (what else?) not catching a fish. Yet 19% of survey participants who fish said they caught nothing on their most recent fishing trip.

    National Fishing & Boating Week, held the first week of June each year (June 6-14 in 2015), provides families a good excuse to give fishing a try. On one or more days during this week, most states allow fishing on public bodies of water without the requirement (or fee) of a permit.

  • Baseball

    As part of a season-long program titled "Calling All Kids", the players of the Boston Red Sox were accompanied by children during pre-game introductions.
    Jim Davis—Boston Globe via Getty Images As part of a season-long program titled "Calling All Kids", the players of the Boston Red Sox were accompanied by children during pre-game introductions.

    Studies have shown participation and interest in baseball has fallen year after year among children. Between 2002 and 2013, the number of children who played baseball dropped 41%. Polls indicate that teens identifying themselves as “avid” baseball fans are on the decline, while the fan base in professional soccer and basketball have been rising. (The NFL has the highest percentage of avid teen fans, overall.)

    Major League Baseball Commissioner Rob Manfred has been on a mission to win over younger fans, which seems like an essential move because the future of baseball as a business relies on it. “Our research shows the two biggest determinants of fan avidity are did you play as a kid? And how old were you when your parents took you to the ballpark for the first time?” Manfred said at the start of this season.

    Hence the proliferation of family ticket deals and kids clubs offered by virtually every MLB team. The promotions include free tickets and team swag, with the hope that playing up to kids now pays off down the road.

TIME People

Family Members Charged for Loud Cheering at Mississippi Graduation

They were charged with "disturbing the peace"

Four people could face jail time for cheering too loudly at a Mississippi high school graduation.

Authorities have charged them with disturbing the peace, punishable by up to six months in jail and a $500 fine, for disrupting commencement exercises at Senatobia High School on May 21.

One of them, Henry Walker, cheered, “You did it, baby!” when his sister’s name was called and was promptly whisked outside, his mother said.

“I don’t think it was right for what they did to him,” Linda Walker told NBC affiliate WMC in Memphis.

The superintendent, Jay Foster, who pressed the charges, told WMC that…

Read the rest of the story from our partners at NBC News

TIME Parenting

Harvard Obstetrician Speaks on Safety of Giving Birth at Hospitals

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Much of the developed world offers only one pragmatic alternative: the hospital

There is a good chance that your grandparents were born at home. I am going to go ahead and assume they turned out fine, or at least fine enough, since you were eventually born too and are now reading this.

But since the late 1960s, very few babies in the United Kingdom or the United States have been born outside of hospitals. As a result, you may find the new guidelines from the U.K.’s National Institutes for Health and Care Excellence (NICE) just as surprising as I did. For many healthy women, the NICE guidelines authors believe, there may be significant benefits to going back to the way things were.

Shortly after the NICE guidelines were issued, the New England Journal of Medicine invited me to write a response. The idea that any pregnant patient might be safer giving birth outside the hospital seemed heretical, at least to an American obstetrician like me. Knowing that no study or guideline is foolproof, I began my task by looking for holes to form a rebuttal.

I soon realized that this rebuttal largely hinged on flaws in the American system, not the British one. While we take excellent care of sick patients, we do less well for healthy patients with routine pregnancies – largely in the form of turning to medical interventions more than strictly necessary.

As the guidelines suggest, some women in the U.K. with low-risk pregnancies may be better off staying out of the hospital. Why? Because the significant risks of over-intervention in hospitals, such as unnecessary C-sections, may be far more likely (and therefore more dangerous) for patients than the risks of under-intervention at home or in birth centers. But women in the U.K. have access to greater range of settings where they can give birth. For women in much of the U.S., the choice is often the hospital or nothing.

Are hospitals always the best option? The view from the U.K.

The British Birthplace Study, upon which the NICE guidelines are based, reviewed 64,000 low-risk births to compare the relative safety of giving birth in one of four settings: a hospital obstetric unit led by physicians, an “alongside” midwifery-led birth center (on the same site as a hospital obstetric unit), a freestanding midwifery-led birth center, and at home. The study included only women with low-risk pregnancies. Women with obesity, diabetes, hypertension or other medical conditions were excluded from the study.

For low-risk women who had never given birth before, home birth led to bad outcomes (such as encephalopathy or stillbirth) slightly less than 1% of the time. That’s rare, but still twice as risky as the other options. Birth centers were no riskier than hospitals for first-time moms, and all options (including home) appeared equally safe for women who had given birth before.

By contrast, this same group of low-risk women was between four and eight times more likely to get a C-section if they started off getting their care in the hospital compared to other settings. Rather than being driven by patient risk or preference, this tendency toward C-sections appeared to be driven by proximity to the operating room.

While the NICE guidelines make it clear that women should be free to choose the birth setting they are most comfortable with, they point out that the risks of over-intervention in the hospital may outweigh the risks of under-intervention at a birth center or at home for the majority of expecting mothers.

The situation is different for women in the U.S. Last year 90% of births were attended by physicians, while just 9% were attended by midwives. Fewer than 1% of U.S. women have their babies at birth centers. While access to care is guaranteed in the U.K., nearly half of U.S. counties have no midwife, obstetrician or other maternity care professional.

C-sections are routine, but not without complications

Today, newborn babies in the U.S. have a one-in-three chance of entering the world through an abdominal incision. In the U.K., the odds are lower – more like one in four, but everyone on both sides of the Atlantic agrees this still represents too much help.

Part of the challenge may be a feature of the species. Homo sapiens have always required some form of extra help being born. Narrow pelvises are required for walking upright, and large frontal lobes are required for nuanced thought. Neither works in our favor when it comes to navigating the birth canal. The unresolved question is how much help is truly necessary – and how much help is too much.

Cesareans are designed to be a lifesaving surgery, but they are now so routine that C-sections have become the most common major surgery performed on human beings, period. It hasn’t been until recently that we started to fully consider the downsides of cesarean deliveries.

For starters, caring for a newborn while dealing with a 12-centimeter skin incision in your own abdomen is the pits, especially when compared to caring for a newborn without having a 12-centimeter skin incision.

Though common, let’s not forget that C-sections are a major abdominal surgery that can lead to threefold higher rates of serious complications for mothers compared to vaginal delivery (2.7% vs 0.9%). These complications can include severe infection, organ injury and hemorrhage.

I should also point out that the first C-section a woman has is an easy surgery – I can train an intern to do one safely in just a few weeks. But most women have more than one child, and most women who have a C-section the first time will have a C-section the next time. Obstetricians are among a small group of surgeons who regularly operate on the same part of the same patient over and over again, dissecting thicker layers of old scar tissue with each surgery.

By the second, third, or fourth C-section on the same patient, the anatomy becomes distorted and the surgery becomes increasingly technical. I recently did a cesarean where the woman’s abdominal muscles, bladder and uterus were fused together like a melted box of crayons.

In the most dreaded cases, a woman’s placenta (a large bag of blood vessels that nourishes the fetus) can get stuck in this mess of tissue and fail to detach normally. In these cases, pints of blood may be lost within minutes, and the only way to stop the bleeding is often to do a hysterectomy.

Why do hospitals mean more interventions? It comes down to risk perception

Since 1970, the number of C-sections performed in the U.S. has gone up by 500%. Some of this increase is because mothers have become older and less healthy, conferring greater risks in pregnancy. But having a baby in this decade is not 500% riskier than having a baby in the 1970s. We know this because C-sections rates in just the women who are young and perfectly healthy have gone up just as quickly. And contrary to popular belief, this has little to do with maternal preferences. First-time mothers who request C-sections with no medical reason make up fewer than 1% of the total.

What’s driving the increase in C-sections in the U.S. is unclear, but much of the drive to do more comes from our perception of risk. Although my professional contribution to childbirth is often just to catch, my responsibility as a scalpel-trained, general obstetrician in the United States is to mitigate risk.

I am acutely aware that even women with healthy pregnancies can develop life-threatening hemorrhage, fetal distress or other unanticipated emergencies during labor that require surgical intervention.

My job is to get the baby delivered before it is too late, and often I’m working with ambiguous information. I know how long labor should take on average, but don’t have a precise estimate of how long labor should take for the patient in front of me. What if the baby is too big or the pelvis is too narrow? C-sections often come down to a game-time decision.

Fortunately, I can make sure this decision is never wrong. If the baby looks a little blue and lackluster right after I do a C-section, I’m convinced I did it just in time. But if the baby is pink and vigorous after I do a C-section, I’m still convinced I did it just in time. Without evidence to the contrary, it is easy for me and many of my colleagues to believe that operating is always the right course of action.

When it comes to the safety of mothers and newborns, most would agree that it is better to overshoot than undershoot. The problem is that we are overshooting by a lot, in ways that lead to more insidious harm. Nearly half of the cesareans we do in the U.S. currently appear to be unnecessary, and come at a cost of 20,000 avoidable surgical complications and US$5 billion of budget-busting spending in the US annually.

C-sections may have consequences for babies as well, in ways that we are just beginning to understand. Exposure to normal bacteria in the birth canal may play a role in the development of a baby’s immune system. A Danish study of two million children born at full term found that those born by cesarean were significantly more likely to develop chronic immune disorders. Others have suggested that going from the womb to an artificial warmer can have an impact on immediate bonding, and even success with breastfeeding.

In parts of the world where women do not have access to skilled birth attendants, large numbers of mothers and babies die from preventable causes. Even for the healthiest among us, walking into the woods to have your baby would be unwise. Still, much of the developed world offers only one pragmatic alternative: the hospital. For more than a half-century, we have believed that spending many hours, if not days, in a hospital bed with a smattering of ultrasound gel, clips, wires, heart tones, random beeps and routine alarms is the safest way to have a baby.

Many of the patients I care for benefit from my surgical training. I get to save lives while also sharing in one of the most profoundly joyous moments that families experience. But obstetricians like me may be hardwired to operate, and too many operations are harmful to patients. One strategy to fix this might be to change our wiring. Another may be the British way: for patients to stay away from obstetricians altogether – at least until you need one.

This article originally appeared on The Conversation.

The Conversation

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