In Which ACOG Admits that Homebirth Can Be As Safe As Hospital Birth...

Neonatal mortality.

This has been used as the nail in the coffin of the homebirth debate. Opponents of homebirth will often concede that homebirths create a better experience for the mother, but usually present this benefit as being only for the mother with an increased risk of injury or death for the baby. In particularly vitriolic debates, this is where the "selfish mother" accusation kicks in.

However...

It’s not entirely true.

Which is why it’s important to go straight to the American Congress of Obstetricians and Gynecologists Bulletin No. 697 from April 2017.

What does ACOG Bulletin No. 697 Say About Homebirth?

ACOG’s Bulletin No. 697 is (in my opinion) a relatively balanced assessment of the research on homebirth. One of the first things that ACOG states is that high quality evidence comparing hospital birth and homebirth outcomes is limited. The “gold standard” in medical and scientific research is the randomized control trial (RCT) and this is almost impossible to pull off with birthing practices. A RCT is where you randomly assign your participants to receive one or the other treatment/intervention/ experience. So in the case of homebirth and hospital birth outcomes, we would need thousands of women who honestly don’t care whether they give birth in a hospital or at home. In developed nations where homebirth is more common than in the US, attempts have been made at conducting a RCT. But these have failed to launch because women were unwilling to have their birth experience be assigned at random.

Birth is also one of those things that is very hard not to affect by location and mother’s preference. It’s not like a surgical procedure where you can put your patient under anesthesia and implement certain procedures. Women who feel threatened during labor will often have a stalled labor as their body releases catecholamines in response to the stress. So whether it’s at home or in a hospital, the woman who wants to be birthing somewhere else is going to have a poorer outcome than the woman who feels safe where she is birthing. So a RCT is really not going to be a possibility. This leaves us with observational studies.

Observational studies present a number of problems. Some are so small that they can’t give us a picture of what homebirth would entail on a large scale. Many rely on birth certificate data— which is notoriously inaccurate. For example, when it says there was an attendant at the birth, was it a husband, boyfriend, CPM, DEM, old hippie lady, CNM, paramedic, naturopath, neighbor down the street...? Often, the birth certificate doesn’t specify what “attendant” means. Sometimes the studies don’t differentiate between planned and unplanned homebirths very well— a big problem because a woman who gives birth suddenly at home because of an emergency is in a different situation than a woman who has a full-term, spontaneous birth with a qualified attendant there. And it’s also hard to ascertain whether complications resulted from care during a transfer to after transfer to a hospital. ACOG does point out that there have been some studies from other countries where home birth is well-integrated into the hospital system and these studies have been high quality. Unfortunately, the results of these studies aren’t necessarily what we would see in America because homebirth tends to operate on a fringe here instead of being a part of the normal system of birth care.

But all that being said, ACOG says that there are some common threads that emerge from observational studies on homebirth where the neonatal mortality rates are comparable to those in hospitals...

What ACOG found in all the studies where homebirth and hospital birth neonatal mortality were similar:
Rigorous selection criteria 
Experienced, well-trained (usually credentialed) attendants
Safe and timely transfer

So in a nutshell, yes, homebirth for a low-risk pregnancy with a qualified attendant and a hospital close by for transfer is as safe as a hospital birth for a low-risk pregnancy. ACOG still believes that a hospital birth or birthing center with CNM are the safest options, however, they acknowledge that homebirth can have comparable rates of infant mortality.

That being said...

I think there is a potential for some “high-risk” pregnancies to be safely birthed at home, depending on the particulars of the pregnancy and skill of the attendant. The Farm in Tennessee has delivered breeches, VBAC’s and twins with an extremely high success rate. And while there are accounts of poor midwifery care for breeches, twins and VBAC’s we can dig up examples of successful homebirths for these conditions. As for hospital care, most twins and breeches are simply delivered by c-section and few VBAC’s are attempted and fewer achieved. This gives the illusion of safety since many twins, some breeches and most VBAC’s could probably be delivered safely vaginally with the right care. ACOG notes that research from the UK showed comparable levels of neonatal mortality VBAC’s at home and in hospital— but that in the US the rates of neonatal mortality were higher for HBAC’s. This indicates that safe HBAC is possible, but there are problems with how HBAC’s are sometimes managed in the US.

But here's where ACOG gets a little hypocritical...

The two criteria of low-risk pregnancy and competent attendant apply to hospital births as well!!!! Some pregnancies just can’t end in a natural birth like genuine CPD and some are just more likely to have a poorer outcome even with the best technology, like a very early pre-term birth. So skill of the attendant is also crucial even with a OB-GYN in a hospital. For example this doctor- an honors graduate from CalTech and elected vice-chair of obstetrics to Huntington Memorial Hospital- failed to treat a mother for retained placenta causing a severe hormonal deficiency, injured two babies during labor resulting in brain damage to both and failed to treat a mother or call in a perinatology specialist when a mother was leaking amniotic fluid at 30 weeks and the baby’s heartbeat was abnormal, resulting in the infant’s death. The hospital stuck by him during these and many more instances only taking action when the LA Times published an expose. Or this doctor who refused to perform additional tests on a mother classified as high risk despite recommendations from specialists and then caused permanent damage to the baby during birth.

Bad decisions and poor care from anyone can kill a baby and credentials- or lack thereof- are no guarantee of good or bad care. The aforementioned doctor at Huntington Memorial permanently injured a mother who was low-risk. After suddenly shouting that he needed to do an emergency c-section, he instead decided to make several deep cuts into the mother’s vagina. The baby was born healthy and the mother’s bowels were permanently damaged. Specialists who examined her were shocked that a woman under the care of a licensed physician in America could have such severe injury. Let’s ask ourselves a question: had she delivered in ambulance or by the side of the road, might there have been a better outcome? Remember, the doctor gave no reason for why a c-section needed to be done, then decided that it wasn’t necessary and medical examinations determined the injuries she suffered were shocking and unnecessary.

An obstetrician who fails to give appropriate care is just as dangerous to a baby or mother as a midwife or mother who fails to give appropriate care. Doctors who want the respect and trust of mothers can’t expect that their credentials are enough. They must be able to provide appropriate and competent care. And if a doctor is allowed to provide care that endangers the lives of mothers and babies and still be elected to a prominent position in a hospital, then how well can women trust the credential of OB-GYN over midwife? The same arguments that midwives are incompetent and unregulated can also be leveled at OB-GYN’s and pretending that one or the other credential is more or less safe distracts us from the real issue: competent birth attendants will have good outcomes for the vast majority of births. Incompetent attendants are dangerous. It’s not the place of birth or the credentials of the attendant that make a birth safe. It’s the competency of the attendant and supporting caregivers.

Why C-Sections Are Like Apollo 13

By April 1970 space travel was largely regarded as mundane. Two successful moon landings had taken place and the public had started to view space travel as an endeavor with as much risk as road tripping to see family in Ohio. For the crew of Apollo 13 though, it was the culmination of years of training. They were all stand out pilots who were excited to have the chance to go to the moon- a genuine, once-in-a-lifetime opportunity. For Commander Jim Lovell, this was the top of pyramid. He had clocked more time in space than almost any other astronaut and had even seen the moon on flyby
when he was part of the Apollo 8 crew's Christmas mission. (You can still  see the video coverage where they filmed the Moon from space, reading from the first chapter of Genesis.Whatever your religious views, it will give you chills as you think about just how vast and ancient our universe is.) Lovell had had an incredible career. Apollo 13 was his last mission and visiting the moon was everything he could have wished for as a pilot and astronaut.

The third moon landing mission Apollo 13 launched with little fanfare or attention... until a malfunction left astronauts Jim Lovell, Fred Haise and Jack Swigert stranded in space while NASA engineers worked day and night for almost six days to solve an ever increasing list of problems and bring the astronauts back home safely. The situation was far from ideal. A routine stir of the oxygen tanks had caused an explosion on the spacecraft leaving the astronauts with no other option than to leave the spacecraft Odyssey (which was meant to ferry the three men to and from the moon) into the lunar landing module or LM (which was designed to carry two of the crew to land on the moon from lunar orbit). With three occupants instead of two, the LM's carbon dioxide filters quickly started becoming overwhelmed and the filters between the Odyssey and the LM were not interchangeable, so NASA engineers had to figure out how create an adaptor using only the materials the astronauts would have on board. The LM was not designed for multi-day usage, so they had to turn the power down to an absolute minimum to subsist for the entire journey back to Earth. (For a point of comparison, there is a famous line in the movie where one engineer protests this idea shouting "You can't run a vacuum cleaner on 12 amps!")

This meant that the onboard guidance computers had to be shut down. It meant turning off the heat so the astronauts were floating around in temperatures as low as 38 degree temperature with no warm clothing. Water had to be rationed to last the entire trip (Fred Haise developed a UTI and subsequent kidney infections during the whole ordeal.) And no waste dumps were allowed for fear it would mess up the already tenuous trajectory of the injured space craft. All human waste was confined to bags and kept in the craft. The odds were not good. But as lead flight director Gene Kranz would later say, "Failure was not an option." They refused to let three men die in space and simply kept working problem after problem. After a lot of hard work, courage, and a few lucky breaks (like the onboard computer not shorting out when it was powered for reentry and missing a hurricane at splashdown), the crew of Apollo 13 made it safely home to their families. The mission was considered a successful failure. They failed to reach the moon and none of the crew would ever have the chance to visit the moon again. But despite all the challenges, they made it safely home. NASA and other space agencies don't make a habit of pushing spacecraft to work in ways that defy design and specification. It would sure save a lot of power, but turning onboard computers and heating off are not routine because of the risks involved to the astronauts. Nobody wants to make those types of sacrifices unless it's absolutely necessary.

On the other hand, if you ask anyone at NASA who had to live through Apollo 1 (fatal fire during training), Challenger (explosion on the launchpad) or Columbia (disintegration upon reentry), which they would choose, they would take Apollo 13 in a heartbeat. No one wants dead astronauts. A c-section should be the same way. It's not ideal. You are surgically cutting open the womb. There is a 12 percent chance of damage to the mother's internal organs. There is an increased chance of hysterectomy, blood transfusion, uterine infection and future placental abnormalities for the mother. There is a 1.1% chance of some kind of injury to the baby, ranging from minor to serious. The baby is very likely to experience respiratory problems which will require a NICU stay. Breastfeeding is frequently more difficult because of the problems associated with nursing after major surgery. We're talking about additional risks over a normal, uncomplicated vaginal birth, but when faced with a life and death situation, we all want safe mothers and babies. And if that means the obstetrical equivalent of pulling out a lifeboat in space, turning off the power, and fashioning a carbon dioxide filter adaptor from duct tape, we're going to do it because it has a good chance of saving lives.

When we talk about c-sections, we're not talking about a choice between risk and no-risk. C-sections carry additional risks over normal, uncomplicated vaginal birth. The engineers and astronauts realized that every decision they were making about the Apollo 13 mission carried an additional risk of death over an uncomplicated mission, but those risks were worth the chance of bringing the astronauts safely home because they were not dealing with a normal, uncomplicated mission. C-sections should not be seen as a routine procedure. Health professionals, parents and birth workers need to keep in mind that c-sections are the obstetrical equivalent of Apollo 13. If we start confusing "normal" with "emergency" we are creating a situation that exposes mothers and babies to additional risks.

Free handout posted- Drugs and herbs that may reduce milk production

Burning questions... We all have them and breastfeeding moms are no exception.

I have a few of the handouts from my breastfeeding as public documents on Google for this purpose. These handouts cover some of the most popular hot topics and big questions I hear from breastfeeding mothers.

This is one of those questions I hear a lot. Can I take an antidepressant? Tylenol? Birth control? Drink herbal tea?

Here is a crash course in breastfeeding and medications and herbs.

The Public Health Case for Lower Cesarean Rates

This is from a paper I wrote for one of my classes on the public health benefits of reducing cesareans. Please feel free to quote from this as long as you give proper attribution to me and the authors of the cited sources of this paper. Thanks and enjoy!

The cesarean section is now the most common surgical procedure in the United States and accounts for 32.8 percent of all deliveries as of 2011 (Kozhimnnil, Law, and Virnig, 2013). This is a substantial increase from what it was decades ago. As Dr. W. Lawrence Warner stated in a 2013 article for the American College of Obstetrics and Gynecology, “When I began medical school in 1970, the overall cesarean delivery rate was 5.5%… I practice in Utah, where the rate is 22.2%, the lowest in the country. In New Jersey, the rate is 38.3%, the highest in the country. There are some individual hospitals with rates well over 50%.” 

There are many factors that have been cited as driving the increase in cesarean rates, including an increase in multiple gestations due to fertility treatments, rising rates of maternal obesity and conditions such as gestational diabetes and preeclampsia. However, other issues that are not related to the actual health of the mother or baby also come into play, such as convenience and doctors’ concerns about liability and malpractice (Kozhimnnil, Law, and Virnig, 2013). 

Cesarean sections play a vital role in maternal and child health. There are situations which absolutely indicate the use of a cesarean, such as transverse lie, preeclampsia or other hypertensive disorders of pregnancy that have progressed to a life-threatening stage, cord prolapse and placenta previa. However, these cases account for only a small number of c-sections performed, which means that many c-sections are not actually a medical necessity. This has important implications from both a cost and health perspective for mothers, babies, hospitals, insurance companies and Medicaid. C-sections are more costly than vaginal births and also carry increased risks for both mothers and newborns. Lowering the overall rate of cesarean surgery could mean reduced healthcare costs as well as important gains for maternal and child health. 

Though cesarean surgery has become extremely common, it is actually a procedure which entails more risks for both mothers and babies than a vaginal birth. Intraoperative damage to internal organs such as the bowels, bladder, urinary tract and unintentional damage to the uterus or cervix are relatively common, occurring in approximately 12 percent of cesarean sections. Other maternal complications include an increased occurrence of placenta abnormalities in subsequent pregnancies, admission to the intensive care unit, blood transfusion, infection, blood clots, hysterectomy and death, with the chances of these complications increasing with each subsequent cesarean (Dodd and Grivell, 2011). 

Kozhimnnil, Law and Virnig (2003) found that even among women who fit the American College of Obstetrician-Gynecologists’ (ACOG) definition for low-risk pregnancy, cesarean rates are still very high and that clinical factors alone could not explain the increase in cesarean surgery. They theorize that rising cesarean rates might be explained by physicians’ practice patterns and hospital policies along with a failure to educate women about the real instead of perceived benefits and risks of cesarean and vaginal delivery.

Safe delivery of the baby is one of the most common goals in performing a cesarean section, yet cesareans carry additional risks to infants as well. It is well-established that infants born via cesarean section are at a significant risk for all types of respiratory issues than infants delivered vaginally, often necessitating newborn neonatal intensive care unit admission (Dodd and Grivell, 2011). Cesarean surgery can also make it more difficult to establish breastfeeding because it is often impossible or impractical to nurse the infant during the first hour of life due to the challenges of anesthesia and suturing (Marasco and West, 2005). Another risk to infants from cesarean sections that is often not discussed is birth injury. Birth injuries complicate about 6-8 our of every 1,000 deliveries in the United States (.6 to .8 percent) (Laroia and Rosenkrantz, 2015). However, a 2006 report from the American College of Obstetricians and Gynecologists by Alexander, Leveno and Hauth et.al. found that fetal injury occurred at a rate of 1.1 percent for cesarean deliveries- higher than the overall average.

Along with the risks to mothers and babies, there are significant healthcare costs that accompany a high c-section rate. A cesarean section costs $12,739 as opposed to $9,048 for a vaginal birth for private health insurers in 2010. The cost difference for cesarean surgery has significant implications for Medicaid since public insurance pays for about half of all births in the United States. In 2009, Medicaid paid $3 billion for cesarean sections (Kozhimnnil, Law and Virnig, 2003). Along with the costs for cesarean surgery itself, there are also accompanying costs for infections, intraoperative and birth injuries, NICU stays, blood clots and transfusions as well as the increased risk of subsequent cesarean birth. In short, cesarean sections are a very expensive way to give birth. 

Hospitals also take on additional costs when their cesarean rates become too high. Hoag Memorial Hospital Presbyterian in Orange County, California was almost dropped by its insurer when its maternity costs became too high from too many c-sections. With an aggressive action plan that monitored doctors’ cesarean rates, decreased financial incentives to perform cesarean surgery and policies that allowed women more time to labor before opting for a cesarean, the hospital administration managed to decrease cesarean deliveries by approximately 5 percent and increase vaginal births after cesarean by 11 percent (Gorman, 2015). 

When the choice is between death or serious injury to the mother or baby and a cesarean delivery, then the costs and risks are worth it. But in the majority of cesarean sections, there is no clear indication of imminent harm to the mother and baby. In fact, many of the physicians at Hoag pointed out that cesareans were frequently performed at the hospital because doctors did not want to wait out a labor and a perception among both doctors and patients that a cesarean section was an easy way to time a birth and a relatively harmless procedure (Gorman, 2015). A study from the Harvard School of Public Health found that a hospital’s culture and practices can substantially influence whether a mother ends up having a cesarean section or delivering vaginally. Liability and insurance, being a teaching hospital, hospital admission practices, and the presence of midwives may influence c-section rates as do lack of clinical guidelines or standards on when a cesarean should be performed (Harvard School of Public Health, 2013). 

Fear of liability influences the decision to perform a cesarean section for many doctors. The perception that a c-section means the doctor has done everything to intervene and therefore protects him or her from a liability remains a powerful idea and adds significant pressure to many doctors- whether the situation is statistically low-risk or not. Parents are also frequently subject to perception errors in making a decision about birth. Stories from family, friends and the news can weigh more heavily in their decision making process than actual statistics and medical facts about their own situation simply because these isolated incidents carry so much emotional weight (Lake, 2012).

Doctors have been reluctant to talk about actually decreasing cesarean section rates. Dr. W. Lawrence Warner stated in his 2013 article for the ACOG, that “Care must be taken to not have the unintended consequence of physicians becoming reluctant to proceed with clearly indicated cesarean deliveries because they fear criticism after later review of the care by the quality committee.” A 2015 study from Stanford University argues that the World Health Organization’s upper limit for cesareans of 10 to 15 percent should be reexamined and raised to 19 percent. However, while the results from this study argue that there is no additional risk of maternal or neonatal mortality from a 19 percent cesarean rate, they do not address the increased health and financial costs that come from performing cesarean sections that have no clear medical indication.

While doctors’ fears seem to be that a lower rate of cesarean surgery will mean greater mortality and morbidity for mothers and babies, the statistics indicate this fear is not well-founded. There really is no data showing that higher cesarean rates equate with lower rates of maternal or neonatal mortality (Lake, 2012). Many circumstances where a cesarean is clearly indicated such as placenta previa or severe preeclampsia should be clear to any competent obstetrician as they will be accompanied by symptoms of a life-threatening emergency like vaginal bleeding and hemorrhage, seizures, blood pressure changes, and vision disturbances. In the case of transverse lie, a simple ultrasound will show the position of the baby. In cases such as maternal infection with HIV or hepatitis B where a cesarean section is indicated to prevent transmission of the infection to the baby, testing can be done to ascertain the mother’s infection status. Other circumstances for a cesarean surgery need to be more clearly outlined by hospitals and even in medical school curriculum and practice. 

Helping both doctors and patients understand the actual risks and benefits of a cesarean surgery will be crucial in decreasing the overall rates of cesareans. Patients need to understand that a cesarean section is a major surgery and not a benign procedure. While vaginal birth entails risks, so do cesarean sections and the choice between a vaginal birth and cesarean is not a choice between a dangerous option and a risk free option, but rather weighing the actual risks and benefits in each patient’s specific case.

The risks and benefits of vaginal birth after cesarean may not be fully understood by many women. The risk of uterine rupture is frequently cited as a a reason that a VBAC could be too dangerous, but the actual risk of uterine rupture and even the actual risks to the baby are not necessarily well communicated to mothers. The ACOG’s 2010 bulletin on VBAC shows that the risk of uterine rupture is 0.4 to 0.5 percent for planned, elective cesarean, 0.7 to 0.8 percent for a trial of labor after one cesarean and between 0.9 and 1.8 percent for a trial of labor after two cesareans. Ironically enough, it is statistically more likely that a baby will be injured during a cesarean section than suffer from a uterine rupture- especially with a trial of labor after one cesarean. 

ACOG’s 2010 bulletin further explains that many risks associated with VBAC are negligible when compared with those of elective repeat cesarean section. The risk of neonatal death during a trial of labor after cesarean is 0.05 percent for elective cesareans and 0.08 percent for a trial of labor after cesarean (TOLAC). The rate of perinatal death due to hypoxia was greater for TOLAC than elective repeat cesarean mothers at 0.13 percent versus 0.01 percent, though still extremely rare. Helping more women to accurately weigh the risks and benefits for their pregnancy and achieve a successful VBAC will help with reducing cesarean rates and the accompanying costs and risks.

The usage of cesarean surgery has been controversial, but based on data about the risks to mothers and infants and the accompanying costs associated with cesarean rates, it would be in the best interest of women, infants and healthcare costs to reduce the rate of cesarean sections. This will require doctors and expectant parents to adjust some of their perceptions about vaginal birth and cesarean birth, but a reduction in cesarean rates is possible and desirable. Reducing cesarean sections does not have to mean that cesareans are withheld from women who need them or that doctors should be reluctant to perform them when medically indicated. Instead, care should be taken to establish the circumstances when a cesarean is actually necessary and reserve the usage of cesarean surgery for instances when it is truly needed. A cesarean section is major surgery and should never be performed for the comfort and convenience of the physician. Women should also be fully aware of the real risks and benefits when they decide to have an elective cesarean. 

References

Alexander, James M., Leveno, Kevin J., Hauth, John, Landon, Mark B., Thom, Elizabeth, Spong, Catherine Y., Varner, Michael W., Moawad, Atef H., Caritis, Steve N., Harper, Margaret, Wapner, Ronald J., Sorokin, Yoram, Miodovnik, Menachem, O’Sullivan, Mary J., Sibai, Baha M., Langer, Oded, and Gabbe, Steven G. (2006). Fetal Injury Associated with cesarean delivery. American College of Obstetricians and Gynecologists 108(4).Retrieved from http://content.lib.utah.edu/utils/getfile/collection/uspace/id/395/filename/3560.pdf

American College of Obstetricians and Gynecologists (2010). Vaginal birth after previous cesarean delivery. Practice Bulletin- Clinical Management Guidelines for Obstetrician-Gynecologists, no. 115. Retrieved from http://www.acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Obstetrics/Vaginal-Birth-After-Previous-Cesarean-Delivery

Gorman, Anna (2015, May 13). How one hospital reduced unnecessary C-sections. The Atlantic. Retrieved from http://www.theatlantic.com/health/archive/2015/05/how-one-hospital-reduced-unnecessary-c-sections/392924/

Grivell, Rosalie M. and Dodd, Jodie M. (2011). Short- and long-term outcomes after cesarean section. Expert Review of Obstetrics and Gynecology, 6(2). Retrieved from http://www.medscape.com/viewarticle/739458_1

Harvard School of Public Health (2013, March 19). Pregnant women’s likelihood of cesarean delivery in Massachusetts linked to choice of hospitals. Retrieved from http://www.hsph.harvard.edu/news/press-releases/pregnant-womens-likelihood-of-cesarean-delivery-in-massachusetts-linked-to-choice-of-hospitals/

Kozhimannil, Katy Backes, Law, Michael R. Virnig, Beth A. (2013). Cesarean delivery rates Vary 10-fold among US hospitals; reducing variation may address quality, cost issues. Health Affairs 32(3). Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3615450/

Lake, Nell (2012, November). Labor, interrupted. Harvard Magazine. Retrieved from http://harvardmagazine.com/2012/11/labor-interrupted

Laroia, Nirupama (2015). Birth trauma. Retrieved from http://emedicine.medscape.com/article/980112-overview#a1

Marasco, Lisa and West, Diana (2005). How to get your milk supply off to a good start. New Beginnings, 22(4). Retrieved from http://www.lalecheleague.org/nb/nbjulaug05p142.html

Stanford University(2015, December 1). Optimal C-section rate may be as high as 19 percent to save lives of mothers and infants. Stanford Medicine News Center. Retrieved from chttps://med.stanford.edu/news/all-news/2015/12/optimal-c-section-rate-may-be-as-high-as-19-percent-to-save-lives.html

Warner, Lawrence W., (2013). Arriving at the appropriate cesarean delivery rate. American Congress of Obstetrician-Gynecologists. Retrieved from http://www.acog.org/About-ACOG/ACOG-Departments/District-Newsletters/District-VIII/July-2013/Cesarean-delivery-rate

Welcome to Sunflower Mothering!

Sunflower Mothering is the new home for information related to Birth Multiverse classes in childbirth and breastfeeding as well as my new books. Welcome