I was never good at strolling.

If I had a destination, I walked quickly. Not because I wanted exercise, mind you, but because it felt natural.

That all changed with my first pregnancy. The nonpregnant me bolted across a street with five seconds left on the crossing signal. The uber-pregnant me much preferred a full 30-second allotment. Anything less and I waited for the next traffic cycle.

This change of pace was entirely out of my control. As I neared my due date, my once-brisk stride was shorter, my stance wider, my torso tilted farther backward.

I had morphed into a waddler! And I could only waddle so fast.

Now, at 28-weeks pregnant with my second child, I’m beginning to waddle again. I’m thrilled to be expecting, but I’m already missing my normal speed.

Obstetricians tell us that there’s a good explanation for why pregnancy changes our gaits.

“There are a lot of joints in the pelvis. Those are going to loosen as the pregnancy goes on, which is probably how the body adapts to allow a fairly good-sized baby to fit through,” explains Dr. Daniela Carusi, director of both general gynecology and surgical obstetrics at Brigham and Women’s Hospital in Boston. The loosening of the joints and the downward pressure from the growing belly actually cause the pelvis to get wider, she says. A wider pelvis means a wider stance.

That explains part of the waddle. The other part, according to Carusi, is caused by a shift in our center of balance. “As the belly gets bigger, which is the spot in the body which marks the center point, the weight moves forward and that makes the spine curve more inward,” she says.

We pregnant women can’t help but lean back.

I wondered what would happen if I attempted to trade comfort for more graceful motion, if it was even possible to force myself to return to something closer to my former stride.

Carusi warns that it wouldn’t work. “You could reposition your legs, but it’s hard to make your hips narrower,” she says. “What you’d be doing is compensating for the change instead of overriding it.”

“I don’t think it makes sense to narrow the gait,” agrees Stephanie Prendergast, a physical therapist at The Pelvic Health and Rehabilitation Center in Los Angeles. “Keeping the gait wider is safer for balance reasons.”

Prendergast says we could consider making slight adjustments to the way we stand. “When they’re standing still, many pregnant women will push their bellies out and lean backward,” she explains. “But then your ligaments at the front of the hip are holding up your weight.” If we don’t lean back so far, she says, our gluteal muscles could take some of the weight and our hips would hurt less.

I tried to adjust my stride anyway, of course. Unsurprisingly, it felt terrible. When I straightened my back, my shoulders arched forward. When I narrowed my stance, my balance was all off. Other women have had similar experiences.

“I tried to walk with my feet closer together, but after a while that hurt more than changing my gait,” says mother-to-be Keke Gibb, a science professor at Baker University in Baldwin City, Kan., who spoke with me on her due date. “It’s most comfortable if you widen your stance a lot,” she explains. “It feels like my thighs hate each other. I try not to let them touch while I do a really awkward sashay through the neighborhood. I use my whole body to swing one leg forward at a time.”

There is no fighting the pregnant waddle.

I take some comfort in knowing that there’s a small community of scientists investigating how this altered motion affects our lives. These researchers attach reflective stickers to a pregnant woman’s body and then use special cameras to capture the 3-D movement of the stickers as she walks, stands up, or does other simple tasks that can become challenging late in pregnancy.

“When we look in our software, the women look like stick figures moving in 3-D, so we can capture different aspects of how they move, rotate, flex and extend,” says Jean McCrory, a biomechanist at West Virginia University who studies gait and balance in pregnant women.

McCrory documented, for example, how pregnant women walk with pelvises tilted backward and feet spread wider apart. Others have shown how we rise from chairs more slowly, and with a greater attention to balance.

In a recent study, scientists at Hiroshima University studied the mechanics of movement as pregnant and nonpregnant women rose from a chair, picked up two stacked plates, turned to the right, and then walked away. The researchers showed that pregnant women flex their hips less while walking and lean back more while standing.

These findings will come as no surprise to obstetricians or anyone who has ever had a baby bump of her own. But studies like these might one day help scientists figure out how to make everyday tasks safer for pregnant women. McCrory, for example, wants to use her knowledge of pregnant motion to find ways to prevent pregnant women from falling — a worthy goal since over a quarter of pregnant women fall at some point.

I joined that statistic during my last pregnancy when I got overexcited about an old friend visiting. As she got out of her car, I momentarily forgot to waddle and leaped forward to hug her. My toe caught the sidewalk and I fell so slowly and awkwardly that she thought it was intentional — that I was trying to entertain her with some sad attempt at pregnant lady slapstick. The baby and I were fine.

So far I’ve managed to stay on my feet this pregnancy. For the moment, I also still have some of my prepregnancy speed. I know this because, like so many aspects of pregnancy, people comment on it. Last week, as I strode past two men on my way to work, I overheard one say, “Whoa! Look at how fast she walks — for a pregnant lady.”

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Episiotomy, a once-routine surgical incision made in a woman’s vaginal opening during childbirth to speed the baby’s passage, has been officially discouraged for at least a decade by the leading association of obstetrician-gynecologists in the United States.

Nonetheless, despite evidence that the procedure is only rarely necessary, and in some cases leads to serious pain and injuries to the mother, it is still being performed at much higher than recommended rates by certain doctors and in certain hospitals.

In one recent case, Kimberly Turbin, a 29-year-old dental assistant who lives in Stockton, Calif., is suing her former obstetrician for assault and battery after he performed an episiotomy on her in 2013. A video of the birth, with Turbin begging the doctor not to cut her, has been viewed more than 420,000 times.

After the episiotomy, Turbin says, “I had major, major, major, major pain.”

In 2006, the American College of Obstetricians and Gynecologists released a recommendation against the routine use of episiotomy, finding that except in relatively rare cases, the procedure benefited neither mothers nor newborns. In 2008, the National Quality Forum also endorsed limiting the routine use of episiotomies.

Since then, the use of this surgical incision has dropped significantly — from 21 percent of all vaginal births in California in 2005, for example, to fewer than 12 percent in 2014. National trends have been similar.

But that overall drop masks some giant disparities. While the majority of California’s hospitals now have episiotomy rates under 10 percent, according to state data, the technique’s use at individual hospitals can be five or six times as high.

Dr. Alexander Friedman, an assistant clinical professor of obstetrics and gynecology at Columbia University Medical Center in New York City, who has studied the issue, says sky-high rates at some institutions are surely based on factors that go beyond medical need.

“If you perform an episiotomy, you’re more likely than not going to cause more postpartum pain and discomfort,” says Friedman, who was lead author of a 2015 report, published in JAMA, the Journal of the American Medical Association, about the variation in episiotomy rates among hospitals nationally. While the ideal rate of episiotomy is unknown, he says, it should likely be less than 10 percent.

As recently as the late 1970s, episiotomy was used in more than 60 percent of vaginal deliveries across the U.S. because doctors believed a clean incision helped prevent tears between the vagina and rectum, that a clean cut was easier to stitch than a tear, and that the incision prevented overstretching of the muscles surrounding the vagina.

In the past few decades, though, research has shown that the cuts sometimes cause serious pain and injuries, including deep tissue tears, incontinence and sexual dysfunction. The repaired incisions often prove slower to heal than a natural tear.

Armed with this information, many pregnant women started refusing the procedure, and most obstetricians stopped doing it routinely.

But certain doctors are going against that trend.

Dr. Emiliano Chavira, a maternal and fetal medicine specialist at Dignity Health’s California Hospital Medical Center in Los Angeles, says he suspects three main reasons why some providers continue to perform routine episiotomies: They’ve always done them; they lack awareness of best practices; or they want to speed up deliveries.

“Certain segments of the obstetric community are very slow to modernize the practice,” Chavira says. “They’re very slow to abandon procedures that are not a benefit and, in fact, may be harmful. And it’s really disappointing.”

There can also be great variation from hospital to nearby hospital, research shows.

For example, in Los Angeles each of the six hospitals owned by AHMC Healthcare have continued to do episiotomies in more than 29 percent of vaginal births, according to state data. And two of the institutions — Garfield Medical Center in Monterey Park and Whittier Hospital Medical Center in the city of Whittier — have episiotomy rates close to 60 percent. Representatives of the chain and its hospitals didn’t return repeated calls and emails requesting comment.

Meanwhile, Kaiser hospitals in Northern California have seen huge reductions in the use of the procedure since the Oakland-based managed care organization undertook an intentional effort to address overuse.

Dr. Tracy Flanagan, director of women’s health and maternity at Kaiser Permanente in Northern California, says her office began examining episiotomy rates at different hospitals four or five years ago. They first looked at rates at the hospital level, then at the physician level, she says, and found ” a lot of variation.”

They first sent the data to the individual hospitals. Then, doctors at each hospital who rarely performed episiotomies were asked to educate their colleagues about the appropriate use and relative risks of the procedure.

Physicians tend to respond best if other physicians present them with a compelling argument to change their ways, Flanagan says. Reliable data, transparency and peer-to-peer education, she adds, is a good recipe for narrowing variation.

The average episiotomy rate for the Northern California Kaiser hospitals is now about 3 percent, Flanagan says.

Zero percent would be too low, she adds; in some cases — if a baby’s shoulder is stuck, for instance, or the infant’s heart rate drops, or if the mother is exhausted and wants an episiotomy — the procedure’s use is warranted.

Dr. Elliott Main, medical director of the California Maternal Quality Care Collaborative and a clinical OB-GYN professor at Stanford University, says the episiotomy data offer a lesson in how quickly practices can change. This evidence also highlights the hospitals where doctors refuse to alter their ways, he says.

In the case of C-sections, doctors may be motivated to perform the procedures because they allow for faster deliveries or better pay, Main says. But the main reason some doctors still perform too many episiotomies is probably that they always have done so — in some cases for decades.

“It is always hard for people to relearn,” Main says.

His organization is leading an effort to provide doctors and hospitals with data on certain childbirth practices, to show them how they compare with their peers around the state. Beginning in 2010, the group partnered with the March of Dimes to educate providers about the dangers of elective delivery prior to 39 weeks. Within three years, that practice had dropped off rapidly, he says. The organization is currently undertaking similar efforts related to C-sections.

Chavira, the maternal and fetal medicine specialist at California Hospital in Los Angeles, says he would like to see similar transparency with data on episiotomies.

“If you have a hospital where people are doing 5 percent episiotomies and one guy is doing 60 percent episiotomies, all of a sudden he sticks out like a sore thumb,” Chavira says.

A lot of women don’t want the procedure, Chavira notes, and doctors are supposed to honor their patients’ wishes.

In June, a Superior Court judge in Los Angeles County ruled that Turbin’s lawsuit against her former obstetrician can go to trial in the fall. Meanwhile, Turbin says she is terrified of getting pregnant again.

“If I go back to that day, there’s nothing I could have done,” she says. “That doctor was going to cut me, no matter what.”

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. (Kaiser Permanente has no relationship with Kaiser Health News.)

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At Edgewood Summit retirement community in Charleston, W.Va., 93-year-old Mary Mullens is waxing eloquent about her geriatrician, Dr. Todd Goldberg.

“He’s sure got a lot to do,” she says, “and does it so well.”

West Virginia has the third oldest population in the nation, right behind Maine and Florida. But Goldberg is one of only 36 geriatricians in the state.

“With the growing elderly population across America and West Virginia, obviously we need healthcare providers,” says Goldberg.

That includes geriatricians — physicians who specialize in the treatment of adults age 65 and older — as well as nurses, physical therapists, and psychologists who know how to care for this population.

“The current workforce is inadequately trained and inadequately prepared to deal with what’s been called the silver tsunami — a tidal wave of elderly people — increasing in the population in West Virginia, across America, and across the world really,” Goldberg says.

The deficit of properly trained physicians is expected to get worse. By 2030, one in five Americans will be eligible for Medicare, the government health insurance for those 65 and older.

Goldberg also teaches at the Charleston division of West Virginia University, and runs one of the state’s four geriatric fellowship programs for medical residents. Geriatric fellowships are required for any physician wanting to enter the field.

For the past three years, no physicians have entered the fellowship program at WVU-Charleston. In fact, no students have enrolled in any of the four geriatric fellowship programs in West Virginia in the past three years.

“This is not just our local program, or in West Virginia,” says Goldberg. “This is a national problem.”

The United States has 130 geriatric fellowship programs, with 383 positions. In 2016, only 192 of them were filled. With that kind of competition, Goldberg laments, why would a resident apply to a West Virginia School, when they could get into a program like Yale or Harvard?

Adding to the problem, the average medical student graduates with $183,000 in debt, and every year of added education pushes that debt higher.

Dr. Shirley Neitch, head of the geriatrics department at Marshall University Medical School in Huntington, W.Va., says students express interest in geriatrics almost every year. But, “they fear their debt,” she says, “and they think that they need to get into something without the fellowship year where they can start getting paid for their work.”

This trend troubles many people, including Todd Plumley, whose mother Gladys has dementia, and lives in West Virginia.

“It’s kind of scary that [older patients] don’t have the care that they really need to help them through these times, and help them prolong their life and give them a better life,” Plumley says.

There are no geriatricians in the family’s hometown of Hamlin, so Plumley drives his mother almost 45 minutes to another town, Huntington, to see one. He says seeing this specialist has helped stabilize his mother’s symptoms.

“Right now, if we didn’t have the knowledge and resource,” he says, “I believe my mother would have progressed a lot further along, quicker.”

Plumley is in his 50s. He worries that if he needs the care of a geriatrician as he gets older, driving even 45 minutes may not be an option.

This story is part of NPR’s reporting partnership with West Virginia Public Broadcasting and Kaiser Health News.

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