Tuesday, May 20, 2014

Your doula: Shake it like Shakira

by Jessica English

Watching this season of NBC's "The Voice," I've been amazed by the way pop superstar Shakira has doula'd her team members. She nurtures, supports, encourages and praises with the perspective of an insider. Doula! Now those who love me know that I can turn just about anything into a birth analogy… But hear me out, friends. Read on and I'm convinced you'll see the connection too.

Frederic Legrand / Shutterstock.com
She's genuine and passionate.
Can't you just feel Shakira's genuine warmth? She seems to truly love music and her spontaneous outbursts help make the show fun! Shakira's hugs seem real. Similarly, your doula is in this work because she (or he!) truly believes in women and in birth! She believes in you. We can talk birth into the wee hours, and our passion drives us to stay on call for you 24/7, not to mention staying up all night with you in labor. Your doula is genuinely proud of you and excited to see you become a mother!

She knows when to nurture and when to push.
As a voice coach, Shakira has great instincts about when to be gentle with her singers and when to get more assertive to drive them forward toward their goal. Your doula understands that balance too! Professional doulas are trained to maximize oxytocin and help shape birth memories by nurturing the mother, but we also know how to recognize those moments when "taking charge" is just the right thing to help guide a woman on her journey. The trust bond you have with your doula makes her just the right person to both soothe you and help you dig deep for strength grit and when you need it.

She understands the business.
I can only imagine how much Shakira's contestants need their families. Their husbands, wives, partners and parents bring them strength and connection on a crazy journey through "The Voice." But Shakira… Shakira knows the music business. Along with emotional support from their families, the singers also need Shakira's expertise in how to engage an audience and how to bring out the best in their voice. Your partner can be an amazing support person during your birth – this is the person you have chosen to spend your life with! Of course you want the people you love by your side during labor. But your doula knows birth. She understands how to navigate the physical and logistical aspects of your labor and your birth place. It helps to have a full team to help you navigate your birth experience: each member with his or her own strengths. If there's an unexpected twist in your journey to meet your little one, your doula can stay calm in the moment to help you regroup and restrategize to create your best birth.

She's with you no matter how the tides shift.
Shakira is no fair weather coach! America can be fickle, but Shakira's heart stayed strong and steady with her singers to the end. She believed in them! Similarly, birth can be unpredictable. Your doula will do everything she can to help you "stack your deck" and achieve your ideal birth experience, but even the best preparation can't guarantee any one outcome. Although she can't guarantee exactly how your birth will go, your doula can say that she will be by your side, supporting you through, cheering you on, no matter what. Unmedicated birth? Epidural? Cesarean? You doula is your biggest supporter! No. Matter. What.

She knows how to shake it!
It feels like an understatement to say that Shakira is famous for her moves. The woman knows how to shake it. Throughout time, the rhythms of women's dance have been based on the movements of sex… and birth. Your doula knows a lot of moves! I remember one of my clients reflecting back on her birth, saying, "You started helping me move and everything opened right up! I was amazed at how well you understood a woman's body." Exactly! That's how we roll. Your doula can help you figure out just how to move your body to help ease your baby into the world. Often women who are well supported find those moves instinctively, and in that case your doula will be right there to assure and encourage you – "That's it. That's the way. Beautiful." In a complicated labor, a professional doula also knows ways to move that may help your baby into a better position and facilitate a smooth birth. Shake, shimmy, sway, spiral and squat. Your doula's got the moves!

What did we miss, friends? How else is your doula like Shakira? Did you enjoy this comparison? Tell us about it in the comments section below!

Jessica English is a DONA-certified birth doula and Lamaze-certified childbirth educator. She is owner of Birth Kalamazoo, a Midwest agency that offers birth and postpartum doula services, natural birth and breastfeeding classes, in-home lactation consults and a renewal circle for mothers. As a DONA-approved birth doula trainer, Jessica mentors (and learns from!) new doulas entering this amazing work.

Tuesday, September 17, 2013

Without my doula...

by Teesha Bancroft
Without my DOULA, I would not have had an amazing natural birth class and a huge network of resources;

Without my DOULA, I would not have had the tools during the intensity of labor to get into different positions so that things would progress;

Without my DOULA, My labor might have plateaued at 5 centimeters dilation just like my mother in labor with me;

Without my DOULA, I wouldn't have had any idea how to manage my pain naturally and from within;

Without my DOULA, I wouldn't have pushed and pushed and pushed for three hours... It might have been longer;

Without my DOULA, my husband wouldn't have been able to take a break to use the bathroom, eat, feed me, get me water and do what he needed to take care of himself;

Without my DOULA, I wouldn't have had a warm meal an hour after my delivery;

Without my DOULA, I would not have had gentle guidance that had a huge impact on the success of my labor;

Without my DOULA, I would not have had breastfeeding support that actually made sense to me;

Without my DOULA, I wouldn't have had someone to message at 3 a.m. when I was lost and struggling as a new mother;

Without my DOULA, I would not have had someone to simply offer support in so many ways with like minded parenting advice and ideas, making sure I care for myself so I can be a good wife and mother.

I am proud of my birth, breastfeeding and parenting and I know in my heart that without my DOULA, things may have been different.

Teesha in labor with her husband Blake and their doula, Jessica.
(C) photo by Megan Kolaja, all rights reserved.

Teesha Bancroft is a Birth Kalamazoo student and client, and mom to Ada. She's also a talented massage therapist who loves working with pregnant and postpartum moms. As Teesha prepared for Ada's first birthday this month, she shared her reflections on her relationship with her doula. Thank you so much for the gift of your words, Teesha. We love you!

Friday, July 5, 2013

Birth through the lens of time

I stopped by a local office recently to drop off some brochures a former client had requested. The receptionist looked at my materials a little skeptically, and asked if doulas were like midwives. I explained how doulas offer non-medical physical and emotional support, and how we help make birth better not only by offering our expertise but also by nurturing the family. "You," she said, suddenly excited. "You are doing something so important!"

The woman proceeded to tell me the birth story of her second baby, 37 years ago. It was a difficult birth and a challenging transition for the baby afterward. Throughout the birth and in the days that followed, she felt disrespected, dismissed, powerless and alone. "Nobody would be honest with me, nobody really heard me," this mother told me. She went on to share some pretty clear symptoms of post-traumatic stress, which she experienced throughout her baby's first year. And then she shared that when it came time to think about a third child, she completely shut out the thought. She wanted another baby, but how could she risk going through that again?

As she told me her story there in the lobby, her eyes welled up with tears. Mine did too. I heard her voice shaking and I consciously let go of the groceries in the hot car and my long to-do list, just trying my best to hold that space for her. I wanted to hold the space that no one had been there to hold for her as a tender new mother.  "That must have been so hard," I affirmed. "I'm so sorry you had to go through that, it sounds like you were really strong in that moment," I said. "Thank you for sharing your story. You are not alone."

I had my 7- and 9-year-old boys with me that day. They're usually tugging at my sleeves to encourage me to move along on these errands, but as soon as this woman began her passionate tale, they were riveted too. They sat quietly, watching and listening. Even they could feel the power of her story, told almost four decades after the fact. I think they already have a sense that women's birth stories are our epic tales – for better or for worse.

This powerful encounter left me thinking about Penny Simkin's groundbreaking research on birth memories. In the early 1990s, Penny contacted former students from her childbirth class who had completed labor and birth questionnaires after their births 15-20 years earlier. She asked these women to fill out another questionnaire and also interviewed them about their birth experiences. In connecting with these women, Penny found they retained powerful, accurate memories of their births. Many of the women wept while retelling their birth stories, either from joy or sorrow. In identifying these women as either satisfied or unsatisfied, Penny noted that their reflections of their birth didn't have so much to do with how quickly their births went, or even whether or not they experienced a lot of interventions or complications. Instead, women were most affected by whether they had felt powerful or powerless. Were they treated with kindness and respect or callousness and disregard? The women in Penny's study remembered how people treated them during their birth and how they were made to feel. Yes. The woman's story I heard that day echoed all of these themes.

I so wish the woman I spoke with would have the support she needed during her difficult journey. I wish I could have doula'd her through those intense and difficult moments, instead of just trying to share a bit of compassion now, so many years after the fact. I can't change her journey, but I will use it to remind myself in difficult moments that the work of a doula matters. Nurturing the mother matters not just in the moments surrounding birth, but potentially for an entire lifetime.

As I got ready to leave, I felt so blessed that this woman had trusted me with her story. But she wasn't done. As we said goodbye, she turned to my kids. "I love little boys!" she told them, her eyes lighting up. "You two remember, when you mommy is away from you, she is doing something really important. These mommies need her, just like you do. She makes a big difference." My boys (and the children of doulas everywhere) really do make sacrifices of their own to support families and birth. I'm still thinking about their wide eyes as they took this in from the person who had just told such a dramatic story.

Birth matters. Doulas make a difference. We must not be disheartened by challenges. Keep on! Thank you, beautiful sage. You gifts have touched my heart.

Jessica English is a DONA-certified birth doula and Lamaze-certified childbirth educator. She is owner of Birth Kalamazoo, a Midwest agency that offers birth and postpartum doula services, natural birth and breastfeeding classes, in-home lactation consults and a renewal circle for mothers. As a DONA-approved birth doula trainer, Jessica mentors (and learns from!) new doulas entering this amazing work.

Wednesday, April 3, 2013

Childbirth Classes and Natural Birth: One Mom's Perspective

Dawn took our natural birth class several years ago and also had a Birth Kalamazoo doula with her at her birth. She wrote us this sweet note today, which we're sharing with her permission. Thank you so much for the kind words, Dawn! We feel so blessed to do this amazing work, and grateful to all the women who teach us by allowing us to be part of their journey.  ~Jessica

Good morning! I just wanted to send a note of thanks.
First, for the wonderful birthing class that my husband and I took nearly 3 years ago. I always knew I wanted to have a natural childbirth, but had no idea how much I didn't know until I took your class. I felt so prepared, informed and supported.
Second, I could never have imagined how this life experience would be a springboard to a whole new chapter in my life. I would never have imagined I would be drawn to being an advocate of natural childbirth. Though there are times it seems daunting.
The saying "ignorance is bliss" is so untrue. I am currently taking a prenatal water class twice a week. I took the same class my first pregnancy and really enjoyed it. This time has been a whole new experience. The class is all first time moms (except myself) and not one has taken a birthing class.
Comments made just in the last two weeks:
"I am too afraid to take a birthing class. I don't want to get worked up about the whole process."
"I'm not taking a birthing class, nothing really fits our schedule. Plus, my best friend told me that they'll just tell you what to do [at the hospital]."
"Birth plan? What's a birth plan? That seems silly. I'm just going in and telling them do whatever you gotta do to get it out!"
(Due in four days) "I'm going to write my birth plan up tonight. I'm pretty much going to walk in with a sign on my chest that says give me drugs and my birth plan is going to say, no forceps or vacuum, no episiotomy. Not much else I need to include."

I may need tape over my mouth to get through the last five sessions. It's actually gotten me to think about enrolling in a yoga class instead!
I wish I was more eloquent in these situations. I actually find it hard to not stand (in the water mind you) on a soapbox and try to passionately and sympathetically let these moms know how much education will help them alleviate their fears, that they have choices about their birth and that birth is such a powerful life experience.
I don't mean to ramble on, just really wanted to express appreciation for what you do! I plug Birth Kalamazoo every opportunity that is presented!

Tuesday, December 18, 2012

Juliet's Birth: Joanna's Story

Early labor started for me around 2:30 a.m. on a Sunday morning. I was only having one to two contractions an hour that were strong enough to wake me up. My husband, Neil, brought a futon into our bedroom so that I could wake up to manage the contractions on the floor and then go back to sleep.

I had read that it’s best to try to ignore early labor, so while we tried to get some rest, we still went about the regular tasks of our day on Sunday. Still anticipating that we might end up at the hospital that night, we decided to go out for what we thought might be our "last supper" before the baby arrived. However, things continued in about the same manner through to Monday, although my contractions were getting stronger and more frequent. I could no longer go out in public because I needed to deal with the contractions vocally.

By Monday night I was starting to get a little frustrated because I had been in early labor so long. I was starting to get restless and wondered when “real” labor would begin. That evening I was craving Indian food, so we ordered take out and again waited to see what the night would bring. By Monday night I started moving in the direction of active labor and was unable to sleep at all. Contractions were still intermittent, but coming strong and about every 10 minutes.

Around 3:30 a.m. Tuesday morning I asked Neil to call our doula because I wanted extra support to deal with the growing physical and emotional intensity of labor. When our doula arrived, along with another doula who was shadowing her (bonus!), my labor slowed a bit, so we decided to try to rest for a little while.

I continued to labor at home throughout the morning, trying my best to continue to stay in the moment. I was beginning my third morning of labor and feeling that it could go on indefinitely. Throughout the morning we used gentle touch and massage, heat compresses, verbal encouragement, the shower, a labor ball, and various laboring positions as comfort measures, all of which helped me to take one contraction at a time and not get discouraged.

As things picked up further later Tuesday morning I started to have some contractions that made me start to bear down, which made me want to get to the hospital. I had always heard that first time moms think they are further along in labor than they are, so I had not wanted to rush to the hospital, but I knew it was finally time.

On the way to the hospital I cried a little bit, not because I was in pain, but just as an emotional release. I remember looking out the window at the other people in their cars heading to destinations unknown to me and thinking about how a single day can be both so ordinary and so extraordinary in our various lives. I also thought about all the other women around the world who were giving birth the very same day. Thinking about these women comforted me and made me feel like I could make it through whatever the rest of the day held for us.

Although my ride to the hospital was smooth, by the time we got to the hospital I started to have intense contractions that were causing me to bear down again. This alarmed all of us a little bit, so I was quickly whisked up to labor and delivery in a wheelchair.

Luckily the transition to the new labor space slowed things down. When we got to our room, the midwife examined me and told me I was 100% effaced and 7-8 centimeters dilated. I was extremely happy to hear I was so far along. This was the first time I allowed myself to believe that we would meet our daughter that day. In the meantime, our doula had drawn a bath for me (battery operated candles included) and I labored in the tub for a while, which provided a fair amount of mental and physical relief. After I got out, I briefly labored on the birth ball.

Finally, my doula asked me if I was interested in encouraging my water to break, which of course I was. She showed me a position to try by leaning against the bed and within 5 seconds of trying it, my water broke in a huge gush. It was definitely a “doula magic” moment, and I would have laughed had I not been dealing with the intensity of labor!

After my water broke, I was fully dilated and went through transition, trying several pushing positions throughout this final stage of labor. The moment our daughter, Juliet, finally arrived, I saw the spontaneous tears of joy in my husband’s eyes. That's the moment I'll always remember.

The midwife placed our daughter on my chest for skin-to-skin and she nursed for about 25 minutes. Later, she enjoyed some skin-to-skin time on her dad’s chest as well. We were completely thrilled to meet our little girl and to see her bright alert eyes after she was born.

Our birth team, including midwife, nurses, and doulas were amazing. Juliet was born on a gorgeous, sunny fall day, and we are grateful to have so many wonderful moments to remember from our birth experience.


Sunday, July 1, 2012

“Be Flexible:” Red Flag, Wise Advice, or Both?

Do you know this scenario? A woman takes her birth plan into her doctor or midwife for discussion. The provider reviews it and tells her, “You need to be much more flexible than this.”

It makes me cringe when women tell me this has happened. My first thought is that it’s a major red flag, assuming the birth plan is asking for a normal, natural birth. In my experience, the vast majority of women I work with are able to achieve everything on their birth plan! My hope when a woman brings in a natural birth plan is that her provider will reassure her that her requests are reasonable, that birth usually unfolds just beautifully, and barring something unexpected, there’s no reason to think she won’t be able to achieve that kind of birth. Is someone who scoffs at your plan the right provider to help guide you to the birth you’re hoping for? If they honestly don't see natural births that often, are they really a good match?

So what kinds of things might be included in a “reasonable” natural birth plan? Some common elements I see on birth plans include the following:

• intermittent monitoring with Doppler
• no pain medication, and please don’t suggest it
• please don’t ask me to rate my pain
• patience preferred over Pitocin
• freedom of movement, access to bath/shower
• eat and drink as desired
• no IV or hep/saline lock
• to push and give birth in whatever position feels best
• allow the cord to pulsate fully
• no drugs for third stage except in case of hemorrhage
• continuous skin-to-skin for 1-2 hours after birth
• decline a bath for baby
• no supplemental formula or donor milk

We see so many births that include these elements, it is sometimes hard to remember that it’s not the norm.  All of these requests are backed by solid research. It is absolutely reasonable for every low-risk woman to expect that her birth will likely unfold this way, even in the hospital environment. Of course a small percentage will run into complications and benefit from intervention, and we have to stay open to that possibility. But we also shouldn’t expect complications and intervention more than we expect a normal, natural birth.

Given that our medical system is not intrinsically designed to support these types of births, a certain inflexibility might be helpful in order to achieve a natural birth. If natural birth is very important to you, you might need to be very firm about avoiding an epidural if the birth is long or complex. You might have to insist on more time to overcome a plateau instead of turning quickly to Pitocin. You might really have to advocate for yourself and your baby and be strong to turn down a bottle being offered for normal newborn behavior like cluster feeding. Or you might get lucky and not need to advocate at all, depending on the complexity of your labor and the providers on shift at the time. But in the current American birth culture, women who go into their births planning to just “go with the flow,” especially for their first baby, often end up with a cascade of interventions they never expected. 

That said, there are certainly birth plans and expectations that would benefit from some flexibility. There are some requests that are just very hard to accommodate in the hospital, like if a woman wanted zero vaginal exams or insisted on water birth at a facility that didn’t offer that option. You really can’t have a home birth in the hospital, there are usually some trade-offs.

It’s also true that there are some times when inflexibility can actually lead to more interventions. If a woman insists on pushing only in the squatting position, or only on having a water birth, she might be closing herself off to other options that could work better for her particular journey. Birth definitely can’t be scripted and there are often some surprises along the way. Women who are flexible enough to release rigid expectations and flow wherever their labor takes them seem to enjoy their births more in the moment, and reflect more positively on the journey postpartum, too.

And we definitely don’t want women to set their hearts so fully natural birth that they will be completely crushed if they end up with an epidural or if they are one of the small percentage who benefit from a medically necessary cesarean birth. Some women have told me they skipped over the section on cesarean birth in their books or they tuned out that discussion in class, thinking it surely couldn’t happen to them. In reality, many experts believe that a 10 – 15 percent c-section rate is reasonable for an overall population, including both low-risk and high-risk mothers. Even Ina May Gaskin and the midwives at The Farm have a 1.7% cesarean rate, after all. A one in 10, or even one in 20 chance of having a cesarean birth is not so unlikely.

I tell my students that it’s helpful to reserve just a small corner of your heart for that possibility of necessary and helpful intervention – the medical tools are such a gift when truly needed! Unfortunately, there are no easy or magical answers on how to know when interventions are “truly needed.” It’s my hope for every woman that she will find a provider she deeply trusts to help guide her through her birth, and that together they can make a shared, thoughtful decision if things get complication and it seems like intervention might be helpful. The research of Penny Simkin has shown us that when women are part of the decision making process and when they are treated with respect, they usually feel good about their births long-term, even if intervention was needed.

Back to the title of this post – is it helpful or harmful to tell women to “be flexible?” Women seem to respond when providers spend most of their time reassuring them that birth works, and affirming that they should expect a normal, natural birth. Maybe the percentage of comments about staying flexible should correspond with the percentage that intervention is actually needed. For a low-risk woman, what’s that percentage? Home birth might give us some clues. Nationally, the transfer rate for home births usually comes in around 10 percent. That means about 10 percent of the time, the low-risk women having their babies at home need to be transferred to the hospital for medically necessary interventions. So wouldn’t it make sense for a hospital-based provider to spend 90 percent of their time reinforcing normalcy of birth, and maybe spend 10 percent of their energy discussing how important it is to prepare for the unexpected? Far too often, women tell me that the opposite is true – 90 percent of their comments they hear are directed at preparing for a very medical birth.
So yes, mamas, be flexible. But do go out of your way to find a provider who really believes in birth, and builds you up to believe that you will most likely get the natural birth you’re planning. After all, it’s a pretty reasonable expectation.

And when your baby’s birth day actually arrives? I trust your wisdom will guide you to be just flexible enough.

Written by Jessica English, CD(DONA), BDT(DONA), LCCE, owner of Birth Kalamazoo. 

Friday, July 1, 2011

Reducing the cesarean rate for first-time moms

A new study from researchers at the Yale University of Medicine pinpoints two primary reasons for the skyrocketing cesarean rate in the United States: more c-sections in first-time mothers and decreasing rates of VBAC (vaginal birth after cesarean). Having a cesarean for your first baby changes your choices and increases risk for future pregnancies and births. It can be life-saving surgery, when used appropriately, of course. But with vaginal birth after cesarean (VBAC) increasingly harder to access in hospitals nationwide, it’s critical that birth activists work to get mothers the information they need to avoid an unnecessary first cesarean.

So how can a first-time mom maximize her chances for a vaginal birth in a culture where a third or more of all women are giving birth via major abdominal surgery? We’ve identified 10 key points that can help a woman stack the deck in her favor.

1) Hire your provider with extreme care. This point is number one for a reason – it’s absolutely critical. You need to know your provider’s cesarean rate, and the overall rate of the practice. Group practices typically share call time, and while an individual midwife or doctor may have a lower cesarean rate, unless that person is guaranteed to be at your birth, you must consider the cesarean rates of everyone in the practice. Does this provider practice in the medical model or in more of a midwifery model of care? The labels “obstetrician,” “family doctor” and “midwife” sometimes tell you surprisingly little about philosophy. We have worked with midwives who practice in an extremely medical model, essentially practicing as “junior OBs.” Conversely, we have seen physicians who will go the extra mile to support a woman and patiently give her body all the time it needs to work. To make it all that much more complex, it can be hard sometimes to get straight answers or sort out lip service from genuine information. Not sure how to scope out the real deal on docs and midwives? Ask a doula. We see a wide variety of practices, and know those providers who will go the extra mile to help a woman avoid a cesarean, as well as those who might have a woman-friendly reputation but will throw in the towel on a vaginal birth much more quickly. Doulas see the women seeking VBAC who were traumatized by their first birth experience, and those VBAC mamas who felt their cesareans were necessary and that they were treated with kindness and respect. Your first birth (or any birth) is far too important to blindly trust to the kindly OB who has been doing your pap smears since high school, but whose birth philosophy you know nothing about. Or that midwife your friend had a great birth with? Maybe your friend got lucky, or maybe the midwife’s philosophy and approach have shifted in recent years. And the flashy high-volume hospital with a big NICU might not actually be the best place to have a normal, low-risk birth. Who has the skills to help you find natural alternatives for a complex labor, and who has only a medical/surgical toolbox? Ask a doula. Trust me, they will be delighted to offer a recommendation and it’s your best bet for locating a truly woman-friendly provider. If it becomes clear that you are not with a supportive provider, it is never too late to switch – never.

2) Hire a doula. This isn’t self promotion, it’s evidence-based care. A meta-analysis of studies (thanks to DONA International for the data) shows that women who use a doula are 26 percent less likely to have a cesarean birth, among other dramatic benefits. Continuous support of any kind is helpful, but the best outcomes are doula-specific. That is, according to a recent Cochrane Review, having continuous support during your birth from a doula improves outcomes significantly more than continuous support from family members, friends or medical staff. The Lamaze International blog, Science and Sensibility, offers a wonderful overview of the best research. What exactly is the doula magic? The research hasn't pinpointed that, but I believe the unique combination of physical, emotional and informational support, plus gentle advocacy makes a huge difference. Doula care helps women to feel safe and comfortable so the hormones of labor can work at optimal levels, positioning ideas and tricks can help babies work their way out, and evidence-based information and advocacy can help women maximize their chances within a system that doesn’t necessarily support normal, natural birth.

3) Take an independent natural childbirth class. It’s not so much that you need to know a lot about giving birth, but rather that many women (and men) need to undo what society has taught them about birth. Independent classes tend to be longer and more in-depth, with an interactive rather than lecture-based format. A good instructor can help increase your confidence in your body and instill some trust in the normal birth process. She’ll teach you the tools you need to let your body do its work, and reinforce the value of avoiding unnecessary interventions and keeping your body moving throughout the birth journey. Breech baby? Your instructor can tell you about ways to help a breech baby turn, and maybe even point you to providers who will attend vaginal breech births if that is an option you want to pursue. Hospital classes often stress compliance with routine procedures – “This is what we will do to you, trust your provider.” In an independent class, it helps that your instructor works for you, not the hospital. If you hope to successfully navigate a system that finds surgery necessary for a full third of all births, it’s a huge advantage to have someone who can give you the straight scoop on advocating within that system. Did you know that in low risk births, continuous electronic fetal monitoring increases your chances for a cesarean as compared to intermittent monitoring with a Doppler, but doesn’t improve outcomes for moms and babies? Your independent instructor will tell you all about this research, but you’re not likely to hear it in a hospital-based class. An independent instructor is not bound by hospital politics or policies, and she can tell you about all of your options and rights without worrying about repercussions from administrators or providers. An independent Lamaze-certified instructor will base her class on the six Lamaze Healthy Birth Practices, an amazing resource that lays the groundwork for the best possible birth. (And no, Lamaze doesn’t teach “the breathing” anymore. This isn’t your mother’s Lamaze!) An independent instructor can reassure you that although you hire your provider and birthplace for their expertise and recommendations, and you should take those recommendations seriously, in the end it is your body, your baby and your birth.

4) Avoid induction unless clearly medically necessary. As a first-time mom, some studies show that simply walking in the door for an induction of labor doubles your risk of a cesarean. Doubles it. That’s huge! Avoiding induction is never more important than with a first baby. But if you must be induced, call on your natural childbirth instructor and your doula (remember them?) to help you with tips to keep it as normal and natural an experience as possible, given the unexpected circumstances. If mom and baby are not in imminent danger, low-and-slow inductions can result in a better chance of a vaginal birth, but you’ll need great support on the journey.

5) If birthing in the hospital, stay home at least until strong, active labor. Your independent childbirth instructor will help you understand the signposts to watch for. If you follow the common hospital recommendation to “come in when contractions are five minutes apart, at least a minute long, for at least an hour,” most women having their first baby will be very early in labor. The signposts of intensity are your guide, not the contraction timing. Minimizing the number of hours spent in the hospital can also help minimize the number of interventions and potentially lower your risk of cesarean. In her book “Pushed: The Painful Truth About Childbirth and Modern Maternity Care,” Jennifer Block tells the story of a hospital in Florida that lost power after a major hurricane. The generator kept the essentials running, but there was not enough power for air conditioning. In an effort to maximize their resources and keep laboring women reasonable comfortable and cool, for a full week they turned away any woman who was not in full-blown, active labor. Their emergency cesarean rates during that week plummeted.

6) Avoid an epidural, at least in early labor. Research is a bit mixed, and the quality of studies is often tainted by comparisons of epidural births with those in which the women had IV narcotics, rather than comparing women with epidurals to those who birth naturally. But still, the best evidence available does seem to show that epidurals, especially those administered early in labor, do increase the cesarean rate in first-time mothers. Childbirth Connection is a great resource for benefit/risk information about epidural analgesia. There are rare times, of course, when getting an epidural can actually help a woman have a vaginal birth, if she simply doesn’t have the strength to go on. Each labor is unique, and must be evaluated in the moment. But an epidural also makes it harder for a malpositioned baby to reposition, limits the mother’s mobility, and introduces a host of other interventions (IV, continuous monitoring, bladder catheter, etc.). Your doula and your independent childbirth class may give you enough natural tools so that you won’t even need the drugs. Most women don’t.

7) Read only the best in childbirth books. Get these books, and devour them cover-to-cover. Seriously, throw away “What to Expect When You’re Expecting,” and dive into these gems instead.

• “Ina May’s Guide to Childbirth,” by Ina May Gaskin

• “The Thinking Woman’s Guide to a Better Birth,” by Henci Goer (Written in 1999, this book is getting a little long in the tooth, but it’s still excellent information and routine procedures and hospital technology have not changed significantly since that time. Henci also runs a helpful Q&A forum on the Lamaze International web site.)

• “Your Best Birth: Know All Your Options, Discover the Natural Choices, and Take Back the Birth Experience,” by Ricki Lake and Abby Epstein (they also offer a great web site and community)

• “The Official Lamaze Guide: Giving Birth with Confidence,” by Judith Lothian and Charlotte Devries (check out their "Giving Birth with Confidence" blog)

And while you’re at it, buy the DVDsThe Business of Being Born” and “Orgasmic Birth” – they're even on Netflix. That’s right, “Orgasmic Birth.” Stretch yourself, sister.

8) Get your partner on board. It's tough to do this alone, you need support! Even with the best doula, your partner is still an integral part of your birth journey. Penny Simkin’s book “The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas and All Other Labor Companions” is a wonderful place to start. Be sure your partner attends that independent childbirth class with you – sometimes partners benefit even more than moms from that information and support.

9) Consider an out-of-hospital birth. It’s certainly possible, with the right support, to have a great first birth in the hospital – vaginal and unmedicated, even. We see them all the time, and the hospital is the perfect choice for women who feel safest and most comfortable there. We also see women who were deeply traumatized by their first hospital birth and find out-of-hospital options for their second child because they simply can’t bear the thought of going back to the hospital. The best research is quite clear that your odds of a vaginal birth are better outside those sterile walls, at home or in a birth center. In 2005 the British Medical Journal published a large prospective study investigating home births in the United States attended by Certified Professional Midwives. The women who birthed at home had similar outcomes to low-risk hospital birthers in terms of safety for moms and babies, but with a cesarean rate of 3.7 percent for the home birth women and 19 percent for their low-risk counterparts in the hospital. The current cesarean rate in the United States is 32.9 percent, according to the Centers for Disease Control. Study after study shows the same positive outcomes and low cesarean rates for planned out-of-hospitals births attended by a qualified midwife (as opposed to unassisted and/or unplanned home births, which are statistically not as safe). Sometimes women say, “I’m interested in home birth, but for this first baby we’ll stick with the hospital, just in case.” Just in case of what? If there’s any birth for which it’s most important to maximize your chances of a healthy vaginal birth, isn’t it your first? The research shows that out-of-hospital birth maximizes your chances of a positive outcome and is equally safe for moms and babies. Given that data, I'll reiterate that women should birth wherever they feel safest and most comfortable. At the very least, out-of-hospital birth is worth considering.

10) Believe in your body! The cesarean rate for women who birth at The Farm in Tennessee is less than 2 percent. The World Health Organization recommends a cesarean rate of 10 percent or less, and says no country in the world is justified in a cesarean rate of more than 15 percent. Women have been doing this for millions of years! Your body works. Birth works, in all its complex and amazing variations. Surround yourself with knowledgeable support, of course, in case of rare and unexpected complications. But truly… trust birth.

Written by Jessica English, CD(DONA), LCCE, owner of Birth Kalamazoo.