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 DVDs “The 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.

Letting go

This post is written by Birth Kalamazoo's Beth Hawver, CD(DONA)

Reading Ina May Gaskin’s new book, "Birth Matters," I was struck by a passage in one of the birth stories. A woman recalls a moment during her labor when her midwife says: “Your body is about to teach something to your mind.” I kept thinking about those words, and their inherent power and wisdom. As a birth doula, childbirth instructor and natural birth advocate, this might just sum up most of what I try to communicate to women and families.

We’re always talking about letting go, letting your body take over and using the primal part of your brain. But how do you teach someone how to do this? In my own births, did I consciously let go, or did it just happen to me? I believe it was the latter. Most of us have rarely – if ever – been able to access that deep, instinctual part of ourselves. We don’t use it. We live in a thinking society that struggles to turn off our brain. When we do choose to turn it off, it’s usually in the form of mindless entertainment, numbing drugs, or giving our power away to someone else – not turning inward and within.

When I think about many women who enter their childbearing year, they so often turn their power over to others, fueled by fear of pain and lack of information. Those who become informed and know their options tend to have read books such as Henci Goer's “The Thinking Woman’s Guide to a Better Birth” and have usually taken independent childbirth classes full of information about interventions, choices and the natural process. But after all this necessary and vital preparation, how do you let it all go? Especially when it’s something you’ve never done?

I often tell women in my life how with labor and birth, most women need to lose control, and you never know what you’re going to get. This sounds confusing. Then why all this preparation? Why am I reading all these books and investing so much when I have no control over it anyway? I remind them about stacking their deck. Now is the time to stack the deck, not during labor. Every choice you make during those months your babe is in-utero, you are increasing your odds of getting the birth you hope for. Every time you eat that kale soup or Greek yogurt, every time you take a walk, every time you show up to birth class when your exhausted and really just want to stay home, when you change providers… With every informed choice you make – from caring for your body to knowing your options – you have contributed to your deck. You have increased the odds. Labor is the time to let go, and you need a safe place to do it.

It can be overwhelming to think about all the things you have to remember to do, to not do, the questions to ask, the positions to remember. But you don’t have to remember. You don’t have to know everything about labor and birth. You just have to do two things. One, surround yourself with people you trust and whom you can ask. Two, release. It comes down to protecting your birth space, which includes who you let in/ having the right people there, and being in an environment that gives you the best possible chance of turning your brain off and allowing the experience to catch you. Who can best hold that space for you when you drift off?

It’s not always quite so simple, but those two elements will certainly help you protect your space so that you can find your authentic self, your primal you. Mammals often birth in seclusion. They need privacy, darkness and safety to be able to release their bodies. Consider the things you might need to let go…..

Ways to encourage your primal self:

• Watch videos of mammals birthing.

• Stay in the moment. Let go of thoughts of yesterday or tomorrow. Focus on right here, right now. Focus on this breath, this birth.

• Meditation, guided meditation, positive affirmations, and simple mantras can be helpful. Reading an excerpt from “25 Ways to Awaken Your Birth Power” or repeating phrases like “Ooooooopen,” “Down and Out...” “Come baby, come…” can be helpful during labor.

• Quiet your mind’s chatter by having an object of focus: a song, birth art, a mantra, your breath.

• Surround yourself with others who believe in your power, trust birth, can answer questions, have seen the miracle unfold, and who can protect your space.

What do new mothers need?

What do new mother's need in those tender postpartum days? We examined that topic at a recent "Birth Matters" meeting here in Kalamazoo. Here's the list our birth and postpartum doulas came up with... Anything you would add? What did you need as a new mother?

What New Mothers Need

(in no particular order)

1) Meals! (preparing them for her or organizing others to do so)

2) Housework. (dishes, sweeping and mopping, toilets and shower – ask her!)

3) Your ear. (a safe, nonjudgmental space to share her emotions and, if needed, process her birth)

4) Community. (moms groups, mommy-baby activities, friendships)

5) Entertainment for older siblings. (play with them, bath them, read to them, take

them to and from school)

6) Self care. (permission to take care of herself with baths or naps, the time to do so, and space to ask for help when she needs it)

7) Visitors. (figure out what she needs and respect boundaries about how long to stay)

8) Breastfeeding support. (from her partner, family and friends, doula, an IBCLC lactation consultant; encouragement that, by and large, the human breast still works!)

9) Space to mourn her old life. (if she needs to do so, say goodbye to her old life and embrace her new and beautiful, but often intense world)

10) Courage to follow her heart. (unless the baby is in danger, she doesn’t necessarily have to do what her best friend/mom/grandma/doctor suggests… embrace the new world of making informed decisions that feel right in her own heart)

11) Support for her partner, too! (postpartum depression for dads is very real, he may need time and space and someone to care for him so that he can stay strong and helpful to her... the same holds true for same-sex partners, of course)

12) Ask her! (every woman, every baby, every postpartum experience is unique, and women's needs vary... offer suggestions, ask how you can help and be ready to respond!)

Birth Kalamazoo honors mothers!

In honor of Mother's Day, Kimmelin Hull of Lamaze's Science and Sensibility blog recently asked birth professionals to share how they honor mothers. We are so blessed to work with such amazing women, here is how we try to honor them in all we do.

Birth Kalamazoo honors mothers!

In our childbirth education classes, we honor mothers by helping them know that their bodies were made for birth, and teaching them time-honored techniques (shared by other mothers!) to help them navigate their own journey. We teach them that there is no one “right” way to birth, and that they are strong and amazing. We honor mothers by preparing their partners to support them on the birth journey and beyond, to surround them in love and support. We teach them to avoid unnecessary interventions but embrace them in the rare circumstances where they might prudent. We help them understand that on the occasions when a birth veers away from the original plan, as mothers they still have choices and are deserving of kindness and respect. We connect them with other strong, amazing mothers who talk about birth with reverence and show them that it truly can be done without excessive technology. We teach them that birth is an amazing passage to be embraced, not feared.

As birth doulas, we honor mothers by walking beside them on the birth journey. We encourage them to trust their bodies and the process, and to find their own way through this intense, amazing passage. We hold their hands, rub their backs, sit quietly, pour water, wipe brows, offer reassurance, suggest positions, or simply stand back. We help their partners recognize what’s normal and that she is doing well, and to figure out how they can best help her on the journey. When needed, we offer gentle suggestions. We affirm that mothers are strong and amazing, and we help them find their strength and voice. We let them know there are options and we trust their decision making process. We support them unconditionally, without judgment. We honor mothers by celebrating with them, crying with them and holding their space. We surround them in love.

As lactation consultants, we honor mothers with evidence-based breastfeeding classes that acknowledge common pitfalls but also celebrate all that is right and beautiful with breastfeeding, not just all that can be difficult. We help them to realize that the human breast works! We know that they are strong and amazing, and we help them recognize that too. We connect women with community resources that can support them on this journey and help them find other like-minded mothers. When there are challenges, we come to their homes, listen to their worries and offer gentle, customized, expert guidance to help them achieve nursing success. We ease their fears, and help them recognize and cope with the occasional serious problem. We honor mothers by celebrating the beauty of breastfeeding!

As postpartum doulas, we honor mothers by nurturing them as they become mothers. We listen and encourage without judgment, offering support and evidence-based information. We share tips and tricks for baby care, from diapering to feeding and bath time. We help women wear their babies so they can have a free hand every now and then! We take care of the “little things” around the house that no one else might notice, but you can bet the mother has been noticing. We reassure them that they are strong and amazing mothers! We entertain and wear out big brothers and sisters, then offer tips on how moms can do the same while still caring for the baby and staying sane. We honor mothers by making sure she is eating well, resting and feeling as centered as possible as she enters into this new phase of her life. We honor new mothers by loving them up!

We honor mothers, and we are so very honored to serve them.

Call me counterculture

A local nurse midwife recently attended one of Birth Kalamazoo's meetings and declared afterward that she was glad to see the birth counterculture was alive and well.

Counterculture? At first I was a little taken aback by the term. Really? That made us sound so... Ahem... Hippie-ish.

Then I stopped to think more deeply. Are the things we discuss truly counterculture? We call for respect for birthing women. We want families to have evidence-based information about the risks and benefits of interventions. We trust women to make informed decisions about their bodies and their babies. We believe in the sacredness of the birth space. We see birth, in most cases, as a normal, natural process — not a disaster waiting to happen. We honor women's right to choose where and with whom they give birth. Are these such crazy ideals? How can they be counterculture?

As I've continued to mull the midwife's comment, I've come to realize that of course, she's exactly right. We sometimes get caught up in our supportive birth bubble, but in reality, what we are doing really is counterculture. It's a pretty sad commentary to realize that as a whole, our maternity care system does not respect birthing women and doesn't often provide truthful information about risks and benefits. Our system doesn't trust families to make their own informed decisions, and it certainly doesn't believe in any sort of sacred birth space. Birth is definitely not seen as a normal, natural process. And by and large, women who go outside the traditional system are not respected in their choice of where and with whom to birth.

There are oases of quality, evidence-based, respectful care. Absolutely. But sadly, they too are counterculture.

So I've decided I'm ready to own that label. I've never been one to delight in making waves, but this boat truly needs some rocking. Around the world, it feels like there's a growing groundswell of support for quality maternity care and a return of respect and reverence to the birth space. New films, blogs, journal articles, book and a variety of organizations are all drawing attention to the critical issues facing our ailing maternity care system. The choir of voices is growing, we feel it in our own community too.

I do believe things are changing, but we have so very far to go, and we face so many obstacles. We'll get there eventually.

Until then, call me counterculture.



Jessica