The Big Baby Myth

"Your baby is at least 8 pounds now, and you're only 37 weeks pregnant! You should probably induce at 38-39 weeks or you'll have to have a c-section!"

"There's no way you can birth this baby vaginally; it's getting too big. We're going to have to schedule a c-section."

"I'm predicting you'll have at least a 10-pounder if you go past 40 weeks."

"Your baby is only 5 pounds, and you're 39 weeks? You might have IUGR (intrauterine growth restriction). We have to induce NOW or your baby could die!"

Does any of this sound familiar? Were any variations of these things said to you or someone you know by your OB or ultrasound tech? Were they right? Or did the baby come out smaller than predicted? Bigger? Healthier? Or born too early?

Evidencebasedbirth.com recently published an article about this that is absolutely amazing and eye-opening. I don't even have to do extra research. I'm just going to use some of my favorite quotes, and then link to the original article and all of the sources listed there.

Let's start with what is considered to be a "big baby."

"What is a big baby?
The medical term for big baby is macrosomia, which literally means “big body.” Some experts consider a baby to be big when it weighs more than 4,000 grams (8 pounds 13 ounces) at birth, and others say a baby is big if it weighs more than 4,500 grams (9 pounds, 15 ounces). A baby is also called “large for gestational age” if its weight is greater than the 90^th percentile at birth (Rouse et al. 1996).
How common are big babies?
Big babies are born to about 1 out of 10 women in the U.S. Overall, 8.7% of all babies born at 39 weeks or later weigh between 8 lbs 13 oz and 9 lbs 15 oz, and 1.7% are born weighing 9 lbs 15 oz or more (U.S. Vital Statistics). You can see the percentages listed separately below for women who are diabetic and not diabetic."



So, how does "modern medicine" handle a suspected big baby? What do doctors suggest as far as birth options?

 

"Although big babies are only born to 1 out of 10 women, the 2013 Listening to Mothers Survey found that 2 out of 3 American women had an ultrasound at the end of pregnancy to determine the baby’s size, and 1 out of 3 were told that their babies were too big. In the end, the average birth weight of these suspected “big babies” was only 7 lbs 13 oz (Declercq, Sakala et al. 2013).
Of the women who were told that their baby was getting big, 2 out of 3 said their care provider discussed inducing labor because of the suspected big baby, and 1 out of 3 said their care provider talked about planning a C-section because of the big baby.
Most of the women whose care providers talked about induction for big baby ended up being induced (67%), and the rest tried to self-induce labor (37%). Nearly 1 in 5 women said they were not offered a choice when it came to induction—in other words, they were told that they must be induced for their suspected big baby.
When care providers brought up planning a C-section for a suspected big baby, 1 in 3 women ended up having a planned C-section. Two out of five women said that the discussion was framed as if there were no other options—that they must have a C-section for their suspected big baby.
In the end, care provider concerns about a suspected big baby were the 4^th most common reason for an induction (16% of all inductions), and the 5^th most common reason for a C-section (9% of all C-sections). More than half of all moms (57%) believed that an induction is medically necessary if a care provider suspects a big baby. So in the U.S., most women have an ultrasound at the end of pregnancy to estimate the baby’s size, and if the baby appears large, their care provider will usually recommend either an induction or an elective C-section."


 Is this method of assessing babies' weight, and subsequent treatment, evidence-based? Is it accurate? Has it been proven?

 

"This approach is based on 4 major assumptions:

1. Big babies are at higher risk for problems.
2. We can accurately tell if a baby will be big.
3. Induction keeps the baby from getting any bigger, which lowers the risk of C-section.
4. Elective C-sections for big baby are beneficial and don’t have any major risks."

 
"It is possible that women who give birth to big babies are more likely to have severe perineal tears (3^rd or 4^th degree). However, research studies have found conflicting results. For example, one large study found no difference in 3^rd and 4^th degree perineal tears between women who had big babies and those who had normal size babies (Weissmann-Brenner et al. 2012). In contrast, another study of hospital births in California during 1995-1999 found a higher rate of 4^th degree tears in big babies who were born vaginally (Stotland et al. 2004). However, 4^th degree tear rates in this particular study were very high, even among normal weight babies (1.5%), and the authors did not describe how many women had episiotomies, which is a leading cause of 4^th degree tears.
Overall, the risk of a severe tear (3^rd or 4^th degree) is low in most women (anywhere from 0.2% to 0.6%), whether or not you have a big baby (Weissmann-Brenner et al. 2012). Although having a big baby may be a risk factor for severe tears, severe tears are uncommon to begin with, and a big baby is nowhere near as big a risk factor as other things like vacuum and forceps delivery. To put it into perspective, having a big baby may increase the risk of a severe tear by 3 times (so if your baseline risk was 0.2%, it would increase to 0.6%), but a vacuum delivery increases the risk by 11 times (from 0.2% to 2.2%), and the use of forceps increases the risk by 39 times (from 0.2% to 7.8%) (Sheiner et al. 2005).
Women who give birth to big babies may be at higher risk for postpartum bleeding (hemorrhage). In one large study, researchers found that women who gave birth to babies who weigh more than 9 lbs 15 oz are more likely to have postpartum hemorrhage (1.7%) compared to women who had normal size babies (0.3%) (Weissmann-Brenner et al. 2012). However, it is not clear whether this higher rate of postpartum hemorrhage is due to the big baby itself or the inductions and C-sections that care providers often recommend for a big baby (Fuchs et al. 2013)—as both these procedures can increase the risk of postpartum hemorrhage (Magann et al. 2005).
Some women have said their doctors recommend C-sections for big babies because there is a higher risk of stillbirth. However, I was not able to find any research evidence to support this claim—no evidence suggests a higher risk of stillbirth in big babies of non-diabetic women. The risk of stillbirth has historically been higher in women with Type I or Type II diabetes. However, in recent years the stillbirth rate for women with Type I or Type II diabetes has drastically declined, due to improvements in how we manage diabetes during pregnancy (Gabbe et al. 2012). As far as gestational diabetes goes, the largest study ever done on gestational diabetes found no link between gestational diabetes and stillbirth (Metzger et al. 2008).
Perhaps most importantly, when a big baby is suspected, women are more likely to experience a harmful change in how their care providers see and manage labor and delivery. This leads to a higher C-section rate and a higher rate of women inaccurately being told that labor is taking too long or the baby does not “fit.”
In fact, research has consistently shown that the care provider’s perception that a baby is big is more harmful than an actual big baby by itself. In a very important study, researchers what happened to women who were suspected of having a big baby (>8 lbs 13 oz) to what happened to women who were not suspected of having a big baby—but who ended up having one (Sadeh-Mestechkin et al. 2008). The end results were astonishing. Women who were suspected of having a big baby (and actually ended up having one) had a triple in the induction rate; more than triple the C-section rate, and a quadrupling of the maternal complication rate, compared to women who were not suspected of having a big baby but who had one anyways.

Complications were most often due to C-sections and included bleeding (hemorrhage), wound infection, wound separation, fever, and need for antibiotics. There were no differences in shoulder dystocia between the 2 groups. In other words, when a care provider “suspected” a big baby (as compared to not knowing the baby was going to be big), this tripled the C-section rates and made mothers more likely to experience complications, without improving the health of babies (Sadeh-Mestechkin et al. 2008)."
 
"Time and time again, researchers have found that it is very difficult to predict a baby’s size before it is born. Although 2 out of 3 U.S. women receive an ultrasound at the end of pregnancy (Declercq et al. 2013) to “estimate the baby’s size,” ultrasound results are very unreliable.  
In 2005, researchers looked at all of the studies that had ever been done on ultrasound and estimating the baby’s weight at the end of pregnancy. They found 14 studies that looked at ultrasound and its ability to predict that a baby would weigh more than 8 lbs 13 oz. Ultrasound was only accurate 17% to 79% of the time, with most studies showing that the accuracy (“post-test probability”) was less than 50%. This means that for every 10 babies that ultrasound predicts will weigh more than 8 pounds, 13 ounces– 5 babies will weigh more than that and the other 5 will weigh less (Chauhan et al. 2005).
Ultrasound is even worse at trying to predict babies who will be born weighing 9 pounds 15 ounces or greater. In 5 studies that were done, the accuracy of ultrasounds to predict extra-large babies was only 20-30%. This means that for every 10 babies the ultrasound identified as weighing more than 9 pounds 15 ounces, only 2 to 3 babies actually weighed that much, while the other 7 to 8 babies weighed less (Chauhan et al. 2005)."


"Researchers have consistently found that induction for suspected big babies does not improve the health of moms or babies. In a 2009 Cochrane review, researchers (Irion and Boulvain 2000) combined 3 studies in which 372 women with suspected big babies were randomly assigned to either 1) induction or 2) waiting for normal labor. When researchers compared the induction group to the normal labor group, they found no differences in C-section rates or shoulder dystocia rates. The researchers did not look at neonatal ICU admissions, Apgar scores, death rates, perineal tears, mothers’ satisfaction with care, or any long-term outcomes.
Because Gonen (1997) was the largest study included in the Cochrane review, let’s take a closer look at it. In this study, women were included if they were at least 38 weeks, had a suspected big baby (8 lbs 13 oz to 9 lbs 15 oz), did not have gestational diabetes, and had not had a previous C-section. Less than half the women were first-time moms. Women were randomly assigned (like flipping a coin) to either immediate induction with oxytocin (sometimes with cervical ripening) or waiting for normal labor.
The results? Women in the normal labor group went into labor about 5 days later than women who were immediately induced. Although women in the normal labor group tended to have slightly bigger babies (on average 3.5 ounces or 99 grams heavier), there was no difference in shoulder dystocia or C-section rates. All 11 cases of shoulder dystocia were easily managed without any nerve damage or trauma. Two infants in the normal labor group had mild brachial plexus injury—but neither of these 2 infants had shoulder dystocia, and both injuries were only temporary.  Finally, researchers found that the ultrasound overestimated the baby’s weight 70% of the time and under-estimated the baby’s weight 28% of the time.
In summary, the researchers found that: 1) ultrasound estimation of weight was inaccurate, 2) shoulder dystocia and nerve injury were unpredictable, and 3) induction for big baby did not decrease the C-section rate or the risk of shoulder dystocia."

" Among women who are not diabetic, it would take nearly 3,700 unnecessary C-sections to prevent one baby from having a permanent nerve injury due to shoulder dystocia. If care providers recommend an elective C-section for extra big babies (>9 lbs 15 oz), for every 3 cases of permanent nerve injury that they would prevent, there would be 1 extra maternal death.
Although some care providers will recommend an induction for a big baby, many skip this step and go straight to recommending an elective Cesarean. However, no studies have ever shown that a policy of elective Cesareans for big babies improves the health of moms and babies. On the contrary, researchers have estimated that this type of approach is extremely expensive and that it would take thousands of unnecessary C-sections to prevent one case of permanent nerve injury.
In 1996, a very important study published in the Journal of the American Medical Association found that a policy of elective C-sections for all big babies was not cost-effective and that there were more potential harms than potential benefits (Rouse et al. 1996).
In this study, the researchers calculated the potential effects of 3 different types of policies:

1. No routine ultrasounds to estimate the baby’s size
2. Routine ultrasounds and elective C-section for babies weighing 8 lbs 13 oz or more
3. Routine ultrasounds and elective C-section for babies weighing 9 lbs 15 oz or more.

The researchers looked at the results separately for diabetic and non-diabetic women.
The results? Among non-diabetic women, a policy of elective C-sections for all suspected big babies over 8 lbs, 13 oz puts a large number of women and babies at risk of expensive and unnecessary surgeries.  In order to prevent 1 permanent nerve injury, 2,345 women would have unnecessary C-sections at a cost of $4.9 million dollars per injury prevented (costs were estimated using year 1995 dollars)."

 
"What is the bottom line? In summary, for non-diabetic moms:

• Ultrasounds and care providers are equally inaccurate at predicting whether or not a baby will be big. If an ultrasound or a care provider predicts a big baby, they will be wrong half the time.
•  If a care provider thinks that you are going to have a big baby, this thought is more harmful than the actual big baby itself
  • The suspicion of a big baby leads many care providers to manage a woman’s care in a way that triples her risk of C-section and quadruples the risk of complications.
  • Because of this “suspicion problem,” ultrasounds to estimate a baby’s weight probably do more harm than good in most women.
•  Induction for big baby does not lower the risk of shoulder dystocia and may increase the risk of C-section, especially in first-time moms
• A policy of elective C-sections for big babies likely does more harm than good for most women
  • It would take nearly 3,700 elective C-sections to prevent one permanent case of nerve injury in babies who are suspected of weighing more than 9 pounds 15 ounces
  • For every 3 permanent nerve injuries that are prevented, there will be 1 maternal death due to the elective C-sections

For diabetic moms and moms with gestational diabetes:

• Ultrasounds are slightly more accurate at predicting a big baby, but only because these moms are at higher risk of having a big baby to begin with
• Elective C-sections may be more cost-effective in women who have Type I or Type II diabetes
• Treatment for gestational diabetes drastically lowers the chance of having a big baby and shoulder dystocia"

Basically, no. Having late-term ultrasounds to assess baby's size is wildly inaccurate, and induction or c-section for a suspected "big baby" is not supported by the evidence. So if your OB, midwife, or ultrasound tech says you "probably have a big baby," and suggests an induction or c-section solely for that reason, ignore it. It is not a valid reason, and has no evidence to back it up. Just direct them to http://evidencebasedbirth.com/evidence-for-induction-or-c-section-for-big-baby/ , or http://www.improvingbirth.org/2013/03/march-20-2013-news-from-acog-re-elective-procedures/ , or http://thechildbirthprofession.com/wp-content/uploads/2012/07/What-to-know-about-having-a-big-baby.pdf , or even http://sarahockwell-smith.com/2012/11/04/big-babies-the-curse-of-mis-diagnosing-a-macrosomic-infant-part-1/ . And don't worry. Having a big baby isn't necessarily a problem. But that's a topic for another post ;-)

To Induce, or Not to Induce?: Such a Controversial Question

This seems to be today's hot topic. Everybody and their mother knows someone who was induced, and the stories range from perfection to utter disaster. I was reluctant to blog about it at first, especially before I officially begin my certification process, but this has become so common and is so hotly debated among moms that I can't not address it in some capacity. I want to put the hard facts out there, not personal stories. Those vary too widely to be reliable, but the most recent statistics speak very clearly and can't be argued with. So, I'm going to gather all the information I can find on induction (non-medically necessary, I'll cover medically indicated inductions later), from legitimate sources, and put it all into this post. I will share my thoughts based on my research after giving all the information, because this is a topic that I am very passionate about, but you are free to draw your own conclusions and make your own decision for yourself if you are ever faced with this choice.

Let me define induction first. ACOG (The American College of Obstetrics and Gynecology) defines it as "the use of medications or other methods to bring on (induce) labor." ( http://www.acog.org/~/media/For%20Patients/faq154.pdf?dmc=1&ts=20130627T1602376009 ) Essentially, labor induction is using natural or medical means to start labor before a woman's body does it on its own. How is an induction performed? There are many ways. The most common are:

• Pitocin
• stripping the membranes
• AROM (artificial rupture of membranes)
• foley bulb
• cytotec
• cervidil
• sex
• nipple stimulation
• castor oil

They all have their risks and benefits. The most common of them all today is Pitocin (synthetic oxytocin), usually through an iv, after inserting a cervical ripening agent like cervidil or a foley cath (like a little balloon that is inserted into the cervix and slowly inflated to help you dilate) overnight, and performing AROM at some point in conjunction with the pitocin.

Many moms being induced have what is called an "unfavorable cervix" before they are induced, which makes induction much harder, and less likely to succeed (meaning, more likely to have a c-section). Any mom considering induction should make sure she has a high enough Bishop's score ( http://www.hcpro.com/HIM-279560-8160/Learn-about-the-Bishops-Score-and-its-relationship-to-labor-and-delivery.html ) before she goes in to be induced.

So, on to the main point of this post. What are these crazy induction facts and statistics I keep talking about? Here we go, my friends:

• "The induction of labor can be done for many reasons, including many valid medical reasons. However, the rise in the rate of social inductions, or elective inductions is on the rise. As the induction rate rises there are more babies and mothers placed at risk for certain complications. Here are five risks of induction that you may not know about:

1. Increased risk of abnormal fetal heart rate, shoulder dystocia and other problems with the baby in labor.
   Labor induction is done by intervening in the body's natural process, typically with powerful drugs to bring on contractions or devices that are used to break the water before labor starts. Both of these types of induction can cause the baby to react in a manner that is called fetal distress as seen by fetal monitoring. The nature of induction like contractions may also be more forceful than natural labor. This can cause your baby to assume or stay in an unfavorable position for labor making labor longer and more painful for the mother. It can also increase the need for other interventions as well.
2. Increased risk of your baby being admitted to the neonatal intensive care unit (NICU).
   Babies who are born via induction have not yet sent signals to the mother to start labor. This means that they simply aren't yet ready to be born. This risk is worth it if the baby or mother's lives are in danger, but simply to take this risk for elective reasons may not be well advised. When a baby is in the intensive care unit there is less ability for you to be with your baby or to hold your baby. Breastfeeding usually gets off to a rocky start as well. This can usually be avoided by giving birth when your body and baby say it is time.
3. Increased risk of forceps or vacuum extraction used for birth.
   When labor is induced babies tend to stay in unfavorable positions, the use of epidural anesthesia is increased and therefore the need to assist the baby's birth via the use of forceps and vacuum extraction is also increased.
4. Increased risk of cesarean section.
   Sometimes labor inductions don't take, but it's too late to send you home, the baby must be born. The most common cause of this is that the bags of waters has been broken, either naturally or via an amniotomy. Since the risk of infection is greater, your baby will need to be born via c-section. A cesarean in an induced labor is also more likely for reasons of malpresentation (posterior, etc.) as well as fetal distress.
5. Increased risks to the baby of prematurity and jaundice.
   Induction can be done before your baby is ready to be born, because your due date is off or because your baby simply needed more time in the womb to grow and mature their lungs. Your baby may also be more likely to suffer from jaundice at or near birth because of the induction. This can lead to other medical treatments as well as stays in the hospital for your baby. Being born even a week or two early can result in your baby being a near term or late preterm infant. This means that your baby is likely to have more trouble breathing, eating and maintaining temperature."

 http://pregnancy.about.com/od/induction/a/risksinduction.htm

• "What are the risks of inducing labor?

Risks include:

• Your due date may not be exactly right, so your baby may be born too early. Sometimes it’s hard to know just when you got pregnant. If you schedule an induction and your due date is off by a week or 2, your baby may be . If your pregnancy is healthy, wait for labor to begin on its own. If you need to schedule an induction for medical reasons, ask your provider if you can wait until at least 39 weeks. This gives your baby’s lungs and brain the time they need to fully grow and develop before birth.
• Pitocin can make labor contractions very strong and lower your baby's heart rate. Health care providers carefully monitor your baby's heart rate when inducing labor. They may change or lower the amount of Pitocin you’re getting. Using less Pitocin can make your contractions weaker and help keep your baby’s heart rate safe.
• You and your baby are at higher risk of infection if labor doesn’t begin a short time after your membranes rupture. The amniotic sac normally protects your baby and your uterus from infection. But once it breaks, germs like bacteria can get in more easily and infect you and your baby.
• There may be problems with the umbilical cord. For example, if the amniotic sac is broken, the cord may slip into the vagina before your baby does. This is more likely to happen if the baby is breech (when your baby’s bottom or feet are facing down right before birth), or if the baby’s head is still high in the uterus. Or the cord may get squeezed. If it’s squeezed, the baby doesn’t get enough food and oxygen. These problems can be serious for your baby.
• Sometimes induction doesn't work, and you need to have a cesarean birth (c-section). C-section is surgery in which your baby is born through a cut that your provider makes in your belly and uterus.
• You may have a uterine rupture. A uterine rupture is a tear in the uterus. It can cause serious bleeding. If you’ve had a c-section in a prior pregnancy, you’re at higher risk of uterine rupture because ac-section leaves a scar in the uterus. Uterine rupture is a rare complication of labor induction."

http://pregnancy.about.com/gi/o.htm?zi=1/XJ&zTi=1&sdn=pregnancy&cdn=parenting&tm=1174&f=11&tt=2&bt=0&bts=6&zu=http%3A//www.marchofdimes.com/files/MP_Late_Preterm_Birth-Every_Week_Matters_3-24-06.pdf

• "Years of study have shown that inducing labor often leads to a C-section. 'If you decide to have an induction because your obstetrician is going out of town, or because your husband is going out of town, that may seem like a bona fide reason, but you'll pay the price with an increased rate in C-sections,' said Dr. Michael Klein, emeritus professor of family practice and pediatrics at the University of British Columbia, who's studied C-sections. Klein says studies of first-time moms show that 44 percent of those who are induced end up with a C-section but that only 8 percent of those who go into labor spontaneously end up with a C-section. Doctors say many times, inducing women way before the cervix is ready can lead to unproductive labor, which then necessitates a C-section."

 http://www.cnn.com/2007/HEALTH/08/23/ep.csection/

• "What risks are associated with inducing labor?

While induction is generally safe, it does carry some risk, which may vary according to the methods used and your individual situation. Oxytocin, prostaglandins, or nipple stimulation (explained below) occasionally cause contractions that come too frequently or are abnormally long and strong. This in turn may stress your baby.
In rare cases, prostaglandins or oxytocin also cause placental abruption or even uterine rupture, although ruptures are extremely rare in women who've never had a c-section or other uterine surgery.
One commonly used prostaglandin, misoprostol, is associated with a relatively high rate of rupture in women attempting a vaginal birth after a cesarean (VBAC) and should never be used in women with a scarred uterus. Some experts don't think women attempting VBAC should be induced with oxytocin, either.
To assess the frequency and length of your contractions as well as your baby's heart rate, you'll need to have continuous electronic fetal monitoring during an induced labor. You'll probably have to lie or sit while being monitored, but some hospitals offer telemetry, which lets you walk around during the process.
Inducing labor can take a long time, particularly if you start with an unripe cervix, and this process can be hard on you and your partner psychologically. (On the other hand, among women who go past their due date, the seemingly endless wait for labor to begin may be even more trying.)
And if the induction doesn't work, you'll need a c-section. Having a c-section after a long labor or unsuccessful induction is associated with higher rates of complications than you'd face with a planned c-section.
Remember that your practitioner will recommend inducing your labor only when she believes that the risks to you and your baby of waiting for labor to begin on its own are higher than the risks of intervening."

 http://www.babycenter.com/0_inducing-labor_173.bc?page=3

 "A study released this past February may cause antsy moms-to-be to think twice before scheduling induced labor for non-medical reasons, a now-common practice for pregnant women seeking convenience, or simply an end to the seemingly-endless third trimester. The report, which was compiled by Australian researchers and tracked the labors and deliveries of 28,000 women—some of whom went into spontaneous labor, while others were induced for either medical or non-medical reasons—documents a significant percentage increase in both C-section deliveries (67% increased risk—that’s big), and NICU care (64% increased risk), for women and their babies who undergo non-medically necessitated inductions."

http://www.parenting.com/blogs/natural-parenting/taylor-newman/scheduled-inductions-raise-c-section-rates-should-hospitals-ba

• "As childbirth has become ever safer, and as C-sections are so common as to be routine, those risks might seem trivial. A paper published in the current issue of Obstetrics and Gynecology reminds us that they are not. Labor Induction and the Risk of a Cesarean Delivery Among Nulliparous Women at Term, by Ehrenthal et. al. is an important contribution to the scientific literature. The investigators culled the medical records of over 24,000 women who delivered at one large hospital over a period of years. From that group they identified more than 7,804 women having their first baby (nulliparous women) between 37-41 weeks. An astouding 43.6% of women were induced!
  

… Indications for labor induction as identified by the medical provider were fetal indications in 13.6% of cases, fetal macrosomia in 3.3%, maternal indications in 24.9%, postterm pregnancy less than 41 weeks of completed gestational age in 14.3%, postterm pregnancy 41 or more weeks of gestational age in 18.3%, and 25.6% elective. The overall percentage of elective inductions, if postterm inductions less than 41 weeks were included, was 39.9%…

Since the likelihood that an induction will work is related to the state of readiness of the cervix, the authors were careful to documenent the Bishop score (state of the cervix) for all women.

Among women undergoing labor induction, 40.7% underwent preinduction cervical ripening indicating a Bishop Score less than 6 [an unfavorable cervix]; among women with an elective indication, the proportion was 37%.

These numbers of quite dramatic. More than 43% of women expecting a first baby were induced.Of these nearly 40% were being induced for convenience. More than 1/3 of women undergoing induction for convenience had a cervix that was known to be unfavorable for induction.
The authors looked more closely at the 4,863 women who delivered and had no medical risk factors or pregnancy complications. The overall C-section rate for those women was 25.5%. Being induced doubled the risk of ending up with a C-section, from 13.6% to 25.5%. [note: this section amended to correct percentages that were given incorrectly in the first version].

… Within this low-risk cohort, the risk of cesarean delivery for women with indicated inductions was RR 1.92 (1.61–2.29) and elective inductions was RR 1.84 (1.59 –2.12) when compared with women with spontaneous labor. The odds of cesarean delivery associated with induction for this low-risk group were estimated using logistic regression, and after adjustment for the other risk factors, was adjusted OR 2.03 (1.7–2.4)…

In other words, it was induction itself that increased the risk for C-section, not pregnancy complications or other risk factors. In the case of the indicated inductions the increased risk for C-section is justified by the benefit of reducing perinatal deaths. However, there is no offsetting benefit for inductions without medical indication.
Using a very conservative analysis, the authors estimate that fully 20% of all C-sections done at their institution were the result of inductions for convenience. In other words, if inductions for convenience were banned, the C-section rate would be 20% lower. In their hospital that would mean a reduction in the primary C-section rate for nulliparous women from 25.5% to approximately 20% with no decrease in safety."

 http://www.skepticalob.com/2010/07/inductions-increase-risk-of-c-section.html

• "Induction of labor

In parallel with the increasing cesarean rate, the rate of labor induction also has increased significantly in many developed countries, including a doubling of the U.S. rate between 1990–2000 (from 9.5% in 1990 to 20.2% in 2000, and 22.6% in 2006). In comparison, the overall induction rate was 35.2% in our study (around 2006); the induction rate in women attempting vaginal delivery was 43.8%. These findings suggest that the national figures based on birth certificates may have been an underestimate of the true national induction rate. For medically-indicated induction of labor, the benefits for the mother and/or the fetus are indisputable. However, controversies arise when labor is induced for women with absent or marginal clinical indications. Our data show that induced labor was twice as likely to result in cesarean delivery than spontaneous labor. Half of cesarean sections for dystocia in induced labor were performed before 6 cm of dilation, suggesting that clinical impatience may play a role in decision-making. Some studies also suggest that induction of labor increases the risk of postpartum hemorrhage and blood transfusion. Therefore, while more research is warranted, caution is needed to perform elective labor induction, as it may result in maternal morbidity and repeat cesarean deliveries in subsequent pregnancies."

 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2947574/

So what conclusions have I personally drawn from these studies (and these are just a few examples)? Induction raises, often doubles, the rate of c-section. Having an "unfavorable cervix" increases those chances drastically. Maternal and infant outcomes tend to be worse in inductions than in spontaneous labor. Women are more likely to fall victim to the "cascade of interventions" and feel their birth experience spiral out of their control. Women are more likely to request pain medication, which often leads to more interventions. Overall, if there is no medical necessity for an induction, and you want an unmedicated birth and/or to avoid a c-section, it seems that induction is not the best way to achieve that, according to the current statistics. Again, I will reference the chart from Improvingbirth.org and Evidencebasedbirth.com:

According to this chart, 42% of first-time mothers are induced, even though the evidence shows that induction should only be used for "true medical indications," and it nearly doubles their chances of having a c-section. How many of these moms know the facts, and how many of them would still choose to be induced if they did, and why? If you are considering a non-medically indicated induction, I urge you to visit these websites and read these statistics first. Remember, studies show that 1 in 3 moms is induced. Studies also show that 1 in 3 moms will have a c-section. Do we know for certain that these two statistics are related? No. But it seems likely.

So if you decide that the potential benefits outweigh the risks in your case, then by all means go for it. But do so knowing all the facts. If you want a vaginal birth, and that is important to you, induction will greatly lessen your chances of achieving your goal, so bear that in mind, and be prepared for whatever the outcome may be. There are things you can do to improve your chances, but an induction is the first step towards medical interventions, and one often leads to another, so surround yourself with supportive care providers (OB, doula, partner, etc.) to help keep the control in your hands if you choose to be induced.

Informed Choice: "What is it, Really?" OR "Hindsight is 20/20"

I know, I know, I've already blogged on the importance of becoming educated on the birth world when/before you have kids, but remember how I also said that I thought I was educated with my first, did better with my second, and am going even further now? Most first-time moms fall into the "trust your doctor/mom/society/etc." trap, and find out later that they were flat-out wrong, had outdated information, or were lied to. I know I did. To illustrate my point, let me start with a few fictional (though realistic and very common) scenarios:

1. A pregnant woman, carrying her first child, walks into her OB's office for her 40-week appointment. S/He has been talking about induction since she was 36 weeks, but she did her research and learned the statistics on induced labor (higher risk of c-sections, epidurals, infant distress, adverse effects of pitocin, reduced breastfeeding success, etc.), and as she wants a drug-free labor, she adamantly refuses induction for those very good reasons. So her OB insists on an ultrasound to check on baby's well-being, since it's her due date, and continuing past 40 weeks "can be risky." She agrees, thinking that that's better than more induction talk. But the ultrasound tech tells her that it looks like the baby is at least 9 pounds, maybe 10, and her OB thinks that she could have a very hard time birthing the baby naturally like she wants, and they either need to induce now or do a c-section. She trusts them, because this is a subject she's never heard of or read about, and gets induced. Baby is born, healthy and just fine, but only 7 pounds, and the pitocin-induced contractions were too much for her to take and she got the epidural. She is upset because her birth didn't go the way she wanted, all because a scare tactic that she had no foreknowledge of was used on her.
2. A VBAC-hopeful mom goes into labor, and heads to the hospital. She never labored with her first baby, which was a c-section due to frank breech positioning. She is excited to find that she is dilated to 6 already and her water has broken, but since she's a VBAC, they insist on internal fetal monitors and she gets stuck in bed. Unable to move, her labor stalls, and since she doesn't dilate "fast enough,"they take her in for a c-section for "failure to progress." She later learns that there is no evidence for continuous monitoring, laboring on her back in bed is the worst possible position, that there can be a natural "plateau" in labor, where it seems to stall and then kicks back into gear (usually if you move around), and that no two women are going to dilate at the same rate, and if mom and baby are fine, there's no reason not to wait it out. She wishes she had been told that, and that her doctor would have kept her informed.
3. A mom is told she has to have a c-section for a breech baby, so she goes through with it. She later finds the research that shows that breech babies can be birthed vaginally, though it can be difficult and most OB's don't even learn how to do it anymore. She's upset because her surgical birth may not have really been necessary.
4. A mom has an emergency c-section due to legitimate fetal distress, and she has no regrets. She gets pregnant again, hoping for a vaginal birth this time if all goes well, but her OB tells her the policy is "once a section, always a section." She tries to fight for a VBAC, but her OB spouts all the risks, and over-exaggerates them, and tells her that a c-section would be "safer" than "risking" her baby's life in a VBAC, and fails to mention the potential risks of a repeat cesarean. She believes her OB, trusting that s/he has her best interests at heart, and schedules a repeat section for both her second and third babies. At her 6-week postpartum visit after her third baby is born, the OB tells her that she shouldn't have any more children, because her uterus is too thin and scarred, and she would most likely develop placenta accreta (where the placenta imbeds too far into the uterine wall) and have to have a hysterectomy or she could die, or her uterus could rupture because it's so thin, or she could have a placental abruption (where the placenta detaches too early) or placenta previa (where the placenta lies over the cervix), and risk any future children's lives. She is devastated, because she and her husband wanted at least 4 children, and she feels lied to in that these risks were not presented to her early on, and she would have preferred to "risk" a VBAC than to guarantee herself these complications.

Hindsight is 20/20. Even these moms who thought they were educated, thought they knew the facts, thought they were armed to stick up for themselves, got blindsided and felt duped afterwards. How do you avoid falling into this trap, you ask? Find the latest research. Look up the ACOG guidelines on anything (test, procedure, etc.) your doctor suggests before consenting. Check out any of the websites I've linked to. Get a doula. Get a second opinion. Don't let yourself be belittled or talked down to by any care provider, and if you ever feel that way (even if they're ultimately right), find a new one. Make sure you're receiving evidence-based care, not "well, this is the way we've always done it" care, and you more than likely won't be disappointed. But as I already stated, above all, research, research, research anything and everything before consenting, so you have the current and relevant information in hand, and never be afraid to stand up for yourself. It's your birth experience, not theirs, and you should be in control of it.

Why Hire a Doula?

Okay, so you all know that I am about to start working on my doula certification, and I've already defined what a doula is, what she does, and what she doesn't (shouldn't) do. But why should you hire one? What are the benefits of having a doula? Are there any statistics to back it up?

Why yes, there are! I'm going to be quoting evidencebasedbirth.com a lot, and I just love their article on the evidence for doulas. Here is one of my favorite statistics from the article, compiled from research from 22 studies with over 15,000 women:

"When continuous labor support was provided by a doula, women experienced a:

• 31% decrease in the use of Pitocin*
• 28% decrease in the risk of C-section*
• 12% increase in the likelihood of a spontaneous vaginal birth*
• 9% decrease in the use of any medications for pain relief
• 14% decrease in the risk of newborns being admitted to a special care nursery
• 34% decrease in the risk of being dissatisfied with the birth experience"

 You can read the entire article here . It's definitely worth it.

Essentially, when a laboring mother has someone there to support her who is "outside" the situation emotionally and medically, and purely there to support her in whatever way she chooses, the outcomes are statistically better for both mother and baby than when she receives "standard" care. 

Labor and delivery nurses are great, but chances are that you won't be their only patient, and they will have to frequently leave the room to care for the other moms in their care. They can't be there just for you. Your partner is definitely irreplaceable in the delivery room, but more than likely they aren't trained to support a laboring woman, and they're too emotionally close to the situation to be an unbiased labor support. Partners tend to be too "in the moment," just wanting to make it all better, focused on you, to think about what you really want and how you'll feel about your birth experience after it's all said and done. There's nothing wrong with that, and having her partner's support is invaluable to a laboring mom, but imagine how nice it would be to have your partner kneeling in front of you, staring into your eyes and helping you breathe and focus, while your doula stands behind you, massages your back, or makes sure you can labor in peace without nurses constantly interrupting you, or whatever it is you need her to do. And if your labor is long and your partner needs to get some food, or go to the bathroom, or get some sleep,  your doula is right there to keep on supporting you. What if your partner needs reassurance and support as much as you do? Doulas can do that, too. If you have a doula, you always have someone there, focused entirely on your (and your partner's) needs.

After giving birth twice myself, once in a hospital with an OB, once in a better hospital with a group of midwives, I can tell you that I'm seriously considering getting a doula for my next birth.  I have learned what the benefits are of having someone educated on the ins and outs of birth who is there for no reason other than to support me. Several things would have been different in my first birth had I had a doula there to help me. My second birth was much better, but at least one thing would have been different if I'd had a doula. I did better on my own after educating myself, but it still wasn't exactly what I wanted. Being a doula myself (I'm determined I will be by then) might make me more or less inclined to hire one when the time comes, so we'll just have to see!

The most recent research supports having a doula. Mothers and babies benefit physically, and both mom and her partner tend to be more satisfied with the birth experience when they've had that constant support. I would say, to any couple trying to decide whether or not to hire a doula, "Why not? Better safe than sorry, right?" If you hire one and find that she was ultimately unneeded, then don't hire one next time. There's no real downside to that, other than being out some money. But if you don't have one and things get out of control and you're left wondering if the support of a doula would have made a difference, that would kind of suck. Better to know something potentially beneficial is unnecessary after all is said and done than be left wishing you had at least given it a shot. Especially since the evidence supports the benefits of having a doula :-)

What's the Big Deal About Birth Education?

Why do I keep saying it's so important to "get educated" on pregnancy and birth? It's not because I think doctors are evil and don't care about you. It's not because I think you shouldn't trust your instincts. It's because of the rampant misconceptions and myths about birth that OB's, midwives, your mom, your aunt, your friend, and you still accept as truth, without updating themselves on the current research and evidence. I'm all for evidence-based maternity care, but if you don't know what the latest evidence is, how can you demand it?

You don't have to get a doula certification to be "educated" on the modern birth world, nor do you have to do much at all. Reading What to Expect When You're Expecting, or Your Pregnancy Week by Week, or any of those books, doesn't count, though. They aren't in keeping with the current research, they promote a lot of outdated stereotypes and information, and they really won't get you anywhere. I made that mistake as a first-time mom, I became more educated the second time around, and I'm taking it even farther before I have another baby, because I'm so passionate about the need for birth education in our society, and because I want to be more in control of any more births I have (by being confident in myself, more than anything).

It really is as simple as visiting sites like evidencebasedbirth.com, improvingbirth.org, and the like (and those two sites have plenty of links to other informational sites), seeing the statistics, the evidence, and deciding what you are and aren't okay with. Find out hospital policies in your area. Check your care provider's stats on infant/mother mortality, c-section, VBAC, pitocin use, and the like. Whatever interests or concerns you, ask questions. Look into it. Knowledge truly is power, and if all expectant mothers were armed with the knowledge they need to keep the control over their birth rights in their own hands, the "pushy doctor/midwife" stereotype would become obsolete, and hospitals/doctors/midwives/insurance companies would be forced to practice and cover evidence-based care.

So what are these statistics I keep talking about, anyway? Well, here's a graphic that illustrates the truth pretty well, I think:

How does this make you feel? What do you think about the way our maternity care is heading? I hope this inspires you to do more research for yourself, ask more questions, and not take anything that anyone (not your doctor, me, your nurse, midwife, mom, sister, friend, or anyone) says at face value. Find the truth. Because according to that chart, we're not getting the care we deserve.

And that is why it is so important to be educated in the birth world. Because blind trust certainly isn't getting us anywhere.

When Doulas Go Wrong: What a Doula Should and Should Not Do

I've already written about what a doula is, and I used the DONA International (www.dona.org) definition in my very first blog post. However, I will go ahead and re-post it just for clarity:

"What is a doula?

The word "doula" comes from the ancient Greek meaning "a woman who serves" and is now used to refer to a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period.
Studies have shown that when doulas attend birth, labors are shorter with fewer complications, babies are healthier and they breastfeed more easily.

A Birth Doula

• Recognizes birth as a key experience the mother will remember all her life
• Understands the physiology of birth and the emotional needs of a woman in labor
• Assists the woman in preparing for and carrying out her plans for birth
• Stays with the woman throughout the labor
• Provides emotional support, physical comfort measures and an objective viewpoint, as well as helping the woman get the information she needs to make informed decisions
• Facilitates communication between the laboring woman, her partner and her clinical care providers  
• Perceives her role as nurturing and protecting the woman's memory of the birth experience

• Allows the woman's partner to participate at his/her comfort level"

I love this definition. This is the exact definition I give when people ask me, "What the heck is a doula, and what do they do?" But it does present a problem. It tells you what a doula is. It doesn't tell you as much about what a doula does, and even less about what she does not do. And the things a doula does not/should not do are even more important. For this, I reference one of my favorite sites about everything pregnancy, labor, and birth, Evidencebasedbirth.com:

"It’s also important for you to understand what doulas do NOT do:

• Doulas are NOT medical professionals
• They do not perform clinical tasks such as vaginal exams or fetal heart monitoring
• They do not give medical advice or diagnose conditions
• They do not judge you for decisions that you make
• They do not let their personal values or biases get in the way of caring for you (for example, they should not pressure you into making any decisions just because that’s what they prefer)
• They do not take over the role of your husband or partner
• They do not deliver the baby 
• They do not change shifts"

Isn't that great? It's nice to see it laid out so plainly. Any doula worth her salt adheres to those guidelines. However, not all doulas do. It's a sad truth that the women who are supposed to be the strongest advocates and supporters of birthing women can also be their biggest critics and hindrances.

So if you're interested in having a doula attend your birth, make sure to interview several. You may click with the first one you meet, but it's still a good idea to shop around, especially if the one you choose ends up unable to attend your birth. That way, you already know who else you would be comfortable calling in an emergency. You should be sure to ask lots of questions, to be certain that your philosophies are in harmony (I know, I say that a lot) and that she'll respect your choices without reservation. The American Pregnancy Association (americanpregnancy.org) has a good starter list of questions you should ask:


"Questions to Ask a Potential Doula:

• What training have you had?
• What services do you provide?
• What are your fees?
• Are you available for my due date?
• What made you become a doula?
• What is your philosophy regarding childbirth?
• Would you be available to meet with me before the birth to discuss my birth plan?
• What happens if for some reason you are not available at the time of my birth?"

If you don't like even one of the answers she gives you, walk away. She's not the right one. Remember, you're hiring her to support you, and what you want, not so that she can push or promote her agenda. The last thing you want in the delivery room (wherever that may be) is someone you don't trust to be behind you 100%.

"Is Birth Really as Scary and Dangerous as I Think?"

Tell me if any of these sound familiar:

• A pregnant woman going about her daily life, then suddenly grabbing her stomach, proclaiming that her water has broken, that the baby is coming NOW, and they have to get to the hospital this minute or something terrible is going to happen. They rush her to the hospital (in an ambulance, because simply driving her there without intense supervision would be reckless), and she's screaming from the pain and lying flat on her back on the gurney. Mom is terrified and crying and obviously traumatized and confused. The knight-in-shining-armor doctor runs to her sterile hospital room, she's draped with those blue cloths, pushed onto her back, her legs and feet up in stirrups, the doc says says there's no time to waste, and commands her to PUSH NOW or she and the baby could both die. The mom and baby are ok, and there are no complications, but everyone is saying what a close call it was, and that if that doctor hadn't been there, both would have died.
• Same scenario as above, but the doctor suddenly declares that "the baby is stuck" after about 2 minutes of pushing, and mom is rushed off for a c-section, and the father is left behind wondering if he'll ever see his wife and/or baby alive.
• A period-piece, such as in Elizabethan times, where the woman goes through days and days of horrific labor, finally has the baby, and dies during or just after birth from causes unknown.

I just described a few of the most common scenarios found today on tv and in movies. Who would want to give birth after seeing something like that?? Who would honestly want to put themselves through something so dangerous and traumatic and scary?

It's a good thing that that's not what birth is really like.

I'm sure those scenarios have happened to someone at some point. Birth is unpredictable, and it can (and does) go wrong from time to time. In those cases, doctors are indeed the knights-in-shining-armor. The problem with those portrayals is that they are made to seem like the norm. They make it look like giving birth will be like that, and chances are, it won't. And it doesn't have to be.

So what is birth really like? It's different for each woman, and most women's pregnancies and deliveries are all different from each other. My two were, and I'm sure any more I have will be, too.

Birth doesn't have to be scary. It is very unlikely to become an emergency situation. It isn't a medical condition, or a disease, or a sickness. It's a natural process that all mammals go through. Do you freak out when your cat or dog gets pregnant? Or do you trust that their body knows what to do? Does your vet tell you "we need to induce, she's been pregnant too long," or, "we have to do a cesarean, there's no way those babies will fit?" Nope. They let nature take its course. And more often than not, everything goes just fine. Why are we humans viewed differently when it comes to birth? Why do doctors and the media feel the need to make pregnancy and birth seem so terrifying?

Well, before modern medicine, women and babies very commonly died in childbirth, so it must be a really dangerous business, right?

Bull.

The biggest benefits modern medicine has brought to the birth world are hygiene, an understanding of the human body, and the ability to do surgery (c-section) for those few moms and babies who really do need it. The majority of mothers who died in childbirth "back in the day" died of infection due to poor prenatal and postpartum care, and the same goes for infants. Health in general was poor back then. It had nothing to do with birth itself, but the low health standards and lack of preventative care and knowledge.

So where are we now when it comes to birth? My answer would be that we have erred too far in the opposite direction. We're trying to make it seem too safe, while at the same time protecting against every little teeny tiny thing that could go wrong, which actually tends to cause more problems than it prevents. Doctors are so afraid of being sued for malpractice and "missing something" that they try to prevent problems that may or may not exist (such as a "big baby," etc), rather than trust mom's body and wait it out. This is actually creating more fear than it's alleviating, and a frightened mom will have a much harder time giving birth. Birth is no longer viewed as natural or normal. Because we now know what could go wrong, we expect it to, and see signs of problems where there aren't any.

We're like the child who has just learned about the fact that germs are everywhere, and is now scared to drink a glass of water for fear of becoming infected. The chance of actually getting sick from the natural bacteria and such found in a glass of clean water is minuscule, but because the child knows it could happen, they are afraid. Their fear convinces them, after they've drunk the water, that they have become ill from the bacteria, and they see and feel nonexistent symptoms because they are so convinced of what could go wrong.The same goes for prenatal care. We're pelted with information about everything that might go wrong in a worst-case scenario, we are terrified of it, and so we become self-defeating. We think it's dangerous and that we are incapable, and so we become it. How you view something has a real effect on how it pans out.

Our problem is that we know so much about the bad, that we forget about the good. Our focus has become shifted in the wrong direction. If we were to instead remember that birth is normal, the majority of pregnancies and births are uncomplicated, and we have modern medicine at our disposal on the off chance that anything should go wrong, it would be entirely different.

So, if you find yourself scared of birth, I suggest you turn off the tv. You won't get an accurate representation from the media. Do your research and find out the real facts, become educated, and you'll find that it's not so scary after all.

Your Story

I keep saying this, because I firmly believe it: all moms, and their educated, empowered choices for their birth, deserve respect and support. That being said, it's very difficult to be unbiased, especially when I see a mom making a choice that I don't agree with, or for the wrong reasons, or without all the information and that she might regret once she learns the truth. I don't want my future clients to bear the brunt of my "learning curve" in this respect when I finish my certification, so I want to take steps now to put myself in others' shoes and try to see through their eyes. It will make me a better doula, and a better person, because I'll be able to see past what I would choose for myself - and why - and instead see and understand their choices and reasoning without my judgement being colored. I wouldn't be a good doula if I couldn't do that.

So, to make this happen, I'd like to ask for your birth stories! Help me to see through your eyes! If you would, please share in the comments. I'm looking for diversity here. I want as many different stories, of as many different types of birth, as I can possibly get. I want to be able to offer my clients information and support based not only on my experiences and studies, but on the experiences of real women (especially those that I personally know). If a mom gets into an unexpected situation and looks to me for comfort, I want to be able to say, "You know, I had a friend who went through this, and she and her baby were just fine, and it went great." If a client is making a choice I never would, and asks me my thoughts, I want to be able to say honestly, "I wouldn't choose it for myself, but I have a friend who did, and she was extremely happy with it." I truly, truly want to understand any and all choices, offer support to those who mourn a "negative" birth experiences, cheer on those who want to make different/better choices next time by becoming more educated, be happy for those who had a wonderful birth experience, and put my biases aside.

Here are some guidelines for your responses (so that I get an even survey of information):

1. Your birth story(ies). What happened? Just the nitty gritty details of how, when, etc.
2. How your birth experience(s) made you feel. What were your thoughts coming out of it? Was it positive or negative?
3. Would you do it again? If so, what would you do the same, or what would you do differently? And why? What steps would you take/are you taking to make that happen?
4. What is your birth philosophy, now that you've "been there, done that?" Does it affect how you view other women's birth stories or their views?

Anything you are willing to give me is greatly appreciated, mamas!

Also, if you have not had children and are wanting to, I want to hear from you, too! Here's some questions for you:

1. What are your thoughts on the modern birth world? What questions do you have, what myths do you want debunked, how do you feel birth is presented to first-time-moms? Does the prospect of birth frighten you?
2. What is your ideal future birth experience, and why? Do you have a birth philosophy?
3. What do you intend to do to make your wishes a reality?
4. What kind of stories and advice do you want to hear from medical experts and other moms? What do you not want to hear? What helps, and what doesn't? And what can we do to help?

Again, anything that any of you are willing to tell me, whether anonymously or not, is welcomed and appreciated. This is the sort of thing that will not only help me to be a great doula one day, but will help my future clients, too!

My Chosen Specialization

After all the reading and preparation I've been doing before officially beginning the certification process, I think I've decided what I want my "specialty" to be as a doula.

There are some who are purely postpartum doulas, who support mom and help with baby after birth, dealing with issues such as breastfeeding and the like. Some specialize in loss, and coping with those issues. Some attend only home births. Some attend only hospital births. Some prefer to support solely c-section moms, while others take only vaginal birth clients. There are some who don't want clients who desire pain medication, and still others who push for their clients to get epidurals.

Overall, the vast majority of doulas seem to be natural birth advocates. I, as previously stated, am as well. But I don't want to become biased, because just because that's what I would choose for myself doesn't mean it's the only way to birth, and I don't want to project my views on others. Educate them? Yes. Help them to make the best choices for them and their babies? Yes. Push them to make the same choices I would, if it's not what they're really comfortable with? NO. They should make the choice that they are most comfortable with, and my feelings and opinions, outside of the realm of established medical fact, have no place in that.

So I followed this line of thought, and went back to the beginning of my journey: what made me want to become a doula in the first place? What was my inspiration?

Injustice. Trauma. Mothers feeling bullied. Choices being taken away. Women coming out of their birth experiences in tears, wondering what went wrong, and why they couldn't/didn't get the birth they wanted. First time moms being terrified to give birth. Second/third/fourth time moms being scared to go through another traumatic experience. Doctors who are more interested in getting home in time for dinner than their patients' feelings or what is really best for mom and baby. Unnecessary interventions. Common, wild misconceptions about labor and birth that are still accepted as fact.

I was fed up. I wanted to stop all this from happening, make moms feel strong, and keep the power in their hands. 

Then, who are the moms who really need the support of a doula? Not the confident mom who has had a successful natural home birth and is planning another. Not the mom who is happily at peace with her decision to schedule a repeat c-section. Not the mom with the wonderfully supportive OB or midwife, whose judgement she trusts implicitly, and knows that she won't be pushed into anything unnecessary. Yes, these moms could always use the support of a doula to maintain their confidence and support them should anything go wrong, and I'd happily be there for them, but surely that support is needed more elsewhere.

It is.

It's needed by the mom who wants a VBAC and is scared she'll be pushed into a repeat c-section, and needs to be sure she has someone on her side to help her either achieve her goal or accept a c-section calmly if it's needed. It's needed by the mom with pre-eclampsia who has to be induced at 38 weeks to save hers or the baby's life, and still wants to try for a natural labor because she's scared of the "cascade of interventions" leading her to a c-section. It's needed by the mom whose baby is transverse, or who has placenta previa, and there's no other option than a c-section. It's needed by the first-time mom who doesn't want to end up with a primary "unnecessarian," which would make any future vaginal births a battle. It's needed by the mom who had a traumatic first vaginal unmedicated birth, who wants to make sure she gets to the hospital in time to get an epidural and avoid that fear and pain this time. It's needed by any high-risk mom, any frightened mom, and any mom with no choice but to stick with an unsupportive doctor who has to have someone in her corner.

So that's who I'll be giving it to. Those moms who really need it. The VBACs, the medical inductions, the necessary c-sections, the high-risk moms, the frightened moms, the moms with bullies for doctors. The moms who don't have enough confidence within themselves, and need the support of an educated person to hold their hand, rub their back, reassure them, and comfort them if things don't go ideally. the ones who really need a doula.

Will I happily take a client planning a home water birth? Absolutely! I want to support all moms, and all births. But I want to help those moms in difficult situations first. I want to make them my priority. I want that to be the focus of my studies. I want to be the bodyguard, the advocate, the listening ear, the shoulder to cry on, the hand to squeeze, the pool of knowledge, the builder of confidence, the enforcer of rights. I want to make sure that no birth, however difficult and risky, is traumatic. Because it doesn't have to be that way, no matter the emergencies that pop up. No mom should to feel out of control or confused, and if she has someone there to explain everything, assure her that it will be fine and nothing is happening that doesn't absolutely have to, and make sure she consents to everything that happens (and exhausts all other options first), no mom will.

I know I won't be able to do this for every mom, everywhere, but it has to start somewhere. I read a quote once that really stuck with me: "Be the change you want to see in the world." I took it to heart, and I hope that I am able to achieve my goal, because every mom, everywhere, deserves it.