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Series: Supporting Women When a VBAC Doesn’t Happen – Part Three: Supporting The Mothers

November 12th, 2015 by avatar

By Pamela Vireday

“Remember, no effort that we make to attain something beautiful is ever lost.” – Helen Keller

cbac part 3Today we conclude our three part series on Cesarean Birth after Cesarean, written by Pamela Vireday, who is an occasional contributor to Science & Sensibility.  In this series, Pamela examines the topic of women who experience a Cesarean Birth after a Cesarean. This is when families are planning for a vaginal birth after a prior cesarean, but the birth does not go as planned.  The experiences of women who have a CBAC are often negated and their emotional and physical well-being given short-shrift by both professionals and their social community of friends and family.  The research on this topic is slim and begs for exploration by qualified investigators.  Last week, Pamela discussed the unique grief that CBAC women may experience. Two days ago, Pamela examined the limited research available on CBAC births in part two.  Today, Pamela will provide information on how to support CBAC women in the absence of published research.  There is also great set of resources in the post to share with the families you work with or include in a CBAC Resource packet you provide after birth. You can also read a companion piece of Pamela’s own personal story, “Cesarean Birth after Cesarean, 18 Years Later” on her own website.- Sharon Muza, Community Manager, Science & Sensibility.

In the first post of our series –  Supporting Women When a VBAC Doesn’t Happen – Part One: A Unique Grief, we discussed how women who want and work for a VBAC but end up with a cesarean have a unique grief that is different from a primary cesarean or an elective repeat cesarean. Many women who have experienced a CBAC say they felt unsupported and isolated. They had nowhere to tell their stories, nowhere to process their anger, and got little sympathy from those around them.

In the second post – Supporting Women When a VBAC Doesn’t Happen – Part Two: The Forgotten Mothers, we examined what research there is on CBAC mothers and found limited wisdom to guide us. In the absence of research on how best to help CBAC mothers, we must rely on the words and experiences of CBAC mothers to tell us what they need.

In the final part of our series today, we suggest concrete ways that birth professionals can support CBAC mothers, based on suggestions made by CBAC mothers themselves. Keep in mind that each story and woman is unique, and the needs of one may be different than the needs of another. The best thing to do is to follow the lead of the CBAC mother; she will tell you in word and deed how best to support her.

Create a Safe Space for the Birth Story

One of the most important things that birth professionals can do to help CBAC mothers is to give them a safe space to tell their stories ― their full stories.

CBAC mothers often edit their stories for others, leaving out their disappointment or scary details because people only want to hear the happy parts. When they try to tell the full story, they may hear, “Just get over it already” or “Oh, we’re not going to talk about that again, are we?” CBAC mothers also often self-edit their stories in order not to discourage or scare other expectant mothers. But an untold story is one that weighs heavy on the heart.

Be the safe person to whom the full birth story can be told. Be truly present while listening. Don’t armchair-quarterback her story; suspend your judgment, put aside your own birth agendas, and focus only on supporting this woman, right now, in this situation. Eliminate distractions, use attentive body language, and really focus on the woman so that she truly feels like she is being heard.

Realize that she may need to tell the story multiple times; each time she tells it, she processes it on a new and different level. Ask her, “What do you need from me right now?” so she can tell you if she wants something more than just listening. If possible, check in with the woman’s partner, who may also need help processing or understanding why the mother is still coming to terms with her experience.

“Listen. Listen. And don’t contradict. Just listen. Don’t compare. Just listen. And don’t try to make me feel better. Just listen.”     – Kristina R.

Use Creative Support Techniques

Once the mother is ready to start processing the birth story further, use reflective listening techniques. Listen to what she says, seek to understand what seems most important to her, and paraphrase back to see if you understood her point. Don’t make assumptions about how she is feeling or add judgments. Ask open-ended follow-up questions that invite her to explore her feelings if she is ready. Give her the time and space to come to her own conclusions about her experience.

Many women find that journaling, making art, singing, writing poetry, and participating in rituals is helpful in processing their emotions. This can be particularly helpful for those who get stuck in a negative feedback loop or who need to process significant trauma. Don’t be afraid to refer to a good birth-supportive therapist in your area if needed.

Validate the Mother

CBAC mothers need to have their experiences and feelings validated. Mothers need to be reminded that their hard work and accomplishments during birth are still valid, however the baby was born. Acknowledge the amazing sacrifice she made in giving up her own dreams and bodily integrity for her baby.

“CBAC women need validation. They need encouragement that every birth can be different. Above all, they need to be appreciated for the work they did both before and during the experience, the sacrifices made for their babies, and the special place inside themselves that now carries yet another scar.” – Teresa Stire

“Effort does not always equal outcome. Give yourself credit for that effort, and don’t boil it all down to the moment of birth alone.” -Melek Speros

Encourage Bonding

Bonding can be especially difficult after a physically or emotionally traumatic birth. Others may have stepped in to care for their babies, which can leave some mothers feeling incompetent or disconnected.

Start by encouraging more time with the baby. Promote as much skin-to-skin contact as possible; this helps produce more oxytocin and may help breastfeeding too. Some women find bathing or napping with babies to be very healing.

It can be helpful to compartmentalize grief behind an emotional door so women can focus on their baby’s immediate needs, on their older children, and on their own physical needs. However, it’s important that women schedule time periodically to take out the grief, actively work through it, and then put it away. Otherwise, grief may intrude on the bonding process.

Give the Mother Support Resources

Create a CBAC Resource Packet that you can email or hand out as needed. Include a list of CBAC support sites, CBAC brochures, and names of local postpartum doulas or birth therapists. Edit it to each woman’s unique situation.

The International Cesarean Awareness Network (ICAN) has a new brochure about CBAC, which will be available soon in its store, as well as a website dedicated specifically to CBAC, including an archive of CBAC stories. In addition, there is a closed ICAN support group on Facebook just for CBAC mothers.

Although not all CBAC mothers experience post-traumatic stress symptoms, having birth trauma resources in the CBAC Resource Packet puts the ball in the mother’s court and lets her decide the emotional ramifications of her experience. It also gives her concrete options for reaching out for further support, possibly even long after your working relationship with her is over.

Help Her Connect with Other CBAC Mothers

CBAC moms are their own best mentors. This may be the only place CBAC women find others who truly “get” what they are going through.

The unique feelings around CBACs may mean that birth groups, especially those centering on VBACs, could be uncomfortable for a while. Many CBAC mothers feel intensely jealous when hearing other women’s easy birth stories. They may need to insulate themselves for a bit. Taking a break from birth-related groups for a while can be healthy and self-protective; she can return when she is ready.

Of course, not every support resource is perfect. Encourage CBAC mothers to be careful about whom they seek support from. Many well-meaning people say hurtful things like, “Just be grateful you got a healthy baby,” or “You’re just lucky you didn’t die!” CBAC mothers need to find support that will not inadvertently trigger or hurt them more.

Acknowledge Unique Circumstances

Each CBAC is unique, and each may carry its own particular color of pain.

Some women had CBACs because their providers suddenly withdrew support for VBAC at the end of pregnancy or during labor. Some faced so many interventions and conditions during their labors that a CBAC seemed almost inevitable. Some experienced mistreatment and abuse during their experience.

On the other hand, some women had very supportive providers but still ended with a CBAC. Others felt they had a “prudent CBAC,” a difficult but sensible choice because of fetal distress, poor fetal position, rising blood pressure, or other complications. Some had an “empowered CBAC,” where there was powerful learning and healing to help balance the disappointment.

Some women have multiple CBACs, each with their own emotional resonance. Some have a VBAC and then a CBAC, which has its own particular pain. A few have had the bitter experience of having lasting physical and emotional damage from their CBAC, including uterine rupture, hysterectomy, or loss of their baby.

As always, each person’s experience is different, and each CBAC mother needs their unique experiences honored.

“Try on” a CBAC

“Trying on” a CBAC can help birth professionals have a deeper empathy for the unique grief of a CBAC mother.

Consider what it might feel like to have a CBAC. Let yourself feel what it might be like to hope and dream for a VBAC and then not have one, to have to tell everyone afterwards that you didn’t VBAC after all, to listen to the naysayers who believe your body really is broken and who tell you that you should have just scheduled a cesarean section, to listen to other women’s easy birth stories and feel envious all the time.

Walking in someone else’s shoes for a while gives people a better appreciation for the difficulties and the bittersweet feelings surrounding disappointing life events. More empathy for CBAC mothers is definitely needed in the birth community.

Contact the Mother Periodically to Check In

CBAC is a bit of an emotional rollercoaster and feelings will change over time. The way the mother feels immediately after a CBAC will probably not be the same as a few months or a year later. Check in with her periodically to see how she is feeling about everything and whether there is any way you can support her further. This is especially important for CBAC mothers who have experienced a major trauma.

It’s not unusual for CBAC mothers to experience emotional upset around the six month mark, on the child’s first birthday, or even later. A quick check-in can affirm that someone remembers and cares about what she is going through.

Discuss Future Pregnancies

Another common point of emotional crisis for CBAC mothers is when the mother considers having another child. At that time she revisits her fear and trauma from past births, decides whether to have more children, and if so, may be torn over whether to choose a repeat cesarean or another VBAC trial of labor (TOL).

Although conventional medical wisdom holds that once a woman has had a CBAC, she has shown she cannot birth vaginally, the reality is that a number of CBAC women go on to have a VBAC in future pregnancies, and the American College of Obstetricians and Gynecologists (ACOG) is supportive of VBAC after two cesareans. Women who choose a TOL in this situation may need particularly strong emotional support as they work through their fears and concerns from both a primary cesarean and a CBAC.

However, it’s also important to remember that sometimes a VBAC is truly medically contraindicated, the woman is done having children, or does not wish another TOL. Although VBAC is no longer an option, that doesn’t mean these women are at peace with past or future CBACs. They may still need support too. Little research has been done on how to support this group as they integrate their experiences into their lives. In particular, information is needed on how to support women who experienced significant emotional trauma during birth (Beck and Watson, 2010).

Believe That Healing Can Be Had

Life gives us all disappointments and sometimes these remain bittersweet forever. As with other griefs, you never truly “heal” from a CBAC; the disappointment and loss of that birth is always there, and it never goes away. However, birth professionals need to communicate that – with time and distance – women often come to some sort of peace with the experience.

If given the chance to process their feelings thoroughly, women eventually have enough distance from it to not grieve as sharply, to find lessons or growth in the experience, and to be able to integrate the disappointment of it into their lives.

Some transform the power of the CBAC experience into advocacy, becoming health care workers themselves or advocates in birth-related fields. Others practice micro-advocacy by informally helping birthing women they encounter in their personal lives.

Women don’t have to ever be grateful for their CBACs, but in time they can recognize that good things can spring from difficult things, and that great trauma can lead to great growth. The process is not quick or facile, but it can happen. And birth professionals can be a vitally important part of that process.

“My joy [in my births] has gradually returned. I am learning now to honor my experiences…We are not failures, we are no less brave than the women who accomplish the VBAC goal. I keep reminding myself that I will never climb Mount Everest, either, and will probably not accomplish some of the other things I think I want in my life. Maybe this missed childbirth opportunity is just that ─ another missed opportunity ─ and maybe we can find some other accomplishments/ life experiences to compensate. Maybe.”       -K

“Today, 12.5 years after my first CBAC, I can honestly say how much growing and learning came from it and for that I am grateful.” -Teresa Stire

“My CBAC made me the compassionate advocate I am today.” -Melek Speros

Resources for CBAC Mothers

Here are a few select resources that may be helpful to CBAC mothers. If you know of more, please add them in the comments section.

CBAC Resources

CBAC Support Groups

General Birth Trauma Support Organizations

Articles on CBAC Recovery

Birth Trauma Articles



Beck CT, Watson S. Subsequent childbirth after a previous traumatic birth. Nurs Res 2010 Jul-Aug;59(4):241-9. PMID: 20585221

About Pamela Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 20 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.


Cesarean Birth, Childbirth Education, Guest Posts, Maternal Mental Health, Maternity Care, Medical Interventions, PTSD, Series: Supporting Women When a VBAC Doesn't Happen, Vaginal Birth After Cesarean (VBAC) , , , , , , ,

Series: Supporting Women When a VBAC Doesn’t Happen – Part Two: The Forgotten Mothers

November 10th, 2015 by avatar

By Pamela Vireday

“CBAC mothers have powerful lessons to teach, if you are willing and able to hear us.”  — Melek Speros

CBAC part 2We continue our current series on Cesarean Birth after Cesarean, written by Pamela Vireday, who is an occasional contributor to Science & Sensibility.  In this series, Pamela examines the topic of women who experience a Cesarean Birth after a Cesarean. This is when families are planning for a vaginal birth after a prior cesarean, but the birth does not go as planned.  The experiences of women who have a CBAC are often negated and their emotional and physical well-being given short-shrift by both professionals and their social community of friends and family.  The research on this topic is slim and begs for exploration by qualified investigators.  Last week, Pamela discussed the unique grief that CBAC women may experience. Today, Pamela examines the limited research available and part three (on Thursday) will provide information on how to support CBAC women in the absence of published research.  We will also conclude the series with a useful resource list to share with the families you may work with who find themselves in this situation.  You can also read a companion piece of Pamela’s own personal story, “Cesarean Birth after Cesarean, 18 Years Later” on her own website.- Sharon Muza, Community Manager, Science & Sensibility.


In Part One of the series – Supporting Women When a VBAC Doesn’t Happen, we discussed how women who work for a VBAC but end up with a cesarean have a unique grief that is different from that of a mother who has a primary cesarean or who chooses to have a repeat cesarean.

There is a pressing need for better support for CBAC mothers, but often birth professionals and family members have no idea how to go about offering this support. Does research have any insight on improving CBAC support to these women?

CBAC Research

Unfortunately, there has been very little research done on CBACs. Most VBAC-related research deals with VBAC rates, complications, cost-effectiveness, or the woman’s decision-making process. Women who choose VBAC but don’t end up with one are largely ignored in academic studies.

However, there are a few studies with implications for the CBAC mother, including those that address physical recovery and a few that address emotional recovery.

Physical Recovery

Most CBAC research focuses on physical morbidity, which can certainly have an influence on how a woman feels after a CBAC.

Although most CBAC mothers recover just fine, women who have a trial of labor cesarean do have higher rates of infectious morbidity, postpartum hemorrhage, hysterectomy, blood transfusions, and neonatal morbidities (El-Sayed 2007, Hibbard 2001, Durnwald and Mercer 2004).

One study found that 2.1% of women with a trial of labor experienced major maternal morbidity (Scifres 2011). How much more complicated is emotional recovery if the mother is also dealing with the aftermath of a serious infection, a sick baby, surgical injuries to nearby organs, anemia from a major hemorrhage, or heaven forbid, a uterine rupture, hysterectomy, or stillbirth?

The lesson here is that some mothers will be dealing not only with the disappointment of CBAC, but also with significant physical fallout afterwards. This can greatly complicate emotional processing, but sadly, these are often the mothers who receive the least emotional support afterwards. It’s as if their complications have made them toxic to the birth community because their experiences represent the rare worst-case scenarios no one wants to acknowledge.

The first step in helping a CBAC mother is to help her focus on her physical recovery, especially if there have been complications, even as you help her explore her emotions around the CBAC.

Emotional Recovery

There is only a small amount of research available on the emotional impact of CBACs. How do women feel about the CBAC experience? Do they regret having tried for a VBAC? Would they want to try again? What can be done to help women process the experience emotionally?

One study surveyed CBAC mothers.(Chigbu 2007) Not surprisingly, they found CBAC mothers, particularly those with no previous vaginal birth experience, often had feelings of:

  • Dashed expectations
  • Inadequacy as a mother
  • Frustration of experiencing the pain of both labor and surgery

Some women experience long-lasting trauma from birth. Although many people have written about Post-Traumatic Stress in childbirth, it is unclear from the research what the most effective approach is for dealing with PTSD in birth.

Some research indicates that Eye Movement Desensitization and Reprocessing treatment (EMDR) can be helpful (Sandström 2008, Stramrood 2012). However, research trials have been extremely small and limited in the childbirth field.

A recent Cochrane review (Bastos, 2015) concluded that there was little high-quality evidence for or against using debriefing interventions to prevent psychological trauma after childbirth. Still, many women find counseling helpful after a traumatic birth, and EMDR helpful if flashbacks are frequent or intrusive.

From anecdotal evidence, anger is a common theme among some CBAC mothers. They may be furious with care providers who let them down, with the seemingly random nature of birth fortunes, or with their bodies for “not working right”:

It was very important to me that someone recognize and validate my anger. I was SO FREAKING ANGRY!!!!! And I needed to hear, “You have every right to your anger!”    – Jer 

This kind of anger is uncomfortable for birth professionals to hear. We want women to have happy endings and just be enthralled with their babies. But denying anger doesn’t make it go away; it just makes it burrow down more destructively. Helping a mother speak her anger without taking it personally vents it and takes away some of its toxicity so that healing can start to take place.

Many CBAC mothers deal with a strong sense of shame and failure, of feeling broken. Health care providers make this worse when they blame women by telling them their pelvises are “too narrow,” their cervix is “horrible,” or that they have “too much soft tissue” around their vaginas. Health care providers must be careful in issuing judgments such as these because many women told these things have gone on to have vaginal births. More often it’s a case of “this baby, this birth, this time” didn’t work, not that the woman’s body is defective.

Some CBAC mothers obsess over the “what-ifs” of birth decisions or spend a lot of time analyzing what went wrong. This can be a way of asserting a sense of control over what feels uncontrollable. Analysis can sometimes be useful, but it also can lead to a never-ending rabbit hole of self-blame. Sometimes we just don’t know why birth turns out the way it does, and it can help when health care providers and birth professionals share this.

“Pregnancy/childbirth is one of the most unfair endeavors I’ve encountered. Realizing that has set me free in a way. If something as commonplace as childbirth has so many variations even despite what is actively chosen/done, then how can anything else in our lives go the way we want if we just. work. hard. enough. Life isn’t fair. Childbirth, the ease for some, the struggle for others, just isn’t fair. And that’s been liberating for me.”  – L  

Common Recovery Arcs

Recovery from a CBAC can be an emotional roller-coaster. Many women experience ambivalent feelings and these feelings can change considerably over time.

Immediately after a CBAC, some women are so traumatized that they need to process it immediately. Yet the people around them may feel threatened by any negative feelings around the birth; they don’t understand that women can love their babies but still feel upset about how the baby arrived.

Some CBAC women find a place of temporary peace about the experience. They may be reconciled to its necessity, or may simply need to focus first on the baby and put aside any other feelings. It may only be later that more ambivalent feelings rise up and must be dealt with.

Sometimes right after the birth, women wish they had just chosen a planned repeat cesarean. However, with time, this feeling changes for many CBAC women. One study found that, while women were disappointed at not having a VBAC, 92% of CBAC women “were pleased that they had attempted a vaginal birth” (Cleary-Goldman, 2005). The authors concluded that “Although the most satisfied patients were those who succeeded at vaginal birth, most women valued the opportunity to attempt a vaginal birth regardless of outcome.”

This result was also found by Phillips (2009). Indeed, Chigbu (2007) noted, “This survey revealed that most women still would prefer to be delivered vaginally after 2 previous cesarean deliveries.”

What few surveys have been done show the emotional impact a CBAC can have, but the topic is glaringly understudied. More research is urgently needed on the experiences of CBAC mothers and what can be done to help support them.

In the absence of research to guide us, we must trust what CBAC women tell us they need. More on that in Part Three of the series on Thursday.


Bastos MH, Furuta M, Small R, McKenzie-McHarg K, Bick D. Debriefing interventions for the prevention of psychological trauma in women following childbirth. Cochrane Database Syst Rev. 2015 Apr 10;4:CD007194. doi: 10.1002/14651858.CD007194.pub2. PMID: 25858181

Chigbu CO, Enwereji JO, Ikeme AC.  Women’s experiences following failed vaginal birth after cesarean delivery. Int J Gynaecol Obstet 2007 Nov;99(2):113-6.   PMID: 17662288

Cleary-Goldman J, Cornelisse K, Simpson LL, Robinson JN. Previous cesarean delivery: understanding and satisfaction with mode of delivery in a subsequent pregnancy in patients participating in a formal vaginal birth after cesarean counseling program.  Am J Perinatol. 2005 May;22(4):217-21.  PMID:15906216

Durnwald C and Mercer B.  Vaginal birth after Cesarean delivery: predicting success, risks of failure. J Matern Fetal Neonatal Med 2004 Jun;15(6):388-93.  PMID:15280110

El-Sayed YY, Watkins MM, Fix M, Druzin ML, Pullen KKM, Caughey AB.  Perinatal outcomes after successful and failed trials of labor after cesarean delivery. American Journal of Obstetrics and Gynecology 2007 Jun;196(6):583.e1-5; discussion 583.e5.  PMID: 17547905

Hibbard JU, Ismail MA, Wang Y, Te C, Karrison T, Ismail MA. Failed vaginal birth after a cesarean section: how risky is it? I. Maternal morbidity.  American Journal of Obstetrics and Gynecology.  2001 Jun;184(7):1365-71; discussion 1371-3.  PMID: 11408854.

Phillips E, McGrath P, Vaughan G.  ‘I wanted desperately to have a natural birth’: Mothers’ insights on Vaginal Birth After Caesarean (VBAC).  Contemporary Nurse 2009 Dec-2010 Jan:34(1):77-84. PMID: 20230174

Sandström M, Wiberg B, Wikman M, Willman AK, Högberg U. A pilot study of eye movement desensitisation and reprocessing treatment (EMDR) for post-traumatic stress after childbirth. Midwifery. 2008 Mar;24(1):62-73. Epub 2007 Jan 12. PMID: 17223232

Scifres CM, Rohn A, Odibo A, Stamilio D, Macones GA.  Predicting significant maternal morbidity in women attempting vaginal birth after cesarean section.  Am J Perinatol 2011 Mar;28(3):181-6. PMID:  20842616

Stramrood CA, van der Velde J, Doornbos B, Marieke Paarlberg K, Weijmar Schultz WC, van Pampus MG. The patient observer: eye movement  desensitization and reprocessing for the treatment of posttraumaticstress following childbirth. Birth. 2012 Mar;39(1):70-6. doi: 10.1111/j.1523-536X.2011.00517.x. Epub 2011 Dec 19. PMID: 22369608

About Pamela Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 20 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.


Cesarean Birth, Childbirth Education, Guest Posts, Maternal Quality Improvement, Maternity Care, Medical Interventions, Research, Series: Supporting Women When a VBAC Doesn't Happen , , , , , , ,

Looking Back in Time: What Women’s Bodies are Telling Us about Modern Maternity Care

June 18th, 2015 by avatar

By Christina Gebel, MPH, LCCE, Birth Doula

Christina Gebel, MPH, LCCE, Doula writes a reflective post examining current birthing conditions to see how today’s practices might be interfering with the the normal hormonal physiology and consequently impacting women’s ability to give birth.  Times have certainly changed and birth has moved from the home to the hospital.  A slow but steady increase in out of hospital births is examined and Christina asks us to consider why women are increasingly choosing to birth outside the hospital – and what do hormones have to do with it? – Sharon Muza, Science & Sensibility Community Manager

“Pregnancy is not a disease, but a beautiful office of nature.” These are the words of Victoria Woodhull, the first female candidate for President of the United States in 1872.

Lajja_gauri ancient birth art

© “Lajja gauri

The world in which pregnant women find themselves today looks a lot different than the time of Woodhull’s campaign run. For instance, hospitals didn’t become the mainstream setting for labor and delivery until the 1930s and 40s. While modern medicine has undoubtedly helped millions of women who may have otherwise died in childbirth, mothers and birth advocates across the nation are beginning to ask if we are paying a price for today’s standard maternity care. With increasing protocols and interventions, pregnancy is viewed less like the office of nature Woodhull spoke of and more like a pathological condition.

The Hormonal Physiology of Childbearing, a recent report by Sarah Buckley, systematically reviews existing research about the impact that common maternity practices may have on innate hormonal physiology in women and fetuses/newborns. The report finds strong evidence to suggest that our maternity care interventions may disturb these processes, reduce their benefits, or even create new challenges. To find out more, read an interview that Science & Sensibility did with Dr. Buckley when her groundbreaking report was released.

Let’s examine something as simple as the environment that a woman gives birth in. In prehistoric times, laboring women faced immediate threats and dangers. They possessed the typical mammalian “fight-or-flight” reaction to these stressors. The hormones epinephrine and norepinephrine caused blood to be diverted away from the baby and uterus to the heart, lungs, and muscles of the mother so that she could flee. This elevation in stress hormones also stalled labor, to give the mother more time to escape. Essentially, she told her body ‘this place is not safe,’ and her body responded appropriately by stopping the labor to protect the mother and her child during a very vulnerable time.

Today, mothers are not fleeing wild animals but rather giving birth in hospitals, the setting for nearly 99% of today’s births, where this innate response may cause their labor to stall. The sometimes frenetic environment or numerous brief encounters with unfamiliar faces may trigger a sense of unease and, consequently, the fight-or-flight response, stalling the mother’s labor. Prolonged labor in a hospital invariably leads to concern and a need to intervene, often by the administration of Pitocin, synthetic oxytocin, to facilitate regular contractions. Arrested labor could lead to further interventions up to and including a cesarean section. The fight-or-flight response may be further reinforced by these interventions, as they potentially come one after the other, in what is often referred to as the “cascade of interventions.”

This is just one example of how a woman’s body’s natural physiology can go from purposeful to working against the labor, the mother and the baby. Epinephrine and norepinephrine are both necessary in labor and delivery. In fact, at appropriate levels, these hormones support vital processes protecting the infant from hypoxia and facilitating neonatal transitions such as optimal breathing, temperature, and glucose regulation, all markers for a healthy infant at birth.

Recent data show that mothers themselves may already think what the Hormonal Physiology of Childbearing report suggests. The series of Listening to Mothers (LtM) studies, a nationally-representative survey of childbearing women, shows a shift in mothers’ attitudes towards normal physiologic birth: In 2012, 58% of mothers agreed somewhat or strongly that giving birth is a process that should not be interfered with unless medically necessary, up from 45% in 2000. According to 2013 national birth data, out-of-hospital (home and birth center) births have increased 55% since 2004, but the overall percentage is still only 1.35% of all births nationwide. While low, this shows that a small core of mothers are voting with their feet and choosing to give birth out of the hospital. Though their choice may seem extreme, they’re not alone. In the LtM data, which only surveys women who have given birth in a US hospital, 29% of mothers said they would definitely want or would consider giving birth at home for a future birth, and 64% said the same of a birth center. All this raises the question: What’s happening in a hospital that is leading mothers to consider other settings for their next birth?

One answer to upholding women’s preferences, autonomy, and the value of normal physiologic birth is a mother’s involvement in shared decision making with her provider, along with increasing access to models of care that support innate physiologic childbearing, like midwives in birth centers. Increasing access to these options may present a challenge, as demand seems to outweigh availability.

Leslie Ludka (MSN, CNM) has been the Director of the Cambridge Health Alliance Birth Center (Cambridge, Mass.) as well as the Director of Midwifery since 2008. Like other birth centers, the center has seen a steady increase in demand each year, with patients coming from all over New England. Ludka sees many barriers to having more birth centers available including finances (the reimbursement for birth not being comparable to an in-hospital birth), “vacuums in institutional comprehension” of the advantages of the birth center model for low-risk women, and the rigorous process to be nationally certified by the Commission for the Accreditation of Birth Centers (CABC), requiring “a great commitment and a lot of support by all involved.” In order to overcome these barriers, Ludka suggests marketing the safety of birth centers to the general public, sharing outcome statistics for women and infants cared for in birth centers, and educating insurers and providers about the overall benefits and financial savings of midwifery and the birth center model. With supportive policy and better understanding on the part of insurers, the public, and healthcare institutions, models like the birth center could become more plentiful, more easily meeting the demand.

Women’s bodies are sending subtle messages that our current healthcare system is, at times, not serving their needs. It’s time to respond to these messages, beginning by viewing childbirth foundationally as a life event and not first as pathology, and adapting our models of care to speak to this viewpoint. If we fail to do so, we run the risk of creating excess risk for women and newborns.

It’s been 143 years since Woodhull ran for president. We’ve made progress in getting much closer to seeing our first woman president, but with childbirth, perhaps our progress now starts with looking back in time.

About Christina Gebel

© Christina Gebel

© Christina Gebel

Christina Gebel holds a Master of Public Health in Maternal and Child Health from the Boston University School of Public Health. She is a birth doula and Certified Lamaze Childbirth Educator as well as a freelance writer, editor, and photographer. She currently resides in Boston working in public health research. You can follow her on Twitter: @ChristinaGebel and contact her through her website duallovedoula.com

Childbirth Education, Guest Posts, Home Birth, Maternity Care, Medical Interventions, Midwifery , , , ,

American Obstetrician Takes Rational Position on Home Birth

June 16th, 2015 by avatar

Neel Shah, Harvard Medical School assistant professor and practicing obstetrician, commenting in the New England Journal of Medicine Perspectives section –  “A NICE Delivery – The Cross-Atlantic Divide over Treatment Intensity in Childbirth“, agrees with new United Kingdom National Institute for Health and Care Excellence (NICE) guidelines concluding that healthy, low-risk women are better off at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician. Citing a table comparing outcomes in low-risk multiparous women from the Birthplace in England data, Shah writes:

The safety argument against physician-led hospital birth is simple and compelling: obstetricians, who are trained to use scalpels and are surrounded by operating rooms, are much more likely than midwives to pick up those scalpels and use them. For women giving birth, the many interventions that have become commonplace during childbirth are unpleasant and may lead to complications . . . .

He quite reasonably adds the caveat that the guidelines apply to low-risk women only and that even these women may develop labor complications without warning, but then, responsible home birth advocates acknowledge those same two points. That being said, I can’t resist adding a couple of caveats of my own.

© Families Upon ThamesFirst, one reason why women with risk factors plan home birth, women with prior cesareans being a common example, is that doctors and hospitals deny them the possibility of vaginal birth (Declercq 2013). With their only hospital alternative being unwanted and unneeded cesarean surgery, planned home birth becomes their least, worst option. This dilemma puts their choice squarely in the lap of the medical system. Another reason is that some women have been so emotionally traumatized by their treatment during a previous birth that they reject planned hospital birth and refuse intrapartum transfer even when this may be the safer option (Boucher 2009; Symon 2010). Again, the failure and its remedy lie with the system, not the woman.

Second, if the hospital lacks 24/7 obstetric, anesthesia, and pediatric coverage and at least a Level 2 nursery, which many do, then a woman is probably no better off in the hospital in an emergency than she would be at home or at a freestanding birth center. Furthermore, most urgent situations—a baby who doesn’t breathe, excessive bleeding, even umbilical cord prolapse—can be managed or stabilized by a properly trained and equipped home birth attendant. In fact, what would be done in the hospital is no different from what would be done at home: neonatal resuscitation, oxygen, medications to stop bleeding, maternal knee-chest position and manually holding the fetal head off the cord until cesarean.

Finally, with admirable frankness, Shah notes that unlike the U.K., and to the detriment of safety, “[A]ccess to obstetric care that is coordinated among homes, birthing centers, and hospitals is both unreliable and uncommon.” And while he doesn’t cast any blame, once more, the fault lies with the system. (Just as an FYI, a model guideline for transfer of care developed by a workgroup that included all stakeholders is publically available.)

Shah concludes: “The majority of women with straightforward pregnancies may truly be better off in the United Kingdom.” True that, but it doesn’t have to be that way. Dialing back the overuse of medical intervention and cesarean surgery; respecting the woman’s right to give informed consent and refusal; implementing a culture of care that is kind, compassionate, and respects a woman’s dignity; and ensuring that out-of-hospital birth attendants can consult, collaborate, and transfer care appropriately would have two benefits: it would reduce the number of women refusing hospital birth while minimizing the chance of adverse outcomes in those who continue to prefer to birth at home or in a freestanding birth center. Nonetheless, despite the generally positive responses accompanying Shah’s commentary, rather than inspiring a wave of reform, I would lay odds that the more common reaction to Shah’s piece within the medical community will be to shoot the messenger.


Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health, 54(2), 119-126.

Declercq, E., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, Ariel. (2013). Listening to Mothers III. Pregnancy and Birth. New York: Childbirth Connection.

Symon, A., Winter, C., Donnan, P. T., & Kirkham, M. (2010). Examining autonomy’s boundaries: a follow-up review of perinatal mortality cases in UK independent midwifery. Birth, 37(4), 280-287.

About Henci Goer

© Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.

Evidence Based Medicine, Guest Posts, Home Birth, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery , , , , , ,

Jazz It Up! Using Haiku Deck to Create Snappy Image-Based Presentations

March 3rd, 2015 by avatar

By Jocelyn Alt, CD(ToLabor), MBA

 My favorite way to teach is using interactive, engaging activities that get my families building community with each other, interacting with class members, actively partipating rather than passive listening and often up and out of their seats.  Sometimes, it does become necessary to use a presentation format to present a topic.  Alternately, using such a format can help reinforce one of the activities you are doing in class.  Today on Science & Sensibility, CBE and doula Jocelyn Alt shares a tool, Haiku Deck, that she uses to create interesting presentations to use in her childbirth classes.  Jocelyn reviews it here and shares some of her recent presentations. – Sharon Muza, Science & Sensibility Community Manager.

Some of my most rewarding moments as a childbirth educator are times when former participants share stories about using skills or information during their births that they learned in class. It might be a squatting position we practiced, the benefits and risks of narcotics as pain relief that we teach using an interactive game, or the BRAIN acronym for making informed decisions (see below if you are unfamiliar with this rubric.) My team of educators and I are always looking for new ways to make our classes more engaging and memorable so that our students will have a higher likelihood of recalling the information when they need it most – during labor.

Haiku Deck – reinforcing learning

It’s been known for eons that using images reinforces learning (it’s been said so often, the adage is hackneyed: “A picture is worth a thousand words.” But it’s often true!) So I was excited when I recently found out about a tool that allows you to create beautiful image-based slide presentations in a snap. It’s called Haiku Deck. Presentations created with this program can be used in conjunction with interactive activities as an introduction or backdrop, or alongside lecture components of class.

© Jocelyn Alt

© Jocelyn Alt

Here is an example of a presentation created with Haiku Deck: Top Five Tips for New Moms. If you click on the deck and view it on the Haiku Deck site, you can also see the notes that accompany each slide. After looking at the presentation, try testing its effectiveness on yourself. How many images do you remember from it? How many of the messages do you remember? How many do you think you would have remembered if you had simply seen them presented as text in a bulleted list?

Here’s another Haiku Deck for the acronym BRAIN: Five Essential Questions for Decision-Making in Labor, which I use to teach informed decision making. Each letter of the Screenshot 2015-03-02 16.22.22acronym stands for a question laboring parents can ask themselves and their care providers when faced with a decision in labor – or at any other time for that matter. One dad said that he found it so useful, he started using it as a decision-making tool at work! The acronym stands for Benefits, Risks, Alternatives, Intuition, and Need Time. Acronyms themselves can help with recall, and reinforcing them with images can make them even more sticky.

What I like about Haiku Deck

Ease of Use – The interface is elegant and simple to use.  One great feature is the huge library of images.  You just type in a word that relates to your content, and dozens of photos come up for your use.  With one click, you can add them to your presentation.

Effectiveness – The structure of Haiku Deck forces you to be concise with your words and use images to communicate much of your message. The result is presentations that connect to people.  Many of the most popular slide decks on the large presentation posting site SlideShare were made with Haiku Deck because they draw people in and are memorable.

Accessibility – You can use Haiku Deck to make presentations in a browser on your computer or through the iPad app. Presentations are all backed up on the Haiku Deck site and can be embedded into websites and social media, so you can easily make them available to your participants to reference outside of class.

Just for fun, here’s one last Haiku Deck on the Six Signs of Labor Progression.

Screenshot 2015-03-02 16.32.49

If you try Haiku Deck in your classes, I’d love to see any presentations you develop. Drop the links in the comments section below and let us know if you found the program easy or difficult to use and a bit about your experience.


Defetyer, M. A., Russo, R., McPartlin, P. L. (2009). The picture superiority effect in recognition memory: a developmental study using the response signal procedure.Cognitive Development, 24, 265-273. doi: 10.1016/j.cogdev.2009.05.002

Foos, P.W., & Goolkasian, P. (2005). Presentation formats in working memory: The role of attention. Memory & Cognition, 33(3), 499-513.

Shepard, R.N. (1967). Recognition memory for words, sentences, and pictures. Journal of Learning and Verbal Behavior, 6, 156-163.

About Jocelyn Alt

© Jocelyn Alt

© Jocelyn Alt

Jocelyn Alt, CD, MBA, is a childbirth educator and birth doula who has been working with expecting and new parents since 2006. Jocelyn is the Founder and Director of Ohana, a birth and parenting services company with locations in Chicago and Seattle that offers childbirth classes, prenatal yoga, doulas, new parent groups, and maternity concierge services. The word ohana means “family” in Hawaiian and refers to one’s inner circle of both family and close friends. In addition to helping parents-to-be transition to parenthood, Jocelyn enjoys hiking, cycling, and hosting dinner parties. She lives in Seattle, WA.  Reach Jocelyn through her website  www.OhanaParents.com.




Childbirth Education, Guest Posts , ,

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