Most women plan to give birth vaginally, yet more than one in three babies are born by cesarean in the United States. There are many things you can do prenatally and in labor to help to lower your risk of cesarean.

Start by asking your provider what his or her cesarean rate is, and compare that to others in your area. The World Health Organization says a cesarean rate of ten to fifteen percent is optimal; rates above that increase the risk for mother and babies. While very few American providers have rates that low, the American College of Obstetricians and Gynecologists (ACOG) came out with new recommendations for obstetricians last year in which they strongly urge obs to lower their cesarean rates to make birth safer for mothers and babies.

We’ve long know that cesareans increase the mother’s risk due to higher rates of infection, hemorrhage, and the risks of anesthesia. Newer research is also focusing on the risks to cesarean born babies, including higher rates of allergies and asthma. This may be because they don’t have the opportunity to be colonized by their mothers’ vaginal fauna. Cesareans can also initially complicate breastfeeding and require a longer recovery time. Having a cesarean increases the chances that a woman’s next baby will also be born by cesarean, and the surgical risks increase with each cesarean birth.

“I would absolutely recommend other women to seek a Vaginal Birth After Cesarean (VBAC), and I’d certainly recommend birthing vaginally.” says Jennifer Heller, a mother I spoke with who has had given birth twice vaginally and once by cesarean. Her cesarean was medically indicated and she has no regrets about it, but she told me “At a very visceral level, experiencing my body give birth vaginally to a baby has empowered me in ways I don’t even fully understand. Not to mention the recovery was so much easier!”

One of ACOG’s recommendations for how providers can lower cesarean rates is to work with doulas. A doula’s presence has long been known to lower the rates of interventions including cesareans. She can suggest labor positions and techniques, answer questions and provide reassurance, and help your partner to support you. Women who birth with doulas are more likely to delay or avoid an epidural, which reduces their cesarean risk. A doula’s presence is calming; the calmer you are in labor, the less likely it is that your labor will stall or your baby will go into distress. While doctors, midwives, and nurses are usually on shifts, your doula is a familiar face you can count on to be at your labor, and she’ll be there for the entire time. She can come to your home in early labor if you want her to, go to the hospital with you (the car ride is often a challenging time in labor) and be with you until you are settled in your postpartum room.

I asked Liz Libby, who birthed twins by cesarean and went on to give birth to her third baby vaginally, how having a doula made a difference at her vaginal birth. She told me “having great birth support is really important, and my doulas got me through a lot. I’m not sure I could have done it without them.” Ask your friends and family with young children if they can recommend a doula, or seek suggestions from your childbirth educator, prenatal yoga instructor, or midwife.

In its statement ACOG changed the definition of active labor, saying that now it doesn’t start until six centimeters dilation. This change means women should be staying at home in labor longer. The more established your labor is when you come into the hospital, the less likely you will be sent home, or given drugs such as pitocin to speed up your labor. Labor inductiondoubles a mother and baby’s risk of cesarean, so ACOG is also encouraging providers not to do any non-medical inductions before forty-two weeks.

Take Care of Yourself During Pregnancy
Taking care of yourself prenatally will help to ensure that your baby is born vaginally. Focus on exercising regularly, staying hydrated (dehydration can lead to preterm labor), and looking for ways to reduce your stress levels, such as getting outdoors, sleeping enough, practicing meditation or yoga, warm baths, and treating yourself to a prenatal massage.

Nutrition
Excellent nutrition is so important. Today you are growing your baby’s brain, heart, liver. While reading labels is important, the best food has no labels: a glass of milk, homemade chili, a bunch of grapes. Shop the perimeter of the grocery store, through produce, dairy, meat, and the bakery, and try to avoid the middle isles where the heavily processed foods are. Eat a whole grain, a protein, and a fruit or vegetable at each meal. Simple changes like whole wheat bread instead of white on your sandwich, or a fruit yogurt midmorning instead of a fruit Danish, make a difference.

Childbirth Class
Take an in depth childbirth class. When possible, learn from an independent instructor, not one who teaches for hospital or doctor’s practice. She’ll be able to provide you with an unbiased view of practices and policies, and because she works for you, will only be responsible to you. Practicing contraction rituals and support techniques in class and at home, including massage, positions, hot/cold therapy, and use of the birth ball and rebozo, will give you lots of tools to use in labor. Learning informed consent and decision making skills will help you to make decisions in labor that will create a satisfying birth experience. The Listening to Mothers Survey has shown that understanding interventions and truly consenting to them is essential for postpartum birth satisfaction. If possible, tour more than one hospital to learn about different options in your community.

If your baby is breech after thirty-two to thirty-four weeks, consider alternative options to encourage him or her to turn. Hypnotherapy, acupuncture, and chiropractic adjustment have all been shown to be effective. Turning your baby, when possible, is important because few American women have the option of vaginal breech births. Discuss manual version with your provider.

Many pregnant women who have had cesareans want to give birth vaginally (VBAC) to their subsequent babies, in part because while the risk increases with each cesarean, it decreases with each VBAC. The non-profit International Cesarean Awareness Network (ICAN) is a volunteer-run organization which supports moms by preventing unnecessary cesareans through education, providing support for cesarean recovery, and promoting VBAC. They provide free meetings where women can discuss pregnancy, labor and birth, postpartum, share birth stories, and hear guest speakers. I spoke with Kira Kim, the leader of the Eastern Massachusetts ICAN chapter about ICAN, and she told me “as a mother that had cesareans with my first two, and a natural birth with my third, the group and its mission are close to my heart. ICAN is a great way to learn about VBAC both through education and access to local resources.”

I asked Liz Libby, mother of three, why a VBAC was important to her. She told me,”I have always felt that birth is a tremendous formative experience in a woman’s life, and I felt I was robbed of it the first time around. With my twins, I had a high-risk pregnancy, and was highly managed by physicians who seemed not at all concerned with my experience of birth. I wanted something different the second time: a safe, peaceful, normal birth with care providers who were knowledgeable, caring, and concerned with my experience. Having the right care provider, for me it was midwives in a homebirth setting, made all the difference. I cannot stress enough how important it is to find a care provider who is 100% on board with your VBAC plan. This goes for any mom looking to have a vaginal birth as well. I know my VBAC would not have happened with a different care provider. “

Jennifer Heller, another VBAC mom I spoke with echoes this. “When I was pregnant with my third child, I was confident that a vaginal birth was the best thing for myself and my baby. There was never any doubt in me that I could have a vaginal birth again, but I didn’t want to have to argue about it with providers. Having a provider who supported me and a husband who also had confidence in the birth process helped me worry less. I found a doula who was lovely. I just needed folks around me who shared my confidence.”

Julie Brill, CCCE, CLD teaches natural childbirth and VBAC classes in the Boston area and via Skype. She offers Prepare for Cesarean Birth, Heal Faster phone workshops and trains childbirth educators and labor doulas for CAPPA. She is the author of the anthology Round the Circle: Doulas Share Their Experiences.