Dr. Rebecca Dekker – 00:00:00:
Hi, everyone. On today’s podcast, we’re going to talk about the top 10 evidence-based ways to lower your risk of having a Cesarean birth. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Decker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.Â
Hi, everyone and welcome to today’s episode of the Evidence Based Birth® podcast where we’re going to talk about the top 10 evidence-based ways to lower your risk of Cesarean birth. Before we get started with today’s episode just a quick reminder that this is the last week to get on the waitlist for early bird registration for the 2025 Evidence Based Birth® conference. This early bird registration opens on January 22 for the waitlist only. We will have special bonuses and ticket opportunities that are only available to the waitlist. So, make sure you get on the waitlist at ebbirth.com/waitlist for all the latest info and details sent to your inbox. The Evidence Based Birth® conference will be happening virtually in March 2025.Â
My co-host for today’s podcast episode is Morgan Richardson Cayama, and together we’re excited to talk about evidence-based strategies and options that someone can use to lower their risk of having a Cesarean birth. The information in this podcast episode was originally published as a table inside our recent full-length Signature Article on the ARRIVE trial and elective inductions at 39 weeks. You can access that entire article, including the table about lowering the risk of Cesarean, all of the scientific references, and a free two-page printable handout at ebbirth.com/ARRIVE. Morgan Richardson Cayama, pronouns she, her, is a doctoral candidate in public health and an EBB research fellow and she is going to co-host today’s podcast with me. Morgan helped co-author the Signature Article on the ARRIVE Study and elective inductions at 39 weeks, and she was also co-host on our podcast episode number 334 on that topic.Â
So talking about the ARRIVE trial, you might recall that the purpose of that study was to compare elective induction at 39 weeks of pregnancy to expectant management, and expectant management is a wait-and-watch approach to birth where you wait to see if labor will begin on its own, or spontaneously. Some people who are following expectant management in the ARRIVE trial might have ended up having an induction after 39 weeks if there was a health issue or if their pregnancy went past 41 weeks. One of the big findings from this study that the authors talked a lot about was that the people in the group who were electively inducted at 39 weeks had a lower rate of Cesarean. Specifically, the ARRIVE trial researchers reported that participants who were randomly assigned to elective induction at 39 weeks had a Cesarean rate of 18.6% compared to 22.2% among those randomly assigned to expectant management. This translates to a 3.6% lower absolute risk of having a Cesarean. While we were writing the Signature Article about the ARRIVE trial, Morgan and I felt it was important to dedicate a section to alternative ways you can lower the risk of Cesarean birth that don’t involve an elective induction. So, many of the strategies that we’re going to cover in this podcast and that we covered in the article are much more affordable and less invasive than an elective induction at 39 weeks, and many of these strategies have been found to lower the risk of Cesarean by much more than what they found in the ARRIVE trial with elective induction. So Morgan was reviewing the research on some of these other strategies and we ended up developing an important table in the ARRIVE trial Signature Article to present some of this information. And today we thought it would be helpful for you to focus on what we believe are the top 10 evidence-based ways to help prevent a preventable Cesarean birth. Morgan, we’re so happy to have you back as a co-host.
Morgan Richardson Cayama – 00:03:28:
Yeah, thanks so much for having me back. I am really excited to be diving deeper into this topic with you and with everyone today. And before we do get into it, Rebecca and I really want to acknowledge that not all Cesareans are preventable. Some are medically necessary and even life-saving for birthing people and their babies. Also, some families want an elective Cesarean, and that is completely their choice. However, we also do want to acknowledge that a Cesarean is a major abdominal surgery, and it is one of the most really intensive medical interventions that can happen during birth. And so for this reason, many families are interested in learning ways to lower their risk of having a Cesarean for personal or health reasons. And so our plan for today’s episode is to present, again, some of these top evidence-based ways to lower the risk of Cesarean birth for birthing people and families who are interested in having a vaginal birth or letting labor begin spontaneously. And we’ll also be talking about how common some of these different evidence-based ways are or their routine use, as well as their effectiveness and some other considerations or things to be aware of. And so Rebecca, actually, could you do us the honors and start us off by telling us what is the first evidence-based way that families can reduce their risk of Cesarean birth?
Dr. Rebecca Dekker – 00:04:37:
Of course. So the first strategy or tip that we have to lower the risk of Cesarean birth is to find and receive care from a healthcare provider who has a low Cesarean rate and someone who is patient with you, who will give you enough time in labor and while pushing. So something I think is important for all our listeners to know is that Cesarean rates vary widely by provider. And this is true even for providers who work in the same hospital, the same birth setting, or even in the same clinic. For example, in one hospital, you might have a doctor with a Cesarean rate of 30% and another doctor in that same hospital with a rate of 20%. And unfortunately, most providers, both here in the U.S and around the world, do not publicly report their own individual Cesarean rates in their practice. So it’s really important if you’re interested in having a vaginal birth that you have a conversation early on with your provider to find out more about their specific attitude and approach toward a Cesarean. So you can be honest and say something like, I really want to be given every opportunity to have a vaginal birth and ask some questions like, what is your attitude towards Cesareans? Do you give your patients every opportunity to have a vaginal birth before you recommend a Cesarean? And one of my favorite questions, out of the last 10 patients, how many ended up having a Cesarean in their birth? So not surprisingly, we have research showing that your healthcare provider’s attitudes towards Cesarean and towards birth in general influences their individual Cesarean rates.Â
For example, in one study, healthcare providers with more positive attitudes towards Cesareans where they preferred them and liked doing them had higher Cesarean rates, specifically for every one point increase in their positive attitude towards Cesareans, indicating a stronger preference for Cesareans, their Cesarean rate for low-risk first-time birthing people also went up. So again, it’s really important if you’re interested in having a vaginal birth and lowering your risk of Cesarean, that you find a healthcare provider who is truly supportive of this. Along these same lines, it’s important to find a healthcare provider who is patient with you and will give you enough time in labor. This is especially true if you end up with a labor induction, which could take 24, 48, or 72 hours or longer. And unfortunately, some care providers don’t give people enough time in labor before they diagnose them with something called failure to progress, which we have a whole Signature Article on at ebbirth.com/failuretoprogress. They also might not give you enough time during an induction. And these are very common reasons for Cesareans, both failure to progress and failed inductions. There’s professional guidelines like those from the American College of Obstetricians and Gynecologists that currently are encouraging providers to give their patients adequate time during labor. And studies have shown that providers who follow these updated guidelines to give people more time in labor and while pushing have much lower rates of Cesareans in their practice compared to providers who do not follow these guidelines. However, I do want to acknowledge not everyone who is listening to this is able to choose their own care provider or they might not have options for care providers in their area to choose from. So really whether or not you can follow this first tip is dependent on the health care system in which you’re giving birth, whether you have private or public health insurance coverage and who you have access to as providers and the availability of different providers in your community. So this kind of takes us to our next evidence-based strategy for lowering the risk of Cesarean. Can you tell us what that is, Morgan?
Morgan Richardson Cayama – 00:08:34:
Yeah, of course. So the second evidence-based way to reduce your risk of Cesarean is actually to receive midwifery-led care. And this is backed by multiple studies. So for example, in one study in the U.S, they found a 30% decrease in the relative risk of Cesarean among people giving birth for the first time whose hospital care was led by a midwife compared to an obstetrician. And so this likely has to do with differences between how midwives and obstetricians practice, where the midwifery model of care tends to be more focused on patient autonomy and less use of interventions. And obstetricians follow a more typical medical model of care, and they might have a tendency to recommend more interventions and efforts to prevent rare but serious outcomes. However, in the U.S, it’s way less common for someone to receive care from a midwife than an obstetrician. So only about 12% of all births in the U.S were attended by a midwife in 2021. And that’s pretty different from other countries where midwives provide much more or even the majority of care during pregnancy and birth. And so for example, In the Netherlands, midwives were the primary caregivers in over half, 57% of births in 2019. And some countries, like many of those in Europe, have midwifery units that are locations or centers where midwives actually lead maternity care.
Dr. Rebecca Dekker – 00:09:47:
Yeah. And Morgan, I just want to let our listeners know that we do have a doula from the Netherlands coming on the podcast in March to talk about some of those aspects of maternity care there, including the fact that midwives are the primary caregivers at most births. Their Cesarean rate is 18% or lower. They have really good birth outcomes and they don’t use elective inductions at 39 weeks. So that’s coming up in a few months, but go on and tell us more about the second strategy.
Morgan Richardson Cayama – 00:10:18:
Yeah, that’s great. And unfortunately in the U.S. and other places like Canada, not everyone again has the ability to receive midwifery care. So just like in the U.S., for example, again, there are way fewer midwives and obstetricians and midwifery practice is also more restricted in some states. There’s limitations around that. And home birth midwives too might not be covered by insurance at the same level as care from an obstetrician or a physician or in like a hospital setting. Still, for those who do have access to midwifery care or the means to receive this type of care, that choice can really help reduce your risk of Cesarean birth. So, Rebecca, there’s actually another really important factor impacting Cesarean risk that also closely relates to this. So can you tell us what this third tip or strategy is?
Dr. Rebecca Dekker – 00:11:03:
Yes. So the third evidence-based way to lower your risk of Cesarean is to give birth in a setting with a low Cesarean rate. Specifically, we see much lower rates of Cesareans among those who plan a birth center, a freestanding birth center, I have to say, or a home birth. So studies have found Cesarean rates range from 6% to 12% in planned freestanding birth center births and about 5% in planned home births in the United States. In contrast, Cesarean rates for low-risk birthing people in U.S. hospitals range from 9% to 19%. And of course, this rate is even higher when you’re looking at all Cesareans, around 30% and higher in U.S. hospitals. There are hospitals around the world that have low Cesarean rates, but these are uncommon in the U.S., they’re uncommon in Canada, South and Central America, and other parts of the world. And unfortunately, many people either don’t take into consideration a hospital Cesarean rate when they’re choosing their hospital, or they simply don’t know how big of an impact it can make on their risk of having a Cesarean.Â
For example, in a survey of birthing people in California, only a third, 32%, looked for information on hospital Cesarean rates when they picked the hospital where they gave birth. A different survey found that most people, 77%, don’t think that the hospital they choose will impact their Cesarean rate. But again, similar to who your provider is, where you’re giving birth has a huge impact on Cesarean rates. In reality, choosing a hospital with a low Cesarean rate or having an out-of-hospital birth, what we call a community birth, at home or in a freestanding birth center, if that’s an option available to you, can really help lower your risk of Cesarean. However, community births are still pretty rare in the United States. They have been increasing in recent years, but in 2019, only about 1% of all U.S. births were done at home and even fewer were done at freestanding birth centers. One reason for this is the lack of availability, lack of access to birth centers and care providers who can provide community birth services, especially in the U.S. where there is legislation actively preventing access to these types of care in some states, such as in my home state of Kentucky and Morgan as well. We do not have any freestanding birth centers because of the legislation. Not that it doesn’t permit it, but it makes it so difficult that it’s been impossible for any midwives to start birth centers.Â
So this is something that different groups and birth organizations have been trying to tackle, doing advocacy work, fundraising, and lobbying to provide more of these options to more families in the United States. I also wanted to give you another tip. This is like an expert tip from Rebecca. One way you can find the rate of Cesareans if you live in the U.S. and compare different hospitals in your area is through the nonprofit called the Leapfrog Group, which focuses on patient safety in hospitals. So you can go to ratings.leapfroggroup.org and it allows you, it has a feature to compare several statistics between local hospitals in your area. Now, since it’s voluntary for hospitals to participate, not all hospitals in the U.S. will have their data on there, but a lot of U.S. hospitals do. And it’s a really nice function. You can compare more than just Cesarean rates. There’s other factors related to maternity care that you can look at. And I highly encourage you to do that because, just because a hospital looks beautiful on the inside does not mean that they are delivering the safest care or that you’ll have the lowest risk of Cesarean at that hospital. So that is the third evidence-based way to lower your Cesarean risk, which is giving birth in a setting with a lower Cesarean rate. So what’s number four on the list, Morgan?
Morgan Richardson Cayama – 00:15:09:
So the fourth way that someone can help lower their risk of Cesarean birth is by avoiding routine non-medically indicated ultrasounds near the end of their pregnancy. So ACOG does recommend at least one standard ultrasound during pregnancy between 18 to 22 weeks. But elective ultrasounds or those without any sort of clear medical indication or need, especially near the end of pregnancy, can increase that risk of induction or a planned Cesarean. And that’s especially true if the care provider ends up suspecting a possible big baby. And that’s because care providers who suspect a big baby are more likely to end up recommending a Cesarean. And this actually impacts a lot of people, at least here in the U.S. So a U.S. study found that two in three families were told that their baby might end up being too big or might be too big. And one in three had a care provider discuss planning a Cesarean with them for that reason. However, in reality, only one in 10 babies are actually born meeting that criteria for a big baby, which is typically more than around 4,000 grams or about 8 pounds and 13 ounces. And ultrasounds are wrong about half the time at predicting a big baby. So again, avoiding non-medically indicated ultrasounds near the end of pregnancy can actually help lower that risk that a provider ends up suspecting a big baby and recommending an induction or a Cesarean. And if you want to learn more about big babies, we do have a full-length Signature Article on this topic called Evidence on Induction or Cesarean for a Big Baby that you can find at ebbirth.com/bigbaby. And we’ve also reviewed some of this evidence on podcast episode 190, Updated Evidence on Big Babies.
Dr. Rebecca Dekker – 00:16:40:
I do want to clarify, Morgan, because I know sometimes people get confused about this. I want to make sure our listeners understand that when you hear the words elective ultrasound, we’re not talking about those souvenir ultrasounds. You can get at those places where you just walk in and you get a 3D or 4D image of your baby to frame and your doctor didn’t tell you to do it. You just wanted to do it. So that’s not what I mean when I say elective ultrasound. When I say elective ultrasound or you do, we’re talking about any ultrasound towards the end of pregnancy where there’s not a clear medical complication or reason that calls for the ultrasound. So your doctor might schedule an ultrasound at your regular ultrasound clinic, but there’s not a true medical reason for it. It’s just part of their routine practice to check the size of the baby. And there’s no indication that your baby is really small. So there’s no clear complication. There’s no indication that your baby is growth restricted or anything like that. This is just part of their routine practice. So it’s these kinds of ultrasounds when there’s no true medical indication for the ultrasound that increases the risk of Cesarean, mainly because of the high false positive rate of suspecting a big baby and kind of the down the road consequences of your doctor thinking you have a big baby and then being more likely to recommend a Cesarean.
Morgan Richardson Cayama – 00:18:02:
Yeah, that’s a great point. And so, so far, we’ve mostly been talking about strategies or choices that someone could make during their pregnancy. So now let’s transition into some strategies that someone could use during labor and birth. And a really important and impactful one and number five on our list is receiving labor support like from a doula. So Rebecca, could you tell us a little bit more about that impact of doula support?
Dr. Rebecca Dekker – 00:18:22:
Yeah. So number five on our list of evidence-based ways to lower your risk of Cesarean, doulas are really important because receiving support during labor and childbirth from a doula has a lot of benefits that have been shown in the research. If you want to go into a lot of detail and depth about this, we have a Signature Article updated in 2024 called the Evidence on Doulas. And you can also go back to podcast episode 309 to learn more about how doulas work, why they’re so great, what their benefits are. And we even give you tips on how to interview doulas. But like you said, Morgan, one of the many benefits of doula support is a reduction in the risk of Cesarean birth. There was a Cochrane review published in 2017 that combined lots of different randomized control trials. They found that continuous support in labor from a doula led to a 39% relative risk decrease in the risk of Cesarean. And that’s significantly higher than the risk reduction found in the ARRIVE trial with elective induction at 39 weeks. Can you remind our listeners, Morgan, of what the relative risk decrease was in the ARRIVE trial?
Morgan Richardson Cayama – 00:19:34:
Yeah, that relative risk difference was 16% in the ARRIVE trial.
Dr. Rebecca Dekker – 00:19:38:
Ok, so this is like twice as big as that. And it’s so interesting to see how when the ARRIVE trial was published showing that 16% decrease in the relative risk, which is kind of like a complicated math formula. You have to do doctors all around the U.S. many of them started recommending 39 week elective induction specifically to lower the risk of Cesarean. But if we really, really cared about lowering the risk of Cesarean, we would just ensure that more people have access to doulas because that decreased the relative risk of Cesarean by 39%. Another study found that one Cesarean could be prevented for every nine people who receive doula support in labor. And the impact was even greater among people whose labor was being induced. One Cesarean could be prevented for every two people who received doula support during a labor induction. Even though more people we see today are hiring Doulas or accessing doula support, it’s still not super common. It’s still not used in the majority of births.Â
In a study published back in 2013 in the U.S., only about 6% of birthing people reported having a doula during childbirth. And we still have quite a few barriers to receiving doula care, including the perception or belief that labor support is not necessary, that your doctors and nurses will do everything to take care of you. And also some birth settings and healthcare staff around the world are not always welcoming of labor companions such as doulas, or they don’t understand the value that a doula can provide to their clients. Another barrier to doula care is the cost, which can vary depending on a bunch of factors like where you live, the rates of care in your area, the services the doula provides, any specialized skills, or certifications that the doula holds. So, in some states, Medicaid has begun to cover or reimburse for doula support, which is important because in many states, Medicaid may be covering half of all birthing people’s care during pregnancy and birth. We are also seeing a growth in the number of programs that receive grant funding to offer free doula services or low-cost services to their community. And some Doulas provide sliding scale rates for those who cannot pay full price. But overall, doula care has been found to save money and reduce birth costs, and especially they can help prevent Cesareans and other health issues from birth. So that’s the fifth way to lower the risk of Cesarean birth. What’s number six?
Morgan Richardson Cayama – 00:22:21:
Yeah, so the sixth strategy that we’ve included is waiting to go to the hospital until you’re in active labor or until you require medical interventions or pain relief. And this really does only apply to healthy people in spontaneous labor or those who otherwise have the ability or the means to wait longer. So those with certain medical conditions or who have challenges with things like transportation might, of course, need to arrive at their birth setting a little bit earlier. Or you may need to go to the hospital earlier if your membrane’s ruptured and you need or desire medical care for that. But if everything is going smoothly, waiting to go to the hospital until active labor is important because studies have consistently found that birthing people admitted to the hospital early in labor are much more likely to have a Cesarean. So a U.S. study published in 2023 found that those who were admitted to the hospital after their contractions had become regular and were less than five minutes apart had about half the odds of having a Cesarean compared to those who were admitted earlier in their labor. And another study similarly found that those admitted who were dilated had a cervical dilation of four to five centimeters, had a Cesarean rate of 4% compared to 18% among those who were admitted earlier and were dilated only about one centimeter. And so it does seem like waiting to go to the hospital is becoming more common or is pretty common. 65% of birthing people in one study did report being admitted to the hospital after their contractions had become regular and were less than five minutes apart. And this might have something to do with the growing popularity or awareness of something that you might have heard called the 4-1-1 rule. And that helps you decide when to go to the hospital or birth setting. And that means waiting until your contractions are about four minutes apart, lasting about one minute each, and have been happening for at least one hour. And in addition to just reducing your risk of Cesarean birth, staying at home longer until active labor also means that you have more freedom of movement than you might have in the hospital. You can labor longer in a setting that’s more comfortable or familiar to you. And you can also eat or drink as you wish. And even though, again, these are things that should be allowed in hospital settings, you might have more challenges with that once you arrive at the hospital.
Dr. Rebecca Dekker – 00:24:27:
Yeah. And I think Morgan, one of the problems with waiting for active labor, it can be tricky if you’re not sure how quickly or slowly labor is progressing. So I often hear this with first time parents, you know, it’s the first time they’re going through this. So they don’t know exactly when they’ve reached active labor. And I actually see it also just as frequently with people having their second, third or fourth baby. Sometimes you think you would know when to go, but I’ve had plenty of friends who waited too long to go to the hospital. So you mentioned the 4-1-1 rule. And I just want to clarify that this may not apply to everyone. And I hesitate to call it a rule. That’s because everybody’s labor can be different. And for example, if it’s your second, third, fourth child, or even, you know, subsequent, labor can move more quickly than it did in a previous labor. And it’s thought that if you’ve had a baby before, and this is a subsequent baby, you should be looking for contractions every five minutes apart as a signal to go to the hospital rather than waiting until they’re only four minutes apart. Also, there are other signs of labor progression, such as vocalizations and other behaviors that can be more important or more significant than the timing of contractions. For example, for me, I never had contractions closer than five minutes apart. So if I had waited to the four minute mark, I wouldn’t have made it if I was having a hospital birth. So this is where it can, going back to the strategy number five, it can be so helpful to have a doula or another companion on your labor support team who is familiar with the signs of early labor and active labor. And it can also be difficult to wait until active labor if you’re having difficulty coping with the pain or coping with other symptoms such as nausea and vomiting, or if you live far away from the hospital and so you don’t want to be having a really long car ride at the end of labor. Or if you need more support, then you can get at home. Maybe your home environment is not a comfortable place and maybe you don’t have support people there. But research does show that if you are able to arrive at the hospital later in the labor process, there is a lower Cesarean rate. And researchers think it might have to do with the fact that there’s less time spent in the hospital. So there’s less time for hospital staff to feel impatient about your labor progress. Or perhaps it could be have something to do with the fact, you mentioned, earlier Morgan, about being able to move around more comfortably at home. So that movement in earlier labor may help also lower the risk of Cesarean. So any other thoughts on that, Morgan?
Morgan Richardson Cayama – 00:27:20:
No, I think that’s a great point. And yeah, the 411 rule can, you know, shouldn’t be something I think that people live by and definitely important to pay attention to some of these other signs.
Dr. Rebecca Dekker – 00:27:29:
Yeah. I mean, contraction timing is still a standard part of kind of monitoring what’s going on with your labor. You know, it can kind of give you some benchmark, but again, everybody’s unique and that’s where having people you can consult can be helpful. You know, when is it time to go to the hospital? And another thing to think about is like, this is not something you can do for most people if you’re having an elective labor induction. I know in some countries they’re experimenting, starting to do outpatient labor inductions where they’re doing the cervical ripening process at home, but in the U.S. that’s not common yet. And so waiting till active labor to go to the hospital is really only something you can do if you’re having a spontaneous labor. But speaking of, you know, moving around and all of these things we were talking about, how it’s beneficial, our seventh strategy for lowering the risk of Cesarean is by moving during labor. And also I want to talk a little bit about the peanut balls. So we have a Cochrane review that found that if you’re in an upright position during labor, or if you spend time in upright positions, such as walking, sitting, standing, or kneeling during that first stage of labor, both early and active labor, this lowers the relative risk of your Cesarean by 29%. Again, remember the ARRIVE trial found a 16% decrease in the relative risk of Cesarean. So a 29% relative risk decrease in the risk of Cesarean for upright positions compared to people who are lying on their backs or sides during labor. Unfortunately, many people do not walk around or move much during labor after they’ve been admitted to the hospital and they’re having regular contractions. In one study in California, only 39% of participants reported walking around in labor after being admitted to the hospital. Most people, for whatever reason, end up staying or spending most of their time in bed once they get to an American hospital, which is just really too bad because movement is such an important way of helping labor progress and lowering the risk of Cesarean.Â
Now, some people may stay in bed because they have an epidural. And I want to clarify that if you have an epidural, there are still options to move during labor. You can be switching positions every 30 to 60 minutes. You can get in a supported squat when you’re pushing in the bed. You can also use the bed to get into a kind of kneeling position where you’re kind of leaning over the top of the bed. You can also get in a supported hands and knees position in the bed. And then whether or not you have an epidural, you can also take advantage of a peanut ball, which is a peanut-shaped exercise or birth ball that can help with positioning during labor. Fortunately, we’re seeing that peanut balls are becoming more and more common in hospitals, and they can be used by patients in labor at no extra cost. However, some hospitals might only have a few peanut balls available, and they might not have the size that works best for you. So some people choose to buy and bring their own peanut balls to the hospital, or their doula might bring peanut balls to use with their clients. And we have a handful of studies showing lower rates of Cesareans among people using peanut balls during labor, including people with epidurals who use peanut balls during labor. We have one small randomized trial that found a Cesarean rate of 10% among those who were using peanut balls during labor, compared to 21% among those who didn’t. And it’s also important to note that we need more research with more higher quality studies on peanut balls. But a lot of doulas… doulas and midwives and nurses have been using peanut balls, and they really like how you can use them to mimic different positions. You can almost get into a squatting position while you’re side-lying, and different ways you can help with the pelvic movement with peanut balls. And I just think it’s a fascinating way that we can still use these tools and props to help people move in labor, even if they’re confined to the bed. So if you want to learn more about peanut balls, you should check out EBB Podcast’s episode 45 with Sherry Grant, RN. She’s also known as the Peanut Ball Lady, and she has a really inspiring story. And she gives us a lot of tips on how to use peanut balls, how to pick the correct size, et cetera. So I highly recommend that episode. All right, so that was number seven was movement. So what’s next on our list of evidence-based ways to lower the risk of Cesarean?
Morgan Richardson Cayama – 00:32:08:
Yeah. So number eight on the list is also closely related to that, and that’s avoiding laying on your back during labor. And we’ve talked a little bit about this. And again, as you just mentioned, Rebecca, that Cochrane review found that those who are in what we call recumbent positions, like lying on your back or even lying with the head of your bed raised or even side-lying, still had a 29% higher risk of Cesarean compared to those who were in upright positions. And again, unfortunately, most people do labor and give birth on their backs, despite all of this evidence showing the benefits of upright positions. And most depictions that we see in popular media and culture, like in TV and movies, again, show people laboring and giving birth lying down. So I think there’s kind of this misconception, again, that you have to do that or that you can’t move around. And again, especially if you have an epidural, that that’s not an option to you. And a study in the U.S. did find that only about 4% of people gave birth in an upright position, like squatting or sitting, and only 1% gave birth on their hands and knees. Meanwhile, we had a study in England that found that about 16% of people gave birth in an upright position. And again, giving birth in an upright position is still possible for people with medicated births, like an epidural. And you can learn a lot more about birthing positions. We have a Signature Article on this topic called Evidence on Birthing Positions, and we also cover that in Episode 241.
Dr. Rebecca Dekker – 00:33:24:
Yeah. And I was thinking, Morgan, as you were talking, something with birthing positions and laboring positions, there’s a difference between pushing or laboring in an upright position and then actually giving birth or what the doctor might call delivering in an upright position. So some care providers are fine with you pushing in whatever position you want, but when it comes time for the birth and the baby’s head is about to emerge, they want you to get on your back and they might be really insistent about that for your safety. But studies have consistently found that it’s less safe to give birth lying on your back. There’s harms related to pushing while you’re laying on your back and being on your back when the baby is coming out. So if upright birth is something you’re interested in, you need to specifically ask your provider if they and the other providers in their practice are comfortable in supporting both upright pushing positions and upright birthing or delivery positions. You might have to use the word delivery there, even though it’s not our favorite at EBB. Also, I want to acknowledge that some people, for personal reasons, do choose to give birth on their back. And here at EBB, we are firm believers in autonomy, and we want people to have the power to give birth in whatever way feels best or safest or right to them. Evidence does support that harms are lowered when upright birthing positions are used, but it is your choice and your human right to give birth in whatever position you want, and that is the most important part of birthing positions.Â
So our ninth evidence-based way, you might be thinking, what have we not covered yet that lowers the risk of Cesarean? Number nine is to receive intermittent fetal auscultation that we like to refer to as hands-on listening of the baby rather than continuous electronic fetal monitoring. So electronic fetal monitoring, sometimes called cardiotocography or CTG, sometimes it’s abbreviated EFM or it’s referred to as getting on the monitor. This is the most common type of fetal monitoring and it’s routinely used in many hospitals around the world. However, you can receive what’s called intermittent fetal auscultation or hands-on listening. This is where your healthcare provider or nurse uses a device called a Doppler ultrasound it’s just like the one they hold to your belly at a prenatal appointment. Or they can use a special stethoscope called a fetoscope to listen to the fetal heart rate at regular time intervals. And this has been shown to lower the risk of Cesarean. There’s a systematic review and meta-analysis that found a 17% decrease in the relative risk of Cesarean for those receiving hands-on listening compared to continuous electronic fetal monitoring. And another Cochrane review similarly found a decrease in the risk of Cesarean. So using modern Cesarean rates, they estimate that those with intermittent auscultation would have a Cesarean rate of about 15% compared to a Cesarean rate of 24% for those who receive continuous electronic fetal monitoring. And that lower risk is likely because of the lower chance of false positives in detecting fetal health issues.Â
So fewer emergency Cesareans are performed with intermittent auscultation. Another benefit of the intermittent auscultation is you don’t have to be restricted to bed. You have total freedom of movement during labor. We do have now kind of an increase in the use of wireless continuous electronic fetal monitoring, which can give you more mobility. But one of the things we’ve talked about, we have a Signature Article on this subject at ebbirth.com/fetal monitoring, is that with the wireless ones, they still might discourage you from moving because movement can sometimes interfere with the readings. And so even though it’s supposed to give you more movement, it might not. It’s also important to note that although you might be interested in intermittent auscultation, it might not be available in your birth setting because if staff are not trained on how to perform this type of monitoring, or they don’t feel comfortable with it, or your doctor refuses to let them use it. And it also may require closer, more frequent nursing care, you know, where your nurse has to come to check on you more often, as opposed to the more hands off electronic fetal monitoring where they can like put you on the monitor and then just watch you from the central nurse’s station. So I write a little bit about this. It’s actually one of the early stories I tell in Babies Are Not Pizzas, They’re Born Not Delivered, my book. I tell a story of a friend of mine, somebody I met who was following Evidence Based Birth®, heard us teach about intermittent auscultation, really wanted it. And it turned into this whole drama at the hospital because they’re like, we don’t do this here. Even though her doctor was willing to do it, nobody else agreed with it. And it was this big conflict. So if you want to learn more about that, again, it’s another area where if we adopted this for low-risk people who are appropriate, who are having uncomplicated births, we could really lower the Cesarean rate, but it’s not talked really about that much as an option among obstetricians. Instead, again, there’s this focus on the elective inductions at 39 weeks instead. So last but not least, the 10th evidence-based strategy for lowering the risk of Cesarean has to do with people who find out they’re pregnant with a breech baby. So Morgan, can you tell us a little bit more about this one?
Morgan Richardson Cayama – 00:39:07:
Yeah, certainly. So for people who are pregnant with a breech baby, there’s the option or you could consider receiving an external cephalic version or having a vaginal birth. And so most breech births, which is where the baby is bottom first, end up in Cesareans, about 90 to 95%. An external cephalic version, or ECV, is a procedure that’s done by a care provider to help turn the baby into a head down position. And it’s actually successful about half the time. And most people who have an ECV do go on to end up having a vaginal birth instead of a Cesarean birth. So we know it’s something that can be pretty successful. So a Cochrane review found that attempting an ECV at term reduced the relative risk of Cesarean by at least 43%. But unfortunately, most people who are pregnant with a breech baby and who are eligible for an ECV are never even offered it by their care provider. Even though it’s considered a part of routine prenatal care and it’s covered by insurance, healthcare providers might be reluctant to perform or even recommend an ECV because it does take extra time and resources. So that’s something to consider. And a breech vaginal birth, on the other hand, happens when a breech baby is actually born vaginally with their bottom or feet first, instead of the head like we would see in a normal birth or a non-breech birth. ECV and breech vaginal births are actually different options, though, for people pregnant with breech babies. And each has its own risks and benefits. So some healthcare providers might be skilled in an ECV, but might not feel comfortable or be skilled in performing or providing a breech vaginal birth. We do actually have a lot more information about this and other podcast episodes, including episode number 296 and 297, Evidence on Breech Birth and frequently asked questions about breach and an accompanying full length Signature Article on this topic on our website.
Dr. Rebecca Dekker – 00:40:57:
Yeah, and I think important to remember, although breech babies typically make, what is it, like 4% of births around that, it’s still a significant contributor to the overall Cesarean rate. And unfortunately, it’s something that most people don’t realize is happening to them until the end of pregnancy when there’s not a lot of time to figure out your options or to switch care providers. And we talk more about that kind of dilemma in our series, our podcast series we did on breech. But I think it’s just important to know that there are options available if you’re pregnant with a breech baby to lower the risk of Cesarean, although many families may choose a Cesarean for a breech baby. And that is also a legitimate choice. But I think the important thing is that more people should have access to choices and be able, you know, because the choice between one thing and no other options is not really a choice if you’re kind of forced into it. So something to think about. So that’s it. Those are our. Top 10 evidence based strategies that someone can use to help lower their risk of Cesarean birth. And just as a recap, I think it’s important that if you’re interested in lowering this risk, that you find supportive care providers who have low Cesarean rates, practice in settings with low rates, enlist the help and support of a doula, wait to go to your birth setting until you’re farther along in labor, continue to move around and stay upright as much as possible. And also explore options such as intermittent auscultation and ways to perhaps lower your risk of Cesarean if you have a breech baby. So what are your thoughts, Morgan? Any questions you have?
Morgan Richardson Cayama – 00:42:38:
Yeah. So I was just wondering, now that we’ve kind of talked about these, Rebecca, was there one in particular that sort of stood out to you or a favorite or that was surprising to you or which one, I guess, stood out the most for you?
Dr. Rebecca Dekker – 00:42:50:
Yeah, I think, you know, out of all the 10 strategies, I think my favorite is, you know, getting support and care from a midwife. So I write about this, I was recently rereading Babies Are Not Pizzas, because believe it or not, it’s been a couple years since I read my own book. And there’s a whole chapter about how kind of I learned about midwives, you know, growing up, it was not talked about, it was not an option. The only thing I knew certified nurse midwives could do gynecology care. And so I was interested in that. But I had never really thought about hiring a midwife for, you know, to attend me in pregnancy and birth, it was just not even on my radar. And so to learn that there’s a reason, like a historical reason why midwifery was suppressed, and to kind of see the difference midwives make in people’s lives, both in my life, but in the life of my friends and families. So I love midwives, people often ask me what I do, and one of the things in my description is I like to call myself like an advocate for midwifery care, because I do believe it’s powerful. And midwives don’t get enough credit. We do have a podcast episode all about the evidence on midwives. It’s episode 175. We’ll put all these podcasts we reference in the show notes. But that is one of my favorites. And it kind of goes into the history as well as the research evidence on midwives, how effective they are. And I’m excited also to bring our doula from the Netherlands on the podcast in a few months to talk about how midwives run the healthcare system there for pregnancy and childbirth. So anyways, that’s mine. What about yours, Morgan?
Morgan Richardson Cayama – 00:44:31:
Yeah, I really like moving around during labor or using a peanut ball. And those stood out to me, I think, because they are low or no cost methods that are available to most people. And again, whether you are, you know, choose a medicated birth or an unmedicated birth, they’re still equally accessible. And I myself ended up using both of those options. I ended up with a medicated birth. I had preterm ruptured membranes and I ended up with an epidural. And yeah, I had the support of a nurse and a fantastic doula who helped me still labor over a birth ball and on all fours on the bed and with my epidural. And again, I just think that many people assume that you don’t have those options, medicated or unmedicated. But again, especially if you have an epidural, that those just aren’t options for you. And again, the research shows definitely otherwise that not only is it an option, but it’s actually a great choice to help reduce that risk of Cesarean birth. So those are the ones that stood out to me, I think.
Dr. Rebecca Dekker – 00:45:23:
Yeah, that’s a fun one too. I used to teach high schoolers about birth. I used to show them videos like TikTok videos, YouTube videos of people dancing in labor. And they were both shocked, surprised. And, like thrilled that it looks so fun. They’re like, these people are in labor. What are you saying? You know, it is inspiring to see like all the pelvic circles and, you know, all the stuff you can do when you’re dancing, but also it’s increasing your endorphins and your oxytocin. And it’s, you know, movement has more benefits than just lowering your risk of Cesarean. It can make your labor more joyful, you know, and more comfortable too. So I love that you picked that. So thank you again, Morgan, for joining us today. It was great having you as a co-host.
Morgan Richardson Cayama – 00:46:13:
Yeah, I was happy to be back.
Dr. Rebecca Dekker – 00:46:15:
So we hope you all found this episode useful. We’ve never done anything like this before, but I think hopefully having the top 10 most evidence-based ways of lowering the risk of Cesarean will be helpful for you or for your clients if they’re interested in prioritizing having a vaginal birth, if at all possible. So thanks again to Morgan for helping compile the research on these topics. And you can learn much more about these methods and other ways to lower your Cesarean risk, which we did not cover today, by checking out the full-length Signature Article at Evidence Based Birth® called the Evidence on the ARRIVE trial, an elective induction at 39 weeks at ebbirth.com/ARRIVE. So you’ll look for a table that has all of this information laid out really nicely for you and all the scientific references are there as well. So thanks everyone for listening and we’ll see you next week. Bye.
Outro – 00:47:09:
Today’s podcast was brought to you by the Signature Articles at Evidence Based Birth®. Did you know that we have more than 20 peer-reviewed articles summarizing the evidence on childbirth topics available for free at evidencebasedbirth.com? It takes six to nine months on average for our research team to write an article from start to finish, and we then make those articles freely available to the public on our blog. Check out our topics ranging from advanced maternal age to circumcision, due dates, big babies, pitocin, vitamin K, and more. Our mission is to get research evidence on childbirth into the hands of families and communities around the world. Just go to evidencebasedbirth.com, click on blog. And click on the filter to look at just the EBB Signature Articles.
