By Jessica English, CD(DONA), LCCE

More and more women in the United States (and around the world) are having cesarean births. A recent study from the Yale University of Medicine showed two main reasons for the rise: more c-sections in first-time moms and lower rates of VBAC (vaginal birth after cesarean).

For your first baby, what can you do to reduce your chances of an unnecessary cesarean birth? We’ve identified 10 areas where you can be proactive and stack the deck in your favor.

1) Hire your provider wisely. This point is number one for a reason – it’s critical. In most practices, you could have any one of several doctors or midwives. You get whoever is on call when you go into labor. It’s helpful to know your practice’s cesarean rates. The labels “obstetrician,” “family doctor” and “midwife” don’t necessarily tell you what you need to know about your provider’s philosophy. Some doctors practice more like midwives, and some midwives practice more like a stereotypical doctor. Will they have a toolbox of natural techniques or only medical tool to help you if your labor is complex? If you’re not sure which doctor or midwife to choose, ask a doula. Doulas see all kinds of births with many different practices, and they will be happy to make a recommendation of a provider with a low cesarean rate and good bedside manner.  If you find out that your provider is not supportive, it is never too late to switch, even if you are just a few weeks or even days before your due date.

2) Hire a doula. Simply put, doulas make birth better, and there’s research to prove it. A meta-analysis of studies shows that women who use a doula are 26 percent less likely to have a cesarean birth, among other dramatic benefits. Having continuous support from a friend of family member can be helpful too, but the best results come when women hire an outside doula, according to a recent Cochrane Review. What exactly isthe doula magic? The research hasn’t pinpointed the magic, but I think the unique combination of physical, emotional and informational support, plus gentle advocacy makes a huge difference. Doulas help women feel safe and comfortable so the hormones of labor can work at optimal levels, positioning ideas and tricks can help babies work their way out, and evidence-based information and help communicating with the medical staff can help women have their best chance inside a system that doesn’t really promote natural birth.

3) Take an independent natural childbirth class. It’s not so much that you need to know a lot about giving birth, but many women (and men) need to undo what society has taught us about birth. Independent classes are usually longer and more in-depth, with more interaction and less lecture. A good instructor can help increase your confidence in your body and help you trust in the normal birth process. An independent Lamaze-certified instructor will base her class on the six Lamaze Healthy Birth Practices, a wonderful resource that lays the groundwork for the best possible birth. Another benefit of an independent class is that your teacher works for you. She can teach you how to advocate for yourself within the system, without having to worry about what doctors, administrators or anyone else might think.

4) Avoid induction unless there’s a serious medical problem. As a first-time mom, some studies show that simply walking in the door for an induction of labor doubles your risk of a cesarean. Doubles it. That’s huge! Avoiding induction is never more important than with a first baby. But if you must be induced for a medical reason, call on your natural childbirth instructor and your doula (remember them?) to help you with tips to keep it as normal and natural an experience as possible, even with the unexpected circumstances. If mom and baby are not in immediate danger, low-and-slow inductions can result in a better chance of a vaginal birth, but you’ll need great support on the journey.

5) If having your baby in the hospital, stay home at least until strong, active labor. Your independent childbirth instructor will teach you how to recognize active labor. If you follow the common hospital recommendation to “come in when contractions are five minutes apart, at least a minute long, for at least an hour,” most women having their first baby will be very early in labor. The intensity of contractions is a much better guide than the timing. The more hours you are at the hospital before your baby is born, the higher your risk of intervention (including a cesarean). In her book “Pushed: The Painful Truth About Childbirth and Modern Maternity Care,” Jennifer Block tells the story of a hospital in Florida that lost power after a major hurricane. A generator kept the essentials running, but there was not enough power for air conditioning. They wanted to save resources and keep laboring women cool, so for a full week they turned away any woman who was not in full-blown, active labor. Their emergency cesarean rates during that week dropped dramatically.

6) Avoid an epidural, at least in early labor. Research is a bit mixed, and not all studies have been high quality. But still, the best evidence available does seem to show that epidurals, especially when women get them early in labor, do increase the cesarean rate in first-time mothers. Childbirth Connection is a great resource for information on the benefits and risks of epidurals. There are rare times, of course, when getting an epidural can actually help a woman have a vaginal birth, if she simply doesn’t have the strength to go on. Every labor is different. But an epidural also makes it harder for a baby in a bad position to move into a better one, it limits your ability to move, and it requires a lot of other interventions (IV, continuous monitoring, bladder catheter, etc.). Your doula and your independent childbirth class may give you enough natural tools so that you won’t even need the drugs. Most women don’t.

7) Read only the best childbirth books. Get these books, and read them cover-to-cover. Seriously, throw away “What to Expect When You’re Expecting,” and dive into these wonderful books instead.

• “The Official Lamaze Guide: Giving Birth with Confidence,” by Judith Lothian and Charlotte Devries (the book that inspired this blog!)

• “Ina May’s Guide to Childbirth,” by Ina May Gaskin

• “The Thinking Woman’s Guide to a Better Birth,” by Henci Goer (Written in 1999, this book is due for a revision, but it’s still excellent information and routine procedures and hospital technology have not changed much since that time. Henci also runs a helpful Q&A forum on the Lamaze International web site, so you can ask the expert yourself.)

• “Your Best Birth: Know All Your Options, Discover the Natural Choices, and Take Back the Birth Experience,” by Ricki Lake and Abby Epstein (they also offer a great web site and community)

And while you’re at it, buy the DVDs “The Business of Being Born” and “Orgasmic Birth” – they’re even on Netflix. That’s right, I’m recommending “Orgasmic Birth.” Stretch yourself a little!

Get your partner on board. It’s hard to do this alone, you need support! Even with the best doula, your partner is still an integral part of your birth journey. Penny Simkin’s book “The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas and All Other Labor Companions” is a great place to start. Be sure your partner attends that independent childbirth class with you – sometimes partners benefit even more than moms from that information and support.

9) Consider an out-of-hospital birth. It’s possible, with the right support, to have a great first birth in the hospital – even a vaginal birth without pain medication. As a doula I see them fairly often, and you should definitely choose the hospital if that’s where you feel safest and most comfortable. But the best research is pretty clear that your odds of a vaginal birth are better outside of the hospital: at home or in a birth center. In 2005 the British Medical Journal published a large study that looked at home births in the United States attended by Certified Professional Midwives. The women who gave birth at home had similar outcomes to low-risk women who had hospital births in terms of safety for moms and babies. But just 3.7 percent of the women who had their babies at home transferred to the hospital for a cesarean, while 19 percent of the low-risk women who had their babies in the hospital ended up with c-sections. The current cesarean rate in the United States is 32.9 percent, according to the Centers for Disease Control. Many studies have shown similar results, which makes out-of-hospital birth at least worth considering.

10) Believe in your body! The cesarean rate for women who birth at The Farm in Tennessee is less than 2 percent. Many industrialized countries around the world have cesarean rates of 15 percent or less. Women have been doing this for millions of years! Your body works. Birth works, in all its complex and wonderful variations. Surround yourself with knowledgeable support, of course, in case you encounter any rare and unexpected complications. But truly… trust your body. Trust birth.

Jessica English, CD(DONA), LCCE, is the owner of Birth Kalamazoo, which offers birth and postpartum doula services, natural childbirth and breastfeeding classes, and in-home lactation consults. A DONA-certified birth doula and Lamaze-certified childbirth educator, she teaches an 8-week series of classes called “The Best of Natural Birth.” She is the editor of DONA International’s eDoula newsletter. A longtime writer and business woman, she also works as a consultant for organizations and birth professionals.