Birth (and life) after Cesarean

I love to listen to birth stories. Many of the stories that I hear are a testimony to the pregnant woman's great ability to "animal out" on her attendant. My favorite is the story of a young woman who had her first daughter by cesarean section She became pregnant again the same month and it turned out she was carrying twins. Her doctor was very alarmed and booked her for a cesarean at 38 weeks, She went into labor at 36 weeks and delivered two lovely girls, vaginally.

Of course, women who are trying for vaginal birth after cesarean don't always have such fine stories to tell. Two remarks have stayed with me over the years, and these were both delivered by obstetricians to a laboring woman. The first was: “Childbirth is like war, and I am on the front line.” The second: “This is Monday morning in a busy hospital. There are road accidents, emergencies …” This was said to a woman who wanted to labor a little more before the decision was made to go to surgery, implying that the birth of a child had to be scheduled in somehow between a messy car accident and some other horrific case. Why did this man want to become an obstetrician? How did he feel about his "patients"? How had he been born? What was it about birth that suggested to him images of war?
What is it about childbirth that makes these people think in terms of war, car accidents, death? Is it just fear? And if it is, what exactly are they afraid of? And , more importantly, where does the midwife fit into this mosaic of fear, or does she fit in it all?

Doctors and midwives who are afraid of childbirth are partly afraid because of their training. Allopathic medicine teaches about pathology rather than the whole healthy being, and pregnancy is often seen as a pathologic condition. But there is another more profound reason for this fear, and it has to do with the fact that Western medical training teaches health workers to rely only upon their own knowledge. How does this lead to fear?
Let me explain. During childbirth there is something present that is outside of us as individuals, out­ side our knowledge, even outside our experience or our skill. That "something" has to do with faith. It is only with a leap of faith that you can appreciate or even accept that a new human being comes out of a woman's vagina. Without that leap of faith, what happens? Two things: more obviously, you have to interfere, pull it out, cut it out another way. But another thing happens as well. Strangely, your faith (most of us have faith in something) gets turned inwards. As an obstetrician, you have faith only in your own skill. And that is what is frightening-- that an event which cries out for the presence of God gets reduced to the simply human.

I'm sure that there are obstetricians who works differently, but I think that it is easier for a mid­wife to accept that there is something else, something larger than herself, working through a birthing woman. It is quite noticeable how many mid­wives are religious, how many live in sight of that something which many people call God. But what happens to the sympathetic midwife working within the medical system? What happens to her sensitivity to that Other which touches us when we give birth?
I have met many diverse people over the years of working with birth.I have encountered some women who probably disliked their work, who were overtired, overworked, who had little faith in any­thing. I have also encountered mid­wives who have accepted modern medicine's vision of birth. And I have met many brave and gentle souls doctors, nurses, midwives, and doulas, who are working within the medical sys­tem and trying to maintain their faith at the same time.

What do we see in a hospi­tal? We see, first of all, an exagger­ated reliance upon technology. We know that the use of technology has a snowballing effect, creating the need for more and more complicated interventions. Secondly, we see a rigid hierar­chical structure in which usually one person is calling the shots. Finally, we see the "spiritual" infrastructure upon which this hierarchy is based, to be inward looking and grounded only in human knowledge.
What happens in the hospi­tal when things start to "go wrong," when things don't follow the pre­scribed path? When I went into the hospital in labor with my first child, the nurse, who was actually a mid­wife trained in Scotland, touched by belly and said cheerfully, "This baby will be born by noon." As time went on, she touched me less and less. By the next morning at the start of her shift, she didn't even greet me. As they let me eat and drink less and less, my cervix grew smaller, I was touched less and I began to feel more and more isolated. I was touched only when necessary. The baby's heart­ beat was checked less often. I began to feel abandoned.

Can I offer some advice to birth attendants working with women who are hoping to give birth vaginally after a cesarean section? Remember that the previous cesarean(s) have left scars not so much on the uterus as on the woman's sense that she is capable of giving birth. Accept that having a cesarean can hurt. Please don't de­scribe to her how a ruptured uterus may feel. Watch for danger signs yourself. Keep your concerns to your­self as much as possible. Remember "failure to progress" can be linked to fear and stress.
Keep things easy even when they get hard. Remember that a woman work­ing for a VBAC needs the comfort and security of her own home. Remem­ber that she may need to work on building confidence, on throwing away fear, on finding her "animal" self. Re­member as well, if it turns out to be another cesarean, don't abandon her. Give her the support through the birth and afterwards that you give any birthing woman. If a lady has another cesarean, she may feel very low; it may help her to talk to another mother who has been through the same thing. Avoid the mistake of "You're lucky the baby's okay.That's the important thing." Yes it is, obviously, but ... she may still need to grieve.

I am lucky - I have been blessed to have attended many successful VBACs during my years as a birth attendant. Thank you, again, to all the women who have shown me how fearless and strong birthing women are - not least, the woman who have said "Yes, I am ready for surgery, of course, if my baby's life is in danger."
Here's to a happy marriage of modern medicine and safe midwifery, with lower cesarean section rates and happier and healthy mothers and babies. L'Chaim! To Life!

Birth and Scars

As we grow, we absorb big and small shocks to our bodies and souls. We all know where our physical scars are, and we often assign stories to them. I remember when I was skipping school and the knife chose that day to slice my finger, so I had to get myself stitched up without (I dreamed) my mother finding out. I have a little white line on my finger that tells that story.

Some women have bigger scars, on their skin and their muscles, from birthing their babies. I hear these stories often when I am speaking to women about their birth experiences.

Other women have emotional scars that last for years. These scars have a way of aching and burning during pregnancy and birth. The doula can gently assist the woman when she is feeling these aches and pains. Doulas are not therapists so they do not have to probe, suggest, or hypnotize. What they do is provide a non-judgmental ear, if the woman wants to talk. They let her know that she is not alone, that she has support. They also remind her that there are other women who have traveled the same road and survived.

One of my students is accompanying a woman as I write. The woman has been in labor for most of last night and today. She does have emotional scars, and they are hurting. My student has been with her the whole time, supporting and comforting. And even though my student is a very inexperienced doula, she is still providing the essence of what a birthing woman needs. The expertise, medical know-how and scientific facts is not the realm of the doula. She is there with other skills: the skill of touch, listening, compassion, and presence.

With our world changing every day; with our experiences and our innate wisdom challenged every single day; with our routines and habits changing minute to minute, we are starting to see between the lines of our lives. We are starting to look between the cracks; to probe between the layers of darkness that we have been hiding behind. We, as women, are starting to see what has been hidden: that birth is a unique act, unique to women; that women's bodies are exquisitely designed for this task; that a woman births best when she is surrounded by a loving circle of care.

It is wonderful if that circle of care can include someone, an elder perhaps. who know about the vagaries of Mother Nature and her cruel jokes. But if not, chances are that everything will work out fine. And that is better than being treated like a child, when you are bringing forth new life.

So I see women and their partners and their communities going about their lives, far from hospitals and Covid regulations. And it makes me sad that with this huge machinery of health care that we as a society couldn't have created a safe and sacred space for women to birth in; but I understand why that isn't possible. Can you imagine what would happen if the power of womanhood was actually unleashed? 

Think about the biggest wave you've ever seen. Think about the most love you've ever felt. And the most beautiful place you've ever been. Imagine what it would be like if women grew babies in their wombs and birthed them with respect, honour, and love. 

Scars have a way of healing. With healing comes change, and growth. Womanhood has been injured and scarred for too long. There's a new era coming, so watch out!

The Shaming of Mothers

More and more evidence is coming out about the dangers of cesarean section. Every time I scroll through my birthy friends' Facebook posts, I see another mega-study that confirms what we knew all along: c-sections are dangerous. Of course, this surgery can and does save lives. But it cannot be true that over one quarter of our childbearing population can't deliver vaginally. 

I believe that for a well-fed, healthy population such as ours in the industrialized worlds, the necessary c-section rate should hover around 5%. Do the math: this means that at least one in five women are suffering unnecessary surgery. This surgery sets the tone for a woman's mothering - it isn't always a traumatic event, but it definitely is a physical handicap and a hurdle that many mothers would rather not have to face. 

I don't want to write about the reasons for these unnecessary trips to the operating theatre; the reasons are varied and complicated. I DO want to talk about how we are making women feel when we constantly post about the dangers, risks, and unredeemable damage caused by cesarean section.

Giant study links C-sections with chronic disorders 

Let's shout it out and make women feel really bad about how they birthed their babies. Let's make them feel even worse about an unexpected c-section than they already do. While we're at it, let's talk about how to have a VBAC: all you need is perseverance, inner peace, and you have to be in tune with your body. Right?

Women are having c-sections they don't want. Women are going to the hospital, sometimes with a doula and sometimes (usually) not, and they find at a certain point in their labor that they are not performing well enough, and they are scooted down to the OR. Most women do not want surgery. Most women want a vaginal birth. Many women want to have a vaginal birth even after a c-section. Just one VBAC support group on Facebook has 8,796 members. 

I am asking all of you to spread the word to not spread the word about how damaging c-sections are. Women who have had an unwanted cesarean birth KNOW that they are damaging. Let's try a little tenderness and spread the word instead about loving the mother, home birth, undisturbed birth, midwifery care, all the good things....

Birth Drugs

Just say no? Of course not!

Drugs save people's lives. Antibiotics, antiretrovirals, opiates, anesthetics, statins .... the list goes on and on. Every day, millions of people are kept alive by modern medicine and by appropriately prescribed medication.

In obstetrics, however, as in psychiatry, medications are overused and used inappropriately. The other day I heard a story about a woman who needed surgery like she needed a hole in the head. She is alone, poor, and anxious. She was going to have a difficult entry into motherhood without major surgery, dealing with the stress of a newborn along with the continued stresses of poverty and cultural isolation.

She was scheduled for an induction and her uterus reacted too strongly to a Cervidil insertion and started hyper-contracting. Baby went into distress and surgery was needed to save the baby. 

I would need a crystal ball and a full-on fortune telling kit to figure out if this particular mother-baby dyad would have needed surgery if left alone. But it is true that "Care providers need to consider that induction of women with an unfavourable cervix is associated with a higher failure rate in nulliparous patients and a higher Caesarean section rate in nulliparous and parous patients" (SOGC).

Why are we giving drugs to laboring women? I took a picture of this drug the other day. It is called synthetic oxytocin. It can save women's lives if they are experiencing a serious postpartum hemorrhage. But it is used much too often to speed up or stimulate labor in cases where a good dose of patience is all that is called for.

This is a high risk drug!

Another cocktail of drugs that is commonly administered is the epidural cocktail. The components vary from hospital to hospital. You can find detailed information on the most common ingredients here (page 20). Most epidurals do contain Fentanyl (see below), which is an opiate. I have never heard an anesthesiologist ask a laboring woman if she has a history of substance addiction, but most recovered addicts I know would not willing put an opiate into their bodies unless they really had to.

Which leads me to the next question, which is: when is it necessary to give pharmaceutical medication to women in labor? And I would like to suggest that the answer should be: when the pharmaceuticals are directly involved in saving the life of mother or baby or both. 

We simply do not know the long-term effects of epidural medication on the baby.  

And no, I am not speaking from a pedestal of wonderful candle-lit home births here, either. I have experienced my fair share of birth trauma. And yes, I am fully aware that taking an epidural during labor is often very important for the woman's emotional and psychological well-being, and her sense of empowerment. But these drugs are becoming normalized and their effects minimized. I would like to see the brake put on this candy store mentality where we are offering dangerous drugs to women and newborns.

Here is a brief description of one of these candies:

Fentanyl is a powerful synthetic opiate analgesic similar to but more potent than morphine. It is typically used to treat patients with severe pain, or to manage pain after surgery. It is also sometimes used to treat people with chronic pain who are physically tolerant to opiates. It is a schedule II prescription drug.

In its prescription form, fentanyl is known as Actiq, Duragesic, and Sublimaze. Street names for the drug include Apache, China girl, China white, dance fever, friend, goodfella, jackpot, murder 8, TNT, as well as Tango and Cash.

Like heroin, morphine, and other opioid drugs, fentanyl works by binding to the body's opiate receptors, highly concentrated in areas of the brain that control pain and emotions. When opiate drugs bind to these receptors, they can drive up dopamine levels in the brain's reward areas, producing a state of euphoria and relaxation. Medications called opiate receptor antagonists act by blocking the effects of opiate drugs. Naloxone is one such antagonist. Overdoses of fentanyl should be treated immediately with an opiate antagonist.When prescribed by a physician, fentanyl is often administered via injection, transdermal patch, or in lozenge form. However, the type of fentanyl associated with recent overdoses was produced in clandestine laboratories and mixed with (or substituted for) heroin in a powder form. Mixing fentanyl with street-sold heroin or cocaine markedly amplifies their potency and potential dangers. Effects include: euphoria, drowsiness/respiratory depression and arrest, nausea, confusion, constipation, sedation, unconsciousness, coma, tolerance, and addiction. (National Institute of Drug Abuse (2012). Fentanyl Retrieved from http://www.drugabuse.gov/drugs-abuse/fentanyl on September 23, 2014)

The Curse of the Black Crow

I had a student a few years ago who was attending births with me, and every one of the first six births she attended ended in a c-section. The sixth time, she ran out of the room and down the hall, convinced she had somehow caused the natural birth to go sideways into the operating room.

A friend of mine was standing in the hall, a family physician with a heart of gold, and she caught my student and looked her in the eye, and told her "You do not have the curse of the black crow!" and proceeded to explain how difficult it is for a care provider to accept that their patient's journey is sometimes not what anyone has planned, and that most of the time it is not the provider's fault.

I was taking care of my sister, who was in the hospital after a difficult surgery and several setbacks which were scary for her and worrying for us. She finally made it out of the grey place and we were sitting talking to the surgeon, who apologized to my sister for the fact that things had been more difficult than expected. When my sister reassured her that she had no feelings of blame, and further that the surgeon wasn't responsible, she replied, "Oh no, but I AM responsible. The buck stops here".

But it doesn't. The attendant has a huge responsibility, indeed, to care for her patient. She needs to do everything she can to facilitate healing, or in the case of childbirth, to carefully observe nature at its task. But if she has given her 100%, she has to know that there is always that element of mystery involved. The buck does not stop with us. We do not know why one woman will have a three hour painless labor, and another one will struggle and strain for two days. Yes, we can read blogs galore about how the happy, accepting woman who is comfortable with her body and open to experience will have a quick and easy birth, and the resentful and complicated one is more likely to have a c-section. But these easy generalizations are not true.

No, we don't know why some women have easier births, or why some surgeries end in easy healing and some don't, or why some treatments work on some people and not on others.

When you really believe that the buck stops with the surgeon, then you are closing a door to the mysteries of healing and the mysteries of life.

Ask the Doula - the "too-big baby"

A week has gone by already, so quickly. I am involved in many interesting projects, more about them in a few days...
It's Ask the Doula time again!
Please keep sending in your questions. You can add them as comments below, or send your questions to our facebook page, or twitter @montrealdoula.

Today I am going to be looking at the question of cephalo-pelvic disproportion, or the "too-big baby". This mother generously agreed for me to print her question and the response.


Question Number Three 


"I had my first baby three years ago. I am expecting again and I would like to have a doula to accompany me. I am not sure how it will go. My doctor told me that my pelvis is too small to give birth. My first baby was born by cesarean after I was in labor for two days. I had contractions all day on the first day, then by the next morning they were so painful I couldn't even talk. We went to the hospital, where they broke my waters, and then I took an epidural. My baby didn't come out after two hours and they said she was too big. She ended up weighing seven pounds thirteen ounces, and had an Apgar score of 9 and 10. I have a very small pelvis and a narrow pubic arch. Do you think this is a good reason for a cesarean?"

First of all, let's understand how birth stories work. A woman will tell me her story, and it will be just that - her story about what happened to her. It is a story in the first person, about a primal experience she had. I will listen to the details but I will also listen to the tenor, the resonance, of the story.

This story is about a normal labor that somehow went wrong. The first hint is that she labored all day and after 24 hours had contractions "so painful I couldn't even talk." This is normal labor. Mothers will have contractions for a few hours, or a few days, and they will be uncomfortable and even painful. Then the body gets down to work and contractions become so intense that she cannot speak through them. Then she gets to the point where she doesn't even want to speak in between contractions, and this is when the doula knows that the laboring woman is definitely in good labor.

But in this story, the woman was not prepared for the intensity, and she went to the hospital soon after she entered the beginning of active labor. She doesn't say why they broke her waters, but usually it is done because there is a perception that labor isn't moving quickly enough.

In this case, it appears that the breaking of the waters did stimulate labor, and this stimulation increased the intensity of the contractions to the point where the laboring woman decided to take an epidural for pain relief. She was probably quite tired by now, as well, as no one had told her to rest during the night in between the contractions.

The epidural probably helped in terms of her energy, and her body obviously did the work of opening so that she reached the pushing phase. Then what happened? She pushed for two hours. The staff told her the baby was too big and she went to surgery. I cannot extrapolate too much, but here is a possible scenario:

The pelvis is narrow and small. The body made a baby that, in fact, was a perfect size for this pelvis. Her labor was progressing normally and the baby was doing the appropriate moves to navigate through the bones of her mother's body. At a certain point, she had moved her head to a sideways plane so that she could get some leverage to push it down further.

Imagine one of those wooden toys, where the child has to push blocks through different-shaped holes. The child will turn, and turn, and turn the block until it finally pops through. He learned this at birth.

But suddenly, the amniotic fluid drained, and she found her head stuck upon the bone in a awkward position. She still instinctively pushes her head to the other side, to straighten it in order to descend further. As she is doing this difficult work, she feels her mother's helpful body go limp. She has no more help from the outside, just uterine contractions that are pushing her more and more into a position that will be very difficult for her to move from.

The cervix becomes fully dilated, because the body is doing what it should. But the combination of the narrow pelvis, the crooked head, the epidural, and the impatient staff adds up to an unfortunate turn of events.

If she had decided to stay at home longer, until labor was more active, she may have avoided getting her membranes ruptured. If she had a wider pelvis, the baby may not have gotten stuck. If she had a doula by her side, she may have managed to avoid or at least postpone the epidural. If she had not taken the epidural, vertical or forward-leaning positions could have helped the baby come down. If the staff had patiently waited another hour, she may have pushed the baby out.

But we do not know. We really can never know what could have happened, had things been otherwise. But if we agree that we could never know what might have happened, then we have to also admit that we do not know if another baby, perhaps with a slightly smaller head, in a better position, without an epidural, with a doula assisting the mother, could successfully navigate through the birth tunnel and be born vaginally.

My answer? I do not know the reason for your first cesarean. But I do know that you do not have any conditions that definitely preclude your giving birth vaginally. There is a saying: "labour is the best pelvimeter". In layperson's terms, this means that the best way to measure your pelvis is with a baby's head, when you are in labor.

My advice? Hire a doula. Make sure you have a good relationship with your doctor or midwife.Stay positive and open. I wish you the best of luck!

Ask the Doula - epidurals

I am always getting letters, phone calls, or face-to-face questions about birth, doulas, and such.

Every week, I am going to  try to answer and explore a different question that is presented to me, and, in doing so, perhaps answer some of your questions, and perhaps learn a thing or two myself.

Please send me your questions as comments, and I will select one question each week to answer.



Question Number One

"I was at a birth the other day, and the doctor said to my client that there was a recent study done that proves that an early epidural [that is, administered before 4cm] does not lead to a rise in c-sections. What is your opinion on this?"

I think more doulas and women will start to hear about this study, and I think it reflects a dangerous trend. The doctor who quotes recent research seems very with-it and up-to-date - she's done her homework. But let's have a little look at the research in questions:

The study is a systematic review of six studies that included over 15,000 women. Please click here to retrieve it. As you can see, it is a nice little study, I suppose, with one serious flaw that jumps out on first reading.
It states that the ..."review showed no increased risk of caesarean delivery or instrumental vaginal delivery for women receiving early epidural analgesia at cervical dilatation of 3 [c]m or less in comparison with late epidural analgesia." Early epidural analgesia was defined as that administered at 3 cm or less. Late epidural analgesia was not defined, so it could have been administered anywhere from 4 cm well into the pushing phase. Well, when was it? Was it at 4.5? Or was it after an hour and a half of pushing?

The danger is that, the media being the creature it is, someone could simply snip this conclusion, as I have done, and weave a generalization from it. An unsuspecting woman reads the two-sentence generalization and thinks "ahhh, well, that's a relief, I don't have to wait to take my epidural."

Let's look at the reality:
What do we see, as doulas? As I suggest in my book, IF a baby is not optimally positioned (and, by the way, this is also something that we have studied and studied, and we still can't ever really tell when and if a baby is well-positioned, except by watching her  weave successfully down the birth tunnel), and IF a woman takes an epidural early in her labor, and IF the baby's descent could have been helped by a resistant pelvic floor, then this mother and baby could end up with a surgical delivery.

So, in fact, when I see a nice easy birth and:
a mother who has always taken an epidural (and this is her sixth baby and hey! who am I to argue?)
or a mother who always maintained she would ask for pain meds
or a mother who needs meds for another, outstanding reason (sexual abuse being one - we'll get to that another week)
then I have a better feeling about outcome when she decides to take an epidural (even if I know she doesn't really need it).

But when I see a labor that is not going well, for whatever reason: for example, if a woman is having the particular kind of pain that may indicate a poor position, or a woman is undergoing an induction (more about induction coming up too) that looks like it may fail, then I worry about an early epidural, and its effects on labor.

So what can we do about it? "No, little missy, you cannot take the drugs. I as your doula know best"?
Of course not. Maybe there is not really much we can do in the moment. Maybe prenatal education is absolutely paramount. We need to sit with our clients and talk with them about what they are reading, what they understand, what they believe. We need to work with them and open up to them about our own experiences as doulas, and let them know that although a natural birth is definitely simple, it is not usually easy, and that even during labor they will probably have to make choices. And that her choices WILL affect the way her birth unfolds. If she wants a natural birth in a hospital, she will have to work for it. Part of that work will be not accepting pain medication too early in labor.
I know it goes against the review.
But I have evidence that early epidural administration DOES interfere with the normal progress of labor. That evidence comes from my own observation. No studies, no funding, no university degrees. Just women birthing.

Doula Love and Accountability

I have raised a lot of eyebrows with yesterday's post so I would like to go back and comment and try to clarify. One message I was sent was this:
"Doulas don't cause Cesareans. Emphatically. Doctors, emergencies, and women's choices do."
Yes!! Absolutely! And we, as doulas, need to remember this. It is ALWAYS the woman's birth, and not the doula's. No matter where the path leads, it is the doula's mission to follow, and to respect and nurture the woman she is accompanying.

Another message went like this:
"When I'm at a difficult birth, even though I've only been practicing for a few months, I know that I am providing something that no one else can, and that is unconditional support. I know that I'm not responsible for the outcome of the birth, and I hope you realize that inexperienced doulas may take your words seriously."

Still another:
"Yes, we need to take responsibility for what we do - and if a woman in my care has an unnecesarian, I take responsibility, I try to work through it to improve my care."

Wow! Please comment on my blog. I appreciate your messages but I would like to make this discussion public.

To clarify, I would like to publicly apologize to any young/inexperienced doula who was hurt by my words. That is the last thing I wanted to do. I would like to engage in an ongoing discussion about responsibility and transparency. How do you feel when your client has an unexpected outcome? How do you feel when you have a feeling she will end up in surgery, even though she is planning a natural birth? Do you change your practice? Do you call in a more experienced or differently trained doula? What do you do when you are at a birth and things start going haywire? Do you reach out to other doulas?

Whenever I am at a birth that ends in an unexpected c-section, I always look back at my actions and the prenatal and labor process to see if I could have worked differently. Sometimes I know I did everything possible. Other times I know I could have done more. I know as doulas we are not held accountable, as medical professionals are. We form associations and collectives but we are accountable, in the end, only to ourselves. I know I am very hard on myself, always wanting to do better, and I would do good to accept that meconium happens.

To all of you, keep up the good work, and keep on loving.

Natural Birth

Here in Montreal, a woman has a few choices when it comes to giving birth:

We have several large hospitals, most of which have maternity centers. If you are birthing in a hospital, you will be followed either by a family physician or by an obstetrician. Because doctors here in Montreal get paid less, are more overworked, and have to work under worse conditions than in the rest of the country, there is a real problem of access and availability. This means that a woman may not find a doctor who necessarily agrees with  her approach to childbirth. The larger hospitals are also teaching units, so women in labor are under the care of several people other than the doctor she is officially being followed by.

There are three midwife-run birthing centers in Montreal. Two of these offer women a choice to birth either at the center or at home. The third provides home-birth midwives to eligible women. Demand for these provincially registered midwives is high, and the eligibility requirements are strict.

There are women in Montreal who do not want to follow the provincial rules, and these women have two choices. Some hire "lay midwives", who have been trained elsewhere and are not registered with the Quebec college. Still others give birth on their own or with their partner or a friend.

For years I was getting swamped with requests from women who were desperate about their chance of having a natural birth. The conversation would go something like this:
 "I was on the waiting list for the Birthing Center but I know I have a very slim chance. So I've decided to go with Doctor x at y hospital, because I have heard they have a more natural approach. I would like to give birth at home with a midwife but I do not feel comfortable with an unassisted childbirth, and my husband is not happy about hiring a lay midwife. So we feel our best choice is to hire a doula."

Yes, the presence of a doula can reduce interventions. Yes, my c-section statistics (6%) compare well with most of the Montreal hospitals' statistics (25-30%). Yes, birth can take unexpected turns and you are well advised to have a trained attendant. But to be able to stay in your own bed after giving birth, and bring your child into an environment that is your own means a great deal not only to the mother, but also to the newborn.

And my concern is, I am not getting those phone calls any more. The calls are still about hiring a doula, but they are usually not from women who are serious about natural birth. The women who are on the midwives' waiting lists are actually getting in to the birthing centers. They are not hiring lay midwives, and they are not giving birth unassisted. I know that the birthing centers are not working at over capacity; they have rules about how many they can take on. So my conclusion can only be that the desire for a midwife-assisted birth is becoming more rare, and this makes me wonder. Is the doula-accompanied birth in the hospital the way of the future?