#380 | Henci Goer on Taking Charge of Your Birth

More than twenty years ago, Henci Goer's renowned book, The Thinking Woman's Guide to a Better Birth, profoundly shaped Cynthia's understanding of pregnancy and birth, setting her on the path that eventually led to her own natural births and a career in birth education and client advocacy. In this special conversation, we sit down with the author herself, now one of the most influential voices in evidence-based maternity care.

Today, we discuss Henci's newest book, Taking Charge of Your Birth, along with evidence-based maternity care, physiologic birth, induction, cesarean prevention, and informed decision-making. Henci explains why "physiologic care" is about using the least intervention necessary—not avoiding intervention altogether—and why preserving a woman's agency may be one of the most important factors in creating a positive birth experience.

We also explore the evidence surrounding induction, Bishop scores, Pitocin protocols, cesarean rates, choosing a care provider, the role of doulas, and why preserving a woman's agency may be one of the most important factors in creating a positive birth experience.

Whether you're planning a home birth, birth center birth, or hospital birth, this conversation offers practical, evidence-based guidance for taking charge of your birth.

Choosing Induction: When it Might Be Needed

Henci Goer's Website, Books, & Articles

Henci Goer on Instagram

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Transcript

I'm Cynthia Overgard, birth educator, advocate for informed consent, and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Show. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Henci Goer, it has really been a dream of Trisha's and mine for years to get you on our podcast. You are the person I've consistently said, ever since I was pregnant and gave birth to my son in 2005, who single-handedly altered the course of my birth and my life with your incredible book, *The Thinking Woman's Guide to a Better Birth*. I had the honor of meeting you after my daughter was born. I have a photo of us together in my bedroom with my daughter just a day old. Anyway, thank you so much for being here. Trisha and I are thrilled to have you.

And I am delighted to be here.

You have lived a fascinating life and have made an enormous contribution to the birth world. Your book, *The Thinking Woman's Guide to a Better Birth*, was just so important. One of my favorite things about it—I still remember this all these years later—is that right at the beginning you addressed what so many people say: "Well, are you a doctor?" And your answer was essentially, "I read."

That's actually a Penny Simkin story. I'm sure I attributed it to her at the time, but things get cross-linked because you read it in my book. Penny had produced a handout on the pros and cons of epidurals because she continued teaching childbirth education throughout her career. An anesthesiologist called her into his office and asked about it. She said, "Is there anything inaccurate in it?" He replied, "No, but what are your credentials to do this?" She later said it was one of those rare moments where you think of the perfect answer immediately instead of afterward. She simply replied, "I can read."

So can I, because I'm not a doctor, a midwife, or a professional researcher.

Well, I would actually say you are a professional researcher—not in the university sense. One of your books is a textbook that you co-authored with Amy Romano, who happened to be my midwife when Trisha attended my own birth, which is incredible. I know you asked us to read your recent books and come up with questions, and we've done that. We have lots we want to ask you. Trisha, why don't you kick us off?

Henci, before we get into all of those questions, can you give our listeners a little background on how you got into birth work and the books you've written? You're famously known to us for *The Thinking Woman's Guide to a Better Birth*. It's still sitting in my closet of birth books. Best book title ever, by the way.

I actually remember when Cynthia and I were starting the podcast. She said, "Whoever came up with that title just hit the jackpot."

I thought it was perfect because it appealed to me so much. I thought, "Well, I'm a thinking woman."

Exactly. It's exactly what a woman needs to be in birth. It's the whole idea behind taking charge of your birth. You're not a midwife, you're not a PhD, you're not an OB...

I was a doula, and I was a certified childbirth educator. I'm not doing either of those things now.

So just give us a brief synopsis of how you got into birth work, the books you've written, and what you're doing currently.

I think, like a lot of people who get into birth work, it started with the contrast between my first birth and my second birth. My first birth, by all medical standards, was perfectly uneventful. I had a healthy baby, but for me it was a very difficult experience. I ended up depressed. I didn't feel attached to my son. It was months before I felt anything other than a sense of responsibility to take care of him. Fortunately, that faded with time, but it was a very difficult period, and I blamed myself for failing to be the mother I wanted to be.

As I prepared for the birth of my second child, I read Suzanne Arms' book *The Immaculate Deception*, and that was my wake-up book. I realized that the things that had happened to me in labor—the things that caused me distress and made it such a negative experience—weren't actually necessary. We had moved to California, and I knew I wanted something very different. I started asking around because I wanted someone who could give me a home birth in the hospital. At that point I didn't even realize you could actually have a home birth at home. This was 1977, and everyone said, "Oh, you want Don Crevy." He was a very progressive obstetrician, and indeed I did.

That birth was a completely different experience. With my first birth, I'd taken Lamaze classes and I was doing fine, but they talked me into a narcotic, which really threw me off. I still felt the contractions, but I was woozy and couldn't cope with them. When I got to pushing, I was flat on my back, pulling my knees up, and I remember saying, "I think I could do better if I could just get up." Instead, they talked me into a caudal block.

They're absolutely useless because you can't even get one until you're already pushing. It stops your ability to push, so you haven't gotten any pain relief during labor. It was really so they could wheel you into the delivery room and deliver the baby with forceps. Epidurals really weren't common yet. A caudal block was a total nerve block, but much lower, and it stopped the contractions.

I remember reaching for my son, only to be restrained because there were straps on my arms. I was told, "This is a sterile field." Then they gave him to me because the latest thing was that you could breastfeed your baby on the delivery table. They basically plopped him on my chest, watched me fumble around for a minute, and then took him away for the standard twelve hours of observation in the nursery, even though he was perfectly healthy. My twelve hours happened to end at midnight, so by the time they brought him back the next morning, I was exhausted and in pain. I don't know whether I'd had a deep episiotomy or whether I tore because it was a forceps delivery.

With my daughter, I had no interventions. I wanted an unmedicated birth, and this time, when I got to pushing and said, "I don't think I can do this," everyone around me simply said, "You're doing fine." She was posterior, and Don did a manual rotation. Once he did, she practically fell out. He supported her head and shoulders, then looked at me and said, "Do you want your baby? Pull her up."

We didn't know it was a girl at that point. I pulled her up onto my chest, and she pushed herself up on her hands and looked me right in the face. That experience changed how I thought about myself forever. For one thing, I loved my body. I remember showering a few days later. Women spend so much time disliking their bodies. Their breasts are too small, or their hips are too big, or whatever it is—we don't like our bodies. But I remember thinking, "I did this amazing thing. I didn't know I had this kind of courage. I was strong." That's what made me decide, almost immediately, that I wanted to tell other women about this.

So I decided to become a Lamaze teacher. When I looked at the curriculum, I realized I needed to wait a little while before doing that. In the meantime, I wanted to find out whether this was truly a deep interest of mine. My background was in biology. I was a biology major, although I wasn't pre-med, which was unusual. There was a freestanding birth center and resource center starting up in a nearby town. I believe it may have been the only community-owned and operated birth center that ever existed because most birth centers are founded by midwives. I got involved with them, and when the birth center opened, there had only been a couple of doula studies at that point. This was really back in the early days. The birth center supplied labor support to its clients, so I became one of those labor support people.

Eventually I became a Lamaze teacher, and then I got involved in writing because of what I was hearing from my childbirth students. It was appalling. I'd hear things like, "My doctor said that not having continuous fetal monitoring would be like driving your car down the highway at 95 miles an hour on the wrong side of the road." Or, "My doctor told me he only does cesareans when they're necessary." I knew that doctor had a 25% cesarean rate, which was considered high at the time. It's been around 32% in this country since 2009.

When I got started in 1980—that's when I became certified as a childbirth educator—cesareans really weren't an issue yet. Back in 1974, when my son was born, there were plenty of other things to object to, but cesareans weren't one of them. They were around five or six percent in the early 1970s. There was a conference held in 1980 because the cesarean rate had climbed to what was then considered the unbelievable rate of 15%.

I thought it was 10%.

I know where you're getting the 10%. You're thinking of Marsden Wagner, who was still involved with the World Health Organization. They conducted a large international study and concluded that the cesarean rate for countries and large regions should not exceed 10%.

That's right. Even in countries with poor access to healthcare and high rates of malnutrition, they emphasized 10%, with perhaps 15% in the most extreme circumstances. They were very clear that 10% was the goal for developed countries.

Marsden Wagner said that happened at a major conference as something of a nod to the United States because by then we were already at 15%.

Now you could say that was many years ago and perhaps the research wasn't as strong. But by the mid-2010s, there were new studies showing that the sweet spot truly is between 10 and 15%. Above that, there is no additional reduction in newborn deaths. Below that—if you get down into the six or seven percent range—the perinatal mortality rate starts to rise again because you're looking at countries without adequate access to cesarean surgery. So now we actually have much stronger evidence confirming that the original World Health Organization conclusion was correct.

The sweet spot for cesareans, on a population level, is between 10 and 15%. That doesn't tell you what any individual practice should look like. But for a full-term, singleton, head-down pregnancy without major medical complications, about 10% would be expected for first births. Once you've already had a vaginal birth, the cesarean rate should only be a few percent.

There are many factors contributing to our high cesarean rate. One of the shocking developments in just the last few years is that the United Kingdom, which used to have cesarean rates in the mid-20% range, is now over 40%. That happened very rapidly, and I still haven't seen a good explanation for what went so wrong there.

The trajectory shot up quickly in the United States, too.

Maybe. Maternal mortality in the United States actually reached its lowest point around 1987.

Right around that time, Congress signed legislation that fundamentally changed hospital financing, and after that cesarean rates climbed dramatically while birth became more dangerous again. We really had reached that sweet spot in the mid-to-late 1980s.

The cesarean rate in the United States has been about one in three since 2009. Furthermore, among low-risk first births—that means one baby, head-down, full term, first pregnancy—the cesarean rate is still more than one in four. Those are low-risk pregnancies.

Henci, everything we've just discussed leaves women wondering why so many unnecessary cesareans happen. We can honestly say that probably half of the cesareans performed in this country, and in many other countries, are unnecessary. Women are left wondering whether their own cesarean was truly necessary. Doctors, obstetricians, and even some midwives are often very good at convincing women that it was.

One thing we know automatically increases your risk of cesarean is the hospital where you choose to give birth. If you walk into a hospital with a 60% cesarean rate, your odds immediately become much higher simply because you're giving birth there. Can you talk to us about what mothers can do to maximize the chances of having the most physiologic birth possible in the hospital and reduce their chances of ending up with an unnecessary cesarean?

Now, here's something women don't really have control over. You can't realistically tell your obstetrician, "I don't think you should be using one of those high-dose Pitocin protocols." The response would probably be, "And where did you get your medical degree?" But the evidence does suggest that more physiologic oxytocin protocols—ones that don't exceed what the body would naturally produce, or only slightly exceed it—work well. You may have to be a little more patient, but the baby still comes out.

I think one of the biggest ways we misuse Pitocin is with those high-dose protocols where we just keep turning it up because labor isn't progressing as quickly as expected. Instead of immediately increasing the dose, why not allow more time at a lower dose and keep it more physiologic? Or even turn it off temporarily.

If...Let the mother rest. Let the baby rest.

That's where it's so important to have the right care provider. You can absolutely say yes or no to rupturing your membranes, but you can't really dictate what dose of oxytocin they're going to use or how frequently they'll increase it. Another thing a physiologic approach would include—and this is something a woman could discuss with her provider ahead of time—is turning off the Pitocin once she's in active labor. Sometimes Pitocin simply primes the pump. Once labor is well established, you can stop the Pitocin and let the body's own oxytocin take over. Sometimes that works. If it doesn't, you simply turn the Pitocin back on.

I've seen that work.

I think that's such an important recommendation and one that should be used much more often. Once a woman is truly in active labor, just pause for a bit. Let her get up. Let her move. Turn the Pitocin off and see whether her body continues on its own. If not, you can always restart it.

I wanted to ask you something about what you said earlier. You recommended choosing a physiologic provider if someone is planning an induction.

Actually, I'd simply recommend choosing a physiologic provider, period. The induction part comes later.

Fair enough. Do you still consider an induced labor to be physiologic, or has the physiology already been fundamentally altered once we introduce something like Cervidil or Pitocin?

If you're defining a physiologic birth as one with no interventions, then obviously no. You've introduced a significant intervention. But that's why I prefer the American College of Nurse-Midwives' concept of optimal care. It's not about achieving a perfectly pure birth. It's about asking, "Given this particular situation, what intervention—or lack of intervention—produces the best outcome?"

Imagine someone who's in active labor. She's been laboring for hours. Progress has stalled. She's seven centimeters with good contractions. When I was attending births at the birth center as a doula, the midwife might say, "Let's rupture the membranes and see if getting the baby's head more firmly onto the cervix gets things moving." It's not black and white. It's about asking what options make sense in this particular situation and escalating gradually rather than immediately reaching for the biggest intervention.

That really gets to what I think is the fundamental philosophical divide. One model is medical management. The other is physiologic care. There's a profound difference between management and care.

Medical management starts from the assumption that birth is dangerous and something could go wrong at any moment. Therefore, we need constant surveillance. If anything falls outside a very narrow definition of normal, we intervene. If that intervention doesn't work quickly enough, then it's time to get the baby out.

The physiologic approach starts somewhere entirely different. It begins with the understanding that birth is a normal physiologic process. In the overwhelming majority of cases, it proceeds just fine. Most of the problems that arise resolve with patience or relatively simple measures. Occasionally they don't. In those situations, thank goodness we have interventions available. But those situations are much less common than we've come to believe. Most labor problems are the equivalent of catching a cold. Some are pneumonia.

It's an interesting conversation because I think there's been so much pushback against the atrocities that have become common in modern birth culture. There really are atrocities in the way women are treated during birth. Because of that, there's been such a strong reaction against any medical management of birth—anything that disrupts the physiologic process in any way. The goal becomes this perfect, undisturbed physiologic birth. It's even gone so far that I've heard some women argue against using water during labor because they believe water immersion itself disrupts physiology.

I think it's an interesting conversation because women end up feeling this tremendous pressure to have a birth with absolutely no physiologic disruption whatsoever. But I really like what you said about physiologic care. Physiologic care is different from medical management. It means having someone there who is committed to supporting your body's physiology and only intervening with the smallest possible intervention when things are truly approaching the outer limits of normal. To do that respectfully, your care provider has to have a very broad understanding of what normal birth actually looks like—not the narrow version that's often taught in medical school. Even some hospital-based midwives seem to have narrowed their definition of normal. Certainly not everywhere, but in many places. Women are left thinking, "Then I just want nothing. Don't touch me. Don't do anything." They start believing that's the only path to an optimal physiologic birth.

Yes, and that's almost bound to create problems. The other thing I'd add is that even when interventions truly are necessary, the care team should continue preserving everything that can still be preserved. It becomes, "Of course we want your partner in the operating room. Of course we want your doula there too." It's not, "You can make your own choices until something goes wrong, and then this becomes our territory." That attitude makes a tremendous difference.

I also think we've developed the same kinds of unhealthy polarities around birth that we've developed in politics. I don't know whether social media is partly to blame, but we've created these extremes. We've done the same thing with motherhood.

I think human beings naturally do this. When people become emotionally attached to one way of thinking, they often conclude that their way isn't simply their preference or even their informed choice—it becomes the right way. And once we believe we're right, the next unconscious conclusion is that everyone else must be wrong. If I've found the right way to give birth, then your way must be wrong. If I've found the right way to feed my child or raise my child, then other approaches must be wrong. We've certainly seen that happen in politics. It's unfortunate because if we actually examine the underlying values, people on opposite sides often care about many of the same things. They simply approach them differently. With birth, though, yes, I think that definitely happens.

We're talking about these polarities, but I think the root issue is agency. Agency is at the heart of what makes birth a positive or negative experience. People become traumatized when they feel helpless. That's really the fundamental problem with our medical system. The woman who wants a low-intervention birth knows about the overuse of interventions but often feels she has no real ability to participate in the conversation.

I'll tell you a true story. A woman hired me for her second birth and was telling me about her first. She had labored for hours and hours. She wasn't progressing. She developed a fever. The baby was thought to be large. The heart rate was becoming concerning. She agreed to a cesarean but felt very negatively about the experience. As she described it, I remember thinking that the cesarean itself certainly sounded justified.

Fast forward to her second pregnancy. She was again carrying a very large baby. Her obstetrician suggested that because of her previous experience she might want to schedule a repeat cesarean. She wanted to labor, and her doctor said, "Okay, let's try." She labored and labored. Eventually the doctor came in and simply asked, "What would you like to do? We can keep going if you want."

She said, "No, I'm ready for a cesarean."

The nurse, who was wonderfully supportive, knew she'd been laboring without medication and asked, "Would you feel better if you walked into the operating room yourself?"

She said yes.

She felt completely at peace with that birth. In the first birth she'd agreed to the cesarean but had no agency. In the second birth it was truly her decision. Even something as simple as the nurse acknowledging, "We know this is a difficult decision," made all the difference. That's what agency looks like.

Henci, over the years I've had many clients ask me how to choose a doula. I've known dozens of doulas over the years. They all have different personalities and different ways of supporting women. I really believe there's a right doula for each individual family. Women often ask me, "What questions should I ask? How do I know I've found the right one?" I'm curious what your answer is.

One of my most recent Resource Library articles is called "What Can a Doula Do for You?" The takeaway from that article is exactly what questions to ask when interviewing a doula. I'd suggest people go to hencigoer.com/resource-library and search for "doula." Rather than trying to summarize all the questions here, they're laid out there. But yes, chemistry matters.

One thing I've heard recently is that if someone is planning to have an epidural, they should make sure they choose a doula who's supportive of that plan. I absolutely think women planning epidurals benefit from having doulas too. But you probably don't want someone whose attitude is, "I'm only here for natural childbirth." Doulas are people. Most are wonderful, but they all bring their own experiences and biases. Sometimes they simply aren't the right fit. Sometimes they remind you of the teacher you hated in high school. Chemistry matters.

I'll add that a doula also needs to have good chemistry with your partner.

Yes. I had a doula once tell me she was disappointed that her client ended up choosing an induction. I remember saying to her, "It's not for you to experience disappointment, just like it's not for you to experience pride if she has a completely physiologic birth. It's not your birth."

What you should ultimately hope for is that your client feels at peace with her birth in both the short term and the long term. If she's at peace with having an induction, then you've done your job by showing up and supporting her through that birth.

I think one of the most important lessons for doulas—and perhaps one reason we see such a high turnover rate—is recognizing that boundary. It's what you were saying about agency. It's recognizing that this is her birth. You're going to care deeply about her and about how her birth unfolds, but you also need a healthy boundary. The family is inside the circle, and you're standing just outside it. Your deepest hope is simply that she leaves her birth feeling at peace.

That can be hard for some doulas. It's hard to watch things unfold differently than they would have hoped. But that's part of the humility required in this work.

I agree. And I think every doula, as part of her training, should really work through her own birth experiences and how she feels about them so she isn't projecting them onto other people.

Especially because many doulas come into this work because of their own birth experiences. They come with a passion that grew out of something deeply personal. That passion and desire to help other women are wonderful qualities to bring into this work. But if you're still actively working through your own trauma, you can unknowingly project it onto your clients and bring it into their birth space. I think it's really important that doulas come to peace with their own birth experiences, whatever they were.

Even on the positive side, you might come away believing that if you just do everything right, everything will always go well. That's probably less common among people who become doulas, but it's certainly possible.

One final question for you, Henci. One of the most challenging situations we see involves women in our community who are planning home births or birth center births. In many states, once you reach 42 weeks, you can no longer give birth at home or at the birth center. Some practices even have a cutoff at 41 weeks. What would you say to the woman who's approaching that limit—41 weeks and 5 days or 41 weeks and 6 days—and is trying to decide what to do?

First of all, in some places it's actually 41 weeks rather than 42. Once you get beyond 41 weeks, things become a little stickier. By 42 weeks there is evidence that the risks, including perinatal mortality, do begin to rise. They're still small numbers, but the risk does increase.

If you live in a state where home birth or birth center midwives are regulated and they're not allowed to attend births beyond a certain gestational age, then as you approach that limit—and community birth was your plan—the first thing I'd recommend is reading Chapter 7 of my induction book, where I talk about the various methods of getting labor started and what the evidence says about them.

Nipple stimulation is effective. I also think membrane sweeping has become far too routine, and there are reasons not to do it routinely. But if you're looking at the choice between losing your community birth or having your membranes swept, I would probably choose membrane sweeping. I would also be using nipple stimulation to see whether I could get labor going naturally.

Then the question becomes whether, as you approach 42 weeks, you choose induction. I think that's a very personal decision. It's exactly the kind of situation where, if you have the information, you can make the decision that's right for you.

If you do decide to be induced, we come back to what I said earlier. If your cervix isn't ready, and this isn't an urgent medical situation, wait until it's ready. If it's a subsequent baby, that's less of an issue because induction doesn't increase cesarean risk to the same degree that it does with a first birth.

There are a lot of factors that only the individual woman can weigh. Is this your first baby? Is your cervix favorable? Once again, don't rupture your membranes. If the induction doesn't take, you can stop and come back another day.

My tagline has always been: Get the data. Make a plan. Take charge of your birth.

That word "charge" is important. It's not "control," because you can't control birth. You can take charge in the sense that you have agency, but you don't get to decide what hand of cards you're going to be dealt.

One final clarification. Earlier, when we were talking about induction, you said not to induce unless the Bishop score is at least eight. You also said that cervical ripening methods don't reduce the risk of cesarean.

That's exactly why I recommend waiting until the cervix is ready. There are studies looking at this. If you simply correlate Bishop score with cesarean rates, it's no surprise that a low Bishop score is associated with a much higher likelihood of cesarean. The body simply isn't ready for labor.

The assumption has been, "Well, we have medications and mechanical methods to ripen the cervix, so we'll just use those first." You use a Foley catheter or prostaglandins, the Bishop score improves, and everything should be fine.

But that's not what the research shows.

Even after you've successfully ripened the cervix, if you started with a low Bishop score, you haven't reduced the cesarean rate.

On the other hand, if the cervix was already favorable when the induction began, the odds of a cesarean for a first birth are roughly the same as if labor had started spontaneously.

I don't give opinions. I tell people what the research says and what my analysis of that research suggests. Then they can decide for themselves. They can go read the studies if they want.

I've always believed that women deserve the evidence. I don't care what decision they ultimately make because I don't know their lives or what circumstances are influencing their choices.

My work for more than forty years has simply been helping women access data-based, evidence-based information so they can truly make informed decisions.

Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and as always, hear everyone and listen to yourself.