Is Natural Birth Worth the Effort?

Just how sincere is your desire for a natural birth? How committed are you to a birth without medical interventions? In today's highly medicalized birth setting natural birth is not just going to happen as a matter of course. It takes serious commitment, diligent study, thorough preparation, competent labor support, and a great deal of patience. So why do all that work and endure the pain of it? What makes natural birth worth all the trouble and effort to accomplish it? How could feeling the pain of natural birth be a good thing?

There are many articles, books, and studies that make a compelling case for why natural birth is best and well worth the pains and efforts to achieve it. However, what I wish to discuss in this essay is the emotional and cultural battle over the question rather then the facts (since they rarely become part of the conversation at large). Though the scientific facts support the physical and emotional advantages of natural birth, emotions are what drive most women in answering these questions. Whether or not you think the effort and exertion of birth is worth the trouble is largely dependent on the attitudes and opinions that you have been exposed to.

Natural Birth is Best

As mothers we naturally want to do what is best for our babies and when a mother is convinced that natural birth is best even a great deal of pain and effort is a small sacrifice. Discussions about whether or not natural birth is best often become contentious and emotionally charged. I believe this is largely because women have deep and sincere desires to be the very best mothers they can be; they often feel belittled by natural birth advocates when they do not choose natural birth or are unable to avoid medical interventions.

When I say "natural birth is best", I do not say that without understanding that there are natural complications inherent in the birth process. For this reason I am keenly aware of the great blessing of modern medicine in saving the lives of mothers and infants faced with these unsurmountable circumstances. When things go wrong we need doctors, but what I contend is that labor and birth aided by proper preparation, reliable constant labor support, and free from medical constrants will proceed safetly and complication free 95% of the time.

With natural birth advocates passionately asserting that natural birth is best and doctors taking the position that as long as the outcome is a healthy baby the process used to get there is relatively insignificant, it becomes difficult to know which is truly best and therefore we are left with the impression that there is no real difference between the two, making the decision less imperative and therefore more optional.

Mothers are not strangers to fatigue and hardship in the care of their children. Such things are inseparably tied to motherhood. Learning to except the pains and distortions of pregnancy, the extraordinary pains of labor, and the sleepless nights and sore nipples of infancy are only some of the things mothers face in the bearing of new life and the nurturing of new human beings. Mother's know all too well that what is often best for their babies is inconvenient, exhausting, and difficult, and yet it is the nature of mothers to give their bodies, might, mind, and strength to their children.

It is because of this that I am convinced that if women understand that natural birth will greatly benefit their babies they will seriously commit themselves to the study and preparation necessary to achieve a natural birth, and will patiently put forward their best efforts as they cope with and endure the pains and exertions required.

The "Old Ways" Reborn

A good example of how women respond when they understand what is best for their babies is the history of breastfeeding in our society. Breastfeeding has gone from only 20% of US women breastfeeding in 1957 (about the same percentage of women today who choose "all natural" birth) to 61.0% in 1980 a 210% increase. There has been a decline in this rate over the past twenty years, but it is a largely undisputed fact that "Breast is Best".

The continual decline of breastfeeding at the onset of the industrial revolution resulted from "bad advice from pediatricians in an era where industry and schedules" were seen as superior to the "old ways", and recent declines are mostly an extension of the trend that has convinced mothers that there is no need to sacrifice their bodies, their beauty, or their careers to provide the best nutrition and nurture to their infants. The cultural attitudes toward natural birth mimic these same assumptions and many women today believe that medicalized childbirth is superior to the "old ways" of labor. Ignorant assumptions about the reasons for unimaginably high infant mortality rates "before modern medicine" has lead to a belief that medically managed labor is safer for babies and their mothers. On closer examination of history will uncover the conditions that caused these high rates were rarely a result of common labor complications, but rather poor nutrition, hygiene, and sanitation.

In the case of breastfeeding advocates like the La Leche League educated the public about the real physical and emotional needs of infants. Today the medical community takes the issue of breastfeeding seriously and supports a wide spread initiative to educate mothers about the benefits of breastfeeding on the physical and emotional health of their babies. The American Academy of Pediatrics states that "Advocating for children through the protection, promotion, and support of breastfeeding is a high priority." In almost every OB's office today you will find posters and pamphlets that encourage breastfeeding. Where are the posters encouraging natural birth?

The Disconnect Between Facts and Practice

Most women today are skeptical of natural birth because the medical community puts such a low priority on the practice. The trust they place in their doctors leads them to believe that if natural birth were better for women and children doctors would advocate for more natural birth practices, as they have done with breastfeeding. In the case of breastfeeding advocacy both inside and outside the medical community applied pressure to make the health of babies paramount. It has proven more difficult to effect this change in birth practices. Therefore, the truth about natural birth is not so readily available and the advantages not widely advertised.

In my discussions with doctors about natural birth they talk about the benefits of natural birth over medically manged labor as a matter of fact, but they believe that it is impractical. The doctors I know believe that the success of natural birth is in large part out of their hands and is the result of the efforts applied to it by laboring women. As doctors they are there to handle challenges that arise, not to provide constant natural labor support. Therefore, it is because mothers are not committed to a natural outcome that it is so rare.

"Even those who come to the hospital wanting a natural birth almost always end up demanding the epidural." One doctor said. "They take little thought for the preparation and support side of birth, and my primary concern must be a healthy mom and healthy baby. So if it becomes necessary to manage the labor I will not hesitate!" In a good conversation with an OB after the delivery of one of my clients the doctor commented, "Well, this is something I don't see much in my practice." She had thoroughly enjoyed the "all natural" birth she had just witness and expressed a sincere desire to see more of this type of labor and birth. So, who is responsible for educating women about natural birth? Is the low natural birth rate in the U.S. the fault of the uninformed public or the medical community?

I think that the answer lies somewhere in the middle, women need to take a greater role in seeking out the best birth for their babies, and doctors need to be more proactive in promoting natural birth. It is sad to me that doctors who know that natural birth is better don't employ greater effort in advocating for it. One of the lessons of the successful public education initiatives that improved breastfeeding rates in the U.S. is that the medical community has a critical role in advocacy. It makes sense that more women could be persuaded to choose a natural birth, seek adequate preparation and support, and therefore benefit from the healthy outcomes of natural birth for their babies and themselves if only it were a high priority among doctors.

Why have American women said "NO" to natural birth?

With no clear direction on what is best for mothers and babies, the vast majority of American women have decided it is not worth the trouble and that the pain is too great, and birth options become largely a matter of convenience. Women have come to believe that there is no difference between natural birth and medicalized birth. I was astonished at how often women made comments like, "There is nothing un-natural about using medication." or "It's completely natural to have an epidural."

Over 80% of American women choose the epidural for pain management, and labor inductions have more then doubled in the past ten years. What most women don't know is that women who are induced are twice as likely to have a C-section as those who experienced spontaneous labor and epidural use significantly increases the chances of further medical interventions; including a 20% increase in c-sections.

As a doula you can imagine that I find myself part of conversations about birth on a regular basis. I must admit it is disheartening to hear the apathetic attitudes women have toward the routine use of epidurals and inductions. Even more astonishing is the number of women who have no plan to ever attempt a natural birth. Planned epidural births make up just over half of U.S. epidural rate and I believe this is the result of peer pressure. A first time mom said that, "every single one" of her friends with kids told her to "Get the epidural!" It's just a fact today that natural birth is rare and that almost every woman you meet today will enthusiastically recommend the epidural, and most will say it was the best thing they ever did.

A growing segment of this peer pressure is coming from women who at one time had sincere desires to labor naturally. This is especially concerning to me because these mothers had their initial desires squashed by poor preparation and labor support and not natural ability; such as this mother who said she wanted to have a natural birth until she, "found out that labor hurt really bad". Sadly her experience convinced her that though other women are capable of coping with labor, in her words, "unfortunately it's not for me." Very often these women advise other reluctant friends to have planned epidural births spreading their own damaged confidence to others and the cycle continues. Therefore, Peer pressure and ignorance perpetrate a growing childbirth industry based on a medicalized model.

Why should you say "YES" to natural birth?

What most American women don't hear are the beautiful experiences of mothers who have been changed by the gentle natural births of their babies. Very rarely are they exposed to the great confidence such women have in their natural ability to cope effectively and bring their babies into the world by their own power and intuition. They may be few, but women do overcome the obstacles set against successful natural birth in our system and solidify their confidence in themselves and in the natural process of labor.

In the words of one mother who experienced the disappointment of her failed first attempt at natural birth, "The second time around I spent the whole nine months preparing myself... and succeeded in the natural childbirth I was looking for." This mother dusted herself off and got serious about making it happen for herself and her baby the second time around and her efforts paid off, she found the satisfaction she desired.

Many years ago at a church luncheon I happened to sit down at a table with a handful of pregnant ladies, of course it didn't take long for the discussion to turn to labor and birth and like most conversations of the type there was lighthearted advise given to "get the epidural" and be done with it. I debated with in myself whether to expose my opinions, something that is always quite a quandary for me, but for some reason I ventured cautiously announcing that I was a natural birth doula. This steered the conversation in a different direction. Though most of the pregnant mothers feigned an interest in my perspective, however, there was one who engaged me with many thoughtful questions and began to share her disappointments over past labor experiences. I gave her several book recommendations and encouraged her to study and prepare.

I saw her again several years later, she stopped to talk to me while I was out to eat with friends, she asked timidly, "Do you remember me?" She was very familiar and when she reminded me of the lunch we spent together I immediately knew her. She said, "When I saw you I just had to stop and say thank you for talking to me that day. I had my baby "all natural", and it was a wonderful experience. I am so grateful you were there that day and that you were willing to speak up about the truth of natural birth."

After two difficult "natural" births, my sister-in law finally asked me to attend her at her third birth. She had known only the "grin and bear it" form of natural birth and had truly suffered through it in bed with her first two. With her third I went to be with her in labor, I did what I always do as a doula, I encouraged her to get our of bed and work with her labor. She walked, and rocked, and danced with her husband. When things got really tough I ran the bath for her and she labored in the water. Things moved quickly and she birthed a nine pound baby in two pushes. She often told me afterwards, "If only I had known with my first two that if you just get out of bed it doesn't hurt so bad." She went on to have two more gentle natural births.

The experiences of such women are the best counter argument to those women who regularly testify to the horrors of natural birth. What women need to hear is that it is well worth the effort and that if they will have the courage to say "Yes" to natural birth they can experience the same amazement and satisfaction these women have found.

In conclusion here are a few beautiful testimonials from natural birth moms who found the joy in birth and rather than speaking of the horrors and an epidural rescue, these mothers know a very different reality.

"The birth had been one of the most incredible spiritual experience of my life, I was filled with pure love for my perfect, beautiful baby boy. It was truly the most empowering moment when I realized that I had done it, that I was strong enough. I did have the ability to birth my child in a gentle, natural way. So when I say I loved my labor, believe me, I loved it. It was the hardest work I have ever done, but the greatest satisfaction came out of that work. It was everything I had hoped for and more, so much more. It was everything I had imagined it would be and everything I hadn’t imagined it would be."

"The birth of my baby girl was beyond anything I ever thought birthing a baby could be. She was born in a warm tub of pure water, about the most gentle and serene way possible. You might cringe at the thought of a baby being born in a tub, but actually it is very safe and much gentler on the mother and baby. I birthed her myself; gentling gliding her through the water till she surfaced and I laid her next to my breast. It was wonderful. I had never dreamed I could have such a lovely labor and delivery. Water birth is truly the most gentle of gentle births; the water creates a comfortable holding environment for the mother and a warm, safe, and familiar environment for the baby. Everything I had read proved to be true in my case, and I am so happy to have been able to experience labor in this way."

Is it worth it?

Judge for yourself, but judge wisely. Do your homework, study the the question out and decide, which is it, do you follow the advice of the vast majority of women who have chosen the separation and mind and body that the epidural provides, or do you dig deep and find the God given power you have to birth your child. On closer examination you may find that when it comes to natural birth it may be well worth resisting the common peer pressure and ignorance that swirls around this subject and study it out on your own.  I hope you will find the passion necessary to choose a natural birth and do what it takes to be successful.

My Thoughts on Why Women Fail

Why do so many American women who "try" for a natural birth fail...only to be convinced that for them it is impossible? In my experience as a doula, women put far too little thought into it at the start...that there isn't enough "try" in their tepid desire. Though most women I come across seem interested in the subject of natural birth and even express a desire to have a natural childbirth, they don’t really want to bother reading a natural birth book or seek the right labor support. Usually they just go far enough to say, “I think I’ll try to go natural.” not realizing that it takes a full commitment and fervent desire to have a good natural birth.

This laissez faire approach to natural birth preparation might have worked long ago when it was a foregone conclusion that babies come into the world in only one way; when women were surrounded by women with extensive knowledge of natural birth capable of aiding them in the process, but today when almost everything women face in the hospital environment hinders the progression of natural birth, it is naive to think that they will be successful without a fervent commitment to natural birth.

Besides the lazy faire attitude of many women toward natural birth, women today face a challenge to their success that women in the past did not. The soft living of our modern age has become a pitfall that often leaves us unprepared to face the "labor" of birth because of the extraordinary exertions it requires. We have become too conditioned by the easy life, constantly having our basic needs meet with little effort.

Convenience and ease is standard in our world of prepared foods and eating out, high-tech appliances, and instant gratification. We have an easy pain free life and so naturally we expect and want a pain free labor (a paradox in itself, perhaps labor should get a new name). To me it is sad that we’ve been taken in by the pursuit of the easy way and the soft life, since “the most worthwhile things aren’t easy”. We are missing out on some of the most worthwhile experience in life when we avoid the difficult pursuits. This is definitely true with child birth.

Women who go into labor with a casual commitment to a natural childbirth rarely make it past six centimeters dilation before they decide they can’t do it. Most women I talk to these days simply tell me they tried and it was too hard. They've come to believe that women who are able to labor naturally simply must have better genetics and easier labors. They draw no connections between methods they used and the types of labor interventions they allowed and the fact that most natural birth mothers fervently reject such interventions as the only way to achieve their goal of "natural birth".

I do not want to marginalize legitimate birth complications which are real challenges for some women, but the statistics clearly show that these complications happen very rarely when labor is left alone and medical interventions are not used. Only 5% of normal healthy women who are supported by doulas or midwives and reject common medical interventions end up with cesarean births, startling when compared to the average rate of 30%.

The sad part about these common experiences is that most of them are avoidable with some preparation and good labor support. Women who think they are unable to have a successful natural childbirth would be wise to take an independent look at their labors and ask themselves what medical interventions were used prior to the problem that arose, and could the problem be caused by those unnecessary medical procedures. It is my experience that very often the emergency measure is needed because of the unnecessary medical procedure that preceded it.

A midwife (who provides continuous labor support) or a doula can do a lot to help a woman who has a history of large babies, lots of back labor, or long and difficult labors. Baby size is one of the most common "medical reasons" for routine inductions which are most often the cause of medically induced emergencies during labor and birth. As a doula I have seen women push for hours only to deliver a 6 pound baby, and another will push twice and a nearly 10 pound baby charges onto the scene. I have watched this phenomenon many times and it is my opinion that the traction that large babies have in the birth canal aids them in the birthing process as long as their mothers are using movement and gravity to help them along. Still baby size is one of the most common "medical reasons" for routine inductions which are most often the cause of medically induced emergencies during labor and birth.

The thing that most often contributes to long and difficult labors is the improper presentation of the infant, an obstacle often overcome by simple positions changes and movement during labor. Medical interventions become the common obstacles to the correction of the baby’s placement because they cause a woman to be held captive to her hospital bed stealing her mobility and therefore snatching from her the most effective means of bringing her baby into the world by the power of her own body.

Women who labor lying down and immobile are not only going to experience more pain, they will have longer labors and more difficulties at the pushing stage. This alone is the most common reason women fail in their pursuit of a natural birth, and one that is easily overcome by the presence of constant capable labor support.

Whatever the reason for the failure the tragedy is that many of these mothers who walked into the hospital hoping for a natural birth walk out disappointed in themselves, or worse, horrified that they ended up on the c-section table. It has been my experience that the vast majority of women are able to labor naturally and bring their babies into the world by their own power so long as they lean upon the support of women who have confidence in and knowledge of natural birth.

Labor Induction, What's the Big Deal?

There has been a dramatic rise in the labor induction rate in the last 15 years. According to the National Center for Health Statistics, the rate of inductions was 9.5% in 1990. In 2003, the rate more than doubled to reach 20.6%. There is reason to believe that the most current labor induction rates might, in fact, be under-reported. According to a 1999 review of 7,000 consecutive inductions, published in the American Journal of Obstetrics and Gynecology, the number of labor inductions may be closer to 40% in some community hospitals. Similar findings were reported in the 2002 Listening to Mothers survey. Of the nearly 1600 mothers interviewed, 49% who gave birth vaginally reported that their medical provider attempted to induce their labor and 44% actually had their labor induced.

Research dating back to the 1980s and earlier has consistently shown induced labors more often end in cesarean section, forceps deliveries, serious infections, and greater complications for both mother and baby. Still, many physicians have not been convinced, largely due to an internal debate as to whether these eventual complications are caused by the induction or were the natural result of the immediate medical issue that prompted the induction. Though this debate seems logical it hardly holds water against findings that indicate that 18% of mothers said they were induced for a non-medical reasons and another 16% cited a non-medical reason along with a medical indication. The sharp rise in inductions also reflects the loosened definition of what constitutes a medical induction, for example women who have healthy non-complicated pregnancy are routinely being induced because doctors suspect a large baby. The difficulty in late pregnancy is accurately predicting the baby's size since ultrasound measurements are based on percentiles. These percentiles measure the "average weights" of babies; however the estimates are not always accurate.

For example, one of my doula clients had an ultrasound a couple weeks prior to her due date that estimated her baby's weight to be 8 pounds and her doctor suggested that they induce the baby the next week (pre-term) which she resisted only to have him insist they do it by her due date for sure. She called me after her appointment with her doctor very upset that an induction would thwart her natural birth. I told her that her doctor does not know the size of her baby and that he is just guessing. I reassured her that big babies can come naturally as well as little ones. She told her doctor she would wait to go into labor spontaneously, during the pushing stage of her labor, which was long (not unusual for a first time mom), she later confessed she was silently cursing me believing I had been wrong about pushing big babies out only to be surprised when her new little girl weighed in at 6 1/2 pounds! When doctors advise women to induce due to the size of the baby when there is no other medical concern it is a highly speculative “medical” opinion that does not accurately indicate a medical need.

This common reason for recommending induction is steeped in falsities, the belief that a big baby means a more dangerous and difficult labor. It is true that women who receive epidurals have a more difficult time pushing their babies out and therefore are already at higher risk of c-section and the size of the baby could further complicate the birth; but it is not equally true when speaking of natural birth moms in un-medicated labors, and yet, as with the example above, doctors still recommend the induction regardless of the mothers desire for natural birth. In my experience, as a doula, it is not necessarily a foregone conclusion that a woman with a big baby is going to as a matter of course have a more difficult or even longer labor. The things that most often contribute to long and difficult labors are the obstacles of medical intervention that cause a women to be held captive to her hospital bed stealing her mobility and therefore snatching from her the most effective means of bringing her baby into the world, the power of her own body. Women who labor lying down and immobile are not only going to experience more pain, they will have longer labors and more difficulties at the pushing stage. As a doula I have seen women push for hours only to deliver a 6 pound baby, and another will push twice and a nearly 10 pound baby charges onto the scene. I have watched this phenomenon many times and it is my opinion that the traction that large babies have in the birth canal aids them in the birthing process as long as their mothers are using movement and gravity to help them along. If you will take a look at some of the other content on my

The findings of a study, conducted in Belgium, clearly shows that inductions alone are the cause of birth complications and emergency procedures and prop up the idea that births that are allowed to proceed naturally will not become complicated. The study compared over 15,000 births occurring over one year (1996-7) in first-time mothers. All women had healthy, uncomplicated pregnancies. At their request, half had labor induced artificially shortly before their due dates. The other half went into labor naturally. The women with induced labors used significantly more pain medication and had more cesarean births due to both fetal distress and stalled labors. That group also had more forceps and vacuum births and had more babies admitted to intensive care. This most recent Belgian study is but one of several in the last five years which have attempted to address these questions by studying only clinically similar, uncomplicated pregnancies. Most have found strikingly similar results.

Another reason for a provider to advise an induction is when the mother's due date has passed. Babies who are truly post-term can have more complications. However, this diagnosis must be made based on more than simply dates, since due dates are a loose estimate of gestation. Specific testing can be done, such as a biophysical profile, which measures the amount of amniotic fluid in the uterus, the breathing movements and the baby's heart rate. This would give the provider and parents a more accurate indication of a post-term baby (and ultimately a labor that needs to be induced!) rather than looking at the due date alone.

For example, one of my doula clients delivered her baby three days past her due date but had several common complications attributed to late term delivery including no amniotic fluid, while in contrast another client delivered her baby nearly two weeks past her due date and had no late term complications. Just as there is a weak connection between baby size and labor difficulty, it is also foolish to predict complications based solely late term deliveries.

Not only are doctors inducing women routinely at only 7 days post-term (not even the full 40 weeks that used to be the standard), an even more alarming trend is on the rise, the induction of pre-term infants. Preterm births and induction of labor preterm are increasing at an alarming rate, and it is increasingly evident that even late preterm babies are less healthy and incur higher costs than infants born at full term. In November 2009, the Agency for Health Care Research (AHRQ) published Thinking About Inducing Your Labor: A Guide for Pregnant Women and a companion guide for clinicians. The two publications summarized the current clinical evidence on elective induction of labor (defined as induction without medical indication), which is on the rise and is linked with the increase in late preterm birth. While the evidence base on this issue is still being established, current research indicates cause for concern: Between 1990 and 2006, the U.S. preterm birth rate (birth at less than 37 full weeks of gestation) rose by more than 20%. It is becoming increasingly recognized that infants born late preterm are less healthy than infants born full term. Late preterm babies are more likely than full-term babies to suffer complications at birth such as respiratory distress, to require intensive and prolonged hospitalization, to die within the first year of life, and to suffer brain injury that can result in long-term neurodevelopment problems. They also incur higher medical costs.

Another disturbing trend contributing to the dangerous increase of inductions are the growing number of inductions that are scheduled purely for convenience. The last weeks of pregnancy are uncomfortable and many women simply get tired of being pregnant and ask to be induced, some schedule the induction because their doctors schedule and they want to be sure their doctor is there for the birth, working mothers often schedule inductions for the ease of working it into their schedules. It is hard to imagine that any mother would knowingly open herself and her babies up to such risks as fetal distress and emergency c-section for a scheduling conflict or the annoyance of heart burn and aching muscles, but it seems that this is happening more often and even more disturbing is that it is happening with the support of medical professionals who took an oath to “do no harm.”

It is hard for women who trust their doctors and believe they have their very best interest at heart, to believe that their doctors would recommend medical procedures for them that are not prudent or necessary. This phenomenon may be perplexing, but it may be unwise for mothers to ignore the implications of such studies. With a sharp increase in elective inductions, cesarean rates twice what they are in other industrialized nations, and only 20% of women laboring drug free American women and babies are at greater risk. We have become too dependent on our doctors to educate us rather than taking the time to research our options. Most women are unaware of the real risks of induction and the link between induction and cesarean births.

If a woman is trying to avoid medical interventions in her labor such as an epidural (read my article on epidurals) or a cesarean delivery but allows herself to be induced when there is no pending emergency she will find it nearly impossible. The way doctors induce is aggressive, it is so common to use the epidural with inductions that they don't take any thought for trying to keep the induction as close to a natural simulation as possible. I have known midwives to use pitocin this way with success at giving women a pretty natural experience without drugs. The standard induction makes the contractions harder and faster than a natural labor progression would be.

An induction stacks the deck against natural birth and one medical intervention inevitable leads to another and another. The induction makes the continuous EFM a necessity to safeguard the baby, which causes unmanageable pain and stress for the mother. The EFM is very physically uncomfortable because of the placement of the EFM around the abdomen a very sensitive area during labor, but it is even more upsetting to the labor process because the constant interruptions to adjust the EFM straps disrupt the woman’s concentration and relaxation which is essential to the progress of natural birth. This is all significantly compounded by the limits the mother's mobility so much so that the mother has no physical pain relief at her disposal. She can't really move very easily and usually ends up in bed on her back so the nurses can adjust the straps just right to get a good reading on the EFM, in order to prevent fetal distress.

Women who are induced are also seldom allowed to use the shower or birthing tub to get relief from the pain (except with some midwifes who provide continuous labor support and supervision). It is my opinion that if you are induced you will not be able to cope with labor naturally and will just feel like you failed in the end. What you need to know is that failure in natural birth is most often related to medical intervention and not the mother's ability. A women's best chance at having a natural drug free birth is for a women to go into labor naturally, be free from as many medical tools and interventions as absolutely possible, and have natural birth support from a wise woman who knows natural birth well, like a doula or midwife.