BIRTH STORY SUBMISSION

Name*

First Last

Email*

Which one best describes the hospital birth you'd like to talk about on the show?*

I aim to discuss one birth story per episode. If you have more than one birth story, choose the one you'd like to discuss the most. If time permits we can discuss more!

Vaginal
VBAC (Vaginal Birth After Cesarean)
Planned Cesarean birth
Unplanned Cesarean birth

How did you manage pain during your labor?*

Completely unmedicated (did not use any medication)
Mostly unmedicated (used nitrous oxide or intravenous (IV) pain medication)
Epidural
Spinal (for Cesarean birth)

Check all that apply for your birth:*

Please describe your birth story in a few (4-6) sentences.*

What unique perspective do you feel your birth story will bring to other pregnant women?*

I ask the following 4 questions to be sure I include stories from a diverse group of women.

How many children do you have?*

Where do you live?*

City State

What is your age?*

< 19 years of age
19-24 years of age
25-34 years of age
35-44 years of age
> 44 years of age

What is your race/ethnicity? Check all that apply.*

non-Hispanic White
Black or African American
Hispanic or Latino
Native American or American Indian
Asian/Pacific Islander
Other

Thank you!

Name

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