Doulaing For Friend’s Births

Feb 25, 2016 by

DoulaingForFriendsIt’s so thrilling to imagine being a doula for your friend’s pregnancy and birth! For some doulas this is what draws them to the work from the beginning. They want to make sure family members and dear ones have the best experience possible and to help make that happen. But underneath these altruistic desires is the reality of what going to our friend’s births really means. Sometimes it’s a harsh learning.

Ever since I started doulaing, I wondered what was different about it. I thrashed the topic over with my fellow trainers and experienced doulas for years, and then I started asking about it in my doula interviews. Eventually I had enough data to analyze (stories to pick apart!) to get to some core truths. Author Julie Brill, in her compilation book, “Round The Circle: Doulas Share Their Experiences” graciously invited me to write my findings for a chapter in her book. Along with 22 other experienced doulas, we offer advice on unexpected home births, surrogacy, encouraging the mother-baby bond, self-care, and supporting religious belief that is not your own, as well as many other topics. But here is a sample of what I learned:

1. Despite your best efforts, you have an agenda. Pregnancy and birth are times of tremendous life change and shifting of identity. When you walk alongside your dear one, you are attached to them. You want things to go well and you will do what it takes to get a positive outcome. Contrast this with your clients. You care about them and want the best, but our role is to support their efforts and not be invested in their choices. You will likely see them a few times after the birth, but your role is to see them through this transitional period. With your friends, you expect to be in their lives and their child’s lives and to see them grow up. This attachment to a particular outcome shifts and changes your support and you can’t get around it.

2. No matter what happens, you will be associated with that birth and its outcome. Forever. Because of your expertise, you may be blamed if something does not go as expected. In order to get distance from the birth, the family may need distance from you. This need may be expressed by the partner or grandparent, not your friend. However they need to honor those feelings. That may mean not being invited to gatherings or even not having casual visits. It’s so easy to blame the doula, which is not a problem when it’s a client. We shrug it off. But when it’s your friend, you want to explain or work it out, but some feelings you can’t work out. They just are. Often it’s a big surprise to the doula when this happens.

If something goes really well, you may be assumed to have “magical powers” that you know you don’t deserve, which can also be disconcerting. What really matters is how closely the laboring person’s labor and birth expectations meet the reality. If expectation and reality are a close fit, then it is usually a positive for your friendship. If they don’t, it can have negative consequences.

3. Your relationship will change and neither of you can control it. Beyond the rollercoaster ride of many friendships, which have ups and downs and varying levels of intensity, birth does not bring out the best in us. It isn’t supposed to. It brings us face to face with who we are – our strength, our weaknesses, our fears, our beliefs about the world and our place in it. When a stranger is with you, you are able to be intimate, understanding that knowledge is held in a special private place and will not have repercussions for your future relationship. When your close friend sees you, they will know you that way forever. That knowledge and intimacy can make some people really uncomfortable afterwards (including you).

You will also see their partners and family members in a new light, which may or may not be a favorable one. As doulas of friends, we have a much greater emotional load to bear. When we care deeply, it’s very difficult to hide our feelings about a partner’s actions or a care provider’s options. We are more transparent. They aren’t used to our doula mask, and they know when we’re upset or hiding resentment. It can be done, but it’s darn hard.

So what’s a doula to do?

First, buy Julie Brill’s book and read the two chapters on attending the births of friends!  (BTW, I get no money from the sale or promotion of this book. I just think it’s a great resource so you should know about it.)

Second, contribute your baby shower, birthday and holiday gift money towards a doula’s fee and encourage other people to do the same thing. Your friend or family member still needs a doula, just not you! Imagine what a fabulous supportive friend you can be: a sounding board for feelings, an extra resource for information, and all without the full burden of responsibility. You get to show your excitement and your disappointment honestly, offering an extra set of hands whenever they’re needed.

Lastly, as an older woman I want you “youngers” to know how precious your friendships are! Having people in your life who knew you from decades ago doesn’t happen without conscious effort and cultivating compassion, caring, and humility in each relationship. As doulas we often have a leg up on those qualities – but sometimes not with our friends. There’s you, and your friend, and your relationship that all need tending – make sure that you’re looking after each one before deciding to be their doula.

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Showing Up

Aug 20, 2015 by

The Road Goes On Forever, And The Party Never EndsOne of the doula research interviews that influenced me profoundly happened at a 2004 conference.  That morning a birth colleague, Sophie*, came striding in to my hotel room with coffee and her breakfast on a plate.  We’d met in 1988 at a retreat for birth professionals.

“I didn’t think you‘d mind if I ate while we talked,” she said as her plate clunked down on the glass table.  When I transcribed the interview later, I could hear her chewing and cutting her lox and bagel with a knife and fork on the recording.  It was so like Sophie to assume my loving acceptance of her quirks; just like she would about mine.

I turned on the recorder.  With her first story, Sophie said, “Amy, the most important thing you do isn’t a double hip squeeze. It’s not whether she gets drugs.  It’s showing up. Showing up is 50% of what we do as doulas.”

As the interview progressed, she told more stories and reflected on what she’d learned.  Sophie said, “I change that!  Showing up is 75 % of what we do as doulas!”

By the end of the two hour interview, she changed her mind again.

“It’s 99% of what we do as doulas!  The rest is just fluff.  Showing up for her, that is what counts.”

Showing up is an approach of non-judgment and a series of continuing actions over time that support the mother wholeheartedly even when others are unable to accept or support the mother’s needs (Gilliland, 2004).

In my research, doulas who had been to a hundred or more births usually told stories about this deep level of acceptance, or what Sophie called “showing up”, being the most important and most significant service that the doula can offer.  Many proficient and expert doulas mentioned the need to accept mothers whatever they are feeling or doing, and to believe them when they say they want something, even if it is different from their stated wishes prior to labor.  Here’s the excerpt from my original interview with Sophie:

“In my life there is always compromise, always negotiation, always other people in mind.  I have to take everybody else into consideration.  So I think when someone shows up for me one hundred percent, supports me one hundred percent, hears everything I have to say and amplifies it, that’s what I mean by showing up.  That to me is the greatest gift.  That’s it.  I think that’s 99%.  I’m going up to ninety-nine. [laughs heartily] I think that’s huge. I really do. Because I think very few women get to have that.”

Women have to compromise for everyone in their life.  They have to compromise for their partners, for their kids, for their pets, for their parents, bosses, and on and on.  Women shouldn’t have to compromise for their doula at their own birth!  Instead our role is to be present and mindful in the moment, and do that for hours and hours. answering her needs so she is free to labor.  What she says she wants, even if it’s surprising, isn’t there to be challenged.  Explored and confirmed, yes, not challenged.  Additionally, when women feel that whatever they do or say or behave will be acceptable to their doula, they will feel free to enter fully into their experience of birthing their baby.

What does that look like?  Let’s say I’m at a birth, with a mom who had previously been adamant about not using pain medication.  She looks at me and for whatever reason, says, “I think I want an epidural.”  The doula’s “showing up” thought process prompts me to consider the mom and ask, “What can I do to best support her in this moment?”  The attitude of the doula has to be one of caring detachment.  If we get caught up in our clients doing things a certain way or having certain things happen, the experience becomes about us and not about them.  Effective doulas need to find a way to be caring and loving of the woman and her intimate family, without being attached to what she does, how she makes decisions, or what choices she makes.  It’s essential for our own mental health, but also for our effectiveness as labor support.

What do I say to that mom?  “Would you like to talk about it more or try something first, or do you want me to get the nurse?”  If she says to get the nurse, then that’s it.  I’m there to support the woman in labor, not her birth plan.

But the reality for us is that we WANT things for our clients, we WANT them to have great births, we DO get attached.  What helps me is understanding that the birth is her journey; she is the leader, she tells me the route.  If I think she’s making a “wrong” turn, that is me comparing her journey with some idealized one I have in my head.   I know birth influences the course of women’s lives forevermore.  So who am I to judge what’s best?  I don’t know her path.  When I can say that inside of me and really own it, I am much freer to support a wide variety of women making a wide variety of choices, and to truly show up for them.

 

*her name has been changed                “Just Show Up” image courtesy of Edward Tufte.  http://www.edwardtufte.com

 

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Not Any Woman Can

Jun 30, 2014 by

One of my most hated myths about doula care is the idea that any woman can be a doula.  Just put a person born with a uterus in a labor room and she’ll be able to help effectively – with no preparation.  This is a myth that devalues what doulas do, and gets in the way of us being perceived as professionals. It also devalues the men who offer good doula care.  The myth that “any woman can” is even perpetuated by doulas, who may not realize the damage this idea does.

Effective labor support requires sophisticated emotional skills that rise to the level of a skilled counselor.  A good doula has to be able to correctly read everyone’s behavior in order to positively influence the emotional tone of the room.  She or he needs to know the mother’s need before the mother knows it.  In my published research on emotional support skills [pdf: GillilandMidwifery], it became clear that these skills take many births to master.  The components of emotional intelligence are at the heart of doula work.  Good doula support cannot be accomplished without keen self-knowledge, empathy, emotion management, and relational skills.

In addition, doulas utilize a wide variety of positioning techniques and comfort measures.  In order to establish a position correctly, the subtle placement of a shoulder, foot or ankle can make the difference between comfort and pain for days after the birth.  Having a wide variety of ideas and stamina are essential for the physical demands of labor support.

The key to understanding empowerment is knowing that a doula cannot empower anybody.  A person has to take advantage of an opportunity presented to them to state what they want and to ask questions.  Doulas create these opportunities.  But it only happens smoothly by using complex communication strategies.  Doulas need to be able to relate to everyone’s concerns:  medical care providers, nurses, the mother and her immediate family.  This begins with keen observational skills and compassion for conflicting agendas.  Her choice of words and attitude is deliberate and intentional.

These are not skills possessed by most people!  They are cultivated, practiced, and honed over years of attentive living and attending births.   Doulas go over and over each support experience they have in order to squeeze as much knowledge as possible out of it.  They learn that birth is about what the mother wants and not what the doula wants.  This is central to labor doula effectiveness.

In this post, I’ve only begun to scratch the surface of what birth doulas do.  Its necessary to establish a rapport with strangers and educate without overwhelming at prenatal visits.  Many births involve trauma prevention and navigating the landscape of past abuse.  After the birth, doulas are critical to recovery from a difficult birth or normal postpartum challenges.

We MUST establish our own value in the world.  The work of birth doulas is vitally important in people’s lives!  It cannot be done by just anybody.  When we don’t value the complexity of our carework, no other professional – nurses, doctors, or midwives – can do so either.

 

Upcoming:  How Doulas Undermine Our Own Value (it’s not money)

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The Doulas Have Arrived! Nurses, What Does This Mean For You?

Feb 9, 2014 by

Dear Nurse,

When doulas move into a new area, nurses are often skeptical and hesitant rather than welcoming.  This is a normal reaction to change especially when you are uncertain about how it is going to affect you – and how you do your job.  Here is a list written by an experienced doula trainer that might be helpful for you:

  1. Professional doulas want to work with you to help a laboring mother’s needs get met.  She views you as an important ally who has some of the same objectives and priorities.
  2. The doula’s goal is to remind their client to tell you and her physician or midwife what is most important to her about her birth.  She may have listed her preferences on a one page birth plan or may only state them verbally.
  3. Professional doulas do not have any agenda for a “natural” birth.  Every woman benefits from doula support – even mothers planning an epidural or cesarean section.  She and her family can benefit from the added nurturing, reminders they can discuss options, and extra hands that a professional doula can provide.  A doula birth is a supported birth.
  4. Professional doulas are familiar with the research evidence and best practices for maternal and fetal health.  Doula clients tend to also be familiar with this information – which is why they hire a doula.  Because of this, patients with a doula may make more requests than an uninformed patient.  Some of these requests may be a part of hospital protocols even though the obstetrical unit’s culture does not usually promote them.  Some examples:
  • No routine amniotomy
  • Intermittent fetal monitoring
  • Freedom to choose second stage positions outside of bed
  • Hands and knees, kneeling and semi-sitting positions with an epidural
  • Delayed cord clamping
  • Baby’s naked body on mom’s naked body immediately after birth and not removing it for 90 minutes or more
  • Delaying routine newborn procedures (not health assessments) for 90 minutes or more
  • Newborn exam on mother’s body or her bed
  • Weighing and bathing of baby in the patient’s room
  1. When patients prefer a cooperative decision making relationship with their care provider, they usually hire a doula.  The doula will help to remind them to ask questions about their care.  This interaction style may be rare in some obstetrical settings.  Rather than having their physician autocratically making decisions, these patients expect to be consulted and give explicit consent for each intervention.  With these patients, the doula may ask if the mother and her partner have any questions about a proposed intervention.  The ensuing discussion about benefits, risks, and options may be seen as an interruption or a delay.  However, involvement with decision making has been shown to increase patient satisfaction, birth satisfaction, lower anxiety, lessen the incidence of postpartum depression and prevent post traumatic stress disorder due to a traumatic birth.  This has been repeatedly shown in the nursing literature to be more important than complications, length of labor, or location of birth to short and long term maternal well being.
  2. In order to facilitate involvement in decision making, a doula may tell the patient about an unannounced intervention the physician is about to do. This way the mother may give explicit consent or ask for clarification.  This may be seen as an interruption by the nurse or physician but this is what a doula accompanied patient expects her doula to do.
  3. Despite these interruptions to the usual flow of care, the professional birth doula is your ally.  She knows the patient and can help you to get to know her too.  She will observe almost every contraction and can keep you informed of any issues the mother has or adverse symptoms shy mothers may keep to themselves.  They help mothers to stay focused.
  4. With a 60-80% epidural rate in most hospitals, nurses do not see many unmedicated labors. Doulas have been trained in normal physiologic birth, as defined by the American College of Nurse Midwives (ACNM).  Mothers without pain medication may become louder and listen to their bodies’ urges to move around as labor intensifies.  When mothers are coping well they are calm between contractions.   The doula will help the mother to continue her coping ritual – which may become louder and more intense as labor progresses.

Three Clinical Recommendations:

When you are introduced to the doula, ask her about her training and experience.   Professional doulas are usually excited to tell you about their organization and background.  If she has not taken a training, then she is the client’s friend who is doulaing her. She is not a professional, so none of the descriptions in this essay apply.  The “doula” friend may act in ways that a professional would not do, such as speaking for the mother, touching you or the physician inappropriately, arguing with you, giving medical advice or telling the mother what to do.  These are NOT in the scope of practice of a professional doula.   If she is doing these things and has been trained, she is considered a rogue doula, behaving outside the circle of professional practice and ruining our reputation.  We hope she goes away even more than you do.

New doulas may make beginner mistakes.  There are more new doulas than experienced ones.  This is a challenging profession and many promising new doulas find it is not a good lifestyle fit.  Please be patient with the beginning doula and help her to learn how to treat you.  She wants to do her best to get along with you while helping her client to have the best birth possible.  She may ask more questions about procedures and provider preferences until she becomes familiar with your facility.

Labor and birth are changing due to the doula’s influence.  But this is not necessarily a bad thing.  Nurses are learning alternative approaches in non-pharmacological pain management and positioning techniques to rotate malpositioned babies.  They are relearning the satisfaction of emotional connection to a patient that the doula helps to facilitate.  They are seeing normal physiologic birth happen in their facility (even though it may require suspension of usual interventions).  But most of all, because of nurses and doulas working together, mothers and babies are having emotionally healthy outcomes as well as physically healthy ones.

Here is a pdf copy of this post: The Doulas Have Arrived

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How Not To Be THAT DOULA In A Nurses’ Mind

Dec 13, 2013 by

THAT Doula is the one the nurses roll their eyes at and don’t want to see in the labor room.  The one they aren’t certain about, the one who leaves them wondering how their patient may be negatively influenced, the one they feel oversteps her boundaries and has her own agenda – not the patient’s – in mind.  I’ve done extensive research interviews with doulas and nurses, consulted with nursing unit directors and had served as a mentor doula.  To me, the vast majority of the time these concerns arise from misunderstandings and miscommunication between nurses and doulas.

So how do we counter these negative perceptions that nurses may have about a doula when we arrive at the hospital?  (Now this is much harder when the hospital staff has had experiences with a rogue doula who behaves in these ways on a regular basis.  That may require a more direct approach.)  What I am talking about here is building your own reputation as a trustworthy doula.  Often we can’t do anything about the past, we can only begin with the next birth.  Here are best practices culled from experienced doulas and labor and delivery nurses:

  1. Smile.  Smile when you meet someone, smile when they walk into the room, smile when you walk down the hall.  Be genuinely yourself, don’t fake smile.  A person’s brain perceives a smile as welcoming and automatically changes their behavior to be more receptive towards the person smiling at them.  This is unconscious.  So shifting your behavior to be welcoming by authentically smiling can use this to your advantage.
  2. Adjust your nonverbal behavior to be welcoming and acknowledge the MCP’s presence when they come into the room or closer to the laboring mother’s personal space.  A head nod, slight shift in your shoulders or body orientation can indicate your awareness of their presence.  You can do this while not taking your attention away from the mother in her laboring, or wait until the contraction passes if needed.
  3. Introduce yourself, share a little bit about yourself and what you are there to do.  “Hi, Nancy.  My name is Amy, I’ve been a doula for 20 years off and on.  I’m here with Nick and Nora to help them with comfort measures, remind her to change positions, fetch things, and to remind Nora to speak to you and Dr. X about what is most important to her about her birth.”
  4. If needed, explain what you do not do.  “I don’t do vaginal exams or anything clinical.  I don’t speak for Nora and Nick, I just remind them when it’s a good time to discuss their wants and needs with you or the doctor and midwife.”
  5. “Wonder with” and include the nurses when they are present.  “I wonder if we might try…”  “Nora seems to be tiring, maybe a position change would be good???  What are you thinking?”  “Are you noticing Nora’s cxns slow down when her mother is in the room or is it just me?”  Nurses have been to hundreds of labors and may know coping strategies that we’ve never thought of.  It is a courtesy to ask – remembering mom is the decider.
  6. Include the nurse in the mother’s coping ritual whenever you can.  Any connection you can enhance between the mother and her nurse is good for their relationship.  It also helps the mother to feel safer and cared for.  Nurses like to provide comfort measures but their other responsibilities limit their time.
  7. Acknowledge the nurse’s rank and her territory.  If you are thinking about a big change, such as laboring in the tub or walking the unit, find the nurse and ask her before you do it.  Maybe ask her in a general way an hour or two before you make your move.  “Nora wanted to try laboring in the tub today.  Is there any reason we ought to check with you first before doing that?”  Some nurses don’t need this communication, while others feel put out when their patient is doing something unexpected.  There’s nothing like going into a patient’s room and finding her not there!   If the physician calls and the nurse is out of the loop, she looks less competent.
  8. Do simple things that make the nurse’s job easier.  Pick up the dirty laundry, offer to get her something to drink when going to the kitchen.  Imagine yourself working together on the same team and building a relationship.  You are!  You are both on this mother’s birth team along with her family members.
  9. Urge Mom to speak up verbally about what she wants to each nurse and MCP.  “I really want to avoid an epidural” or “I want an epidural but Amy is going to help me to use the tub first to see if I like it.”  “Don’t tell me to ‘push, push’.”   Get mom and her partner used to speaking up.  Get their voice in early and often.
  10. Prompt mom to speak up:  “Nora, do you want to tell the resident about your approach to pain medication?” Maybe a slower, gentler approach is better: “Hmmm, Nora, I’m wondering if you want to share what’s important to you with Dr. Y since she’s going to be involved with your care.”  You want your voice to be remembered as the one who is reminding mom, not the one who is saying the words for her.
  11. If you’ve done the prompting and mom doesn’t say anything, let it go.  It is her birth and if her vision is not happening because she isn’t saying anything then you have to let it go.  A good general guideline: “I’ll stick my neck out as far as my client does, but I won’t go farther than she does.
  12. When a medical decision needs to be made invite the nurse to stay in the room.  “ Since Nick and Nora have some time to discuss what to do next, Nancy, do you want to stay in case they have any questions?”  By inviting the nurse to stay you avoid the appearance of being manipulative or unduly influencing your clients toward other approaches than the one being initially recommended.
  13. Don’t give medical information.  Help your client to solicit that information from the medical staff.  You know what you know so that you can tell if they are getting the information they need to make a good decision.  You don’t know it so that you can say it out loud to your client.  The doula’s role is to enhance connection and communication, not be the source of medical information.  It is okay to ask leading questions IF your client has indicated she wants more information but it doesn’t seem to be forthcoming.  “Isn’t there some kind of number or score about her cervix to consider when breaking her bag?  I think Nora and I were talking about that a while ago.”
  14. Know what you know and don’t claim to know what you don’t know.  If you are unfamiliar with position changes with an epidural, say so.  “I took a workshop where getting in a kneeling or hands and knees position with an epidural was helpful in preventing posterior positioning and labor dystocia.  I haven’t done it before, but Nora would like to try it if possible.  Do you think we could work together and see if that is good for Nora and the baby?”
  15. Realize that everyone present is providing what they feel is the best care for mother and baby.  Almost all physicians, midwives and nurses are making the best recommendations possible based on their knowledge and experience while taking your client’s preferences into account.  It is the rare MCP who is misogynist or disregarding the emotional importance of childbirth.  I’m not saying that it doesn’t happen.  I am saying that making that assumption without direct experience of it does a disservice to you, your clients, and the medical staff you are working with.
  16. Repeat after me:  “It’s not your birth.  It’s not your birth.  It’s not your birth.”  Tattoo this in your memory, embroider it on the inside of your birth bag.  It’s not our birth!  Our role is to follow the woman’s lead even if it seems she is doing the opposite of what she said she wanted prior to labor.  Don’t have your own agenda for this birth or this mom.  Her birth is her life experience.  Don’t cheat her out of it just because we want it to be a different way.  Our job is to support the choices she is making now even when she may not stand up for herself or what she said she wanted earlier.
  17. Your reputation precedes you and nurses will talk about you after you leave (perhaps even while you are there).  Make sure that this nurse has good things to say about you – or at least nothing specifically bad.  It may take more than one birth for positive feedback about you to circulate but it’s worth it.  Hopefully you will experience greater satisfaction in your relationships with medical staff by following these strategies too.
  18. Nurses have personalities, struggles with coworkers, worries, and families waiting for them.  In other words, they are whole people.  Show respect for them and concern for their needs.  An approach that works with Nurse Nancy won’t work with Nurse Abby.  A large factor in your success as a doula is your ability to pay attention to other’s cues and adapt your behavior to get along successfully with them.  Our job is complex because we have to do this with our client, her family, her care providers and members of the nursing staff – simultaneously!!

These are advanced communication strategies that seem deceptively simple.  It takes courage to change even when behaving in a way that is natural to us isn’t getting the results we want.   All of them are ways of being at a birth that highly effective doulas practice and that labor and delivery nurses said they appreciate.  My hope is that they will help you find increased satisfaction and harmony in this critical aspect of doulaing.

 

Here is a pdf copy of this post: How not to be THAT DOULA in a Nurse’s Mind

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Their Doula Disappointment

Oct 26, 2013 by

Recently these two news stories came across my desktop.  “My Doula Disappointment” outlines one woman’s story with her birth and postpartum doulas. The second is a petition which is a response to North Florida Regional Medical Center’s recent move to create a registry of birth doulas who are “allowed” to attend women in labor at their hospital.  What do these stories have to do with the current discussion of certification?  Plenty.

In the first issue, the woman noted that the doula she hired had twenty years experience and was highly recommended but not certified.  The mother disregarded the doula’s lack of certification, remarking that since she came highly recommended, certification was not necessary.  Now that she is not satisfied with her experience, she realizes that there is no one to complain to nor to mediate her dispute (or even to listen to her feelings).  While I know nothing about the circumstances or doula’s perception of what happened, that isn’t relevant.  My point is that the mother bemoans the fact that there is no one with any authority who will listen to her concerns, so she is forced to air her concerns on the internet – for all to read.  If there was a certifying body, the story she shares might be different.

In the second instance, NFRMC is reportedly instituting a doula registry in order to clear doulas who will be allowed into the hospital in a doula role.  [This is unverified as the only mention I have found online is the petition.]  Undoubtedly, they have encountered unprofessional behavior and are doing what they can to provide a “reasonable” working environment for their staff and providers.  Part of the problem is that doctors and nurses deal with novice doulas, hobby doulas, friends of mothers calling themselves doulas, and rogue doulas*Very few of these people feel any allegiance to other doulas or the professional standards most of us hold dear.  They can’t tell them apart from the professional doulas – we’re all the same to them.  We use the same title and there is no visual distinction between us.  Every doula gets blamed when one person calling herself a doula acts in a way that medical professionals do not care for.

Even though we are not part of the medical culture, it behooves us to structure our profession in a way that garners their respect.  We can either control and patrol ourselves or hospitals will do it for us.  As someone who has consulted with hospitals regarding their conflicts with birth doulas, I am not surprised by NFRMC’s purported action.  It makes perfect sense to me when I consider the bigger picture of their possible doula experiences.

On the other hand I hear doulas rejecting certification because it interferes with their freedom to offer services to their client.  What is it you want to do for your client that is outside the doula’s scope of practice as defined by DONA, CAPPA, and similar standards?  This “I want to follow my own conscience” does NOT work for doctors, accountants, or even personal trainers.  No one is protected by an “anything goes” attitude.  According to DONA and CAPPA SOPs you are welcome to use aromatherapy, therapeutic touch, even massage, homeopathy, and herbal remedies IF you have additional education or certification.  Counseling that these alternatives are available is certainly within your SOP.  Giving your mom a recipe for an herbal tea to start labor is too IF you are a trained herbalist and her MCP of choice is consulted.  Herbs, homeopathy, and essential oils are drugs!  They have effects on the body; that is why we use them.  The same goes for acupressure.  To think that these effects are always benevolent is deluding yourself.  States and provinces even require massage therapists to be licensed.  But many alternative remedies have been classified as supplements which means they are available over the counter.  But OTC does not = benign.  Both of these SOPs state that if the mother is considering doing something to her body that may have a deleterious effect, even if it is a rare occurrence, that she discuss it with her care provider of choice first.  Some doulas interpret this as asking for permission; I see it as consulting.  The mother hired her MCP for their expertise on her physical health.  If she is considering taking a drug or having a treatment that may affect her health, it is important for her to get their opinion and for her medical record to be complete.  It is the mother’s choice to make; we only counsel her to do so.

We live in a society where few people take personal responsibility.  You may think your client will never blame you or a technique you recommended for a poor outcome.  Just ask the doula who has had 100 clients – she’ll set you straight.  According to my own research participants and the hundreds of  doulas I’ve known over the years, scapegoating occurs in both small and large ways.  The limits for the doula’s standards of practice and condition that the client consult her medical care provider PROTECT you and your client.  If you really want to prescribe rather than support (or in addition to it), get the education and credentials to do so.  No one is stopping you.

But remember that the doula’s magic is her ability to support unconditionally and be present with a woman when she is vulnerable, uncertain, and challenged on every level.  It is believing in her ability to find her own voice.  It is not being another voice telling her what to do.  That is what the research evidence supports.  If prescribing, diagnosing, and treating are important to you, then perhaps your path is not to be a doula.  There are many other roles where these desires can be accommodated – just don’t do them and call yourself a doula.  Be fair to the rest of us – the choices you make individually do not end with you – they affect all doulas.

 

*rogue doulas:  A doula who willfully behaves in a way that is dishonest, unethical or against established standards for doula behavior.

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Why You Should Keep Your Hands To Yourself

Sep 23, 2013 by

Answer:  “Vaginal exams.”  Jeopardy question:  “What is one thing a doula does not do?”  Most of us hear these reasons in our doula trainings :  doulas are not experienced at it; it introduces germs; it is a medical diagnosis (liability); or that it “muddies the waters” between the doula’s role and that of other medical professionals.  There are doulas and other birth professionals who feel that doing vaginal exams at home in early labor is an advantage.  When I first started as a labor assistant in the mid-1980’s it was assumed that I would someday provide vaginal exams and other clinical skills.  We thought being able to offer more medical information to the mother would be empowering.  After years of personal experience and research, I now theorize that it is more empowering for the mothers and more powerful for the doulas to avoid doing vaginal exams.  Here’s why:

1.  Everyone else wants to put their fingers in her vagina.  Triage nurses, doctors, residents, midwives, midwifery residents, nursing students, you name it.  Even though I would likely be using these skills at her home to gauge when to go to the hospital, I don’t have to add my name to the list.  Doing vaginal exams doesn’t help me be a better doula. I just become another person who is entering the private spaces of her body.

2. It changes the balance of power in the client doula relationship away from an act of service. As a doula my role is to empower and support this mother one hundred percent.  If she wants something I help her to get it; if she doesn’t want something I help her to say “no”.  My role is to help her believe in herself.  As a professional doula, I have no agenda other than to support her and her loved ones. As women we are equals and I am there to serve her as she labors and births her child.

Once I put my hand inside of her we are no longer equals – she doesn’t put her hand in my vagina.  The social roles between us have shifted.  In her mind who I am symbolically has changed.  I used to be there to serve her and now I have touched her intimately and evaluated her!  This shifts the power balance between us so that I have more power than she does – I have personal private knowledge of her she does not have of me (and very likely will never have of me). Our support relationship is no longer the same.

3.  With that one act, the doula role shifts from support to evaluation.  I am judging her body.  I am giving her information about herself that we don’t believe she has any other way.  I am subtly communicating that I don’t trust her to know where she is in labor.  Her intuitive knowledge of her own body and labor isn’t good enough – we need to check the cervix just to be sure.

4.  The doula misses the opportunity to empower the mother.  When you aren’t doing the evaluating, you need to rely on the mother’s internal messages.  She lives in her own body, for goodness’ sake, which is something most people tend to forget.  You can call it intuition or receptivity to subtle nerve pathways perceived by the brain. The mother has access to what is going on in her body and as a doula I can assist her to listen to these messages. If we can help her to identify what she is experiencing and feeling, she can discern for herself what she wants to do.  When we model early on: “It’s your body, what do you feel?  What do you want to do?”, it starts a pattern that can carry on throughout her labor.

5.  Not relying on vaginal exams means that the doula hones other observational skills.  Patterns of breathing, skin color changes, cartilage and bone changes, even the usual bloody show and contraction patterns can all tell us where the mother is in labor.  Combined with her own internal messages we can present her with information so she can decide.  We can also observe signs of progressing labor, dehydration, or other concerns which might lead us to think that going to the hospital or birth center is a good idea.

As doulas, our very presence is an effort to put the mother at the center of her own birth experience.  Our role of unconditional support is special and no one else can offer what the doula does.  Rather than being a limitation, avoiding vaginal exams empowers both the mother and the doula.  Why endanger that when the price can be so high?

 

**Having said that, there are some mothers that really want at home labor support that includes vaginal exams.  That is why we have monitrices who possess both clinical skills and labor support skills and are covered by midwifery or nursing standards of care – even as students.  There are also midwives who will teach the mother’s intimate life partner to get to know her cervix during pregnancy so they can feel for labor changes.  But the expectations that are brought to the midwifery relationship and nursing relationship are different than with professional doula support. 

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If the Doula Disappeared…No One Would

Sep 5, 2013 by

Shut the door

Cover every toe with the blanket

Make sure the curtains overlap

Persevere until we find just the right spot

Remind you to ask questions

Repeat what was said to you during a contraction

Move the yukky towels from your sight and smell right away

Shut the door again

Restart the playlist

Work with your nurse, helping him or her to get to know you

Repeat your visualization with each contraction

Be calm

Be the extra pair of hands

Fetch anything you wanted

Anticipate what you need

Keep a catalog in their head of what makes you feel better

Have your comfort and well being as the #1 priority

Make sure your loved ones are informed

Know how to interpret your medical provider’s concerns in language a tired laboring brain can understand

Shut the door again

Give your partner a break and remind him or her its okay to eat

Keep the focus on you

Remind you that you are having a baby

Help the nurse

Tape your photos in the room

Understand medical procedures and explain what you might feel in advance

Believe in you and your ability to birth your baby

Remind you that you can say “no” or “not now”

Help you find your voice

Be there with you the whole time

Make sure your partner got to do what he or she wanted to

Shut the door again

Remember to fetch the baby book

Change the room temperature

Recall your deepest birth dreams and help to make them happen

Console you when they don’t

Reflect your rhythms

Take detailed notes of what people say and write down what happened

Empower you to advocate for what you want

Try other things first

Disappear when you need privacy

Understand how each pain medication may affect you and your baby

Know your birth memories and satisfaction will affect you the rest of your life

Protect the space

Keep irrelevant activities from distracting you

Offer unconditional support free from future obligations

Be your doula

 

I’ve often said that no one notices what the doula does; they only notice if she’s not there.   The professional doula often works in the background to make things run more smoothly and help people to get along.  Of course doulas do more than what is on this list but those activities (i.e. comfort measures, encouragement) can also be done by nurses and loved ones.  This list is about what we uniquely bring to the labor room.  It is based on my interviews with sixty doulas and parents about their experiences.

Use this post with your clients and other professionals!  Research articles are great but sometimes a detailed list of what we actually DO seals the deal.

For your own pdf copy of this list, click here:  If the Doula Disappeared…No One Would

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“Being Whoever She Needs You To Be” – Part One: When It’s Easy

Aug 6, 2013 by

On the surface, this seems like a deceptively simple concept.  Many of us understand that different mothers have different needs.  Some women need a sister, some a mother, some a grandmother, some a new birth knowledgeable friend.  As I’ve said before, women hire you based on what they need – which is an intuitive process.  She already senses you have the potential to fulfill her needs.  What comes next is a process of adapting one’s skills and communications to best meet those needs. You can think of “being whoever she needs me to be” as a description of HOW you doula a mother.  Maybe you can relate to these two doulas’ words:

As one doula put it:  “I will match the energy in the room.  I will match their moods.  I will take on the music that they’re listening to.  I will join in the conversations that they’re discussing.  I will ask more about their life because I want to know more about them, I may pray with them.  But I don’t think I actually lose my inner self.  My inner self actually connects with their inner selves.” 

Another doula says:  “It’s taking your cues from them, picking up on the energy and just relating to them in whatever capacity they need. Sometimes I’m an information giver and I don’t do anything hands-on because they want that between them. Sometimes the dad doesn’t want to do anything hands-on, and I’m totally hands-on. And sometimes they don’t want the information because they have all the information that they believe they need in their heads. So it really depends totally on the couple.”

When I was analyzing my first few doula interviews, this concept arose spontaneously. After that, I heard almost every experienced doula describe it.  Later on, I selected passages from over 40 interviews and analyzed them, grouping similar ideas together.  From that I’ve been able to outline this process and come to understand that sometimes ‘being whoever she needs you to be’ is very satisfying, and other times it can hurt you down to your core.  Today’s post is focusing on the process and when it is easy to be the doula she needs.

Emotional support, physical support, informational support and empowerment – these are the four cornerstones of how doulas support mothers.  The doula is sensing what the mother and her partner need and being as effective as possible in providing good care. But it is the mother who is shaping the doula, who is bringing out of the doula what is inside to meet her needs.  Most of the time we enter a labor room curious about how the labor will unfold and not knowing what will be demanded of us.  We just roll with whatever comes our way.  Because we are adapting our skills to meet their needs, parents get to determine what roles we play in their lives.  We have extend ourselves in a position of service for them – and they get to choose how they wish us to serve. 

There are several roles or ways mothers need their doula to be that were fairly common.  Doulas did not struggle at all with these functions.  Here, different doulas describe roles that are common and easy to adapt to. Sometimes mothers want you to be the person who provides:

Informational Support and Empowerment:  “This mom said, “I don’t want any of this hippie-dippy stuff.  I need answers. I need someone who will help me ask the right questions and gather information.”

Forceful Guidance: “I think she needed to have a strong person who wouldn’t back down when she resisted and said, “Oh, but I’m so comfortable here.”  She needed someone who would insist that she move around and do things to make the labor more effective.”

Sometimes I’ll hear the partner in the other room say, “[The doula] said you have to get out of bed and take a shower. Because she said you’re going to feel much better.  So let’s go.”  And then two seconds later they’re in the shower and Mom’s going, “Oh, my God, I can’t believe I didn’t want to, this is so much better.”

Physical Strength:  “Right now I probably couldn’t pick up that television, but at a birth I could hold you up as long as you needed me to.  It’s amazing! I am an amazingly strong person at a birth.  I am that kind of a doula. I will sit up in a bed behind her and push with her.  I will catch her puke. I mean, I know doulas who won’t catch puke. I’ll catch her puke.  I’ll do anything.  I will do anything.”

Comforting Presence:  “As soon as I walked in the door, her husband left, went home, ‘the construction guys were coming’. It was me and the woman, and I sat there and I held her hand. She was sitting in the rocking chair, and I knelt in front of her, and basically what I did was, I staved off the people who were coming by every 20 minutes or so asking if she wanted medication, which she never did even though they gave her the pitch. She never took an epidural or any other medication. Put a sign on the door and said, “Leave us alone.” And then literally all I did was hold that woman’s hand. She would open her eyes and look at me. And she would close her eyes back, and I sat there and held her hand. And she told me afterward she could not have done it without me. Amy, all I did was hold her hand. I did nothing. I didn’t do a comfort measure. I did nothing.”

Acceptance and Humor:  “They were an Orthodox Jewish couple.  So her husband could not be there for the actual birth. But he sat behind a curtain and prayed.  At one point I said, like from the Wizard of Oz, “Pay no attention to that man behind the curtain!” And oh, I’d never say that to anyone else!”

To Let Her Lead:  “I’m thinking we’re in for a long night because she is so high need so early.  She doesn’t sound like she’s having coping related responses to what’s going on at 1-2 centimeters.  But she was not willing to relax, and she’s not going to sleep anyway no matter what I try to do positioning wise or massaging or whatever.  She’s not gonna sleep so we might as well work.  And that’s where she was at.  She did not, she did not want to relax enough to try and fall asleep which I felt would benefit her labor if she would relax and let go.”

Many of these roles or needs could not be predicted.  While we might know that we are expected to help with position changes, what we don’t know is whether she is resistant or not.  We don’t know if simply sitting with her will be all she needs or we’ll be exhausted from walking, stroking, massaging and holding her up.  While we always strive to follow the mother’s lead, there are times when sleep might be better than activity.  But we have to figure out what is more important – her being in charge or the textbook idea to rest.  How we give encouragement also shifts.  When a woman needs mothering or grandmothering, your response is different than if she is a logical and practical person.  People are very different from one another.  A good doula responds to become whoever she needs you to be.

 

Next time:  “No, I Won’t”, Hostess, Scapegoat: When “Being Who She Needs You To Be” is Difficult

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Why Not To Share Your Birth Story

Jul 31, 2013 by

A major part of our effectiveness as doulas is being authentically ourselves without revealing a lot of information about our lives.  We are most effective doulaing our clients when we can be whoever she needs us to be.  The less they know about us, the easier that is.  We are free to shape ourselves around our client and her family.  Good doulaing has much more to do with who we are being in the present moment with our clients than our lifestyle choices or personal history. 

The easiest way to start is to set good professional boundaries and not include personal details that aren’t important to your doula-client relationship.  Such as not having meetings at your home – have them either at the client’s home or a neutral place.  What your partner does or your children’s interests or even your housekeeping standards are all unrelated to your ability to be a good doula to her.  Yet, she will take that information into account in evaluating you and your abilities to assist her.  So my recommendation is to take it out of the equation.

After conducting my thesis and doctoral research, it reinforced for me that it is not a good idea to share your own pregnancy and birth stories with your clients.  None of my own clients has any idea what my births were like or the decisions I made.  It is completely irrelevant and gets in the way of her allowing me in.  As women, we can be notoriously self-judgmental.  We will compare ourselves to others to find out whether our own decisions are “better” or “worse”.  Our mothers do this – sometimes when we tell them the story or later during the labor as they make their own choices.  As doulas, our clients consider us experts – thus our choices carry more weight with them.  Many doulas have had a mother turn to them in labor and sob, “What will you think of me if I do this?”  So I keep silent about my own journey.

This can be a dilemma for doulas who are also childbirth educators (CBE).  Sharing about births in an education situation has a different purpose – “Learn from what I know”.  CBE’s are also freer to advocate for certain choices.  When the CBE is hired as a doula, she needs to be prepared to deal with this issue directly and be more aware of the potential impact on the mother during labor.  I heard this from every mother who hired her childbirth educator as a doula in my study: “I wondered what she was thinking of me”.

As a doula, when a mother asks me, “What were your births like?”  I turn it around.  For doulas who have not given birth, “What would you do?” is the same question.  “Tell me more about why you would like to know.”  It could be she is interested in getting to know me better; then it is easy to redirect to another topic to build intimacy.  It could be she is trying to figure out a dilemma.  In that instance, I can offer more information or some more emotional support.  In either case, asking about my births is often metaphorical; it is a question that indicates she is seeking care.  Her underlying needs will be better met in other ways than discussing my births.  In our own heads we need to understand that the question about our births may not be about our births at all.  It is an indicator that she has a need and isn’t sure how to express it.  Our job is to figure out what it is and how to meet it.

I’m not advocating you never say anything – there is no such thing as absolutes in the doula guidebook!  Sometimes it is very simple. “Did you have a long labor like I did?”  is just that – she wants to know if I have faced the same challenge.  “No, but I have attended a lot of women who did and helped them through it.”  Short answer plus emotional support – we aren’t dwelling on our stories, but meeting the underlying need as we perceive it.  However, we need to know that mom pretty well and sometimes we’re still wrong.  “Tell me more about why you’d like to know” can give us so much rich information about our clients!  It invites her to reflect on herself and learn something – sometimes something significant.  Rather than assuming we already know, her answer tells us so much more about how we can best meet her needs.

The really important thing is to be conscious about what you share about yourself and to make sure that information is in your and your client’s best interests.  You need to know her pretty well in order to choose what to say.  Remember this is a professional relationship, not a friendship.  You want to build intimacy and safety, but they are engaging you for a service.  Based on my research and years of experience, mothers and their families want be accepted exactly as they are – that is part of your support role.  Since people automatically compare themselves to others, you want to make sure that the information you share will soften those comparisons.

Now I know there are doulas who share their personal stories on their web sites – they feel it is honest and a significant part of the way they doula.  However it is likely that they attract clients who agree with their choices or feel attracted to the emotions expressed in their story.  This is not bad, only limiting.  People probably self select further contact based on reading the story.  It really depends on the doula, the kind of clients she wants to attract, and the kind of practice she has.  The key message I am making is to be conscious about your choices in what you share, to realize it has hidden impacts, and that mother’s questions are often not what they seem to be on the surface. 

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The Art of Labor Sitting

Jul 22, 2013 by

Labor sitting is the process of being present with a mother when she is laboring and does not require your direct attention, but needs your attentiveness.  In other words, labor is going well but there really is nothing for the doula to do but step to the outer circle and wait.  Common situations for labor sitting are early labor, the first few hours of an induction, when mother is resting with an epidural, or taking turns with another member of the birth team.

Good labor sitting means that the doula seems occupied but interruptable.  The mother does not feel pressured by your presence to be further along in labor or to be doing anything different than what she is doing.  At the same time she can feel your presence, knowing you are available if she should need you.  Often, labor sitting takes place in the same room with the mother.  Effective labor sitting is an active, not passive process.  It may seem we are sitting on the couch working on a little project.  But a good doula is much more aware of what is going on than it seems!

So how do you strike this balance?  Over the years, through trial and error – doing it wrong and by accident doing it right and then repeating it – I have found my way to effective labor sitting.  I do needlepoint.  If I am reading a book or looking at the screen on my phone, I seem occupied by what I’m doing.  My attention is focused on the book or my phone.  Someone might feel they were interrupting me if they spoke to me.  If I am just sitting there, people may feel bad because I’m just sitting in the chair not doing anything.  They might feel badly or pressured because my skills weren’t being used yet.  If I am sitting on the couch doing needlepoint*, my mind is in the room with them, yet I am happily occupied.

One time a father called me saying he and his wife were getting ready to go to the hospital.  They weren’t packed yet so he was rushing around the house.  Her contractions were 4-5 minutes apart with no bloody show.  Mom was relaxing in the bathtub and coping well.  Through our conversation I got the idea that Dad was anxious.  I surmised he wanted to go to the hospital because it would relieve his anxiety.  As we’ve all learned from TV when you go to the hospital the baby comes out.  While this is an irrational belief, it is the way our culture has trained us.

I offered to come over and help.  When I arrived, Mom had just gotten out of the tub and gave me a big smile.  My doula assessment of the labor was that it was not time to go to the hospital.  I asked her preference and she said she wasn’t ready to go (she is the decider, not me).  We talked a bit and I went to sit on the couch and got out my needlepoint.  I didn’t say anything but after a while Dad seemed to calm down.  We chatted and his furious pace of grabbing household items and putting them in the pile slowed down.  He began to pay more attention to Mom.  The message he got from my behavior was:  “Amy’s calm so there must not be any rush.”  When mom had a contraction I would stop and breathe with her, looking at her from across the room.  This visual regard is also a part of effective labor support – if she were to look at me she would see that I was watchful and available.  In due time we went to the hospital; they were both calm and made the decision they were ready.

Another time labor sitting skills come in handy is at the beginning of an induction.  There are many anxieties to soothe and many decisions that are made in those first few hours that have repercussions later.  If I am present I am able to remind them of their choices, make sure their questions are answered, and calm them down.  I create an atmosphere in the room to make it their space.  I can increase the level of connection between my client and the nurse, resident physician, and attending physician.  If I am not there, those things often do not happen.  This is another time to discuss methods of induction and parent’s concerns.  It is often easier to advocate for using the shower or tub, or having a slower, gradual Pitocin drip before any interventions are administered.  Parents may be able to get approval for a plan to go home under certain conditions.  What I have found most often is that a mother may bring up these things and then the medical care providers (MCP) explain to her why they won’t do it that way.  But in the long run, my client has explored her options to the extent she wanted to.  Plus, the MCP and my client have talked and understand each other’s concerns and preferences.  The nurse has heard the mother and she may make more suitable labor support or intervention suggestions.

Of course a discussion about options is fifteen minutes out of three hours of labor sitting.  Even if none of these discussions happen, there are still other fears and plans that are on their minds and choices to be made.  I have never found NOT being there at the beginning of an induction to gain my clients or me anything.  Sometimes with a Pitocin induction, parents want me to leave for a while.  That’s fine and we agree to check in verbally – not with a text – every hour or two.  If they want privacy with a misoprostol induction, I stay immediately outside the room or return every 15-20 minutes.  Those intense contractions can hit without warning and the partner or nurse may not be able to contact me.

Labor sitting is a creative art.  It requires an understanding of the people involved, a perception of possible futures, and an empathetic, compassionate presence.  It is not a passive process – you are not waiting for something to happen and then responding to it.  Instead, you are influencing the present moment.  You are there, caring, mindful, and available.  People take their cues from your behavior and from your presence.  Because of active compassionate labor sitting, labor often unfolds differently.

*Some doulas embroider or crochet something for the baby or make a lace cap out of a handkerchief.  Knitting needles may click which bothers some mothers.

 

 

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Doulas and Informed Consent

Jul 17, 2013 by

One of our primary functions is to empower the mother and her partner to ask questions.  Many of us feel that a nudging, “Do you have any questions about that?” should get our clients more information in the labor room.  Often I can tell them what they need to know, but I don’t consider that to be my role.  It also defeats one of my main unstated purposes:  to increase communication and trust between patient and medical care provider (MCP).  The more I assist information to flow from the doctor, nurse or midwife towards my client, the more improved their relationship will be.  Mother and her partner or family member can also evaluate their MCP and whether their approaches match.  If I do the talking, those important processes don’t take place.  I know what I know so I can tell whether they are getting the information they need.

What if the mother and her family aren’t getting the information she needs?  What if an important piece is missing?  Then I ask.  Depending on the situation, a direct or indirect approach may be best.  Direct approach:  “Is timing an issue with this procedure?  Some other physicians at this hospital had mentioned that to me before?”  I recommend never mentioning that you read something somewhere – it can be interpreted that you are trying to one up the MCP – bad move!  But stating that you heard it from a MCP with equal status or that you observed it at another hospital works better.   The direct approach works best when you sincerely act curious.  You need to be really present with the thought – “Why is it being recommended this way?

If you have another agenda or predominant emotion it is likely that your subliminal behavior will reveal that and be interpreted negatively– often on an unconscious level.  So the direct approach needs to be used attentively by the doula.  Your client also gets the message from your question that there are different approaches – which the MCP may not care for.

The indirect approach can also be referred to as the Dumb Doula approach.  “Isn’t there something about…um, well…the timing, is it called, with this procedure?”   You are asking a leading question in a non-threatening voice.  This strategy is designed to solicit information from the nurse, physician or midwife without challenging them or their authority.  To be honest, I use this approach most often.  It’s been the most effective at meeting my client’s needs over the years.  Now the Dumb Doula approach is not without controversy.  It certainly doesn’t add to our professional reputation or appeal!  “Those doulas might know how to rub a back, but you’d think they’d have learned some more technical stuff by now.”  Additionally, some doulas may think it is manipulative, that we aren’t being authentic.  To me, crafting communication strategies to maximize effectiveness is what I do all over my life: with my family, my students, in mentoring situations.

Some physicians and midwives are happy to answer questions until their patient is comfortable with the recommended treatment or another decision has been reached.  Others seem to feel that asking questions is equal to challenging their authority.  They may seem brusque or annoyed.  Often it is a clash of health care philosophies.  Your client is likely to be wanted to be treated as an individual and to cooperatively make decisions with the doctor or midwife (who is likely a stranger).  However the MCP is likely to see him or herself as the knowledgeable authority whose role it is to make medical decisions.  In addition, they will have to answer not only to the patient, but their colleagues, the hospital administrator, their liability insurance company, and maybe a judge and jury.  So doing what your client wants rather their preference can be a loaded proposition for a physician or midwife.

Having said that, doulas prompting clients to ask questions and receiving answers actually helps informed consent.  When mothers and their partners receive more complete information regarding procedures and intervention, this actually helps the MCP if an action is called into question.  It also decreases the likelihood of a complaint or lawsuit.  Both patient satisfaction studies in public health journals and birth satisfaction studies in nursing and midwifery journals give the same conclusion.  Involved decision making and more complete information from MCPs leads to greater satisfaction, better long term outcomes, and fewer legal actions against physicians.

As doulas our prompts to get more information for our clients is a win/win for physicians and their patients.  The more moms know before something is done, the more satisfied they can be afterward – both immediately and weeks and months afterward.  I just wish more physicians and nurses understood that.

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Why Mothers Choose A Particular Doula

Jul 13, 2013 by

Let’s say you have a problem where you need some advice.  Explaining the situation will require some self-disclosure and revealing personal information.  You are in a meeting for the day with women you have never met before.  The advice you need can’t wait so you’ll need to choose to reveal your problem to one of the women present.  As the day goes on you have the opportunity to observe and interact with everyone.  When you make your choice, what are you likely to base it on?  Is it the intellectual qualities or resume of the person?  Or the woman you feel comfortable enough to disclose your feelings and your dilemma?  If you’re like most women, it will be the person you feel safest with.

The same thing is true about how a mother chooses her doula.  It is based on her gut feeling – who she can be naked with – because she will be.  Who she senses can accept her fears and her lifestyle – because that is our role.  All of these attributes are due to who the mom is:  what she intuits as right for her, which we as doulas cannot influence at all.  A woman’s gut feeling about which doula is right for her has more to do with who that woman is than who we are.

That mom may need a mother, a sister, or a new friend who knows a lot about birth.  She may need someone she can say “no” to safely.  But whatever it is she needs, choosing a doula is an emotional decision not an intellectual one.  Mothers say, “It just felt right.”  “I felt safe with her.”  “I just knew she was the one.”  “I was leaning towards another doula but wasn’t sure.  Then I met our doula and something clicked.”  “Even though she didn’t look as good as the others on paper, we just connected and that was it.”

Effective doulas are nurturers and good listeners.  In an initial interaction, these are the qualities that attract someone to you.  After that, it is all about anticipating and meeting the mother’s needs – and we don’t yet know what they are.  She may not even be able to put them into words, but that doesn’t mean that her brain isn’t communicating them on some level.  Often the brain sends emotional information to the nerve endings in the digestive system.[1]  Her gut feeling about who is right for her is just that.

I often find myself reassuring new doulas about getting clients.  It isn’t about the best web site or the number of workshops you’ve attended.  It doesn’t matter whether you have given birth yourself.  Parents choose doulas based on a number of criteria.  Yes, cost and experience do count.  Some parents enjoy cool websites with professional photos.  But mothers are often looking for someone they can have an intimate relationship with.

Which is why I think competition between doulas is unnecessary.  It is more important to be yourself and work on developing your interpersonal skills and a nonjudgmental attitude.  When we compete with other doulas in our community we may diminish the opportunities for all of us to get clients.  When we band together to promote doula support and have inclusive “Meet The Doula” events, we send a positive cooperative message to other birth professionals and prospective clients.


[1] http://www.scientificamerican.com/article.cfm?id=gut-second-brain

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Labor Support – You Mean That’s A Profession?

Jul 9, 2013 by

In my twenty-five years of offering labor support professionally, there is one persistent challenge that our profession still faces:  that of legitimacy.  While people may be more knowledgeable about what the term doula means, they are still befuddled by what we actually do.  If you asked someone who already knew what a doula was, what a doula actually did, they would be hard pressed to describe it accurately.  Most people think (even those we think should know better) that doulas pat laboring mothers on the back and tell them everything will be okay.  Our clients have learned through direct experience that birth doula support is skilled caregiving.  But even their descriptions are limited by their own birth experiences.

Doula care requires a large skill set.  It requires being able to accurately perceive the needs of people you do not know well and sensitively and contingently respond to those needs in a timely manner.  Doulas need to have many physical and emotional support skills at their disposal in order to effectively apply the correct strategy.  Effective communication skills with a wide variety of people are necessary for a doula to excel.  Birth doulas also know how to navigate the complicated obstetrical health care system in their area.  One of my main purposes of my research has been to illustrate the sophisticated nature of doula skills (Gilliland, 2011).  Caregiving is a skilled profession, and doula support is professional caregiving.

However, most people do not recognize doula care as a skill.  Even if they do, that does not mean that our caregiving has value.  There is a long history of disregarding professional caregiving in the United States.  Many of the other caregiving jobs are not well paid and are often held by people not native to the U.S.  Most Americans do not want these kinds of service jobs – they feel they are beneath them.  The fact that most doulas are white and from middle and upper classes (Lantz, 2005)  has not made us immune from this struggle to recognize the value of giving care.

Then there is the idea that all women are natural caregivers.  Besides being sexist, it is not true!  Many of us can think of women who have few caregiving skills and men who seem to possess them innately.  But perhaps the most insidious part of this idea is that if doula support is something “all women” could do if they wanted or needed to, it makes it easy to devalue.  The more common a skill is, the less it is valued. It is also a career pursued almost entirely by women, which also gives it less status.

If we bring all of these ideas together, it is easy to see why the majority of the public doesn’t value doula work.  All women could do it if they wanted, it’s a job few people want, has little status, and it does not require any special skills.  While women pregnant for the second time may have a better understanding of what a doula has to offer, they may have paid a high price for that knowledge.  If we want to be recognized by medical caregivers, insurance companies and first time parents as a necessary service, we need to increase respect for our skills.  The first twenty years has been about getting the word out – now we need to make certain people know what that word means.

(This blog entry was originally published in June 2012 in www.childbirthtoday.blogspot.com.)

Gilliland (2011), After Praise and Encouragement: Emotional Support Strategies Utilized By Birth Doulas in the United States and Canada, Midwifery, Volume 27 (4) p. 525-531

Lantz, P., Kane Low, L., Varkey, S., Watson, R. ( 2005) Doulas as paraprofessionals: Results of a National Survey. Women’s Health Issues15:109-116.

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