What U.S. Birth Professionals Need to Understand About ICWA

Oct 13, 2016 by

icwa-alex-garland-photo-copyThe Indian Child Welfare Act – why is that relevant to my practice? The laws concerning children’s rights changed earlier this year. Although standards vary among the 544 tribal nations recognized by the United States government, some tribes consider a person with one drop of Native American blood as a member.  While only slightly over five million people have full or partial Native American heritage, the growth rate within the population is more than double that of other racial groups. At 26.7%, birth rates between 2000 and 2010 were almost triple that of the nation as a whole at 9.7% (U.S. Census, 2012). The average age of a Native American is 29 years old, compared to 37 years for all Americans (U.S. Census, 2012). This means most of the indigenous U.S. population is in their childbearing years – when they are most likely to be utilizing our health care services.

Why should we care? Recognition of tribal status is important to the individual, the family, and for the continuation of the tribe. The child may qualify for different social programs because of their heritage, but the most significant impact occurs if they enter a Child Protective Services (CPS) system.

Tribal status begins with correct information on the birth certificate. Even misspelling a name can interfere with identification. (The infamous Veronica case went all the way to the Supreme Court in 2013, which was caused in part by an error in spelling the absent father’s name on the birth registration form. Even though he was registered with his tribe, his misspelled name did not show up in a search. So the child was legally adopted by a White family until the father contested.) Since hospital staff are filling out the forms, it is important that parents and their support team ensure that correct names and demographic information appear on the birth certificate. In a recent briefing session, Oklahoma CPS social workers explained, “Even though we have a higher than average population of Native Americans in our state (Oklahoma), nurses still look at the baby to discern race and ethnicity. If the baby looks white or black, they check that off without ever asking the parents.”

Parents may also not realize why it is important to categorize their child’s heritage correctly from the very beginning. It is difficult, but not impossible, to get that changed at a later date – but it must be done with a court order by a judge.

Doulas can explain to families how ICWA affects their child’s rights, their ability to receive assistance or scholarships, and placement in the welfare system if those services are ever needed.

How does a person become recognized as a tribal member? Heritage is not established by clicking a box; the person must be recognized by the tribe. Each tribe has their own standards and they are not the same. After applying, the first step will be genealogical research on the child’s relative, who may or may not be a recognized tribal member. Most tribes keep complex family trees. Some records are online and easily searched, while others have paper records kept in file folders. If the relative is already recognized, establishing heritage may be fairly easy.

Why does this status change how a child is treated in protective services?  Native Americans are dual citizens, and each tribe has the right to be self-governing as a sovereign nation over its own lands and properties. That means that most large nations have their own child welfare services. They work cooperatively with the state or county CPS agency. Anytime a child needs to be removed from the home and a biological relative cannot be found, the child needs an emergency placement. This could happen if there was an auto accident that hospitalized the parents and it took time to notify relatives, or when abuse or neglect is suspected.

It is considered ideal for a Native American (NA) child to be placed with a NA family rather than a non-NA family, preferably within the tribe. The majority of families who take in emergency placements or foster children in the U.S are White. ICWA is designed so that children will be preferentially placed in a qualifying NA home when a biological relative is unavailable – even if that placement is farther away, even hundreds of miles away, from the child’s school or home community. This is the controversy of ICWA: it states that the child’s status as a tribal member is more important to nurture than the child’s emotional or developmental ties with an existing family or community.

Here is how it gets problematic: Let’s say five year old Melinda needs a temporary foster family. She is not listed as having tribal blood on her birth certificate. As her relatives are contacted, one of her paternal aunts mentions that she is a tribal member so her niece is too. Rather than getting the best possible placement from the start, Melinda would be put in a temporary home while her records are investigated. Since placements with a tribal family are harder to come by, she would likely be placed initially with White or Black foster parents. It may take several weeks or months – if all records are in order – before Melinda’s initial placement is confirmed or she is moved to a new tribal foster family. If she is confirmed as a tribal member, she will be moved, with no exceptions. So, what most of us are wondering is, “Why aren’t they thinking about Melinda and putting her needs first?”

In their own way, they are.

So, the individual child’s welfare is considered secondary to the cultural preservation of the tribe? Yes, that is one way to look at it. But the goal is for both to be important. If records are properly kept from the very beginning, many of the heartaches shown in the popular news can be avoided. The world is seen differently by many tribal peoples and this influences their definitions of health, harmony, and balance. The more we can step back and understand the world from that point of view, the more ICWA’s policies make sense from that perspective. In this informative essay, Clark explains that most western European or American thought is linear, and Native peoples tend to think in relational terms. “In the linear view, the person owns or is the problem. In the relational view, the problem is circumstantial and resides in the relationship between factors. The person is not said to have a problem but to be out of harmony. Once harmony is restored, the problem is gone. In the linear model, we are taught to treat the person, and in the relational model, we are taught to treat the balance.” So ICWA helps to bring their world back into balance.

How is this affected by past racist policies to assimilate Native people into White culture? Between 1790 and 1920, it was considered good domestic policy by the U.S. government to bring as many Native peoples as possible into White culture. By 1890, that meant separating children into residential schools where they would not learn their tribal language or beliefs or participate in events and ceremonies. Children would be effectively cut them off from their past and their people. Adoption became a negative thing because it was used as a method to separate NA children from their culture and families of origin. The goal was not to place the child back in their home, but to find whatever possible reason to keep them from returning. This went on for over fifty years, leading to multiple generations of tribal peoples feeling angry, lost and without a sense of belonging. Many of the social problems that Native peoples face today have their roots in U.S. government policies of assimilation. So part of what is happening with ICWA in 2016 is a response to the damage done by assimilation policies of the past – and to bring indigenous peoples back together and into harmony.

 

For more information about the Indian Child Welfare Act:

http://www.adoptuskids.org/adoption-and-foster-care/overview/who-can-adopt-foster/families-for-native-children

http://www.nicwa.org/what_we_do/documents/NICWA%20FAQ.pdf

https://www.childwelfare.gov/topics/systemwide/diverse-populations/americanindian/icwa/

Photo ©Alex Garland This photo has been altered to highlight the mother and child. https://www.flickr.com/photos/backbone_campaign/27186540216

 

read more

Birthrape And The Doula

Apr 29, 2016 by

The (1)“At many births, while I have my hand on a woman’s arm reminding her to breathe, someone has their hand in her vagina digging around, her eyes are wide, she’s trying to get away, screaming STOP… What do I do? What do I say? How do I help make it right? I hate it. I hate it. I hate it. It seems so wrong.” [excerpt from one email among many I’ve received over the years]

Dear Doula,

I wish I could tell you that these kinds of things only happen to you, that they aren’t worldwide, that people aren’t suffering, that how one is treated during birth doesn’t traumatize a person, and that I don’t have multiple examples of this in my doula interview files. But that wouldn’t be true.

I wish I could explain what the medical careprovider is thinking or understand more deeply the processes that lead this person to conclude that what they are doing is right or that it doesn’t matter to the person in the body that they are touching. But that compassion is hard for me to come by.

What I can tell you is that the careprovider has somehow forgotten they are treating a person, not just a body. The medical detachment they learned to protect themselves has gone haywire, and so much so that they’ve forgotten that a real person is inside the body, and it is the person, not simply a medical situation they are treating. There is no detachment for the patient – and everything is experienced wholistically, meaning it affects their psyche and their spirit as well as their physical selves. Maybe the medical careprovider never learned this or maybe this knowledge has gotten buried.

But our focus needs to be on our client, on the person in the body. We are their amplifier, their voice, their conduit, when others who are caring for them aren’t listening. We are the one reminding that there is a person in the body, and that person has value. So what do you do?

  1. Be the voice. State what is happening in clear language.

“Dr. X, I hear [client’s name] saying “Stop” and “No”. Do you hear them?”

“[Client’s name], do you want Dr. X to stop?”

“Dr. X, is this an emergency or can you stop for a moment and let us all catch up with one another?”

Christine Morton and Elayne Clift, in their book Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America, discuss the “interactional wedge” when doulas ask physicians to stop doing what they are doing and talk about it. It’s one of the main reasons doulas are often disliked by medical careproviders. (My opinion is this an asset for informed consent, which I discuss here). When we interrupt a physician or midwife, we are vying for power, so it must be very clear that we are doing it on behalf of our clients whose voice is not being heard even though they are expressing themselves.

  1. If the medical careprovider does not stop, appeal to the nurse.

“Nurse Y, I hear [client’s name] saying “stop” and “no”. Do you hear her too?”

“[Client’s name], do you want Nurse Y to ask Dr. X to stop?”

“Nurse Y, if this is an emergency, can you explain quickly to [client’s name] why Dr. X cannot stop? She needs to know this for her own well-being.”

Sometimes careproviders don’t stop because they think that whatever they are doing will be over quickly and just want to finish. Unless there is a medical imperative, this is selfish behavior because they are putting their own desire to be done quickly over the patient’s need for understanding and caring from them. Unfortunately, this is their prerogative as careproviders. As doulas we will experience a wide variety of responses to our clients’ needs for compassion and kindness from their physicians and midwives. Often the lack of it within a system is why we are hired as birth doulas.

  1. If the medical careprovider stops, facilitate the communication. Start with gratitude – really. Then help your client to gain information, preview what they can expect especially with bodily sensations, and encourage eye contact and affirming touch (if possible) between careprovider and client and nurse and client.

Your goals are:

  • To assist your client not to feel they are being treated like an object, and for the careprovider not to fall into the trap of treating the body as separate from the person inside of it (objectifying).
  • To assist in obtaining the information they need about what is happening and why.
  • To forecast what is going to happen and what sensations they might experience.
  • To re-establish a positive relationship with the physician or midwife and the client, and the nurse and the client, if possible.

“Thank you, Dr. X. I think [client’s name] needs a breather from all that intensity. Can you explain what is going on?”

“What sensations can [client’s name] expect?”

“What other procedures or people might we expect?”

“[Client’s name], what do you want Dr. X or Midwife Z to understand about what you were feeling or why you were feeling it?”

If the doctor or midwife seems disinterested, show it matters to you:

“[Client’s name], do you want to tell me more about what you were feeling or why you were feeling it?”

  1. What if it really is an emergency and there isn’t time for the physician or midwife to stop?

If the physician or midwife is really concentrating, we don’t want to interrupt them. So appeal to the nurse.

“Nurse Y, I can hear that [client’s name] is becoming really frightened/terrified (make sure you include an emotion) by what is happening and the pain they are in. Can you please get their attention and explain briefly why the doctor or midwife can’t stop?”

Use the Take Charge Routine from The Birth Partner to get through the painful procedure.

If the nurse is unavailable or busy, it’s up to us.

  1. What if the physician or midwife doesn’t stop, the nurse can’t help, and the situation is continuing? What do I do then?

You go further into what I call “trauma prevention mode”. You want to affirm that they are not alone in what they are experiencing, that you heard what they said, that what they wanted is not what is happening, and that you know how to help them get through it. If you can forecast any sensations or what might happen next, do so.

Get your client’s attention and look them in the eye. Grasp their hand, arm, shoulder, or side of their face firmly. Say:

“I’m right here with you and I’m not going anywhere.”

“Dr. X isn’t stopping but I hear your request and your pain.”

“Right now, let’s just get through this together.”

“This might get crampy or sharp before it goes away, but I’m right here.”

In the immediate aftermath, most careproviders and nurses will make some acknowledgement. “Sorry I couldn’t stop right then”, and then just go on to the next thing. For them, it isn’t any big deal. This is what I find the most frustrating – it’s as if they ignore the situation it doesn’t exist. I imagine that in their mind, that’s true, even if it isn’t our client’s reality. Whether to pursue a conversation at that point is up to your client, the situation, and how they like to handle conflict. We have to take our cues from them.

If you are a direct person, who is used to privilege and of having choices in your medical care, this might be very frustrating to not pursue the situation. But your client may feel that any confrontation may make things worse, or that they have to take what they get. Clients may be afraid of the consequences to them and their baby. These consequences may be very real, especially for people of color, immigrants, and those living below the poverty line. If you are white, or otherwise privileged it may be hard to believe but consequences for not being compliant exist.[i][ii][iii] This is hard because you are emotional too, but you have to keep in check what you would want to do. You will be leaving this client and their baby in a few hours, and they will have to deal with any aftermath.

In some cases where the doula is concerned about being asked or made to leave, it may be appropriate to go directly to option #5.  The doula who is in the room can offer more effective support than the one who has been restricted to the waiting area.  Use your skills to assess the situation.

Sometimes I find that clients are not interested in pursuing a conversation at any time. They just want to put the unpleasantness behind them. They may also have a different memory of what occurred, minimizing their experience. Don’t mess with this! The brain works to protect the psyche, and defense mechanisms are called that for a reason. They are defending against the negative impact of an experience. Often how a person thinks about what happened to them (cognitive appraisal) influences whether a situation is coded as traumatic or not. So, in the moment, they may make minimizing statements to try to soothe the chaos of their thinking – but whether that works in the long run remains to be seen. Increasing oxytocin flow by positive touch, eye contact, laughter, holding the baby skin to skin, etc, should be encouraged if it feels appropriate and congruent with your client’s feelings and experience of the moment. Oxytocin lowers stress hormones, which contribute to encoding memories as traumatic. After all, it’s still a birth! If the event really does become a source of anxiety and trauma, we can validate our client’s feelings at that time. Once again, we take our cues from them.

But what about us? As doulas we are often the ones left feeling raw and as if we witnessed a rape. I say that if you feel that was what you saw, then that was what you saw and you should seek counseling with that in mind. Your experience was valid even though it doesn’t jibe with what the medical careprovider, nurse, or client experienced.

If you have a positive rapport with your client’s nurse, you may want to discuss what you witnessed if you have some private and unhurried moments together. “It was really difficult for me when [client’s name] was crying out for Midwife Z to stop. My client sounded terrified, and then the midwife didn’t stop and it just continued. Can you help me to make better sense of this? What was that like for you?”

Hopefully you will get a good dose of understanding and some insight on the nurse’s perspective of these situations. You will get a snapshot of the nurse’s mindset if they feel free enough to share with you. I have found that some nurses feel exactly the same way the doula does, but they don’t know what to do either. Sometimes the discussion with the doula, who is an outsider, is the impetus for them to talk with the director of nursing about it.

Other times, the doula will hear a minimizing statement, “Oh, I knew it would be over in another minute and the mom sounded like she was overreacting.” Or, “Most patients wish Midwife Z would be gentler during that procedure but that’s just the way she does it.” If that’s the case, just thank the nurse for their insight and know that you’ve learned how they rationalize their way through these situations.

Note:  All my suggestions are based on my research, discussions with expert doulas, and conversations with medical careproviders.  I am steeped in white culture, the privileges of education, and being white. Please interpret my suggestions with that in mind – your culture and life experience may lead you to conclude that other actions are more appropriate or better than what I have written.  My goal is give doulas actions that are within their standards of practices as most define them – a beginning point to have a conversation, not to provide the last word for every doula.  

Is it rape? Aren’t you exaggerating?

Some people feel that by using the term ‘rape’, I’m overdramatizing these situations or minimizing the experience of people who have been sexually violated. But I don’t think so. The patient has given over their trust, their body, their life, to a medical careprovider who has a sacred covenant to treat that person and honor them. When they act in a manner that is dismissive, painful or coercive, they violate that trust. The careprovider is touching the most intimate parts of the body – places that may only have been touched by one or two other people besides the careprovider! They have power over the patient and are treating their body like an object. The patient is often lying down and is unable to move or get away. When the patient says, “No” and “Stop”, to me, they are voluntarily retracting their consent.

As a qualitative researcher, our ethics state that the person who is having the experience is the one who defines it. They choose their language and share with us their emotions and mindset. In recent Facebook queries with over forty responses from mothers and professionals, all of the people who felt they had experienced an assault during their labor used the term “rape” or “birthrape”.  Many had also experienced sexual assault or rape, and these people felt many links between the two experiences. The term “rape” has a visceral emotional component that grabs one’s attention in a way that “assault during labor” does not. That is what the victim or survivor wants – for us to acknowledge and see their experience as best we can through their eyes. These people didn’t feel assaulted, they felt raped.[iv]

Rape is defined as “unlawful sexual intercourse or any other sexual penetration of the vagina, sex organ, other body part, or foreign object, without the consent of the victim. An act of plunder, violent seizure or abuse; despoliation; violation. The act of seizing and carrying off by force.”[v]

If the person who had the experience describes it in terms of feeling their body was violated, that is an assault. If they say, “I feel like I was raped”, that counts. They may have signed a legal consent for treatment for a vaginal birth form upon entering the hospital. But that in no way gives medical careproviders, or anyone for that matter, consent to violate their person when they clearly state their wish for that person to stop.

The medical and nursing literature is full of research on traumatic birth and the role of physicians and nurses in creating that trauma. It is also full of the pain that medical careproviders experience when they feel they have been complicit with or damaged by the coercive tactics of their coworkers and colleagues. For more information, I would urge you to read chapter 17 in “Traumatic Childbirth” by Cheryl Tatano Beck, Jeanne Watson Driscoll, and Sue Watson, or access Beck, C.T., & Gable, R.K. (2012) Secondary Traumatic Stress In Labor and Delivery Nurses: A mixed methods study. JOGNN, 41, 747-760.

 

 

[i] Bridges, Khiara, (2013) Reproducing Race: An Ethnography of Pregnancy as a Site of Racialization. UC Press

[ii] Oparah, Julia, & Bonaparte, Alicia (2015) Birthing Justice. Routledge.

[iii] The American Dream of Birth (2016) Video (Free and a good watch!)

[iv] If I was working with a group of medical care providers desiring to change their care practices, I probably would use the word “assault” repeatedly in discussion – it’s no good triggering their own histories of being assaulted or demeaned when the goal is lasting behavioral change. The majority of physicians have experienced bullying behaviors and mistreatment from professors and supervisors. The idea that physicians are perpetuating what they experienced as students and residents to their patients is a valid one. https://portalcontent.johnshopkins.edu/Housestaff/Uploaded%20Files/Medical_Student_Mistreatment_at_Hopkins_BRIEF.pdf

[v] http://www.dictionary.com/browse/rape

There are several good books about trauma and recovery but these are a good place to start:

The PTSD Workbook: Simple, Effective Techniques for Overcoming Traumatic Stress Symptoms by Mary Beth Williams PhD LCSW CTSSoili Poijula PhD

In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness by Peter A. Levine

Trauma Stewardship: An Everyday Guide to Caring for Self While Caring for Others by Laura Van Dernoot Lipsky and Connie Burk

read more

The Time To Ask About Past Abuse or Assault is Never

Apr 6, 2016 by

TheOne of the most upsetting questions I have read on a doula’s personal history form is some version of this: “Have you ever experienced sexual abuse or assault, either as a child or as an adult?” While I realize the doula is trying to be helpful, the attempt is misguided at best, and can actually create problems and stresses for the client that negatively affect the doula-client relationship. What the doula really wants to know is whether there are ways to help the client more effectively, even if what the client wants may seem odd or unusual. There are better ways to obtain that information that don’t create more problems.

Asking the question automatically puts your client in a bind. They have to choose whether to be honest with you before they are ready to do so, or whether to lie. The issue with most survivors of abuse or assault is that the perpetrator took away their power of choice. Their body was not their own, it was the property of the perpetrator. The victim’s only choice was to submit or possibly face worse harm if they resisted. Part of offering healing is for us to allow self-disclosure if it is desired, and when the client initiates it. When we ask the question, it is to meet our own needs even though it is in the guise of good intentions. If our client does not wish to discuss these acts or even for us to know, their only other option is to lie. This dilemma is distressing for our client, which is not the doula’s intention. So don’t ask.

The truth is, what you really want to know is how you can help them more through their birth or postpartum journey. There are ways to get at that information without knowing exactly why. In fact, knowing details about the story is not necessary to offering effective support. Here’s what you really want to know, and I suggest you say something like this on your last prenatal visit (after establishing rapport):

Sometimes people have had life experiences that left them traumatized and that they had to recover from. Sometimes that involves assault or abuse, or even being in a car accident. There may be things that other people do or say that lead you to being instantly scared or startled or remind you of that original traumatizing experience. I just want you to know that I can help you best when I can help myself and others to avoid those behaviors, and what to do if they happen.

You can also offer examples:

  • Sometimes a person is easily startled and doesn’t want to be touched from behind without being asked first and waiting for a response.
  • Another person didn’t want to be in the bathroom alone with the door closed. The door had to be open or someone needed to be with them.
  • Another didn’t want people talking about her as if she wasn’t there. She insisted that they use her name and not call her ‘dear’ or ‘honey’ or ‘mom’.
  • Another was concerned that breastfeeding would bring up negative associations with a past experience involving their breasts. This person needed assistance in being anchored in the present whenever the baby nursed in those first few weeks.
  • Others don’t care for particular words, such as being told to ‘relax’.  

This is the kind of information we really want to know as birth and postpartum doulas. How those needs came to be is not important. We don’t need to know the story in order to be effective.  

At this point your client may choose to tell you the story. But I think it’s important to repeat that you don’t need to know their story to help them. Disclosure should serve a purpose and you want to make sure they don’t feel uncomfortable later if they tell you now. It could be a good time to get a glass of water or use the restroom to make sure their choice to disclose is one they’ve taken a few moments to consider. It is also okay for the doula to not want to know the story! Doulaing is a relationship and you get to take care of yourself too. Perhaps hearing their abuse or assault story would be triggering or upsetting for you, so its okay to ask that they keep their disclosure general rather than including emotional details.

My second point is that childhood sexual abuse is estimated to affect one out of every four women[1] in the United States, and one out of six men[2]. Sexual assault and rape are also common experiences[3], directly affecting at least twenty percent of the population. So, we’re probably better off as doulas if we assume an assault or abuse history rather than seeing it as exceptional. That doesn’t mean that every person who has been assaulted or abused will be affected by it during labor or their postpartum. In fact, some people are relieved to find that it didn’t have a negative effect in that part of their life.

In my experience there are two behaviors that new doulas are most likely to see and that they can effectively address. The first is disassociation – for some reason, the person in labor or postpartum doesn’t seem to be present anymore. They are not in their body, their present moment consciousness is somewhere else. The person may seem distant and unfocused, or may even be looking out the window or down and to the left (recalling a memory). The empathetic neurons in the doula’s gut are giving the message that the client isn’t with you anymore in the room, they’ve drifted somewhere else.

The other worrisome situation is when the laboring or postpartum person’s behavior seems to be totally out of proportion to what precipitated it. In other words, the way they are acting seems to be more dramatic or over the top and is disconnected from what they are responding to. This overreacting may mean they were reminded of something awful that happened in the past. They are responding to that experience rather that what is currently going on.

In both instances, the most effective actions by the doula are the same. Bring them back to the present moment, to being in the room with you, gently and without exerting your power or voice over theirs. This is usually more effective when the doula is quietly and gently persistent, rather than using a loud voice or giving orders.

  • Use your client’s name, use today’s date – or better yet, ask them what day and year it is.
  • Have them look at you, have your client tell you what is happening today, and where they are.
  • Have them notice objects in the room, prompting them with positive ones (flowers, baby book, etc).
  • If invited, touch them in a preferred way (you’ll know them) in a safe place on their body (this will differ). If you aren’t sure, ask. “May I put my hand on your knee, arm, hand?”
  • Rather than ordering them to do something, invite them. Let the client choose – this is very important. “If you can, let yourself come back to TODAY fully.” “When you are ready, let yourself explore feeling safe here in the room with us, letting your body to birth/breastfeed/nurture your baby.”
  • When it seems that your client is mostly back in the present moment, ask something like, “How can I help you to feel more safe right now? Even if it seems silly, please say it. Your brain sometimes has wisdom that doesn’t make sense at first.”
  • Follow through as best you can, with the extra blanket or the pink flowers from the gift shop or finding the right song on the playlist.

These can seem to be scary situations for newer doulas, but we can use the same skills with our friends and family members who have experienced trauma and are triggered in our presence. Sometimes they aren’t even aware that it happened, and our feedback is what helps them to notice that they aren’t in the present moment anymore. To me, because of the commonality of experience of personal violation, these are life skills we all need to see one another through the journey. It’s not about complicated strategies. It’s about being a safe and trustworthy person and allowing the laboring or postpartum person to have their own experience in a supportive atmosphere.

Some doulas have extensive counseling skills, degrees, or training. They have additional strategies to use than what I’ve mentioned here. The book, When Survivors Give Birth by Phyllis Klaus and Penny Simkin, is an excellent resource. There are also facilitators offering two and three day comprehensive workshops for birth professionals wanting to focus on this issue in their practices.

[1] http://www.oneinfourusa.org/statistics.php

[2] https://1in6.org/the-1-in-6-statistic/

[3] http://centerforfamilyjustice.org/community-education/statistics/

read more

Busting The Myth of Privacy in Hospital Birth

Sep 18, 2015 by

woman's fist 4One of the craziest misconceptions that first time parents have is that laboring in the hospital will be private.  Where did they ever get that idea?  You’re in a room that isn’t yours, it’s the hospital’s.  You’re a guest in their house – a paying one, yes, but it’s still their space.  In hospital language, the phrase “private room” means that you aren’t sharing it with another patient, not that you will have privacy in it.  A home-like room does not mean the same privileges as being at home.  Ask just about anyone that has had a long labor and they will set you straight.  The problem is, hardly anyone ever asks about privacy, they just assume they’ll be in control.

“We don’t want a doula because we want our birth to be private.”  This is one of the most common phrases almost any birth or postpartum doula hears.  Pointing out that privacy is an illusion or a myth has never really gotten me anywhere, because I immediately come off as argumentative.  It took me years but I finally figured out what to say. I have learned to ask, “What does privacy mean to you?”

Usually they look at me with a puzzled expression.  Then the person will usually list, “being left alone when we want to, being just the two of us, not having people coming in and out the door, focusing on each other, that kind of thing.”

Depending on what’s been listed, I slip one of these four responses into our conversation:

One:  “You’re right, privacy is so important to laboring with less pain and faster progress.  You’d think hospitals would take that into account with their procedures, but their system hasn’t adapted very well.  An experienced doula knows how to work that system to your best advantage and get along with nurses.”

Two:  “Oh, okay, do you know that you don’t really have any say over who is in your room?  Or that auxiliary staff that needs to talk to the nurse will just come in your room randomly?”  “The nurse’s pager is beeping with people talking to her almost constantly sometimes.  She can’t turn it off.”  [Note: State what is true where you practice; this is true in my area.]

Three:  “What if you need something when it’s just the two of you and you don’t want your partner to leave?  What happens then?”   “Labor usually lasts a long time.”

Four:  “Doulas have lots of strategies to maintain your privacy, that are difficult to establish and maintain on your own.  She can make signs on the door, talk softly to trigger others to do so, sit outside your door as a smiling guard, update and talk to visitors in the family area, and handle your texts and replies so you can focusing on laboring as a couple.”

Then I’ll usually conclude the conversation with one or both of these statements:

Your doula maintains your privacy for you.  She will sit in the corner or outside the room when you want, and be at your beck and call.  She’s there to support you both doing whatever you need to do.”

“Remember the movie Top Gun?  She’s your partner’s wingman.  (You can suggest an updated pop culture reference in the comments!)  That’s her job.  She can keep other people out or minimize any disruptions.  Wouldn’t it be great just to have some wait on both of you, who is there only to meet your needs?

This tactic of asking people what they mean by a concept gives us more information to expand the discussion.  Often an idea or concept, such as “privacy” stops us because we get caught up in our feelings about it.  Whenever we’re going on the offensive – even in the guise of giving information – it puts other people on the defensive.  Yet, when we ask questions, and listen to the answers, we avoid making assumptions. People reveal more about their priorities and perspective when we ask.  We learn more about what is important to our clients and potential clients and can target our information to their interests.  This ups our effectiveness as communicators and shows us as the caring people we are.

 

read more

When A Past Client Dies

Jun 20, 2014 by

In my 30 years of doulaing, I have faced the death of a past client a half dozen times. Doulaing is intimate work and caring for mothers and partners creates a unique bond between us.  Each of the situations I faced was different but each time I started out feeling sad, uncertain and confused. I took the time to figure out the right course of action, one that I could feel good about long term. My hope is to guide you to the same peace.

This is not a time for immediate action. So if you find out on Facebook, you don’t need to type something right away. Think of anything online as permanent – even ten to sixty minutes of careful thought can modulate what you might write. Instead start with some important questions.

  1. Does this require an immediate response from me or do I have a few days? Unless the death occurs in the first few months after the birth, you have some time to figure out the right thing for you to do.
  2. What do I feel? Spend some time writing in a journal or talking with yourself or a close friend. It is normal to have many different and conflicting feelings such as shock, sadness, anger, ambiguity, dread, relief, fear, and so forth. It may bring on your own fears of death or vulnerability. We may not feel very close or identified with this family and feel badly that our own emotional response isn’t stronger. All of this is normal. The important thing is to figure it out before acting.
  1. What do I want to do? You could do nothing, write a note, send a card, go to the service, do a favor, make a meal, provide photos or a display, send flowers, or make a donation. What you decide to do will depend on the depth of your feelings, how recently your relationship ended, your own responsibilities and budget, and how close they live. Carefully consider what you need and what the family might need. If you’ve sorted through your feelings it will be easier to figure out what is supportive of the family. So often people’s actions at this time have more to do with what they need than what is best for the bereaved family!  It can be avoided by taking time to evaluate your own feelings and possible actions first.
  1. If you need some assistance in writing a condolence note, here are some suggestions. Include your feelings of sadness or sorrow, a quality or two that you admired and a personal anecdote about the person who died. The family members may treasure special memories of prenatal appointments or something that was said or done during the birth. Taking the time to write these details shows that you care. Make sure to mention your relationship as the doula; the person who is opening and cataloguing correspondence for the family may not know who you are. Sometimes the remaining parent may not read notes for months after the death. But it is nice to know who wrote. A note is more personal than a sympathy card and it can be challenging to find a prewritten card that expresses your feelings and matches their point of view. It gets even more problematic if you don’t know the circumstances of the death or their religious faith. Nice stationary or a blank card can work just fine. If they have moved, you can send the note to the funeral home.
  1. Posting on social media: Why? Carefully consider what your motivation is. Is this sensational news that will get attention? Do you need support? Make sure that whatever you write is something you would want to read if you were the bereaved parent. This is a time to put your best doula self forward. I wouldn’t recommend: “One of my old clients just died! Isn’t this the weirdest thing ever?” Instead try, “One of my past clients from a few years ago just passed away. I’m feeling bewildered and sad. Anyone have any suggestions or support?”

Here are some of my experiences and how I chose to respond:

Toby* was killed by random gun violence seven years after the birth of his third child. I wrote his wife and children a letter describing my most vivid and loving memories of our visits and the birth.  Nick* died of a drug overdose after a messy divorce and custody battle (5 years after being their doula). I kept quiet after hearing of his death because I really did not know how his ex-wife was dealing with it all. We hadn’t had any contact after the first birthday. Writing her felt like an intrusion into her personal business.  Karl* was a very loving father who passed away unexpectedly during a short hospitalization 16 months after their fifth child’s birth. I had kept in touch on Facebook. For this family, I made a montage of birth photos into a poster and had it sent (prepaid) to a Walgreen’s in their hometown. It was a treasured display at the memorial service.  When Lenora* died in a car crash four years after her last birth, I went to her service. Her husband recognized me but couldn’t place me – even though we had spent 20 hours together. That’s the nature of grief. But my presence let him know that she had affected my life enough for me to attend. I signed the guest book as their doula.

In my research interviews, one doula told me this story. “I had this great couple, they were a joy to work with. He came to every prenatal appointment full of questions and they wanted to work together at their birth. Very loving couple, so excited for their first baby. He was a family practice doctor, so he was learning not only for himself but for his future patients. I had a blast at their birth it was all so easy. He was in love with his baby girl. About four months later he died in a car crash. Right away, it was a huge fireball, horrible thing, just horrible. I went to the funeral and the mom turned to me and said the most important thing. She said that their baby girl would never know what a great man her father was and how much he wanted her except for my birth story. The story I wrote will be her memory of him. I totally broke down and cried. It was so horrible, such a tragedy.” Since hearing her talk, every birth story I write has that idea in mind.

I don’t think many of us get into this work thinking it will make us face death and develop adult skills. We love babies and empowering women! We want to build strong families through facilitating connection at birth! When we open our hearts, we grow and sometimes it hurts. We learn how to manage our emotions successfully and write condolence cards, too.

 

 *All of the names have been changed.

read more

Doulas! Charge What You’re Worth!

Jan 28, 2014 by

In support of the effort made by YourDoulaBag.com, I’ve decided to repost the graphic from their blog this week.  Feel free to post it on your web site to help prospective clients understand how doulas set their fees.

blog_DoulasChargeWhatYouAreWorth1

 

read more

The BFF You Need To Meet: Pelvic Floor Physical Therapists

Jan 20, 2014 by

You’ve never heard of a pelvic floor physical therapist?  You are not alone. Obstetricians and gynecologists are often unaware of the help PFPTs can offer their patients.  As a sexuality and birth professional pelvic PT’s are one of the most important referrals I make.  Women should not have to suffer sexual, urinary, rectal, or pelvic discomfort or pain!  A legacy of shame about our genitals may keep women from discussing postpartum and sexual problems.  When she does seek help, a woman may also be told nothing can be done, it is in her head, or just a part of having a baby.  Because of the easy intimacy of our relationship, clients are likely to discuss pelvic discomfort or pain issues with their birth or postpartum doula.   We are an important link in offering women information about pelvic PT.

When is a referral to a pelvic floor PT a good idea?  If your client mentions she…

Wets her pants when she coughs, laughs, or sneezes

Has to pee every half hour

Has to run to the bathroom frequently or daily

Can’t use a tampon because it hurts

Dreads sexual touching or intercourse because it is no longer enjoyable and is actually painful

Experiences pelvic pain when picking up her baby or with common daily movements

Things “just don’t feel right down there”

Has orthopedic problems with the pelvis/sacrum/lower back/feet have not improved with traditional treatment

While most of us might think that too “loose” or laxity in the pelvic muscles and ligaments is often the problem, too much “tightness” or stability of the muscles is an equal problem.  The muscles and ligaments of the pelvis work together as a dynamic system, which may need treatment postpartum to perform optimally.  When you recommend Kegel exercises to your clients, make sure they are spending equal time deliberately tightening and relaxing their vaginal muscles. 

Pelvic PT’s specialize in maximizing the function and remedying the dysfunction of the muscles, ligaments, and soft tissue areas of the pelvis.  They work with both men and women although the keyword “women’s health” is often used when searching for this specialty.  Common referrals to pelvic PT’s are urinary, fecal and flatus (gas) incontinence, getting up at night often to void, constipation, pelvic pain after childbirth, nerve damage, abdominal muscle separation, internal or external cesarean scar pain, and pain with urination, bowel movements, or sexual intercourse.  Somatic pain (pain with no known physical cause) that may be the result of emotional, sexual or physical trauma can also be successfully treated.  A woman who feels her childbirth was traumatic – even one without obvious physical trauma – may feel somatic pelvic pain.  PPT’s may also specialize in sexual problems such as severe genital or pelvic pain and muscle spasms that prevent sexual pleasure and intercourse.   Anything less than a feeling of wellness and optimal function in these areas may benefit from evaluation and treatment by a qualified pelvic physical therapist.  Even after years with a particular problem, pelvic PT may help.

While we might think that women with lengthy or problematic labors are more likely to have problems postpartum, this would be misleading.  Even women with ideal pregnancies and normal labors may have problems postpartum.  In my practice I make it a point as my two or three month check in to ask about these issues.  “Is everything in your pelvic area back to normal?  Are you peeing and pooping okay?  Other than needing lubricants when breastfeeding, is your body functioning so that you are without pain or discomfort?  If it isn’t, I have some recommendations for you.”   Sometimes I just send a “thinking about you” email or letter with local PT information.  If my client had any complications whatsoever – cesarean delivery, operative delivery, lengthy second stage, posterior presentation, epidural, episiotomy, or 2nd degree or greater tear, I will inquire specifically and directly about pelvic problems.   Every one of my clients who received PPT found out about it through me.

What can a person expect from an evaluation and treatment from a pelvic floor physical therapist?  The PT will take a complete history including any pregnancy issues, birth events and feelings, and past or present sexual, urinary and continence problems.  The PT will likely do an internal pelvic exam when the patient is ready.  This may be at the first visit or several visits later.  Understanding exactly where the pain is, pelvic tone and response to different exercises can help the PT focus on the correct therapy.

PFPT’s utilize a variety of therapies depending on the patient’s issues.  For postpartum patients, therapy may include exercises, recommendations for changes in daily movements, abdominal binders, TENS units, and education about positioning and posture.  If there are issues from an operative delivery (vacuum extraction or forceps), there may be nerve damage.  Manual (hands on) therapy techniques can address myofascial restrictions of the pelvic floor and remodeling of scar tissue.  PT’s also use biofeedback to help clients become more aware of sensations and to develop controlled responses.  For sexual problems, education about optimal sexual functioning and maximizing pleasure and arousal can also be helpful.

As doulas, we are in a place to encourage women to seek high quality and compassionate treatment.  We may need to gently coach clients that they not accept pain or altered circumstances as part of having a child.  This is not normal.  Our reassurance that their condition can be treated by specialists can make a vital difference in the quality of women’s lives for years to come.  We can also learn a lot about the pelvis and birth from PFPT’s.  When you add your local PPT to your referral list, ask them to make a presentation to your local birth group too.

Resources:

Good first stop:  The Pelvic Guru Explains What PPT Is

 Case history example with diet

Pelvic Pain and Rehab on pudendal nerve entrapment

 Managing Pregnancy and Delivery in Women with Sexual Pain Disorders

Physical Therapists As Sexual Health Professionals

Find a Pelvic PT  (choose women’s health even though PPTs work with men too)

read more

Another Reason Why Birth Is Sacred

Jan 1, 2014 by

Long ago I learned that rescuing people from their own actions is often a trap, one that ensnares us as well as the person we are trying to help.  When it comes to my client’s birth it can be really hard as she makes decisions that are not going to take her in the direction she previously desired.  As a doula I want to grab her and say, “No! Nooo….No!”  The more attached I am to her personally the harder it is…until I shift my thinking.  Once I remind myself to respect the transformation and challenges of pregnancy and birth as a sacred path it becomes much easier to support and serve this mother.

Several decades ago there was a lot of interest in vision quests* and understanding the deeper spiritual nature of existence.  These journeys of challenge and hardship were entered into to discover one’s strengths, weaknesses, inner nature, and relationship to the Divine.  For some groups it also involved the risk of death.  Joseph Campbell wrote extensively about the “hero’s journey” and the meaning and interpretations of this myth in contemporary society.  (Today we have Frodo and Harry Potter.)

Early on in my path as a doula, I saw the potential of birth to hold these same meanings for today’s women.  Women faced these same challenges by gestating, giving birth, and nursing – they didn’t always need a vision quest in the wilderness.  While our culture has not adopted the idea of a ritualized journey, the experience of childbirth still holds this potential for women.

If we appreciate a woman’s birth story as her own personal myth it has the potential to reveal to her deep truth and knowing about herself.  It can be a mirror of who she is.  Within her birth story is how she deals with challenge, how she deals with authority, how she supports herself, what strengths she brings forth that she didn’t know she had.  It reveals her relationship to what is unknowable and undefinable in human existence.  She must give herself over to a process that may be unknown to her that she is not in control of.  How does she respond?  What allies does she call upon?  When the crisis comes, what does she do?  How does she deal with her deep fear as it faces her in the mirror?  How does she experience pain and what does she want to do about it and what does she do about it?  How does this mother see the world?  How does she see her place in it?

To me, every laboring woman I am with is traversing this terrain.  My role is to guide her to finding her own way not to show her which way is right.  There is no way I can know her inner experience or how her history has shaped her to act in these moments.  I don’t need to know – I just need to trust that this journey is unfolding as it should for her.  Women have taught me to trust them to find their own truth.

This doesn’t mean it’s easy.  This doesn’t mean I don’t speak up; it means I trust her to let me know she wants me to.  It means I have developed an automatic questioning in response to my “No! No!”: “Is it about me or about her?”    It means I trust that when she whispers, “I think I want an epidural.”  I whisper back, “Do you want to talk about it some or do you know that’s what you want?”  If she nods “yes”, I get the nurse.  I believe she KNOWS and I do not rob her of that power of choice.  To dither about her birth plan is to diminish her as being able to know what is best for her in that moment.  My service is to trust her unconditionally as the heroine on her own quest.  She will find herself whether she wants to or not.

In my decades of doulaing I have found that many women come back to me and say that their birth taught them so much about themselves.   They learned who they were.  They faced their fears and lived the consequences of their choices.  When a woman has support, true support without an agenda, she finds her voice.  We amplify it so others can hear it too.

Women change their lives based on their births.  They end bad relationships, become fiercer mothers, move across the country, yell at their obstetricians, yell at their midwives, hug and cry with their obstetricians and their midwives, grieve for not knowing.  They grieve for the woman they left behind and embrace the woman they now are.  Who am I to know what is best for that woman in the midst of her birth?  I know nothing!

This acknowledgement of the deep spiritual nature of birth and the risks it contains for crisis and change, keeps me humble.  It also frees me.  I am a chosen companion for the journey, an ally who will respond as needed. Sometimes offering wisdom but always offering patience and calm.  I follow her lead because this is Her Story, the myth she is living and creating with each breath.  I trust Her and I trust my service to her, which is why birth and the path of doulaing when practiced this way is sacred.

 

“It is by going down into the abyss that we recover the treasures of life.  Where you stumble, there lies your treasure.”   -Joseph Campbell

 

* The term “vision quest” has different historical and cultural meanings in Native American or First People cultures.  I’m using a popular culture definition of the term.

 

If you wish to explore these ideas further:

The Women’s Wheel of Life, Elizabeth Davis* and Carol Leonard, Penguin/Arkana, 1996     (*midwife and author of the midwifery textbook, Heart and Hands)

The Wholistic Stages of Labor by Whapio Diane Bartlett    http://www.thematrona.com/apps/blog/the-holistic-stages-of-labor-by-whapio

The Woman Who Runs With The Wolves: Myths and Stories of the Wild Woman Archetype by Clarissa Pinkola Estes, Ballantine Books (1993)

Joseph Campbell and the Power of Myth DVD Documentary, PBS, 1988, 2013

Transformation Through Birth, Claudia Panuthos, Bergin and Garvey, 1984 (still being published!)

Birthing From Within, Pam England, Partera Press, 1998

 

read more

What It Means To Be A Professional Birth Doula

Nov 26, 2013 by

There is a line between doulas who are professionals – where this is the source of their livelihood and the mainstay of their lives next to family and self – and other women who doula occasionally.  Not all doulas are professionals nor is it a goal for all doulas.  There is a place for all kinds of doulas and we need everyone if we are to reclaim our understanding of birth as important in women’s lives.  We lost it in the last century and taking a doula training or doulaing friends and family is a way to reclaim that.

Being a professional does not diminish the spiritual value we find in our work or the fact that many of us find it to be a calling.  We would be diminished in some way if we could not be doulas.  We have the joy of being in a life situation that enables us to do work we are passionate about, change the world for another family, and create income at the same time.

In my writings, I frequently use the term “professional doula”.  It is on a lot of web sites – even in the names of international organizations.  But no one has really defined specifically how it applies to our profession.  So I analyzed data from my 60 doula interviews, sifted through what I was reading on social media, and read through several books on professionalism.  This is what I have come up with to describe the internal identity and behaviors exhibited by doulas who consider themselves professionals.  I’d also like to introduce the term “emerging professional”, to represent doulas who are growing to meet professional standards.  So what does it mean to be a professional doula today?

1.  To be a professional means that you have completed education and training to gain the necessary knowledge and skills recognized by others in your profession.  Much of doula education is self-study, reading books and completing assignments, combined with taking a workshop and using hands-on skills correctly.  Training may involve working with a mentor and on the job training without any supervision.  Improvement comes from appraising our experiences and evaluations from clients, nurses, midwives and doctors.

2.  To be a professional means you have acquired expert and specialized knowledge.  This goes beyond learning a double hip squeeze in a workshop.  It means making sense of people’s conflicting needs in the birth room; intuiting when to speak and when to keep silent; how to talk to a physician about the patient with a sexual abuse history; how to set up a lap squat with an epidural; and so forth.  Competence and confidence grow in interpersonal and labor support arenas.  Any additional service you offer to clients means that you have additional study, experience, and possibly mentorship or certification to use it appropriately.

3.  To be a professional means that you receive something in return for your services.  For many of us that is money or barter goods.  However there are doulas who receive stipends that prohibit receiving money for any services performed.  They may request a donation be made to an organization instead.  If they meet the other requirements for professionalism charging money should not be the sole criteria holding them back.

4.  To be a professional means that you market your services and seek out clients that are previously unknown to you.  You consider doulaing to be a business.

5.  To be a professional means that you hold yourself to the highest standards of conduct for your profession.  You seek to empower and not speak for your clients.  You give information but refrain from giving advice.  You make positioning and comfort measure recommendations that are in your client’s best interests.  Your emotional support is unwavering and given freely.  Your goal is to enhance communication and connection between her and her care providers.  You seek to meet your client’s best interests as she defines them.  Several doula organizations have written a code of ethics and/or scope of practice in accordance with their values.  They require any doula certifying with them to uphold them.  But signing a paper and acting in accordance with those standards are two different things.  Even the values represented by various organizations are different.  Holding yourself to the highest standards is shown by how you behave.

6.  To be a professional means that you put your client first.  When you make a commitment to be there, you’re there.  If you become ill or have a family emergency there is another professional who can seamlessly take over for you.  You keep your client’s information and history confidential.  Confidentiality means not posting anything specific or timely on any social media.  Your responsibility to their needs and not your own is a priority.

7.  To be a professional means that you cultivate positive relationships with other perinatal professionals whenever possible.  You respect their point of view even when it differs from yours.  You seek to increase your communication skills and to understand different cultural perspectives.  You keep your experiences with them confidential and private.  You learn from past mistakes.

8.  To be a professional means that you have a wide variety of birth experiences and feel confident in your ability to handle almost anything that comes along.  Other professional doulas respect you and make referrals.  Note that I did not include a number of births.  Because of life and career experiences, some doulas will arrive at this place sooner than others.

9. To be a professional means that you seek out and commit to doula certification that promotes maximum empowerment of the client, using non-clinical skills, values and promotes client-medical careprovider communication, and requires additional education before offering additional non-clinical skills.  Certification means that you are held to standards that people outside your profession can read and understand.  Not being certified means there are no set expectations for that doula’s behavior.  Some doula training organizations have very loose certification standards with no specifics behaviors listed, just general attitudes.  Certification with behavioral standards that can evaluate whether the doula acted according to those standards is important for furthering the professionalism of birth doula work outside our own individual spheres.  It means that a doula is accountable to someone outside of herself and her individual client.   (In other words, certification in the context of professionalism is not about you, but about how it affects other people’s perceptions of you AND our profession as a whole.)  Having said this, not all doulas have certification like this available to them.

10.  To be a professional means that you seek to improve your profession by serving in organizations, representing your profession at social events, and assisting novice doulas to improve their services.  You balance your own desires and needs with the actions that further the doula profession – such as certification.  You know that when you get better – increase your skills, knowledge and integrity – you make it better for all labor doulas.

11.  To be a professional means that you have personal integrity.  Integrity means that your values, what you say, and how you behave are congruent with one another.  Sullivan has written:

“Integrity is never a given, but always a quest that must be renewed and reshaped over time.  It demands considerable individual self-awareness and self-command…Integrity of vocation demands the balanced combination of individual autonomy with integration to its shared purposes.  Individual talents need to blend with the best common standards of performance, while the individual must exercise personal judgment as to the proper application of these communal standards in a responsible way.”  [p. 220] 

“Integrity can only be achieved under conditions of competing imperatives.  Unless you are torn between your lawyerly duties as a zealous advocate for your client and your communal responsibilities as an officer of the court, you cannot accomplish integrity.  Unless you are confronted with the tensions inherent in the practice of any profession, the conditions for integrity are not present:  “Integrity is not a given….” 

In a doula context, this means that when you are in the labor room trying to figure out what the right thing is to do and struggling with it, you are having a crisis of integrity.  “Do I say something to the medical careprovider (MCP) or do I keep my mouth shut?  Have the parents said anything on their own behalf?  Do I just let this happen and help them afterwards?”  What value takes precedent: empowerment of the client or allowing an intervention to occur that may affect the course of the labor?  How will each potential action change my relationship with the MCP?  Situations like these are true tests of integrity that require us to rank our values of what is most important.

Sullivan, William M. (2nd ed. 2005). Work and Integrity: The Crisis and Promise of Professionalism in America. Jossey Bass.

How does this fit with your definition of professionalism for doulas?  What parts do you agree with?  If you disagree, consider why – is it my wording or the spirit of what is written?  Let me know – let’s keep talking about this!

Here is a pdf copy of this post to print or for your doula discussion group.

 

read more

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.

read more

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. 

read more

“Being Who She Needs You To Be” Part Two: When It’s Difficult

Aug 12, 2013 by

Most of us are concerned about mothers not being able to use the bathtub, take a fetal monitor break, delay cord clamping, or get a VBAC.  Beneath all of this is the fundamental truth of doula work:  we enter a woman’s life being a guide as she finds her way through one of her life’s most challenging journeys.  For our clients, birth can be physically, psychologically, mentally, and spiritually challenging.  It may be full of anxiety and conflicting messages from family members and medical caregivers.  We have agreed to provide support that is unencumbered by past history or future expectations.  We desire little but that she be true to herself – as she defines it.  That is what doula work is all about.

Some clients keep us at a distance.  Others bring us into their drama and thrust us into playing a part we would not have chosen for ourselves.  We become what they need to get through labor.  This can sometimes be awkward, unexpected, and challenging.  Have you ever been to a birth and wondered, “What is going on here?  What does she expect me to do?  I’m not sure how to handle this or what to say.”  Odds are you are being thrust into a role where ‘being who she needs you to be’ is uncomfortable.  Sometimes it is painful the way some situations turn out – especially when the doula hasn’t done anything wrong.  This can happen to all doulas no matter what their experience level, if they have prenatal visits or meet their clients in labor.  It is the laboring mother who chooses the depth of the contact and meaning of her doula in her life.

I came to these conclusions after analyzing dozens of formal research interviews and then checking out my ideas informally with other doulas.  Here doulas describe some situations where meeting the mother’s needs was difficult.

Family Member:  “She told me at the beginning that I reminded her of the sister that she never had.  Meanwhile she does have a sister so I don’t know what it was.  I think she just took me on as the role of a family member.  She saw me more of a friend than as a doula.  I was invited to her birthday party and she’d just stop by my house.  ‘I was just seeing if you were home’, kind of thing.”

This doula was cast in the role of family member during her client’s pregnancy.  This situation can be awkward and uncomfortable.  The doula needed to figure out where the boundaries needed to be but also needed to understand whether her client was lonely and what was going on. It is really hard to set a boundary after its already been breached especially if the mother is emotionally fragile or needy.  Figuring out the appropriate response requires good observation on the doula’s part plus sophisticated communication skills.  Another possibility is that the doula likes the mother too and wants to become friends.  But if they became friends could she be a good doula?  With friends one is emotionally involved and there are future expectations.

Hostess Mom:  “My client says, “Did you all have a good time at my birth?”  And I said, “A good time at your birth?  What would it be to have a good time at your birth?”  She says, “Well, did you all eat anything?  Did you have fun?”  Then I kind of thought, ‘Hmm, did she want to hostess?  Did she want us to have a party and have a good time?’  So I said, “When you were laboring in that other room, we were in here having a slumber party.  It was like a group of girls having this wonderful slumber party.”  And the delight came out.  “Oh!  I’m so glad, I so wanted you to have fun at my birth!”

Although the Hostess mom is rare, I have run into her a few times. She may have difficulty getting into her labor.  She wants to make sure the people she cares about are settled and enjoying themselves.  Do they have food? Something to do?  Will they nap?  She may have packed food for the hospital to please everyone else.  Instead of focusing inward, she becomes overly concerned with what’s going on in her environment.  This mom requires patience, reassurance about her loved ones and doula’s state of being, and refocusing on laboring.  She may be overly quiet because she doesn’t want to disturb someone else (part of her “be a good girl” upbringing).

Permission Giving:  “There are a lot of people who kind of just need someone to tell them that getting some kind of help or accepting some intervention or pain medication is not a sign of weakness.  For someone to say, “You know what? A really strong person does whatever needs to be done to get the job done.  And I understand how you didn’t want an epidural, but I’m wondering if you are at your limit and feel bad saying so.”

Sometimes a mother refuses pain medication when she is obviously suffering because she is holding on to some ideal.  She does not give herself permission to shift from the vision she set for herself of how she was going to respond in labor. Often we reassure, validate feelings, and reframe.  We subtly try to help the mother to find her own truth and make her own choice.  But sometimes what she really wants is her doula telling her it’s okay with us.  This can be uncomfortable for the doula because we don’t want that kind of power.  Remember it is the mother who looks to the doula for permission – not the doula who feels she is in the position of giving it.  It has been assigned to us – we did not seek it out.

Scapegoat:  “Second stage was very confusing.  At one point, she had said something like my mom should leave.  I looked at her and said, “Do you want your mom to go now or do you want her to stay?”  And she said, “Well I think she ought to go.” I said, “We can have the nurse say something.”  I looked at the dad and said, “You heard her.  Do you want to talk with the nurse?” So the nurse comes over and they tell her quietly.  I didn’t say anything.  The nurse said to the grandmother, “Why don’t we all kind of chill out and you go get some drinks or something to eat.”  So she missed the birth.  Then at the postpartum visit, the mom says, “I never said I wanted my mother to leave. I wished you hadn’t told the nurse to tell her to go.”  There was another doula there too and she was shocked.  After trying to explain what happened from my perspective, I realized I should just shut up and apologize.  Basically in order for her and her husband and the mother to all come out okay with one another they had to blame it on me.”

Unfortunately I have heard more than one version of this story.  It is much easier to blame the doula than it is to take personal responsibility.  We all know people who don’t take responsibility for their own behavior.  People don’t stop being who they are just because they are in labor.  As doulas we have very little power.  We are also leaving that family’s life.  So scapegoating the doula can be a mechanism for making the family members feel safe with one another again.  Other scapegoating examples:  The partner remained uninvolved with labor support no matter what strategies the doula used to involve him or her.  The partner showed no initiative and resisted the doula’s overtures.  Then the doula gets blamed for the partner not behaving as desired.  In another case, an intervention does not turn out favorably.  The doula may hear:  “Why didn’t you make sure I knew that could happen?” or “You should have told me not to do it – that’s why I hired you.”

Someone she can say “no” to:  No matter what you suggest, she says “no”.  As in, “No, I don’t want to ask any more questions.  No, I don’t want to move.  No, I don’t want to drink anything.  No, I don’t like the way you’re touching me.”  As doulas we sometimes feel frustrated because of the mother’s contrariness and our inability to please someone.  Sometimes, this mom is testing your support or begging for acceptance.  She wants to know that no matter how obstinate or uncooperative she is, you will be there for her.  Perhaps she has been let down in the past and really needs the experience of unconditional support.

Another possibility is this mom feels she has little power in her everyday life.  She may have to compromise for everyone else and do what others want.  However, in labor this mom has permission to say “no”.  But she may only be able to do that to someone who has no authority and where will be no consequences afterwards.  In effect, she engaged your services in order to be able to use you to meet her psychological needs.  Which in this case is to have some power over somebody else – even if her choices are not leading her to the kind of birth experience she previously said she wanted.

People are complicated psychological creatures.  When we enter into this path of service for them, we are entering into a relationship where the mother has control.  This is necessary in order for us to be effective as doulas and to individualize the care she needs.  But it doesn’t always feel good to be in the role where mom has cast us.  Sometimes it feels icky or that we’ve been misunderstood or betrayed in some way.  We may end up not liking this birth very much.

This is usually a shock for newer doulas.  Often they haven’t heard these kinds of stories or never really believed them.  A new doula may think, “If I only doulaed correctly, then I would not feel inadequate or be blamed.”  She is not likely to say anything to her doula friends because she thinks there is something wrong with her. But that isn’t true here.  In this way our discussion about doula work needs to shift.  This is caregiving work that can involve a deep intimacy with our clients and their psychological needs.  We become mirrors for their deepest selves.  But when they don’t like what they see, we may be told it is us that is wrong.

For more information about the concept of “Being Who She Needs You To Be”, read Part One.

Note:  I’d love to hear your comments about your own experiences and with what you think about this part of doula work.

 

read more

“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

read more

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. 

read more

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.

read more

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

read more

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.

read more