Hospital Agreements: An Opportunity For Engagement [Part II]

Jul 24, 2016 by

HospitalDoulaAgreementsAnOpportunity For Engagement (1) copyIf a doula agreement is being waved in front of you, congratulations! It means that your doula community has gotten too large to ignore and is having enough of an impact that the hospital wants to exert some control. Now the real work begins, not with clients, but with the institutions where our clients are choosing to birth. You have an opportunity to create a collaborative atmosphere even if their actions seem hostile at the moment. This is politics, system change, and social change happening in your neighborhood, and I hope to give you concrete suggestions to co-create a synergistic relationship – even if it seems impossible now.

Keep the focus on your long term goal: an open channel of communication between this hospital and the doula community. Your goal is not to get the hospital to eradicate the agreement but to build understanding and strong reliable communication channels between two groups of people. You are using the proffered agreement as an opportunity for greater connection, understanding and dialogue between the people most affected by it. It’s imperative that the doulas who are approaching this conflict negotiation realize that attacking the hospital’s solution, the agreement, is counterproductive.[1] Anytime you openly criticize something, you make that person defensive about it and more entrenched that they are right. Instead, you have to put the emphasis on the conflict and your mutual interest in resolving it. If you focus on the agreement and what’s ‘wrong’ with it, you will get into a power struggle and doulas will likely lose. If not this issue, how you handle this will set a precedent for communicating about any future conflicts. Sorry to increase the tension, but this is an influential time and needs to be recognized as such.

So what can doulas do?

  1. First, have a leadership committee of the people who have the best communication skills as well as doula experience. Prepare yourselves. Read simple books on negotiation and conflict resolution (see below), or see what community or internet resources are available for continuing education. Being prepared and having skills will give you more confidence – but don’t wait too long.
  2. Contact the people in charge and set up a meeting. Make it clear that your goal is to generate solutions to their problem, and not to deny that a problem exists. Explain your perspective is rooted in concern for the long term health of the hospital’s relationship with its future patients and future doulas, and an ongoing relationship with open communication can work to both of your benefits. Doulas are not going to disappear, and trying to exert power over the doula community without seeking to get to know them will not work in the hospital’s favor. Someone in that problem solving group knows that, but their voice may have been drowned out by others. Doulas, there are allies in that hospital, and you will need to find them. Hopefully, you will also cultivate new ones through your sincerity and focusing on the long term goals. This will be harder to do if the atmosphere is hostile or the agreement is written in a way that delegitimizes a doula’s contributions to maternal-infant health or seeks to restrict the doula’s access to a client. However it isn’t impossible. Remember, they don’t understand our values or our role and you can change this over time.
  1. Be gently persistent until you get a meeting. State that you don’t want to get rid of their agreement proposal, but seek to find additional ways for their needs to get met. Do they want someone to call and complain to? Often what people want the most, over and over again, is to feel that their concerns were heard and met with kindness and respect. If you push that aspect of the meeting – “we want to hear more about your concerns” – it will be more effective than “we have to do something about this agreement”.
  2. Use this handout Doula Information for Nurses Sheet (initially designed for a nurse and doula conflict resolution meeting in my city) or a similar one to explain why doulas do what they do and give background about the state of the profession. Make sure you are all on common ground about doula support and what doulas actually DO and don’t do. Issues may arise as you go through this sheet together.  Listen. Listen. Listen. Even if the people at that meeting are not listening to you, listen to them. Reflect back their concerns in your own language. “What I heard you say is…”
  1. Emphasize common interests. “What we both value is…[2] Do this repeatedly as needed throughout the conversation.
  2. Ask, “What other possible ways to address this problem did you come up with besides an agreement?” This is where you’ll find out whether they fully explored the initial problem or took into account the concerns of other stakeholders. It’s possible they may not have and you can initiate it at this meeting. Ideally, you’ll be able to follow up with a small group made up of multiple stakeholders (see list in Part I) who are interested in a more complete problem solving process. Resist the urge to rely on one or two people from either group to do the negotiating or attend meetings – if one person leaves their position you’re back where you started from – without an ally.
  3. If the atmosphere is hostile or untrustworthy, it is critical that you do not allow emotions to cloud your judgment. Your communication needs to be intentional, not reactive. Don’t take bait – slurs on a doula’s past actions, a doula’s motivations, etc. Let it go for now.  Frame it as “learning about the tactics of your negotiating partners”.  Recognize that establishing trust takes time and repeated interactions where people behave reliably and do what they say they are going to do. Promise what you can deliver, not what you can’t. Set reasonable deadlines and meet them. People learn the value of a doula by experiencing you doing what you do, not from reading or talking about it.
  1. Be prepared for the presenting problem to not be the true problem. In one hospital I consulted with people were angry that doula clients kept insisting on special treatment for their newborns. Administrators discovered that while there were protocols for one hour of uninterrupted skin to skin contact in place, that was not what nurses were actually doing. Unless the doula reminded the parents and both parties actively advocated for it, usually repeatedly during that first hour, parents were not getting the care that the protocols were written to encourage. Nurses didn’t like the criticism and resistance they experienced from doula attended clients, and it was labeled as a ‘doula problem.’ However, once different stakeholders were interviewed, they discovered a deeper issue. It turned out the nurse’s workloads were so high that they felt pressured to do newborn procedures even when that interfered with the one hour skin to skin mandate. So what was initially perceived as a doula conflict, was instead a conflict between policy and workloads, with parents and babies being the losers and doulas as the scapegoat. This can also work the other way, so be prepared to listen to criticism of doula behaviors. Remember, listening is the most important thing you can do at this stagethere may be years worth of resentments pouring out if you’ve never had a meeting before.
  2. Focus on the possibility of a positive outcome. You can create collaborative relationships that don’t compromise the doula’s autonomy, ability to represent and serve her clients, and satisfy the hospital staff’s needs for predictability. In doing research for these blog posts, I found examples of several birth communities who had already created collaborative long term processes. (Please add yours in the blog comments.)

Susan Martensen, a doula and trainer in Ottawa, Ontario, Canada, states that her local doula group has worked hard to be recognized as part of “The Care Team” and not as a “visitor”. The instigating situation that brought doulas and nurses together was the SARS outbreak in 2003. Hospitals sought to limit access for anyone into the hospital. Doulas in the area formed a new group to develop a standard of practice and code of ethics based on ones from their different training organizations. All doulas in the area agreed to sign the document they had created. “Two hospitals in the area agreed to regular meetings to build bridges and establish doulas as part of the Care team (and not included in the usual visitor policy),” according to Ms. Martensen. “It took several in-services to introduce, or re-introduce, the role of the doula to the nursing staff, so that we all understood the collaborative model of care. The meeting was multi-disciplinary, so there were doctors, anesthetists, pediatricians, etc, there, but not everyone and not all at the same time.”

The next step was to establish nametags for the doulas that were created by the doula group and a book at the nurse’s station that listed photos, names and contact information for the doulas. “Over time we developed a complaint process as well as establishing a system for addressing any conflicts during a labor,” adds Ms. Martensen. “It is a collaborative model that has worked well for the most part, and it is not administered by the hospitals.” They continue to have regular meetings with key personnel and doulas to provide feedback and assess their collaboration with one another. Ms. Martensen feels that the emphasis on collaboration and being seen as a valued member of the care team is what has made all the difference.

Ana Paula Markel, of BiniBirth in Los Angeles, California, USA, initially worked with a small task force at Cedars Sinai Medical Center. A rising number of conflicts was leading to a tense atmosphere, and Ms. Markel was talking to a labor and delivery nurse about it. Out of that casual conversation, a small group of interested individuals got together and outlined several steps which they have been implementing in the last year. They created a Cedars-Doula Advisory Committee made up of labor and delivery nurses, midwives, the nurse manager, and six doulas from the community who each have a different level of experience. Ms. Markel feels that having new doulas involved is crucial, since they often present a different perspective. The CDAC meets monthly, and has its own email address where people can write with questions or complaints. It is used by both doulas and nurses. Based on this feedback, they created a teach-in day for doulas, which was also attended by much of the labor and delivery staff. They did several role plays of challenging scenarios and explored the point of view of both nurses and doulas and what each thought the other “should” be doing. It was very enlightening for everyone. After attending the teach-in day, doulas received a recognition badge to wear. In this way nurses were reassured about the doula’s perspective and background knowledge.

Both the Toronto and Los Angeles doula communities were able to turn potential conflicts into opportunities for collaboration and enrichment. So, take heart! It can be done – you can create a process that benefits many stakeholders long term.  It is up to us, as doulas, to do the work and it is a task to be embraced. To have the ear of hospital leaders, even if it is coming in the guise of an untenable agreement, is what decades of doulas have been waiting for: an opportunity to create positive change in the system.

 

Here is a pdf copy of this blog post: Gilliland Hospital Agreements Engagement

[1] Fisher and Ury, Getting To Yes, p. 41 (first ed.)

[2] Fisher and Shapiro, Beyond Reason, p. 53

Fisher, R., Shapiro, D., (2006) Beyond Reason: Using Emotions As You Negotiate. Penguin Books. 

Fisher, R., Ury, W., (1981 through 2011) Getting To Yes: Negotiating Agreement Without Giving In. Penguin Books. 

Other conflict resolution, negotiation, or mediation resources may be available through a community college, university extension, adult education, or state or provincial small business support organization.

 

 

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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

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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/

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Fewer Blogs but More Amy

Dec 30, 2015 by

AmySmile2This year has been about serving you, committed birth and postpartum doulas, in a different way. I’ve written fewer blogs, but posts on higher impact topics like essential oils and universal certification. When I’m not blogging, it’s because I’m writing something else. This year alone I’ve had two book chapters published, one podcast, three videos, developed four new continuing education sessions, and one peer-reviewed journal article, all relevant to what YOU do. I also wrote a 350 page memoir, but that was a personal project!  Several of these resources are FREE. I’m committed to improving our profession and your experience of being a doula.

Round The Circle: Advice for New Doulas includes a chapter on the results of my research on Doulaing Friends and Family Members. Basically, it turns out well when what the laboring person expected to happen and what really happened are close to one another. If the birth or postpartum doesn’t turn out as expected, the relationship between the doula and friend or family member will change dramatically, and usually not for the good. Want more?  [Link to Amazon]

Doulas and Intimate Labor is an academic book published this month by Demeter Press. Edited by Andrea Castaneva and Julie Johnson Searcy, my chapter covers my scholarly work on Doulas as Facilitators of Transformation and Grief. As doulas we are present as the woman becomes a mother and must surrender her old self in order to become her new self (this research was done on cisgendered women). Change implies grief, which is one of the unacknowledged journeys of postpartum. In addition, this chapter covers doula’s experiences when the partner dies during pregnancy, and when the baby dies before birth (fetal demise), at birth, or in the immediate postpartum period. I’ve also turned this topic into a successful continuing education session. [Link to Amazon]

Why Do People Attend Doula Trainings? is an original solo research project. I collected data in 2010 and 2014, asking over 400 people why they were taking a doula training (before the workshop). Surprisingly, many people taking a training are not there to become doulas, but because they want a general education about birth! This topic is also a successful continuing education session. The full article is forthcoming in a 2016 issue of the Journal of Perinatal Education!

Sexuality and Birth Video and Podcast – In October, I had the opportunity to be interviewed by Penny Simkin on Sexuality, Birth and Postpartum. This eight minute video is going through approval to be recommended by Lamaze as a resource for parents and professionals. I’m thrilled that this free video, which gets at the sexual and emotional needs of people becoming parents, primarily connection and pleasure.  [Sexuality After Childbirth Youtube video]

Amy Neuhadel, of The Cord in Sweden, also interviewed me on sexuality and birth. We’ve gotten great feedback on how helpful this TEN minute interview has been for parents and for educators.  [Intimacy and Pleasure In Your Birthing Year Link]

Giving Fathers What They Really Need In Birth  – This YouTube interview conducted by Penny Simkin gave me the opportunity to summarize the research on men and fathers (male cisgendered perspective).  You’ve loved my conference sessions on this topic, so here’s a short resource you can use as a discussion starter in your classes, small groups, or just for yourself!  [The Role of Fathers YouTube video link]

Giving Birth, the birth video that I executive produced with director Suzanne Arms (it really is her baby) is now finally available on Amazon Instant Video!  It took me a year, but its now up!  Suzanne Arms sells it on DVD through her site.

Northwest Doula Conference presentation covering The Top Eight Challenges of the Birth and Postpartum Doula Professions. After two hours of listening to me and what I think, I got a standing ovation. And that’s after getting people to commit to making behavior changes to meet those challenges, not just passively listen and go on their way! I had multiple requests to turn this address into a podcast, but I’d really love to give it again live at another conference and record that. Anyone interested?

New workshop content – this year I wrote several new sessions for continuing education. Hospital Based Doulas: What’s The Difference? is based on multiple waves of research interviews with this HB doulas around the United States; Doulas as Facilitators of Transformation and Grief focuses on how to be this significant person in our client’s lives, as they shift into parenthood, face the possibility of loss, and experience grief as part of the transition into a different phase of adult life. It also gives us space to breathe as we recognize our shared responsibility for the emotional well being of our selves and each other as doing doula work changes who we are as human beings.

Communication Skills for Birth Professionals is a skill building workshop where you learn by doing – you leave with skills you didn’t have when you walked in the door! It is available in two, three, and four hour formats. Two hours focuses on listening; the third hour focuses on preparing yourself to communicate successfully; and the fourth hour adds conflict resolution skills focusing on typical situations that birth and postpartum doulas face. These sessions are not formulas, telling you what to say. They teach you how to think about a situation, so you can be authentically yourself in all of your encounters.

PTSD: How It Affects Childbirth And How To Improve Your Outcomes is the latest addition to my catalogue, which came my way because of requests from physicians and nurse groups. Yay! What most doctors and nurses don’t learn in school is how to show they care. They don’t learn the physical and emotional skills that communicate their internal feeling of caring for a patient on a personal level. In fact, for many professionals their educational experience is to have the emotional center pummeled away in order to follow good practices in medical care.  The ‘cure’ for preventing childbirth to make existing PTSD worse is authentic human connection.

If that isn’t enough for you, I also wrote a 350 page memoir of the experience of taking care of my terminally ill mother, who was misdiagnosed for the first half of her illness. Tentatively titled The Summer of Mimi, I hope to complete the second and third drafts in 2016. This was a personal goal of mine, but as I can’t stop being a doula all over my life, its has juice in it for all doulas too.

2016 promises more content and more projects!

As always, please subscribe!  [Box is on the lower left.]  Thank you for your support!

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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.

 

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Want To Change Birth Tomorrow?

Mar 16, 2015 by

TeenPhotoTalk to the teens in your life today.  From what I can see, the decision about where to give birth and how to cope with labor is made long before conception.  Unlike previous generations, teens today are exposed to media misrepresentations of labor and birth on multiple television shows (Elson, 2009).  Based on a recent literature search (Toohill, 2014), it seems that more young women and men today are afraid of birth than at any previous time.  While the issue is multifaceted (Laursen, 2008; Saisto, 2001) the simultaneous rise in birth “reality” shows and studies of birth fear doesn’t feel coincidental.

Developmentally, girls aged 12-14 begin to ponder their adult future and consider what it means to get pregnant and give birth.  So naturally they turn to TV and to Youtube.  While many home videos are intended to show the raw power and coping potential of women, to an unknowing teen they can be downright scary.  Even videos posted to humor (Two Men Watch  Childbirth For The First Time] – can validate the fears that young people of all genders may have.

As birth professionals, we know the truth.  Given the right circumstances, labor can be coped with.  For the most part, labor is boring, with not much happening for hours at a time.  So TV producers create drama with music, narration, and selective editing.  Women’s bodies know how to create and grow a human being and get them out.  The more we interfere with that process, and that includes TV cameras and lights, the harder it can be on the mom.  Like any major undertaking, including moving house or completing a science project, labor and birth requires planning and support to do in a satisfying way.

Teens need our messages about the real nature of birth and manufactured depictions they see on TV and some uploaded videos.  They need to be engaged with, not talked at.  Even twelve year olds have critical thinking skills and despise being treated as if they are only passive consumers.

So how do you have a conversation with a teen about birth?  Make sure you are having a discussion, not a lecture.  Listen to their answers, and build upon what they share with you.  If possible, let them lead the discussion.  If teens are shy or used to being talked at, your conversation starters may be met with silence.  Use your doula skills to observe their “nonverbal leakage”; people don’t always need words to communicate!

You can start a conversation by responding to a family walking by with a baby, seeing a pregnant woman in a magazine, or even without any reason to at all.  Let your passion give you courage, and proceed from there.  “Hey, you know I’m a doula, right?  Do you know what I do?  Do you know why I do it?”

Another approach is to build on teachable moments.  “Remember that birth scene in ——-?  Did that seem realistic to you?” Build on what was valid in their comment or the scene, but don’t bash if their answer is “yes”.  Say, “I’m concerned when people see that, they’ll think that’s what labor is really like.  Because it scares people/makes birth seem dangerous/makes it seem like its painful for hours without ending.  That’s not the way that I experience it.”  Be REAL – so many people tell teens what they ought to think or do, rather than realizing they are thinking human beings making important life altering decisions almost every day.

Make sure to emphasize that both men and women need support in birth.  This is absolutely critical.  We place a disproportionate burden on men to do labor support and deny their own feelings and the developmental processes of fatherhood.  This is in the process of changing, but only if we continue to hammer home the message that men matter too.

Offer to speak to Girl Scouts (Cadettes, Seniors, and Ambassadors may have health badges), Boys and Girls Clubs, and church teen meetings.  Using the first fifteen minutes of Vicki Elson’s video, Laboring Under An Illusion, can be a great conversation starter.  It’s engaging, to the point, and it will make them laugh.  People remember more when they laugh and that helps to break the ice with groups of adolescents.

Keep your message basic, simple, and repetitive.  Labor and birth aren’t scary.  Ninety-five percent of births are normal and nothing bad happens.  Some people see birth as so safe and normal, they give birth at home and in birth centers.  Pregnancy and birth are wellness conditions, not illnesses.  Given enough support, women’s bodies function well and coping with labor is possible without resorting to medications and interventions.

Young adults will often do what feels right to them and that depends on what perspectives they’ve been exposed to previously.  If we want more informed consumers, we need to start at the most impressionable time: in adolescence when they first see themselves as potential mothers and fathers.

Like what you read?  Please subscribe!  The box is below on your right. Thanks!

Elson, Vicki (2009) Laboring Under An Illusion. DVD, BirthMedia.com 

Laursen, M., Hedegaard, M., Johansen, C. (2008) Fear of childbirth: predictors and temporal changes among nulliparous women in the Danish National Birth Cohort, BJOG, 115 (3), 354-360

Saisto TSalmela-Aro KNurmi JEHalmesmaki E. (2001) Psychosocial characteristics of women and their partners fearing vaginal childbirthBJOG 108:4928.

Toohill, J., Fenwick, J., Creedy, D., (2014) Prevalence of childbirth fear in an Australian sample of pregnant women. BMC Pregnancy Childbirth. 2014 Aug 14:14:275

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Not Any Woman Can

Jun 30, 2014 by

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

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

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

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

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

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

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

 

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

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Doulas: Why You Need To Be Nice First

Feb 17, 2014 by

A doula was complaining on Facebook in response to one of my posts about getting along with nurses.  “Why do I have to be the one to put forth the effort?  I wish some nurse would try to get along with me first.”  Here’s why it’s up to the professional birth doula:

  • You are a guest in her house.
  • Making the first move sets the tone for every communication and interaction that follows.  Why not use this opportunity to your advantage?
  • You only get one chance to make a first impression – and it takes three times as much experience with you to change someone’s mind.  Make those first minutes count.
  • You are an ambassador for all birth doulas.  Your actions reflect on all of us.
  • Social skills and emotional intelligence are a significant part of a doula’s success.
  • “Hostess” is implied in our job description.
  • Hospitals are set up for the mass production of a number of patients moving through the system.  When you ask the nurse to change what she usually does to personalize care for your client (even when it is evidence based), she may get flak from other nurses or doctors for doing so.  Therefore you need to be grateful when you hear “yes” and accept “no” graciously.  (It doesn’t mean your clients stop trying – it means you are polite.)
  • The last doula may not have behaved optimally.
  • As unfortunate as this is, a client may be treated negatively by the nurse or medical care provider for a poorly behaving doula.  I think we can all agree it is unacceptable to stress out anyone at a birth over our behavior.
  • When you make an effort, especially a big one, the “norm of reciprocity” states the nurse will naturally want to keep things in balance.  So you get what you give.

 

 

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