Why The Doula Research We Need Doesn’t Exist: Part II – Medical Politics and Practices

Nov 6, 2017 by

DSC03787As a young woman, I naively thought that the evidence was so overwhelming that we’d steadily see doula research in major medical journals. Nursing and medical students working on research degrees would pair with their professors and community members to answer these pressing questions. The fact that our answers could impact future generations would provide enough incentive. We could stop women’s bodies from being permanently damaged by outmoded obstetric practices and facilitate trust and communication between client and caregiver. We could help mothers and babies have the best possible connection from the very beginning. We could increase physician and nurse sense of connection to patients and colleagues thus positively impacting their mental health outcomes. Doulas do this by offering two commodities that are scarce in the hospital system: time and a listening ear.

I am no longer young. Anyone wanting to study doulas from a medical perspective has been shushed or shut down – that’s my only explanation. They’ve been quietly steered to other topics that would be more acceptable to medical or nursing professors serving on the approval or review board committees. While there are plenty of theses and dissertations on doula topics, very few of them actually add to our understanding of doula support. They are almost exclusively from the social sciences not a medical field. Most focus on the way labor support is experienced by parents or doulas because that aspect is accessible.

My conclusion is there are few doula research studies because of obstacles from medical politics and outmoded beliefs which I explore here. Part III will cover difficulty in research approvals, funding and publishing access; and the feminist political agenda of the U.S. women’s movement.

Politics and Power:

  • Doulas represent the laboring person. They don’t want to maintain the system as it is, they exist to disrupt the system from offering impersonal care. Their very existence demands that the hospital see the patient as an individual, with their own particular needs. Anyone who has a vested interest in maintaining the status quo will actively resist any research on birth doula support.
  • Doulas are unpredictable. Because they make a stand for the primacy of their client’s interests, no one is quite sure what they will do. Ask for the squatting bar? Even wanting a spontaneous labor to take as long as it needs to rather than following a predictable timeline is heresy in some labor and delivery units. Doulas actually interrupt physicians from doing interventions so they can be discussed with the patient first.
  • Doulas disrupt the power imbalance in the labor room. Doulas insist that power be shared with the laboring person (patient) and that medical careproviders discuss benefits, risks, and alternatives. Doulas assist their clients to develop a collaborative relationship with their doctors, even when that is not the wish of the physician. Many doctors are used to making autocratic decisions and not having their opinions questioned. They do not see the benefit to the patient or to themselves, even though it leads to charting of the conversation that benefits the physician if there is need for a review or inquiry.
  • Doulas empower women. Current western society is still built on the premise that women are not equal to men. These patriarchal beliefs are woven into our majority culture along with white supremacy, colonialism, and racism. Anytime an oppressed group exceeds their allotted power in the system, the fear grows that it will spread to other groups. The existing system sees sharing power as a loss rather than a gain. Since doulas are basically disruptive to the status quo they cannot be empowered in any way including research funding or internal review board project approvals.
  • There’s no clear way for hospitals or medical systems to make money exploiting doula support. Although there’s a lot of controversy about the unpredictability of maternity care billing here and here, as a general rule the current system pays more money for a birth when more interventions are used. Since doulas have been shown to reduce the need or use of those interventions, and doulas cost money, there’s no financial incentive to explore labor support. Until the billing and funding systems change there will remain no financial reason to explore doula care except for Medicaid patients.
  • The only medical systems that employ doulas do so because it solves their other problems not because it primarily benefits women or babies. That’s why these systems haven’t published on positive obstetrical outcomes, because there aren’t many. In my own observations, these programs only exist when they help the hospital to attract customers or when the doulas solve other problems in the labor and delivery unit. They don’t exist to get better outcomes, lower complications from interventions, or empower patients in the medical system.

Outmoded Beliefs:

Our medical systems don’t value individual people very much. This is ironic because our medical system is supposed to help people, but when it comes to how obstetrics is practiced people are damaged as well as helped. This is true for physicians, midwives, and nurses as much as it is doulas and patients. No one personally benefits from our current system of labor and delivery care. Only the system itself does. We have to remember that the hospital system of obstetric care was founded on several beliefs:

  • Babies don’t feel pain or remember what happens to them so whatever you do to them doesn’t matter.
  • Women’s bodies are mechanical in nature, so treating the body as a machine with technical difficulties is the right approach. The fact that there is a person inside the body influencing how the body functions was not a part of that original thinking.
  • Physicians function best when divorced from their own lives and feelings and practice in a vacuum, focusing solely on the mechanics of the body and objective data.
  • Nurses are there to be the physician’s hands and eyes, not to have a voice or their own unique knowledge and contributions.
  • A mechanized system of medical care delivery, based on a factory model, provides the best results for the majority of people and the system itself.

We can see how toxic each of these beliefs are. Yet they are still present in how labor and delivery units are designed and how people do their jobs. Acting as if those beliefs are wrong is heresy! Yet that is exactly what doulas do. So no wonder no one wants to pay money or spend time to do research on birth doulas unless they are also invested in changing the way medicine is practiced. Think about it. The changes that many wish to see in the way obstetrics or hospital midwifery is performed challenge one or more of those founding beliefs. My cynical side says that they have no reason to worry as it takes 17 years for the best evidence to actually become medical practice.

In Part III of this series, I’ll explore the obstacles inherent in the research process.  Part IV covers how the lack of any kind of childbirth rights agenda from U.S. mainstream feminist organizations affects doula studies.  Part I covers the doula research I thought we’d have in the 37 years since the first doula study was published.

 

Kozhimannil, K.B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., O’Brien, M. (2013) Doula care, birth outcomes, and costs among medicaid beneficiaries. American Journal of Public Health, 103(4).

Morris, Z. S., Wooding, S., & Grant, J. (2011). The answer is 17 years, what is the question: understanding time lags in translational research. Journal of the Royal Society of Medicine104(12), 510–520. http://doi.org/10.1258/jrsm.2011.110180

Free SlideShare Presentation on Why It Takes 17 years  (See Slide 7):  https://www.slideshare.net/iHT2/health-it-summit-san-diego-2015-panel-research-evidence-and-clinical-realities

read more

Why Don’t We Have The Doula Research We Need? Part I of IV

Nov 3, 2017 by

070The Cochrane Collaboration updated their doula research review this year. They added four, only FOUR new studies – and none of them advanced our research conclusions in any significant way. Birth doulas have the potential to be the most influential factor in lowering negative birth outcomes and optimizing positive ones for mothers and babies. We’ve known that for over THIRTY YEARS – that’s a whole generation of people who could have benefitted but didn’t.

No one, and I’m pointing my finger at academics and medical careproviders and political women’s organizations, has bothered to do any significant research or insist that it be done. Instead the established power systems are hoping doulas will just go away. They want to keep us small and bickering amongst ourselves, which happens to any group when they experience some success. The established power structures don’t want to change and any good doula research would show that hospital systems have to change in order to get better results. I’m angry, and I rarely get angry.

Here are the research questions I expected to see answered in the past 37 years since the first (Sosa, Kennell, & Klaus et al., 1980) doula study was published:

  1. In a randomized control study or a matched pair study of people who did and didn’t have a doula, do we see consistent outcomes in perception of pain, length of labor, intervention rates, breastfeeding initiation and longevity, birth satisfaction, partner satisfaction, postpartum wellness, and the feeling that ‘my baby is better than other babies’?
  1. What factors interfere with the doula’s ability to affect obstetrical outcomes?
  1. Does partner involvement with labor support (not the birth itself) make a difference in outcomes?
  1. How do doulas benefit partners and/or have an influence on parenting relationships and partner/marital relationships?
  1. Do prenatal visits make a difference in obstetrical, birth satisfaction, maternal and infant outcomes? The way most birth doulas practice is 2-3 prenatal visits, continuous labor support at the birth, and one to two postpartum visits. But we have no data on whether that is the best way to practice or not. Are labors still shorter? Do laboring people have less pain or use less pain meds? Are people more satisfied with each other or with their doctors or midwives when they have a doula?
  1. Does having a birth doula affect a pregnant person with a perinatal anxiety or mood disorder? When someone is supported by a doula during labor are they less likely to have postpartum depression? How about with a postpartum doula?
  1. Under what circumstances does it make financial sense to fund doulas or doula programs? Rather than spending money on other labor interventions, is it more economical to pay for the doula? Along with Drs. Will Chapple and Dongmei Lee, I published a study in the Wisconsin Medical Journal exploring this question. Katy Kozhimannil co-authored a study on Medicare costs for doulas. Where are the rest?
  1. In 2010, I published a study on birth doula’s emotional support strategies. Four were the same as those in the nursing literature, but the other five were sophisticated counseling or therapy techniques. The doulas in my study were never formally taught those strategies, they arose spontaneously from the doula. Why hasn’t anyone actually observed doulas to see what they actually DO at a birth that makes a difference?
  1. Where are all the research reports on hospital based (HB) doula programs, where the doula is a paid member of the hospital staff? What are their outcomes? Who benefits from the doula program? What models are more effective at getting which outcomes? I’ve interviewed 15 HB doulas from four different programs. Why am I the only one? (Why that data is not published is in the next blog post.)
  1. Are doula programs staffed by volunteers effective?
  1. What are successful models of doulas and nurses working alongside one another that increase both job satisfaction and positive patient outcomes?
  1. There are no studies on physicians and doulas, exploring how people in each role perceives the other, how they can optimally work together, or any models of doulas working for doctors. Why not?
  1. Does continuous care matter? The only reason we know that is from two meta-analyses that are both twenty years old. Is that enough?

These are all of the things that I thought we would know in thirty years.  Each time a research review on doula support is published, I’m eager to discover any articles I might have missed. But there aren’t any.  In my next posts, I’ll explore why we don’t have the research I thought we’d have. My conclusions?  There are few doula research studies because of obstacles from medical politics; outmoded beliefs; difficulty in approvals, funding and publishing access; and yes, the priorities of the U.S. women’s movement. Look for it in your inbox in the next few days.

 

Chapple, W., Gilliland, A.L., Li, D., Shier, E., Wright, E.. (2013) An economic model of the benefits of professional doula labor support in Wisconsin births. Wisconsin Medical Journal, 112(2), 58-64.

Gilliland, A.L. (2011) After praise and encouragement: Emotional support strategies used by birth doulas in the USA and Canada. Midwifery, 27(4), 525-531.

Kozhimannil, K.B., Hardeman, R.R., Alarid-Escudero, F., Vogelsang, C.A., Blauer-Peterson, C. & Howell, E.A. (2016a) Modeling the Cost-Effectiveness of Doula Care Associated with Reductions in Preterm Birth and Cesarean Delivery. Birth-Issues in Perinatal Care, 43(1), 20-27.

Kozhimannil, K.B., Hardeman, R. R., Attanasio, L. B., Blauer-Peterson, C., O’Brien, M. (2013) Doula care, birth outcomes, and costs among medicaid beneficiaries. American Journal of Public Health, 103(4).

Sosa, R., Kennell, J., Klaus, M., Robertson, S. & Urrutia, J. (1980) The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction. New England Journal of Medicine, 303(11), 597-600.

read more

“To Heal and Protect”: Attending Birth Doula Trainings for Personal Reasons

Jan 26, 2017 by

-To Heal And Protect-A small but influential group of people attend birth doula trainings not to become doulas, nurses or midwives, nor to positively influence births in other jobs, but to help heal from their own birth experiences (Gilliland, 2016). In any 10 to 12 person training, one or two people are there primarily to make sense of their own births or to make sure their future births are better. Although small in number, their motivations influence the type of discussions that occur in a workshop which makes their presence a significant one.

In this study, this group was defined in two ways. When forced to choose their top five reasons for attending a doula training, participants chose “understand my own labor(s) and birth(s) more deeply” or “make my future labor and births better” as one of their top two answers (n = 38; 8.2%). They also ranked professional reasons lower in their top five answers or omitted them. In the general question (“choose all reasons that apply”), members of this group also selected significantly fewer professional reasons for attending or none at all. There was a very clear demarcation between the “professional” attendees and the “personal” ones. However, this was the only difference. When these two groups were compared to one another on the other variables (age, births attended, parity, etc.) there were no significant differences.

In addition to this well delineated group, about 20% of all attendees chose “understand my births” as reason to attend. So while it’s a primary motivating factor for 1 out of 10, another two people in that training group also have lingering questions. This is a when my knowledge as a trainer with twenty years experience takes over in interpreting the research results from the study.

People who are in a birth doula training to gain healing from their own experience are not primarily invested in learning doula skills in order to use them with another person. They are there to figure out and make sense of their birth. By gaining information about what people need in labor and the components of support, they think they will better understand their own experiences. My hope as a trainer is that these people also develop more compassion for themselves.

In exploring this theme with small groups outside of the published JPE research study, there were five repeated themes in our conversations. They viewed a birth doula training as an avenue for healing because they felt:

  • People in the doula training will understand my story.
  • I will be treated with compassion and not dismissed.
  • I will be able to figure out what happened to me and why it happened.
  • I’ll be able to figure out why I feel the way I do.
  • I can keep what happened to me from happening again (to me or to others).

People seeking healing from a past birth experience have been a part of birth doula trainings since they started happening. In the 1980’s, I took “introduction to midwifery” workshops as well as ones designed to help you become aware of how your own births and growing up in our culture shaped our attitudes. In my decades as a trainer, I’ve learned how to make sure that people with these needs have opportunities to reflect and make sense of their experience – but not at the expense of hijacking the learning needs of the larger group. My primary purpose is to teach the skills that lead to doula success, not to lead a counseling group.

When you think about it, people who want this kind of healing have few opportunities to get these needs met. Where else can you go in our culture where you can get this level of understanding and compassion? Where can you get the information to assess what you actually needed at a significant time? It isn’t just emotional support but information and context that is often lacking when people are making sense of their births. An effective birth doula training can offer all of these things.

What we need to understand is that doula trainings are about training doulas – and part of that is teaching them to all the skills that come with compassionate listening, boundary setting, and putting clients at the center of their own decision making processes.  We have to be aware of and responsible for our own emotions at someone else’s birth or postpartum. The participants who need to heal offer trainers the opportunity to model compassion for ourselves. Further, they offer a living example that to be of service to another birthing family, we need to leave our own attachments outside the door.

Lastly, with these participants we are able to confront the thought that we can protect our clients or keep bad things from happening. We are not omnipotent nor are we the decision makers. Human beings, which includes our clients, are also notorious for learning best from making poor choices and living with the consequences. So doulas may find themselves second guessing a client’s choices or being judgmental. Participants who are processing their births may voice negativity about their choices or themselves during that past birth. When this situation arises in a workshop, it gives trainers a ripe opportunity to model kindness and tenderness towards oneself and others, and the personal empowerment that comes from owning one’s past choices.

As birth doula trainers, our job is significantly more complex than it looks on the surface. While we think we are there primarily to teach strategies to prevent labor dystocia, we are really there to help a whole society heal from damaging birth experiences and learn a greater sense of compassion for one another as we stumble through life.

Gilliland, Amy L. (2016) “What Motivates People To Take Doula Trainings?”Journal of Perinatal Education Summer 2016, Vol 25, No. 3, p. 174-183.

This is the third in a series of posts interpreting this journal article.  The first reflects on people who don’t want to be doulas but want birth knowledge, “Take A Doula Training, Change The World.”  The second focuses on “Career Minded Participants In Birth Doula Trainings“.

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

Doulaing For Friend’s Births

Feb 25, 2016 by

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

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

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

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

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

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

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

So what’s a doula to do?

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

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

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

read more

Are There Enough Clients For All Of Us?

Feb 6, 2016 by

Are There Enough Clients For All Of Us-Do you feel that you are competing with every other doula for clients? “There’s not enough for me and for everyone else. If someone else gets a client, that’s one I don’t have.”  And then you try to work harder to compete and get ahead. (Or you give up.) Fearing there isn’t enough to go around means believing in scarcity.

Let’s break down that idea – Are there enough clients to go around?

From a rational perspective, the answer is clearly “yes”. According to the Listening To Mothers III survey, 6% of people in the sample had a birth doula but 27% of them wanted one. That’s a huge gap between demand and supply. Granted not all of those people may be willing to pay a doula a sustainable fee. But the doula’s biggest market is second time parents! They are more aware of the doula’s value and will pay money not to repeat their first experience. Unfortunately they did not report on postpartum doulas in the survey, but many people have had postpartum experiences they don’t want to repeat either.

From a marketing perspective, the answer is also “yes”. By profiling and targeting your ideal client, you learn that the best person for you to work with isn’t “everybody who is pregnant”. No matter how wonderful you are, you are not everyone’s best doula. It really is a select group. When you compare your ideal client to those of other doulas, you realize that you are after different markets. Of course there will be some overlap and not all of your clients will fit the ideal profile, but many will be close to the target. I find that reassuring – we’re not all after the same person but different kinds of pregnant people.

From a personal perspective, the answer is always “yes”. People choose their doula based on who they feel safe with in their gut, not on how good your welcome packet looks. (The welcome packet opens the door and introduces you.) We have no control over that decision except to be our authentic selves.

For my nineteen years as a doula trainer, I have been preaching that it never makes sense for doulas to compete with each other, no matter what organization they trained with. There’s no economic reason to do that because the market isn’t saturated. When one doula gets a client, it generates interest in the market among other potential buyers of our services. The more people we serve, the more interest grows, and more our potential market grows. Every nine months there is a complete turnover. So our best strategy to grow the profession is to support each other while also pursuing our own individual goals. Abundance is out there. The more we work for success together, the more there will be for all of us.

Every doula I have trained understands this. There are plenty of potential clients and the more we work together to educate the public and careproviders, the more paying clients we will all get. The doula leaders in our region (past and present) also reflect this attitude, and because of it we have a more collegial and supportive atmosphere in our state than in many of the places I visit across the U.S.

When we choose scarcity, we choose fear. Fear that there won’t be enough. Fear that someone else will get the good stuff first. Fear that if someone else does well, that means we’ll do poorly. There isn’t enough cake for everyone to have a piece even if we slice it small! Our bodies end up feeling tight and tense and we worry about what we can do to get more and to get it for ourselves.

Rather than thinking “not enough”, think “there is enough”. It doesn’t cost you anything to shift from a mindset of scarcity to one of abundance, except your level of personal responsibility. With a scarcity mindset, all of your problems are “out there”. The locus of control is outside of you and thus uncontrollable. But when you believe that abundance exists, your attention becomes focused on how to tap into it. You have an internal locus of control – “what I do and how I do it influences my circumstances”.

As this process advances, you’ll become more optimistic – the best is yet to come! You’re more willing to take risks and share your self and resources with colleagues. You can learn from your competitors because you are all in this together. As your relationships with other doulas grow, you can ask for feedback and help without it feeling like a threat. Babies will continue to be conceived and people will keep recognizing that their emotional needs are not being met by current medical systems. That isn’t going to change anytime soon.

What about not having enough time?

My worst tendency towards scarcity is about time. I fear there will never be enough time to get everything done; that I won’t achieve my dreams much less what’s on my daily ‘to do’ list. “There just isn’t enough time!!” Sound familiar? I’m not competing with other people for time – its not like if I get more someone else gets less. I’m really competing with myself – and I never win.

The funny thing is that it’s not true. I do have enough time. Sometimes it takes me until Wednesday to get through Monday’s to do list, but it does get done. The small tasks and the big projects do get completed, for the most part. So what’s going on here? It’s all in my attitude. Being anxious that I don’t have enough time doesn’t get me more time, nor does it make me more creative or efficient. It just makes me jittery and unpleasant. So, what’s my alternative?

I decided to change my thought. “Time expands to meet my needs.” Whenever I begin to have the impending feeling of doom – “there will never be enough” – I realize it’s all in my head. Whatever really needs to happen will and I will have enough time to accomplish it. It’s been four months now, and I have accomplished everything I needed to do.   Some things got postponed, true, but it was mostly because the time wasn’t right – and even I can’t do everything at once. In some instances my priorities changed. But what was really different was my compassion for myself and my anxieties.

Our approach to life is up to us. We choose how we want to think about life. I prefer to choose abundance.

Many thanks to Jessica English of Heart Soul Business for inspiring this post. 

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

read more

When Midwives Don’t Recommend Doulas

Jun 17, 2015 by

MWBlogphotoSo your local midwife told a prospective client of yours that she didn’t need a doula.  You feel surprised, even betrayed, at her lack of support.  What’s going on?

First, the midwife is right.  No one is compelled to have a professional doula.  Some women have friends or relatives who can serve in that role.  Some midwives have an assistant or student who s/he prefers to doula her client.  Women and their families have needs in labor that a professional doula is trained to meet.  But there are other people who can serve in those support and communication roles.

Second, the midwife is wrong.  Midwives may feel that their role is to support the woman in labor as well as provide expert medical care.  Since they are there continuously as a doula would, they think they can fulfill both roles.  That can be true depending on the midwife, her assistants, and the events and length of the labor.  If a birth becomes medical, there are two patients to care for – the mother and her baby.  Unless there is a third person whose priority is the mother’s emotional wellbeing, those needs go unmet.  You cannot adequately address emotional wellbeing, especially in a medical crisis, if you are monitoring and conducting lifesaving measures on a mother, baby, or both.  You just can’t.

In addition, just because a mother may trust her midwife with her medical care, that doesn’t mean she is the ideal person to meet her emotional needs.  There are many times I have been hired as a doula at a home birth for just that reason. Sometimes the mother feels fine with the midwife but is concerned about her partner’s needs.  With a lengthy labor, having a third knowledgeable person with a professional attitude can be an asset to a midwife and his or her assistant.  All of us are less tired, we can nap more frequently, and think creatively about positions and comfort measures to try.  We are all on the same team, chosen by the mother and her partner(s) to be their support.

However, it’s also not that simple.  Doulas often have strong emotional reactions when this happens.  Doulas often imagine that since midwives and doulas are both professional birth workers, we would naturally support one another.  We recommend midwifery care.  We’re kin, right?  Yes and no.

There are some very emotionally supportive, hands on midwives. These ladies and men give a lot of emotional support and are instrumental in suggesting comfort measures.  Others sit and knit, quietly observing, and only get involved to do monitoring and the eventual birth and aftercare.  Most midwives are somewhere in between – and it may also depend on the clients they are working with.

Some midwives may feel a sense of competition with a doula; as if we are infringing on her territory or passing a judgment on her abilities.  They may even have begun as doulas and feel they can continue in both roles.  They may like the doula role and be unwilling to give that up.

Our histories are also different.  For over six hundred years, midwives have been maligned, persecuted, misunderstood, and demeaned. Lies were told about the abilities of Black Midwives in the American South in order for physicians to get their business.  The worst kinds of discrimination and injustice against women have occurred in midwifery history.  A legacy of this oppression is that they fight among themselves about what kind of midwifery philosophy and training is best.

Doulas, beginning as birth assistants or labor assistants, have been around in a structured way for about thirty-five years*.  I contend that our whole profession would not exist if there was universal access to supportive midwifery care that treated the whole woman.  We exist to fill a gap in the medical system and the American way of doing birth.  While doulas are begrudgingly accepted (sometimes enthusiastically), we do not face the same obstacles that midwives do.  Midwives compete directly with physicians for business, while doulas do not.

There are a lot more birth doulas than midwives in North America today, and with a lot less training and dedication than it takes to become a midwife.  Midwives may witness a revolving door of doulas in her community, and only want to work with certain ones.  After all, a labor can be a long commitment and in the intimacy of a home or birth center environment, the midwife may want to control who is there in a professional capacity.  Perhaps its not all doulas that are being discouraged, but its just sounds nicer to phrase it that way.

What if the midwife is in a hospital setting and still doesn’t recommend doulas? 

Does the midwife feel that the nursing staff is able to support and adequately provide for mothers?  Is there a history of negative experiences with a particular doula or a rotation of mostly novice doulas?  Maybe this midwife doesn’t recognize the emotional needs of mothers the same way most doulas do, or feels that they are adequately met by the way birth is done in their facility.

At other times, midwives see themselves as working towards the same goals as doulas.  Rather than feeling competitive, they realize there are multiple ways for an individual woman to get the support she’ll need for her birth.  They want women to have births they feel good about, which lead to strong mothering and optimal outcomes, but don’t necessarily have to be the provider.  These midwives usually recommend doulas.

So when you’re surprised by your local midwife’s remark, take a moment to consider these multiple perspectives.  Hopefully they will help to explain why she or he might make that statement.  What’s the best reply?  As always, the best doula reply is to turn it around and ask the mom!  “Why do you think the midwife would say that?” and follow her lead.

 

*Silent Knife: Cesarean Prevention and Vaginal Birth After Cesarean, by Nancy Wainer-Cohen and Lois J. Estner, published in 1983, was the first book to recommend a labor assistant. They cite a lecture from 1981 (p. 225-227).

 

Did I miss something?  Want to comment?  Please do!  

You can also subscribe to my blog, it’s over there on the lower right —————–>

read more

The Fears, Downsides, and Challenges of National Certification

Jan 7, 2015 by

rock-climbing-403484_640This post articulates the shadow side of national certification (NC).  Listening to shadows allows us to learn and become stronger from going deeper into a process.  These 13 reflections are from my notes, your emails, Facebook and blog comments.  So please be in a space of listening – and I hope you also feel heard.

1.  No guarantees of results.  Several of my hopes of what NC could do for doulas as a profession are just that – hopes.  One hope is that NC would provide an avenue of acceptance and involvement with medical professionals and hospital programs.  Another hope is that NC would substitute for each individual hospital developing their own doula approval program for independent practice (IP) doulas.  This may not happen especially if we do not involve nationally respected members of those communities to participate in shaping our competencies.  It also may not happen despite our best efforts.  We also may go through all of this work and are still unable to obtain doula specific national billing codes for birth and postpartum doula services.  It may not lead to creating a reliable third party billing and payment system.  But if we do not have NC, there is no chance.  As I see it, NC creates the opportunity.

2.  NC would lead to the continued professionalization of “caring”, which is viewed as a “natural” behavior.  People are not comfortable making a job out of behaviors they wish most human beings would display.  In this concern, there are elements of the idea that doulaing is somehow a natural, innate, human behavior; and that there is no skill involved.  Birth doula work is a highly skilled profession (Gilliland, 2012) which is why so few who take a training end up being successful at it long term.  It isn’t the business part; it’s that supporting a lot of people you don’t know in a professional manner takes “people skills” that cannot be taught in a 24 hour workshop!  Not everyone can be a successful birth doula but everyone should be able to take a training who wants to.  We need an educated population who understands why birth matters and who wants to help ensure every pregnant woman and her baby get the support they desire.

The institutionalization of doula support began when organizations were started to teach people.  Remember, the 1980’s doula movement is in response to a breakdown in the system of caring for laboring women.  In her essay on titling the “Scandanavian Journal of the Caring Sciences”, Halldordottir writes eloquently on how important it is to teach caring – and research the science and behaviors that make a person feel cared for.  Ask any doula who has been to over 50 births what she has learned about caring in that time – she could fill a book.  Caring may be innate for some people, but for most it is a learned and highly skilled behavior.  Does that mean it should be restricted to only certain individuals?  Heck no!! We all need caring skills, but not everyone will pursue them professionally.

3.  NC would lessen the power of experiential knowledge.  Birth teaches us about birth.  Mothers teach us about their needs.  Reflection and support from our birth circles improve our skills.  Education imparts knowledge and confidence.  Since this is the core of doula learning for all, how can NC denigrate it?  We must have experiential knowledge at the core of our learning, and NC competencies would incorporate it.  Similar professions, such as massage therapy and lactation consulting, also have a strong experiential learning core.

4.  “NC belittles the culture and history of doulas and disrespects the knowledge of learning passing from woman to woman.”  NC is a tool for professional doulas to use as they advance in their careers.  No one achieves that by not learning from women.  Institutionalization and traditional and/or matriarchal learning seem to be at odds with one another – I get it.  I’ve been immersing myself in these perspectives for many years, and I understand this dilemma.  We want to be recognized as the women in the village with the specialized knowledge and dedication to this life transition.  We don’t want to have to declare ourselves or compete.  Yet we live in a world where there are barriers to support, and where there is little recognition that support is even important.  We’re surrounded by institutions, many of them patriarchal.  And if we organize and certify ourselves, are we participating in the patriarchy that we wish to transform?

5.  “National licensing didn’t help midwifery.”   Doulas are not midwives.  We have a completely different history; we do not compete for market share with physicians or nurse midwives; certification is not licensing, which is a legal, government process. When you list the differences and similarities there are huge differences, which makes comparing the two professions ineffectual.   Even though we can both be found giving support in the labor room, after that the similarities end.  Doulas have more in common with lactation professionals, who have been refining their own certification processes.

6.  NC would clearly draw the line between doulas who practice according to an evidence based standard and those who do not.  NC is not for beginners; it would be a standard of achievement for people who have made a commitment to the doula profession as one of their highest priorities.  That is not to say these doulas are any better at doulaing than people who only go to a few births a year or only doula their friends and family members. In order for many women to have access to doula support, we need all kinds of doulas.  That is not going to change.  My hope is that we can continue to respect and support one another in our local communities even though the role doulaing plays in our lives is different.  Yes, NC will magnify these divisions – which already exist whether we formally acknowledge them or not.

7.  “The national certification philosophy of doula support will become the only acceptable one.”  NC would set competencies for doula behaviors and knowledge.  It would not set an exclusive philosophy for conducting those behaviors, nor would it evaluate training programs.  It is highly likely that multiple types of learning experiences would be needed to meet all competencies.  The approach of an initial program would be chosen by the individual, just like it is now. If we want a doula for every woman, that doula needs to reflect the mother’s beliefs, language, and behavioral norms.  Which means we need doulas from all communities and multiple training programs with different philosophies.

8.  “National certification would define the standards for appropriate doula behavior, and I don’t want anyone telling me what I ought to do.”  Yes, it would set standards for professional doulas and promote those expectations to consumers, medical professionals, and the general public.  NC is voluntary and it is likely not for everyone.  Some doulas are individualists – they have highly developed moral codes and are not really interested in following or scorning rules set by others.  Other doulas have a rebel or subversive identity.  They want to behave in ways that are “outside the system” or “according to their own conscience” or “tailor it to my client’s needs, not what I’m told by some organization”.  People come to doula work with a variety of mindsets and beliefs and they will use their doula path (and their client’s births) to learn and grow.  No matter what direction we choose, it will be problematic for some doulas on a philosophical level.  For years doulas have been outside the system, working to change birth by showing over and over again that mother’s emotional needs, and those of her baby and partner, are equal in importance to physical ones.  For some, it is being outsiders that is important.  Once we become like the institutions we guide our clients through, they think we lose.  Others have been waiting until there is a critical mass of doulas to set up a national certification system and welcome NC as weakening their outsider status.

9.  “I don’t want to be controlled by “the government” or “the hospital”.  This is a huge misunderstanding about who has power over who accompanies a woman laboring in a hospital.  Many people seem to think it’s the woman.  No, it is the hospital.  Once a woman consents to have a birth in a particular hospital or birth center, she submits to their rules.  Each hospital has the authority to decide who can visit a woman in labor and who she can have with her.  There are no legal patient rights or guarantees about who can accompany her (except Minnesota), but even that is nullified if someone is perceived as getting in the way of the medical care provided by the hospital or a safety concern.

Hospitals in rural areas and large cities are already forbidding doulas and setting rules about who is allowed.  If you don’t know this, you haven’t been paying attention. That’s one of the main reasons for NC now – to set up something that WE can agree on, so we aren’t barred en masse or have to succumb to rules that tell us what we have to do with our bodies, such as blood tests and vaccinations.  When it comes to licensing, doulas do not have any behaviors that would invite licensing by any governmental body at any level.  So this fear is unfounded.  The only involvement of the government with doula care has been to create a law that the hospital cannot get in the way of doula support as long as the certified doula is following the hospital’s rules for her presence (Minnesota), or to allow for third party reimbursement for services (Oregon).

10.  “Clients don’t care whether I’m certified or not.”  They don’t care because we haven’t taught them to.  Right now the client takes all the risk and places their trust in the doula.  Inexperienced parents have no idea of their own needs or all the things a doula can do to muck up their birth, their relationships with their caregivers and even with their partner.  Bad doulas do exist – its naïve to think otherwise. NC could offer optional background checks, assurance about back up doulas; and define standard industry practices (collecting fees before birth, typical letters of agreement, etc), and a grievance procedure with consequences.  NC could offer a layer of consumer protection for parents that they now do not possess at all.  Remember, parents’ primary reason for choosing a doula is whether they feel safe with her and trust her on an intuitive level.  NC may be able to make that leap of faith more secure.

11.  NC would restrict women’s access to doulas.  Right now bringing your own doula into the hospital with you is up to the hospital.  It is the hospital’s rules and women choosing to go along with them that will restrict women’s access to the doula of their choice.  If a hospital states that a doula needs to be nationally certified to or follow a NC standard of practice in order to do labor support in their facility, that is their right.  But that’s the idea: we would do a better job setting standards for ourselves than each individual hospital.  If NC is successful in helping third party reimbursement to occur and in gaining grant monies to expand doula programs, it would actually expand women’s access to doulas.

12.  “NC would restrict what I can charge, how I can charge or who I can bill.”  This is erroneous as any restrictions on fee setting or billing would be considered price fixing under U.S. labor law.  “We would have to listen to what insurance companies would want us to do or not do in developing or changing our standards.”  Since getting insurance and Medicaid reimbursement is a part of this movement, having this information would be important.  How it would be responded to is a different matter.  In some ways its true – we may only be reimbursed for two prenatal visits and not three; a company may set a reimbursement rate for a whole state, which may not be high enough in a metropolitan area.  It would be up to the individual doula whether to charge parents more than what their insurance would cover or not accept third party reimbursement at all.

13.  Is NC coming from a place of fear or a place of power?  I think it’s both.  I think doulas feel powerful enough within to organize and say, “Hey! These are our standards for ourselves.  This is the way we think professional doulas ought to behave, and what they ought to know.”  But I also think its coming from a place of fear of the existing system having ‘power over’ us.  Fear that doulas will not be allowed in hospitals unless following their rules; fear that doula support is becoming a wealthy woman’s indulgence; and fear that doulas will not be available to more women unless we do something.  The idea of national certification brings up deep fear – colluding with the system/patriarchy/institutionalization; as well as providing some solutions to the problems that we face – restricted access in hospitals; and lack of recognition for our skills, achievements and professionalism.  It has potential to shift and change the landscape for current and future doulas.

As a profession, I think we need to ask ourselves, who are we accountable to?  What is our purpose?  Does NC fulfill that purpose and accountability?  Because of the differences highlighted in this essay, doulas will arrive at different answers.  Will we end up at what serves the greater good, allowing the concerns of dissenting voices to also guide us?  Will we consciously decide to stay unorganized and live with our current fragmented system?  HOW we proceed next is just as important as WHAT we will create.

Want to comment?  Like what you read?  Please subscribe!  (Box is on lower right of page)

Posts In This Series:

1.  Social movements – The Next Step In The Doula Revolution

2.   Balancing Dynamic Tension – Respecting All Doulas 

3.  Do We Want A Place At The Table?  National Certification and Public Health

4.  Benefits of National Doula Certification

5.  This post:  Fears, Downsides, and Challenges of National Certification

6.  Back Door or Front Door?  What the Process of NC Would Need to Include

read more

Doulaing At Midlife

Oct 2, 2014 by

flowersmall“When my 60 year old mother insisted she was middle aged and I wasn’t, I replied, “Mom, how many 120 year old women do you know?”    -paraphrased from Postcards From The Edge by Carrie Fisher

I went to my first birth when I was 20 and my first birth as a professional at 24.  Most of my clients were older than I was, some by more than a decade.  As I aged it seemed that my clientele youthed.  At first I was their hip, knowledgeable young friend.  Then a sister, then a companion, and now their mother.  My experience is respected and my perspective has changed.  Overall, I am more patient and more understanding of the stresses on medical care providers.  Obstetrical trends have come and gone and returned again.

Doulaing at midlife is precious and different than at any other age.  Among my research participants and friends there seem to be a few common markers.  Rather than seeing ourselves giving birth, we see our children or nieces and nephews reflected in our clients.  This shift in perspective is subtle but one day you realize it’s not your generation in the bed anymore.

For those of us in female bodies, once menopause is assured, the passing of our fertility comes home to us neon loud at a birth.  There was a time when each of us decided that our family was complete and that we would have no (or no more) babies.  But there’s a difference between the inner feeling of “I’m not going to do that (again)” and “I will never in my lifetime be able to have that experience (again)”.  It is a bittersweet moment, like losing an appendage you didn’t know you had.   The surprise is almost as challenging as the grief – haven’t we traversed that terrain already?

It’s a moment unique to perinatal professionals, but more poignant to doulas.  We’ve got nothing to distract us when we’re at the bedside.  We’re there to feel, to relate, to be sensitive to everyone else’s needs.  So the surge of grief, of personal realization may catch us by surprise.  This moment may be harder if our menopause arrived early or was the result of a medical condition.  If we have lived in service of women’s reproductive bodies, why didn’t our own work perfectly?

Another common experience is acknowledging our physical limitations.  Our bodies are not quite as cooperative adopting odd labor positions.  We don’t recover as quickly from a long birth.  Some of us develop health issues that have to be accommodated.  This means our practices have to change, taking on partners and mentee doulas to help share the load.  But first we have to sit with the emotions that come with those realizations.  We are aging in a culture that spotlights only the drawbacks of growing older.

We have a huge store of knowledge to draw upon – having seen generations of children come into the world.  We’ve seen doctors come and go, inductions rates plummet and surge, and believe in the power of VBACing women.  The third marker is recognizing our own value.  If our majority culture does not see our wisdom, we must see it in each other and in ourselves.  The doctors, nurses, and midwives may be much younger and eager to dismiss us.  We have perspective and history – the lines on our face garner respect if we know how to use them.  This challenge is in acknowledging what we know – and what we don’t. While young women are the future of birth culture, we have already learned many lessons the hard way and can spare them much pain.

With our clients we know that this time is unique and scary and full of growth.  We can say, “Yes, its not what you expected.  But you know, it never really is.”  From a midlife maternal perspective, many firsts have come and gone: first baby, first child in kindergarten, first night your child doesn’t call, and the first one leaving home.  It never really feels how we expect it to – the fulfillment or the angst.  We can join our kin doulas without children in appreciating our clients as pseudo-daughters, dispersing wisdom and reassurance while not replacing their own mothers.

This is also a time of introspection and reorganization.  If they haven’t already, many doulas at this life stage become leaders in their communities.  They may move to parallel careers that are less demanding.  We need growth but we also need rest.  Rest does not mean stagnation.  Indeed periods of rest and introspection are often followed by frenzied creativity.  We give birth to books, to workshops, to programs, to businesses, and to new doulas.

So midlife doula kin, there are similar signposts on our individual journeys.  Look in the mirror and see your value.  I do.

If you like my posts, please subscribe!

read more

A World Where We Didn’t Need Doulas

Aug 3, 2014 by

A World Where We Didn’t Need Doulas

Maybe it comes from being weaned on Star Trek reruns but I’ve often contemplated alternate universes.  The kind where if a different decision had been made the whole future course of humanity would be altered.  Recently I’ve contemplated what if we had a birth culture today where professional doulas weren’t necessary?  Going back in time, the critical point seems to be a little over one hundred years ago with women deciding to give birth in hospitals.

Like most cultural changes the reasons were multifaceted.  Pain relief was possible in a hospital setting.  At that time relief from labor pain was considered a feminist issue.  Rich women also wanted to set themselves apart from women in the lower classes so paying to go to a hospital accomplished that.  There is also the drive for modernism, to do what is new and improved which was hospital birth.  Once the wealthy had established a new norm and the physician profession benefited financially, a social movement for “safe and healthy” births in the hospital was quickly established.  Within a generation, our birth norms had altered the trajectory of our society. **

But what if something else happened instead?  What if wealthy women demanded that physicians come to their homes?  What if they asked to be attended by a midwife as well as a physician?  What if women surrounded each other with their closest friends and family members instead of strangers?  What if women retained their power by being in their own homes instead of transferring it to someone else in an unfamiliar location?  If physicians could bring their pain relieving medicines into the home or trained midwives to use them, we would have enough caregivers to provide for many laboring mothers.  Women and men would grow up with labor and birth, understanding its meaning and its risks.

As in all things there are probably some women and men who would be more drawn to helping during birth.  But they would have the opportunity to be part of a helping team from a young age and many more people would see birth as normal.  They would understand the caring skills that are necessary to see others through difficult times.  Instead of the unique skills set that doulas have now, these skills would be learned at an early age.  We would all learn to doula one another.

The paradigm of needing assistance during difficult transitions would be widespread.  Simply by growing up in a family or village group, we would learn how to care for one another.  Labor and birth would be our teachers.  Midwives, rather than being derided by physicians and seen as competitors for birth business, would be a necessary part of the paradigm.  Hospital birth would be the exception, not the norm.  With plenty of assistance from loved ones and reassurance from being in their own homes, fewer women might have needed pain relief to cope.  We would have an uninterrupted cycle of support, caring, and knowledge that spanned generations.  There would be no need for doulas because we would all be doulas.  In addition to whatever else we did in the world, doulaing would be second nature.

All the other events in the world – multiple wars, the Depression, the Atomic Age, all would have unfolded differently because we were together and cared about one another.  Touching someone’s brow when they are in pain and connecting with them on a heart level changes a person.  We see the inner power of connection and caring.  I do not think those lessons would be confined to the birth room but would be spread across the world.  Our whole social history would be different if we all learned the value and skills of caring.

So I guess I’m saying that doulaing has the power to change the world.  It shouldn’t have been confined to a select few but something all people should have experienced themselves and learned to do.  However we live in a world that has compartmentalized caring and who does and does not do it.  It has demanded that we professionalize caring in order to exist as a group in the current medical systems.  Sigh.  I think I’ll go watch another Star Trek rerun.

 

*This paragraph is a painfully brief summary.  Two good books written by historians are “Reclaiming Birth: History and Heroines of American Childbirth Reform” by Margot Edwards and Mary Waldorf (1984) and “Brought To Bed: A History of Childbearing in America” (1999) by Judith Walzer Leavitt.  There is also “Birth: The Surprising History of How We Are Born” by Tina Cassidy, a reporter.

** We know today that births in the hospital were not safer nor healthier for mother and baby.  However that was not the public perception of the time.  The propaganda circulating derided midwifery and home birth as “dirty”.   The American Medical Association was originally founded to push midwives from the market of delivering babies.

read more

How Doulas Undermine Our Own Value (it’s not free births)

Jul 9, 2014 by

How Doulas Undermine Our Own Value (it’s not free births)

Anytime I read a “doula” writing online that she knows everything she needs to know already, I want to burst. You know what? You don’t. When you say that, you devalue the entire process of skill development in labor support. What you imply is you already know everything you need to and that anyone can do labor support effectively with only a few days of training (or a few months in a correspondence course). I have never interviewed an expert doula or one who had been to several hundred births who said there wasn’t anymore to learn. Typical comments that I read on Facebook:

“I don’t understand why I need to recertify.”

“I like this organization because certification is for life.”

“I don’t need any more education. I learned everything I needed in my doula training.” OR “I don’t even need a doula training.”

The truth is that you know enough to be of more value than someone who knows nothing. Your heart is in the right place and hopefully that will keep you in a space of observance and support rather than judgment and superiority. But you don’t possess many skills. You haven’t applied most of the knowledge that’s in your head. As a novice or advanced beginner doula, you don’t know what you don’t know. It’s fine to be a beginner but have some respect and humility for the profession.

I have talked to thousands of doulas, yes thousands, in the last 30 years. I have spent years of my life dissecting the minute actions of birth doulas at various phases of skill development (novice, advanced beginner, seasoned, proficient, and expert). I wrote the research on those five phases of skill acquisition! There are fewer doulas at each one of these advanced stages because not everyone can meet the challenges of each phase. [While I am currently revising it, the current version is available here.]

Birth doula work is not about double hip squeezes. It isn’t about birth plans. Birth doulaing at its heart is a spiritual path that will rip away your narcissism and your selfishness. It will restructure your values and strengthen your compassion and empathy for all people through pain and humility. It is about learning how to BE in the presence of conflict and the human experience of living at its most raw and gut wrenching. Birth doula work is not for sissies.

And you know what? A three day workshop, even mine, is not enough to teach you how to do that. You need to learn how to show up for somebody without that person having to compromise because of what you value or think is important. Birth will teach you, but you need support and information too. Learning to communicate effectively with people in power, how to deal with difficult people, and how to listen. These are not things that come easily or that are mastered except with years of practice.

As a professional doula, you know there are many areas where you can improve yourself and your practice. Only someone who is ignorant thinks they know everything there is to know – until they’ve put in the decades to achieve expert status.

Certification has never been primarily about impressing clients. It is about achieving credibility that speaks to the other career professionals you work with.

So when you’re whining about educational requirements or recertification dues, think about what those remarks imply.  They say to me that you don’t value developing the skills needed to improve as a doula because you already know it all.  And there really isn’t much to this doula thing – anybody with a smidgen of education and a few births under their belt can do it well.  These attitudes perpetuate the myth that “Any Woman Can Be A Doula”.   Now think about the damage these comments do to all doulas everywhere – and to gaining the respect we need for our profession.

 

 

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

Why It’s a Calling

Mar 17, 2014 by

Doula work is hard!  It is physically challenging, emotionally draining and requires a personal connection that leaves life long impressions.  Doulas sacrifice to be there for their clients.  They prioritize other people’s birth memories above the needs of their own families.  They get paid less than what they are worth – often wages are barely above the poverty line.  There is a limit to how many clients one can physically and psychically manage.  Yet, this work is something that so many of us cannot imagine not doing.  It fulfills some part of who we are – it expresses our life essence.  To help another woman through childbirth – as she is physically going through the process of giving life to another human being – is what we feel we are called to do.

A calling is often referred to in religious terms because that is our most familiar cultural reference.  But a calling means that there is a purpose within us to connect to others and improve their lives.  We want to ensure that another person’s journey is eased by our presence.  What we give is not only a skill or a service, but the essence of our own humanity.  Doulas in my study said it was a passion, a priority, without doulaing they would feel that a part of them was missing.

Ten of the sixty doulas in my study described or mentioned the word “calling”.  Tracy said, “Being a doula is a part of who you are.  You can’t try to be a doula…you either have it in you or you don’t.“  Nancy shared, “It’s my passion and it tests my compassion.  In my real life, I’m a banker!  But that’s a career and this is a passion.”  Sadie said, “It was in my heart.  For so long before I took my workshop I knew it was in my heart and I’ve never been happier even though it’s been so hard.”

The calling of birth doula work often comes at great cost.  I’m not talking about the missed birthday parties or band recitals, although those certainly matter.  It cost us when we sit holding hands of a woman who is being victimized by her own choices, or who is not respected because she is young, not white, or doesn’t speak English.  When we SEE that infants are whole human beings with a full consciousness and no one else acts in a way that acknowledges it, it costs us.  When we know a physician feels he cannot trust the system and acts in a way that is self-protective rather than letting labor continue without interference, it costs us.  When we trust birth but no one else in the system we are working in does, it costs us.

We don’t do this work because we are martyrs.  We do this work because we are willing to pay the price.  We know it makes a difference to this mother, this baby, this family.  We know that our presence will reassure nurses and doctors to allow this mother to labor another hour because she is cared for.  We know that the price we pay is a drop in the bucket to what is gained by everyone else by our presence.  We do birth doula work because we are called to make a difference in the world.

Our spirit yearning for expression in the world says, “Yes!”

This is your role.

Be of service.

Make a difference.

Hold the spirit alive.

Like a soft spring breeze it whispers, “Doula this world –it needs you.”

 

 

read more

We Need ALL Kinds of Doulas

Oct 1, 2013 by

No we don’t.  We don’t need doulas that lack integrity, who interfere with a mother  getting an epidural or a cesarean, or who say nasty things to their clients about hospitals, doctors, nurses, or midwives.  In my experience these doulas may leave damage behind but they don’t usually last very long.  We hope.

What we have is a huge variety of doulas.  Doulaing is so important and integral to the process of supporting women in their birth experiences that it is finding its way everywhere. There are doulas who work only in their own religious or ethnic communities.  There are some who only attend births for free because it is their way of giving back to the world.  There are doulas who can’t imagine getting paid for work of their heart and spirit.  There are doulas who have no problem putting a price on their caregiving skills and need to support their families.  If we’re going to have a social revolution to rehumanize birth we need all the doulas.  Friend doulas, hobby doulas, grandma doulas, and professional doulas who work for programs, hospitals, and have independent practices.  We need inclusivity to change birth.

There are doulas who live in a neighborhood and are known as the “woman who knows about birth”.  There are doulas who move to foreign countries and hold the hands of mothers whose language they don’t understand.  There are doulas who are angry about how women are treated in labor.  There are doulas who cry about the lack of recognition that the baby is a conscious being.  There are doulas who can’t imagine attending a woman they’ve never met before and don’t know intimately.  There are doulas who do that on a weekly basis.  There are doulas who receive additional training and use other skills such as acupressure, homeopathy, Reiki, or aromatherapy.  If we want all women to have doulas available, that means we need to accept all different kinds of doulas.

The dilemma is this:  If we need all kinds of doulas to humanize and change birth, we also pay the price in delaying our claim to legitimacy for our profession.  There is a difference between a professional doula and other doulas.  No other birth profession has this dilemma where the stakes are so high.  There aren’t any hobby doctors, hobby nurses, or even hobby childbirth educators.  It’s no wonder there is confusion and conflict among doulas and medical staff.  Friends acting as a mom’s doula have no allegiance to advancing our profession and no idea that their actions reflect on all doulas.  When doctors and nurses interact with a doula they have no idea whether she is a novice, a professional or somebody’s buddy.  We can look alike from the outside and seem like we’re doing the same thing.

Legitimacy is like the right of way in driving a car.  The right of way is not something you automatically receive, it is something the other driver gives you.  We can claim the space for legitimacy but it is up to other forces to recognize us as having it.  Those key forces are parents, physicians, midwives, nurses, educators, third party payers, and the general public. We need to have professional standards and educate about the differences to doctors, nurses, midwives who will work with all the doulas.  We need to tell them that their expectations can and should be different of professionals.  We need to show them there is a difference.

There are some doulas who feel that a goal of professionalism is missing the point.  Their vision is for every community or neighborhood to have their own doulas.   They would be the go-to person for pregnancy questions, education, and support during labor.  In this vision it is all about connection and creating a knowledgeable empowered female community.  This happens when people have pre-existing relationships that continue as the child grows.  While I can appreciate that vision, many of the mothers we serve don’t live in that world.  Our connections occur most often with the assistance of technology not around the back porch.  Some women feel most comfortable with intense intimacy when they purchase it – they retain control.

The doula revolution was born through social forces and will continue to form itself around existing systems.  In other words there will be all kinds of doulas everywhere – including those that break rules others hold dear.  We are fighting for two separate things – to improve birth where a mother can have the support she needs from the person she wants to serve as her doula.  We are also massing to shift the perception of us as professionals and to communicate there is a separate set of standards.  Sometimes the accomplishment of the former conflicts with the latter: when a non-professional doula acts in a way that a professional would not.  This is messy and confusing for all of us, including nurses and medical care providers.  While we may not need all kinds of doulas (see first paragraph), all kinds of doulas exist and we need to live in that world.

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