Showing Up

Aug 20, 2015 by

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

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

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

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

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

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

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

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

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

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

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

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

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


*her name has been changed                “Just Show Up” image courtesy of Edward Tufte.


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The Next Step In The Doula Revolution

Oct 16, 2014 by

Steps2One of the most urgent issues facing birth doulas today is our future.  Very few doulas seem to realize this because they are focused on their own businesses.  In many ways the social revolution of birth doula support has succeeded.  According to the Listening To Mothers III survey, 6% of women had birth doula care.  ACOG recently recognized birth doula support as an effective method to lower cesarean rates.  Decades of research has shown no negative effects with the presence of a trained birth doula.  Capitalizing on the growing demand for trained labor support, many small organizations are cropping up to instruct doulas.  These groups are of varying quality, but so are individual instructors within a larger organization.

When I look back on 27 years of doulaing and 17 years of being a trainer, I feel a sense of accomplishment.  My mission was to educate women about the importance of birth in our lives and to ensure that mothers and their partners have supported, caring birth experiences.  Usually that means a doula.  Generations of people needed to “get it” in order to create cultural change and to listen compassionately to the women sitting next to them tell their birth stories.  Both missions are incredibly important if we are going to turn the tides.

From my readings on social movements, especially those similar to doula support, the next step is for doulas to become part of the established system.  Yup.  It has started in several ways – hospital based doula care, community based doulas, and doulas who work for physicians, midwives, or birth centers.  For the most part these programs are very tenuous.  They are based on the champion of one person who keeps the program continuing.  When they leave or funding dries up, the program also folds.  It is most likely to last when hospitals are competing for market share and the doula program attracts mothers to their facility.

For many years being a successful birth doula implied a willingness to work independently and to create a new path.  It necessitated some personal sacrifice to promote the cause of labor support.  Newer doulas are less likely to want to do this.  They have matured in a culture that promotes mentorship and the idea that there is an established map for success.  Younger women today act as if doulas were always around!  I don’t think this difference is entirely generational but a part of the success of birth doulas. Many older doulas feel their hold is more tenuous because they had to break ground.  So there is a turnover in attitudes because of our success, and the personality traits needed now are different.

Another change that I see coming is the institutionalization of doulas.  Almost any social movement that has become established in our society has been absorbed by the institution it desired to change.  It developed as an alternative.  Then once the concept was recognized as being a significant and positive thing, it was brought into the fold of the institution.  You can see this with home schooling.  Once an outside alternative movement that had to fight for recognition, it is now an established method of educating one’s children.  You can even purchase established curriculums from public school districts.

When I wrote about this issue last fall, several people brought up the argument that having national certification didn’t help midwifery.  Instead it brought about divisiveness.  However, midwifery and doula work have very different histories.  In addition, we don’t have the institutionalized power struggles that occurred with nurse midwives and professional midwives.  We don’t compete for market share with any other profession like physicians and midwives do.  Does that mean that we don’t have struggles?  No.  But our growing pains are not their growing pains.

What brought this to a head for me is the realization that even though ACOG wrote about doulas in February, we are still not taken very seriously.  There are several public health issues where birth and postpartum doulas could easily be part of the solution.  But we aren’t even mentioned.  Doulas can have a key role in recognizing the symptoms of perinatal anxiety disorders and postpartum depression, yet any training we get is haphazard.  If a mother spends 10 minutes actually interacting with a physician or the nursing staff at a clinic visit, and we spend 90-120 minutes at our visits, who has the better chance of viewing any symptomology?

One of the first questions we need to ask ourselves is do we want to be a part of that system?  Do we want to provide a stronger, organized social support component?  Do we want our prenatal role to be taken more seriously by other members of the health care team?

Of course there are pluses and minuses to each, which I’ll be exploring in future posts.  With less organization, doulas can continue to practice independently incorporating whatever points of view they wish into their practice.  This allows for a somewhat uneven delivery of services and an atmosphere of “let the buyer beware”.  We can vouch for ourselves but not for our doula sisters – unless we know them personally.  With a stand alone certification organization, we could allow for different types of training and practice styles while maintaining high standards for ethics.  As I have stated before, I am quite concerned that if we don’t do it ourselves, physician, nursing, or public health organizations will do it for us. Some hospitals already have rules allowing only doulas who agree to them to accompany mothers.

Legitimization and set standards for birth doula care IS going to happen.  It’s a matter of whether we’re going to be in charge of it or not.  What do we want that to look like?


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Posts In This Series:

1.  This Post: Social movements

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.  Fears, Downsides, and Challenges of National Certification

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


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How Not To Be THAT DOULA In A Nurses’ Mind

Dec 13, 2013 by

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

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

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

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


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

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“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.


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