Birthrape And The Doula

Apr 29, 2016 by

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

Dear Doula,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Your goals are:

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

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

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

“What other procedures or people might we expect?”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Is it rape? Aren’t you exaggerating?

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

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

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

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

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

 

 

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

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

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

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

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

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

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

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

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

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The Time To Ask About Past Abuse or Assault is Never

Apr 6, 2016 by

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

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

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

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

You can also offer examples:

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

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

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

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

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

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

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

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

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

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

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

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

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

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