Archive | January, 2014

Doulas are Ambassadors to the World of Birth & the Midwifery Model

29 Jan


Birth Ambassadors is PUBLISHED!

25 Jan

We are delighted to announce the publication of

Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America

Chapter 3 Excerpt from Birth Ambassadors

14 Jan

Trained Professional or Caring Woman? Doula Dilemmas

A doula applies a cool cloth to a laboring woman as the nurse looks on

A doula applies a cool cloth to a laboring woman as the nurse looks on

Doulas assert specialized knowledge of the complex intersection of emotional, physical and medical aspects of childbirth, yet simultaneously, portray themselves as kind, caring women with a natural, intuitive ability to improve clinical outcomes in medicalized settings.  These claims are complicated by several factors.  First, a profession is technically defined as a group that controls entry into its own ranks and possesses specialized knowledge verified through credentialing and licensing. So admission to the profession is strictly controlled through organizational means. But anyone can call themselves a doula – as yet, an unlicensed occupation.   Further, the doula’s claim to specialized knowledge is largely experiential, and rests on the constructed, collective experience as women who have birthed socially, among women, since ‘the beginning’.

The dilemmas posed by this juxtaposition create challenges for individual doulas and their organizations.  Further, the effect of these viewpoints is that they obscure the real skills, talents and value of what doulas do accomplish. 

Midwife and author Pam England, creator of Birthing from Within, a Zen-inspired revisioning of childbirth education, argues that current childbirth education focuses too much on rational information and not enough on women’s intuitive knowledge of how to give birth.  Her prescription for this problem is to encourage doulas to come to births “empty-handed and open-hearted,” adopting a mindset she calls “birthing in awareness.”

Christine Morton’s research on the history and experiences of doulas in the United States shows how doulas respond to what they learn in training and later, from their doula experiences. One doula she interviewed (all names are pseudonyms), Maisy, is typical of new doulas who feel anxious and uncertain in their abilities to provide labor support while also aware of author and doula trainer Penny Simkin’s research on women’s long term memories of labor.  Maisy was referred to her first client, an Ethiopian Muslim woman, by an experienced doula needing back-up.  When she met the client prenatally, it seemed to Maisy that the mom-to-be “wasn’t interested in childbirth, she didn’t really care.” At this visit, Maisy mentioned that her care would involve touching the woman’s body wherever she saw tension, and the woman should then just concentrate on getting rid of tension in those places.  But the doula had little time to worry; she was called to the hospital soon after this visit.  She later recalled her feelings:

I was really nervous before I got there but it was good that I didn’t have a lot of warning because I just had to go and do it.  I remembered what they said at training was ‘All you need to do is be there—if you are just there it improves the outcome, anything you add on top of that is just a plus.’  Fine, I thought, I can be there.

Her dilemma about what she would do as a first-time doula gets at the heart of the contradictions within doula care.  The training is brief, there is no supervised student learning, the mode of care can be merely touching a body but the outcomes are said to be medically and emotionally consequential for the laboring woman.  Maisy made the commitment to just ‘be there’ and she described the birth as being very satisfactory for her client.  She labored after a Pitocin induction and gave birth to her first child without any pain medications. “Yeah, she did it,” the doula said. “She had no drugs, did the whole thing naturally, and I was amazed.  She thought it was great and she said she’d never in her life been as relaxed as she was in labor!”

Doula Lorie Nelson identifies the requirements of a good doula this way:   Unconditional love. You know, willingness to work with whatever judgment comes up inside of them. I think that is the key factor in a really good doula because I believe that exhibiting caring and respect for the woman regardless of what she’s going through or what she’s choosing is a validating force that that can change her perception of herself in a difficult situation.  It’s the most challenging thing for many us. It takes great physical stamina to be a doula.  I think …it also takes a high level of sensitivity/perception/ intuition to continually track the energy of the room, of the parties present, and what the woman’s needing.

Another doula in the study, Tiffany, sounds a cautionary note in terms of who is a ‘good doula.’  She stressed the importance of technical knowledge and education.  She considers it essential for a ‘good doula’ to know ‘one’s own strengths and weaknesses as a person and boundaries as a doula.’

Perhaps the greatest contradiction of the doula role is the leveling of expertise necessary for quality labor support to one common denominator:  being a kind caring woman.  The gendered dimension of this role is explicit.  Although there are some men who have certified as doulas, their numbers are low.  Doula trainers explicitly contrast women’s and men’s knowledge and behaviors at birth:  “We all know this intuitively, men don’t.”

Doula practice is explicitly considered ‘women’s work.’  The term doula is itself gendered, coming from the Greek meaning ‘woman serving woman.’  Although the term is often reframed to be more gender-neutral, (‘experienced labor companion’ or ‘labor support person’) in cases where a pronoun is called for, the feminine is used.  Doulas themselves see the work as uniquely female.

Although there are some situations that are unrewarding, doulas believe their job is to cope the best they can, knowing they are there, above anything else, to help this woman to the best of her ability.  The emotional support provided by doulas during labor is seen as one of the most fulfilling and rewarding aspects of the role. After her first birth as a doula, Christine wrote in her field notes:

I came away feeling so incredibly HIGH and exhilarated.  I don’t know how doctors or nurses can do this and do it so impersonally.  To me, birth is sacred.  There is a story surrounding each new life—connecting the story to the lives that will be responsible for this new one for some time.  I am in awe of the incredible leap of faith that goes into having a baby.  I felt like I passed the test.  I am a doula.  I can do this.

Still, receiving rebukes while at a birth from either the client or obstetric clinicians can be devastating to a doula’s sense of competency and personal worth.  At a doula retreat organized by local trainers, many women disclosed their own unexpected discovery that they felt unprepared to do the emotional support required of doulas.  It was, however, a revelation for them to share their feelings with others, and give it a label, “doula doubt.”  Many factors contribute to doula vulnerability: personal issues with birth, an insecure role within the medical hierarchy, and lack of experience are implicated in how individual doulas respond to the interactional demands placed on them to provide doula care, when it doesn’t come naturally.

Work that is defined as “caring” has been a rich source of feminist analyses that attempt to balance the humanistic underpinning of such caregiving with the economic devaluation of the work itself.  Caregiving work embedded within reproductive contexts also poses interesting challenges for theorists who explore work, gender and emotional labor.  Doula practice provides us with a unique case study to examine how the gendered and emotional meanings of work are “simultaneously expected and rendered invisible” in a newly emerging occupation.  It is especially important for examining how the emotional component of intense caregiving work can be seen not merely as an example of economic exploitation as well as an exploration of gender, but also as a motivating factor for the work, in its own right.

The caregiving dimensions of doula practice can be compared with the contradictions and tensions emerging in other types of care work, paid and unpaid.   Doulas experience this clash of value systems when the central definition of what it means to be a competent, effective doula also includes a personal identity as a caring, nurturing woman.  Contradictions around being ‘selfless’ and ‘of value’ are heightened at a time of socially recognized, ritualized vulnerability—childbirth.

Chapter 2 excerpt from Birth Ambassadors

4 Jan

What does it take to become, and to be, a Doula?

At the end of a training, doulas weave a star of connection, pledging to support each other and their clients

Doulas weave a star of connection, pledging to support each other and their clients

Doulas often consider themselves unique among women because of their strong attraction to birth and caring for birthing women. At the start of one training workshop, each trainee shared what she thought made her unique.  Answers included such things as deep-sea diving, gourmet cooking, parachute jumping, or being the eldest of ten children.  Then the doula trainer said: “I love to be with women who are having babies.  That’s not unique here in this room, but in the world you’ll find it is.  What’s unique is that we’ve been given this bug to be with women at this exceptional transition in their lives.”

Doulas understand themselves to be ‘special women,’ who have a deep interest and ability to care for other women during childbirth.  This interest and ability is often characterized as ‘uniquely female’ but doulas readily acknowledge that not all women are interested in birth.   Among the many factors that bring women to doula training are a long-standing interest in birth and an orientation toward caring for others.

Many women described their reaction to finding out about doulas and doula training as something they had always been looking for but didn’t know existed.  They did not want or were unable to become a nurse, midwife or physician, but they still wanted to be around births.

It takes much less time and money to become a certified doula than it does to become a certified childbirth educator.  An unlicensed occupation, there are no formal requirements for calling oneself a doula.  However, the steps to certification involve finding an organizationally approved training workshop locally (usually available within a day’s drive of most metropolitan locations), paying for the course and materials, reading some books and spending time at a training.  Attending the required number of births and doing the paperwork to become certified takes a bit more time and effort.

Women come to doula training out of an ideological commitment to caring for other women during birth, often shaped by their own experiences. Doula trainers say women come because “some have had good birth experiences and want to share that with all women, and some have had bad experiences that they need to heal from.” Sometimes, women become emotional as they share their stories.  Trainers encourage personal reflection:  “Think through why you’re here. Those stories matter, there’s a lot to be done in understanding your own story of what brought you here.”

During training, doulas learn the definition and parameters of the doula role, the medical and emotional impact of doula-attended births and in particular, how doulas accomplish their job of providing ‘physical, emotional and informational support’ to the laboring woman while protecting the memory of her birth experience.

Doula care is presented as a return to the community-based, woman-centered care that existed prior to the shift from home to hospital births in the early part of the century.  In conveying this message, doula trainers emphasize collectively shared, community-centered support of women’s birthing experiences.  This focus asserts that birthing has been women’s work, that women intuitively know how to birth but our current culture has developed birth models that interfere with this intuitive knowledge and shared historical practice.  Doula trainers present an alternative model for how woman-centered support can reclaim a place within medicalized childbirth in Western cultures.

Trainees learn that their non-medical role is what distinguishes them from maternity care providers and this fills a gap within the current hospital provision of childbirth support.  Closing this gap takes two forms: first, the doula’s focus is specifically on the laboring woman’s emotional and physical comfort needs, rather than clinical issues.  Second, the doula provides continuous presence and personalized attention to one woman in contrast to the competing demands of the clinicians present, whether nurse, midwife or physician.

In addition to the focus on the non-medical aspects of their own role, doulas learn that pregnancy and childbirth are normal, non-pathological life events.  This notion is embedded in the midwifery model of care, described as a holistic approach; one that attends to the diverse aspects of pregnancy and birth: physical, emotional, spiritual, social, economic, cultural, and sexual. Trainees also learn the basics of childbirth physiology and other necessary information, but the emphasis is on birth as a natural physiological process occurring in healthy women, and the fewer medical interventions, the better the outcomes for both women and their babies.

Despite the emphasis on their non-medical role, doulas are nevertheless expected to be conversant with standard medical practices surrounding birth.  Trainees learn about pain medications used in labor, and the kinds of information they are expected to give their clients prenatally and during labor to help them make informed decisions.   Although critical of the unnecessary use of medical interventions, trainees are expected to be familiar with their indications.   Knowledge of anatomy and physiology of childbirth is encouraged in order to understand how to help labor progress in situations where the baby is not in an optimal position.

Doula trainers present the view that labor support should include unconditional emotional acceptance of women and their choices, practical physical assistance and as much information as women need to make decisions that are best for them.  Although trainers stress that birth is ‘not just another day’ in a woman’s life, and provide scientific rationale for continuous labor support, they also emphasize the importance of not judging women’s choices for their births or advocating one’s own beliefs on behalf of other women in medical settings.

Doulas learn that one of the most powerful ways they interact with their clients at births is by reframing what is happening from something that is negative or scary into something that highlights the normalcy of labor or the agency of the birthing woman.  Trainers communicate the value of reframing events in order for the woman to have a story to tell that places her decisions at the center.  Doulas are often present when the first telling of the birth story is announced to family members, especially when it occurs within minutes of the birth.  The injunction to ‘protect and nurture the birth memory’ is conveyed during training through a variety of means, including hands-on physical comfort measures.  But what the doula says is as significant as what the doula does in shaping the story of that birth for the woman, her partner and their families.

At the postpartum visit, trainees learn that the doula is there to see and admire the baby, and hear the woman’s story of the birth.  Trainers caution the doula to not assume that the woman will agree with the doula’s perspective of the birth.

Thus trainees learn that a large part of the doula’s impact on the woman’s memory of birth is accomplished through continuous presence, unconditional support, and reframing events, as they happen, so as to acknowledge and validate the woman’s effort.  In the event that the woman feels unhappy or disappointed about some aspect of the birth, the doula’s role is to validate her feelings about what happened, but reaffirm choices she made by reminding her of the factors affecting those choices. This reframing activity is a major part of doula training, designed to ensure a ‘positive birth memory’ for the woman, regardless of the doula’s opinion or experience of the birth.

Women who do not actively practice but intend someday to start or resume doula work still have a place in the doula world; they feel part of the community but are likely to have other family or life commitments.  No doula ever renounced the ideology, much like the phrase in midwifery, “once a midwife, always a midwife.”   As they continue doula work, many women move into allied childbirth fields that offer more professional status, better income and stable work.  Other doulas enroll in midwifery or nursing school to further their interest in technical aspects of maternity care as well as increase their earning potential.  Those who came to doula practice from another field, such as social work or counseling, continue to work in those domains but find their newfound experience working as a doula enhances their professional skills and empathy.

The typical practicing doula, then, is a woman who has been drawn by passion to provide care to other women during their births.  She has adopted a belief in the transformative and empowering effects of unmedicated, low intervention childbirth but also in the right and ability of women to make their own choices.  She strives to provide education and information to women that will give them an open mind to experience whatever lies in store for them at their births.  She networks intensively with others who share her beliefs and help her attain her goals.    Ideology, rather than professional status or economic reward, keeps her going, with the conviction that she is changing the world, and making a difference.


the ecosystem approach to obgyn

Ann Douglas

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A collective of African-American, African, Caribbean and multi-racial women who are committed to transforming the birthing experiences for Black women

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Doulaing The Doula

Professional Development for Birth Doulas

Birth Ambassadors

Doulas & Woman-Supported Childbirth


A survey of doulas, childbirth educators, and labor and delivery nurses in the United States and Canada

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