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WHY have a postpartum doula? …

2 Oct

Postpartum doulas provide a much needed service for many new parents, however not all parents are able to pay for someone to come to their home, help them take care of themselves so they can take care of their baby, without judgment, and with a lot of compassion and really great tips for that “babymoon” time.

In today’s New York Times, reporter Zoe Greenberg writes about postpartum doulas in NYC and quotes Dr Christine Morton, one of the authors of Birth Ambassadors!

Birth Ambassadors mentioned in NY Times story: October 2, 2018

Everyone Should Have a Postpartum Doula

Because when a baby comes, friends and families don’t always know how to help.


Why doulas get no respect. It’s not the science, it’s the culture.

26 Feb

My social media feeds lit up two weeks ago after this New York Times story about doulas was published. At first it seemed that doulas, and the benefits of continuous labor support, had been validated by the paper of record.  However, it soon became apparent, from the many comments and later, responses from individual doulas,   the NYC Doula Collective,  a doula training organization, and Miriam Perez of the Radical Doula, that many doulas and their advocates were dismayed that the article failed to articulate what doulas themselves find valuable about what they do.

Slide2The main argument among the rebuttals mentioned above was that the NYT reporter neglected the research often cited as evidence that continuous labor support results in measurable beneficial outcomes for birthing women and their babies. Many also took issue with the characterization of doula support as a personal service, available to privileged women who can afford to pay handsomely for this luxury.

But there’s the rub.  Since doulas only attend about 6% of all births, according to Listening to Mothers 3, a nationally representative survey of women’s birth experiences, it’s hard to support the claim that merely adding more doulas to maternity care teams will make a measurable impact on birth outcomes like cesarean deliveries (currently ~32% in the U.S.).  In some areas, new maternity models of care are making an impact, by creating a “pregnancy care package,” with a continuum of team care led by a nurse-midwife and coordinated with an obstetrician, nurse, doula, pediatrician, social worker and patient navigator. But even those projects are difficult to scale up to meet the demand.

Doulas, working as isolated entrepreneurs, or even as collectives, may not be as effective, or as respected by maternity care clinicians, as they would if they were a recognized, legitimated part of the “team.”  My colleague Amy Gilliland has been writing about the issue of national doula certification, and recently cited the work of another colleague, Jennifer Torres, whose research comparing lactation consultants and labor support doulas found that “both filled a niche in maternity care practice that is not covered by nurses or physicians.  However, lactation consultants have been able to influence medical practice directly.  They entered through the “front door” and have been welcomed by medical professionals, because breastfeeding is seen as a medical event.  However, doulas are not recognized as having anything meaningful to offer to medical professionals, and as such are seen as entering through the “back door.” (see Amy’s blog for a full discussion).

In our book, Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America, we argue that while doulas do provide several benefits to laboring women, the doula role itself is open to critique because of some fundamental contradictions in its definition.  Are doulas trained professionals, or “merely” caring women with a passion for birth? Do doulas unconditionally support women’s birth choices even as they hold strong views on the optimal management and outcomes of childbirth?   Can doulas advocate for their clients in the hospital labor room without being seen as interfering with the medical management or challenging obstetric authority? These various interpretations are clearly evident in the NYT story and even more so in the hundreds of comments it generated.

Our analysis of doula care in the U.S. maternity context, through a careful examination of its history, observations of training workshops and interviews with doulas and organizational leaders found that:

The reason why doulas are unable to gain respect from the press, the obstetric community and the public is that their primary goal of providing emotional support to women during childbirth is not valued by our culture.

It is well known that facts alone are unlikely to change someone’s deeply held beliefs.  Doula advocates’ use of scientific rationale as the warrant for continuous labor support fails to address the underlying cultural belief among many that women’s birth experiences are not that important. Furthermore, unlike lactation consultants, whose goal is to facilitate successful breastfeeding with a client (something of value to hospitals now that The Joint Commission is tracking such rates), the doula’s goal is less clear and clearly less valued by hospitals.  On the one hand, doulas and their organizations cite benefits of continuous labor support such as fewer c-sections, yet caution that as individual doulas, the goal is NOT to ensure a vaginal birth, nor question the decision for a cesarean section for any particular client.  Instead, doulas typically say their goal is to enhance women’s satisfaction with their birth experience, no matter the outcome, wherever the birth takes place.

Changing the cultural meaning of labor support — the value of women’s emotional experience — is a much harder task than citing research on the clinical benefits of a doula.  Any occupation that includes emotional labor is relegated to a lower social status than a comparable one that does not (think school bus driver vs. city bus driver; pediatrician vs. neurosurgeon).  Much social science research finds, that in any organization, those workers who are expected to provide emotional care are less valued and less compensated than those who are not.

Doulas and their organizations need to communicate the fundamental value of emotionally supporting women through childbirth. 

And that may not be possible using economic or scientific rationales alone. It is challenging to communicate the value of emotional support in childbirth in a context where doulas who engage in entrepreneurial practice charge a higher fee than many obstetricians or midwives are paid through insurance.  Furthermore, as we pointed out in Birth Ambassadors, not all doulas speak with one voice, and there is not one organization that speaks on behalf of all doulas.  We can see that diversity in the various responses to the NYT article.  Interestingly we haven’t yet seen a response from DONA International, the primary doula training and certifying organization in the U.S. Without coordinated leadership from a strong, credible organization that can articulate it, the meaning and value of doula care is left up to anyone with the loudest platform.  If doulas don’t want to be compared to Amazon Prime, they need to provide alternative pull-out quotes for articles like the one in the NY Times.  And while you can’t always control what the press says, it’s important to insert your view into the cultural dialogue and not leave to others to have the final say.  In this case, by an obstetrician, no less, who says, “A doula is like a personal trainer. Not that you can’t do it yourself; it’s just nicer if you have a personal coach for it.”

SQUAT Birth Journal Reviews Birth Ambassadors & Interviews Christine Morton

8 Oct

SQUAT Birth Journal, Issue 18 Cover

SQUAT Birth Journal features Elise Rose’s review of Birth Ambassadors & interview with Christine Morton, author of the study that is featured in the book, with stories collected and edited by Elayne Clift.  You can visit the journal and read the review hereSquat_Birth_Review_title

Birth Ambassadors is at #LamazeDONA Confluence in Kansas City!

17 Sep


We are happy to note that you can buy a copy of Birth Ambassadors at the Praeclarus Press at Booth #302.  Tweet to @birthambassador if you’d like a signed copy by author Christine Morton while you’re at the Lamaze/DONA conference!

Five Star Reviews of Birth Ambassadors on Amazon!

22 Jun

The Amazon reviews are unanimous! 

smooth-starBirth Ambassadors is a “must-read,” “amazing,” and a “great study” that provides a “refreshingly candid and accurate look at the complexities of both doula-ing and doula-training.”

Get your copy now and join the doula trainers below who value this sociological perspective on labor support in the U.S.

Something new! By jana wernor on February 26, 2014
I was actually in the middle of teaching a Supported Birth Doula Training when I saw
this book had arrived. It is fantastic! No “re-inventing the wheel” book about doulas,
but a refreshingly candid and accurate look at the complexities of both doula-ing and
doula-training. The inherent inconsistencies we must face and deal with when learning
about a model of birth and then going out to support most women who are NOT having
that model of birth, and why it is so important to acknowledge this, not judge the clients,
and live in the dilemma. I immediately started reading passages out loud to my trainees
before I could even read the entire book. Also, the truth and dilemmas about the fact
that it is a “profession” without any license, real doula stories such as “doula doubt,”
and what doulas DO NOT/should not do. I sent out an email to the 80 doulas I have
trained over the years and told them it’s a must read!
Birth Ambassadors is essential reading to understand, prepare to be or find a doula.
We are beginning a transition in maternity care around the world, as women take back
their power in childbirth. Doulas gently support and help women and their partners to
advocate for themselves and their baby. Doulas are the missing link in our broken
maternity care system and Birth Ambassadors provides the knowledge, personal
stories and insights to inspire the change that will bring balance and nurturing to this
special time in a woman’s life! As a doula and doula trainer for 30 years, Birth
Ambassadors made me cry, smile and cheer! Birth Ambassadors helps us to
understand and reclaim the role of female companionship, caring and touch in
maternity care.
Birth Ambassadors tells the the “other” side of the maternal health story in America.
For the last 30 years the maternal health care system in American has become a model
that relies on technology and largely disempowers women at it’s best, while poorly
serving them at it’s worst. Thankfully, along the way, a small army has been evolving to
provide an alternative to this discouraging trend – enter birth doulas. Christine Morton
has written an amazing book that gives us a picture of maternal health in the last 30
years through the eyes of a group of women who have stood up and stated ‘there is
another way to bring humans in to our world and I’m going to support birthing-women
in this endeavor.’ These women acknowledge that birth can be a powerful rite of
passage in a woman’s life with much to be gained if a birthing woman is truly supported
on her path. BIRTH AMBASSADORS is a must read for any doula, childbirth educator,
midwife, or birth scholar.
This book seems to be the first study about doulas, and what a recognition we get!
The authors wrote an amazing document which covers the origins of the profession in
light of the historical changes in maternity care in the States, the role definition, the
training and practice of the doulas , as well as the challenges and difficulties of this
profession. As a practicing doula for fifteen years, I was moved by the recognition and
the deep understanding of the importance of doulas as birth caregivers in the modern
world. Thank you Christine Morton !

Online Birth Story Workshop with chance to win a free book!

17 Jun

Telling Birth Stories: An Online Writing Workshop with award-winning author & journalist Elayne Clift

How do you write a good birth story? What makes any story compelling? How can we tell our own birth stories, as remembrance and as a gift to other women?

In Birth Ambassadors: Doulas and the Re-emergence of Woman-supported Birth in America (Praeclarus Press, 2014), Christine Morton and Elayne Clift include stories by women for whom a doula was present at their birth. These beautifully crafted first-persons narratives give voice to the extraordinary experience of giving birth. Join the growing chorus of women whose voices, and birth stories, are being heard!

BA Writing Workshop NYC2This 4-week online workshop guides participants – moms, dads, midwives, nurses, doulas, docs – through the elements of good storytelling as they relate their personal experience while giving or assisting birth. Weekly prompts will serve as a guide to setting the scene, involving characters, using dialogue, making wise word choices, and more. Work will be shared each week among participants who will respond to each other. Elayne will offer in-depth feedback and suggestions for each piece and facilitate dialogue among participants.

If you’re interested in painting a word portrait that carries your audience with you as you tell your birth tale, please register by July 15. Register by July 4 for one of two chances to receive a signed first edition of Birth Ambassadors! Space is limited to 8 participants!

WHEN:           The first online workshop will begin August 1 and conclude Aug. 25.

COST:          $95/pp

REGISTER by EMAILING:            802-869-2686

* * * *

Elayne Clift (M.A.), a specialist in gender issues and women’s health, has been an international educator and advocate on maternal and child health issues for more than 25 years. She is Sr. correspondent for the India-based syndicate Women’s Feature Service, a columnist for the Keene (NH) Sentinel and the Brattleboro Commons, and a reviewer for the New York Journal of Books. Her articles, prose and poetry appear in numerous anthologies and publications internationally and her novel, Hester’s Daughters, a contemporary, feminist re-telling of The Scarlet Letter, was published in 2012. She lives in Saxtons River, Vt.

Telling Birth Stories: Writing Workshop with Elayne Clift (May 14, NYC)

4 May

Reposted from


A Writing Workshop with Award-Winning Author & Journalist

 Elayne Clift

 How do you write a good birth story?  What makes any story compelling?  How can we tell our own birth stories, as remembrance, and as a gift to other women?

In their book Birth Ambassadors: Doulas and the Re-emergence of Woman-supported Birth in America (Praeclarus Press, 2014), Christine Morton and Elayne Clift include stories by women for whom a doula was present at their birth.  These beautifully crafted first-persons narratives give voice to the extraordinary experience of giving birth. Join the growing chorus of women whose voices, and birth stories, are being heard!

This workshop draws upon the examples of birth-related stories as Clift guides participants through the elements of good storytelling as they relate to the experience of giving or assisting birth. Prompts will serve as a guide to setting the scene, involving characters, using dialogue, making wise word choices, and more. Come prepared to remember, write, and share.  (Laptops welcome. Paper/pen are good too!) Join in painting a picture that carries your audience with you as you tell your birth tale!

DATE/TIME:  Wednesday, May 14th

6:00 pm – Birth Ambassadors book reading and signing

7:00 – 8.30 pm – Writing Workshop

PLACE: 242 West 27th Street, Kids at Work. 4th floor, buzzer #6, between 7th and 8th Avenues

COST: Writing Workshop $20  (no fee for book signing only)

RSVP to Mary Esther Malloy or Elayne Clift

                                                * * * *

Elayne Clift (M.A.), a specialist in gender issues and women’s health, has been an international educator and advocate on maternal and child health issues. She is Sr. correspondent for the India-based syndicate Women’s Feature Service, a frequent contributor to Women’s Media Center, a columnist for the Keene (NH) Sentinel, and a reviewer for the New York Journal of Books.  Her novel, Hester’s Daughters, a contemporary, feminist re-telling of The Scarlet Letter was published in 2012. She lives in Saxtons River, Vt.

Birth Ambassadors by Christine Morton and Elayne Clift

Birth Ambassadors documents the social history of the emergence of doula care in the United States. What are doulas and where did they come from? Why do women become doulas? What does it mean to be a doula? Birth Ambassadors is the only book to fully answer these questions by connecting narrative accounts with critical sociological analysis of the dilemmas and issues embodied in doula history and practice. Based on historical research and interviews with currently practicing doulas and leaders in the field,

Birth Ambassadors argues that the doula role is underpinned by ideological commitments to several overlapping and, at times, conflicting ideas around childbirth. These include an understanding of pregnancy and birth from the midwifery model, a belief in women’s right to make informed choices regarding their health care, the need for patient/consumer advocacy and unconditional emotional support for women’s choices about their births. Birth Ambassadors explores how this constellation of beliefs within doula practice represents an innovative yet problematic response within the maternity reform movement to empower women during and after childbirth. Doulas are ambassadors to the world of birth, highlighting women’s emotional experience of birth in settings where beliefs and practices of the participants (the woman, her family, the nurses, midwives and obstetricians) are sometimes in conflict. For doulas to fulfill their goal of entering mainstream maternity care, they and their organizations face critical challenges.

“This book is THE definitive work on doulas in the United States. It is clearly and compellingly written, immediately drawing readers into the story of the development of doulas in the U.S. and of the social movement that arose to support their incorporation into American hospital birth. Want to know what a doula actually does for laboring mothers? Read this book! Want to know what a doula can do for you personally, if you are expecting? READ THIS BOOK! Want to know if you yourself should become a doula? READ THIS BOOK! If you are an obstetrician, professional midwife, or obstetric nurse, read this book to find out how doulas can augment your care in ways that support you as well as the mother, the baby, and the family.”

Robbie Davis-Floyd PhD, author, Birth as an American Rite of Passage, co-editor, Mainstreaming Midwives.

 “Birth Ambassadors documents the social history of the emergence of doula care in the United States. What are doulas and where did they come from? Why do women become doulas? What does it mean to be a doula?  Birth Ambassadors is the only book to fully answer these questions by connecting narrative accounts with critical sociological analysis of the dilemmas and issues embodied in doula history and practice. Based on historical research and interviews with currently practicing doulas and leaders in the field, Birth Ambassadors argues that the doula role is underpinned by ideological commitments to several overlapping and, at times, conflicting ideas around childbirth.”

Holly Powell Kennedy, Ph.D., CNM, FACNM, FAAN, Varney Professor of Midwifery at Yale University and Past-President of the American College of Nurse-Midwives (ACNM).

Future directions in doula research

13 Apr

What else do we want and need to know about doulas and doula practice beyond the association with selected birth outcomes? By studying doulas, what else becomes important to investigate in the broader area of women’s experience of birth, the professionals involved in birth and the institutional contexts of birth? Here are some questions and ideas for continued research that emerged in the course of my study.

doula-conceptual-model Dekker 2012

Doula Conceptual Model (Dekker, 2012)

  • One doula recommended that we look at countries where maternity care is sub-optimal. In these countries where social arrangements of childbirth support are inadequate or non-existent, can we find any correlation or causal relationships between rates of infant abandonment; declining birth rates; or illegal, unsafe abortions? What other social and reproductive practices and behaviors might be linked to poor maternity care?
  • To answer the question of whether doulas support the status quo or contribute to changes in social practices around their clients’ birth choices, it would be valuable to examine, what, if any influence doulas have on women’s choice of care providers or hospitals in their current and future pregnancies. How do doula messages about childbirth influence women’s plans for future birth interventions?
  • To answer the many questions emerging from these doula accounts about the current hospital management of childbirth support, and to tease out the relative impact of nurse and physician attitudes and practices, it would be helpful to have more systematic understanding of how doctors and nurses orient to labor pain in their clinical practice. Does labor pain have value in their view? How does dealing with labor pain affect their view of their patients?       Of their ability to do their jobs?       How does their medical training affect how they see pain and methods for its relief, including non-pharmacological methods, and labor support? How do they view doulas?
  • What motivates nurses and physicians to work in obstetrics? Have those motivations changed over time? Is the orientation of birth as the ‘happy event’ still current in today’s litigious culture where we see more physicians dropping out of obstetrics and fewer entering it? What does it mean for women-centered birth as more females are being trained as ob/gyns?
  • How has the sexual element of birth been incorporated and/or transformed in the medical setting?       How are power relationships negotiated and how are women’s bodies and subjectivities employed in these negotiations?
  • Many scholars have examined the motives of women choosing home birth. What motivates women who choose a doula for their births?       What are their experiences with doulas? It would also be helpful to learn more about how their partners and other family members view the doula’s role and actual support at the birth.       What reasons do women give for considering, but rejecting the idea of a doula at their births? How do they reflect on their experience and their decision after the birth?
  • What factors make it possible for women to work as doulas? It would be interesting to hear from the perspectives of others in the social networks of doulas. How do their male partners view doula work? How do they rearrange their lives when the doula is on call and at a birth? How is the work justified? What are other family members’ reactions to doula practice? Examining these questions would allow us to see how doula ideology is conveyed to others in their social networks.
  • We need more cross cultural research on doula care. How is the message of labor support conveyed to other cultural groups?       How is it received? What aspects of the doula ideology are specific to the American context of medicalized childbirth? What are the cultural assumptions underlying doula notions of ‘emotional support’?   How are issues of class, ethnic/racial identity, personal birth experience and age salient for doula practice?
  • How has the Internet influenced, affected, transformed the ways specialized interest communities can collectively share information and organize as social movements? Doulas embraced the Internet from its earliest days, gathering in local and international chat rooms, and offered their vision of birth on a playing field that gives them a platform to respond to mainstream views of birth.
  • How does a couples’ experience of birth affect their parenting practices and their marriage relationship (unasked in many studies of transition to parenthood).
  • How do doulas accomplish their goals within medical interactions?       We would benefit from observational studies of doula care, in addition to the accounts of doulas.       How have the related professions of nursing and social work dealt with the demands of professionalization and credentialization? What can we learn from the history of childbirth educators and lactation consultants about the fragmentation of care and information surrounding women’s childbirth and postpartum experiences?
  • As more hospital based doula programs are developed, it would be helpful to do a comparative study of doula practice in these settings with individual doula practice, especially with regard to information/advocacy roles.
  • How do community based doula programs work? What are their outcomes? How is doula ideology transformed and shaped in cultural contexts beyond white middle class frameworks?
  • How can we theorize doula care, doula practice and doula ideology?       Where do they overlap and where are they divergent?

What are your research questions about doulas?!

Goodreads Giveaway! Birth Ambassadors

21 Mar

We are giving away 5 copies of Birth Ambassadors on Goodreads!

3/23/14:  attention:    the Goodreads Giveaway for Birth Ambassadors is now approved! Effective thru 3/31!

In honor of World Doula Week (March 22-28),  sign up to win a signed copy of “Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America.” This book has been called “essential reading to understand, prepare to be or find a doula” by doula trainer and author Debra Pascali-Bonaro, and “THE definitive work on doulas in the United States” by medical anthropologist Robbie E. Davis-Floyd.  You can read a review at RH Reality Check: Stoking Fire: Doulas as ‘Birth Ambassadors’

Goodreads Book Giveaway

Birth Ambassadors by Christine H. Morton

Birth Ambassadors

by Christine H. Morton

Giveaway ends March 31, 2014.

See the giveaway details
at Goodreads.

Enter to win

Giveaway ends March 28, 2014.

See the giveaway details
at Goodreads.

Enter to win

Chapter 4 Excerpt from Birth Ambassadors

3 Feb

Being a Team Member: Doula Strategies and Nurse-Doula Interactions

This excerpt highlights findings from Christine Morton’s sociological research on the history and experiences of doulas in the United States. The methodology is described in the book’s Appendix.

ImageAs outsiders to the hospital, yet as self-professed insiders to labor support, doulas employ several strategies as they enact their role providing information, advocacy, and physical and emotional support.  Some strategies occur during the prenatal visit, such as becoming familiar with the client’s birth plan and desires for interventions, and discussing communication and negotiation tactics should the birth plan be challenged by either the maternity clinicians or unexpected events, particular to, and complicating the birth.

Doulas utilize “reframing” as a major strategy to help their clients achieve a ‘satisfying birth memory.’

Strategies that doulas describe using in the hospital setting include becoming a team player; backstage negotiations; direct confrontation and silently witnessing depersonalizing behaviors.  All these strategies are associated with both benefits and costs.  The doula may be a ‘good’ team player, but leave the impression that she is ignorant or ill-informed about birth.  Requesting and using backstage time to go over various options in the situation can irritate a busy, time-strapped physician.  Direct confrontation can strain the emotional atmosphere the doula is striving to control, and can be considered speaking on behalf of the client, and thus outside the standards of practice.  Finally, when doulas witness what they consider to be impersonal, disrespectful or dehumanizing treatment of their clients, they may be left with strong feelings of anger and frustration.  In those situations, as in all births, the final strategy, ‘reframing the birth experience,’ becomes a challenging emotional task with the goal of helping the woman achieve a ‘positive birth memory.’

Most doulas report positive experiences working with physicians, nurses and midwives in the hospital setting.  Many invoke the notion of being a ‘team player.’ Nurses are typically the first obstetric clinicians doulas encounter when they attend their clients in labor.  Whether they accompany the woman to the hospital and encounter the triage nurse or arrive after the woman has been admitted, doulas actively assess a nurse’s attitudes with regard to labor support activities in general and to doulas in particular. Doula Deborah Rothman described her strategy of figuring out the nurse’s practice style, and adjusting to that:

Well, it’s really important to get some kind of partnership set up or at least division of labor set up with the nurses.   Most nurses—when there’s a doula—I find that they are content with their clinical assessment-monitoring role.  Or they’ll be chatty and supportive that way.  And there’s a few that obviously love labor support, and there’s always room for more labor support, you know.  That way I get to go to the bathroom, or work together, and that’s really nice.  But the ones that don’t seem to approve of labor support seem content enough to do their clinical role and I’m respectful of their job.

Several doulas in my study reported positive experiences working with nurses who were happy to engage in a division of labor, leaving the emotional support to the doulas. Not all nurses feel this way, and without knowing a particular nurse’s proclivity, many doulas make an explicit effort to reassure nurses that their presence does not mean the nurse has been ‘ousted’ in this area.  A doula described her approach this way:

I try to ask the nurses questions that we have, in a way that allows them to share their expertise.  I like to develop a ‘We’re learning from you, what do you have to share with us’ type of thing, so they don’t feel sort of ousted by the doula and that they’re just like the paper work person.  That they really have something to give to the situation.

This doula strategically orients toward the nurse as a potential source of knowledge and information, to help offset the possibility that the nurse might feel relegated to her documentation or clinical monitoring role.  Interestingly, the doula as hospital ‘outsider,’ works to ensure and reassure the insider nurse that she has a role to play, or ‘really have something to give to the situation.’

Another doula described her philosophy and how she demonstrates to the nurses that everyone is on the same team, but with specific roles:

I consider us all a birth team, there’s no, I’m on one side or another, we’re all on the mom’s side, basically. That’s certainly the way I like to think about it.  I kiss up a little bit in the beginning, I mean, not really, but I introduce myself and I usually ask the nurse what’s going on, if she was there before me, and [I also ask] the mom, but it comes out from both of them while the mom’s there.  I say, ‘Oh, that sounds great’, and I kind of reinforce back and forth, and it feels like a team, and I get out of her way and she does her thing, and I do mine.

She initiated the interaction by asking the nurse what has occurred prior to having come on the scene, and actively worked to create a three-way dialogue between her client, the nurse and herself.  Through this approach, the doula effectively positioned herself as someone with a right to know the patient’s medical history and future plan, based on the nurse’s current clinical assessment of the labor.  She aligned herself with the plan right from the start, affirming the decisions, ‘Oh, that sounds great.’

Tiffany Smith, a doula and a nurse, acknowledges the potentially contradictory roles of informational and emotional support in the doula role, and says this was an ongoing issue in both her doula and nursing practice.  Tiffany’s tactic is different: “It’s a balancing act, to push up to the line but not over.  Always negotiation.  As a nurse, one of my roles is to advocate for patients.  So I use what I call my dumb nurse voice—playing stupid in a non-threatening way—non confrontational.”  Tiffany’s nursing experience and knowledge serves as a resource for her interactions with clinicians when she works as a doula.  She told a story about a birth in which the placenta was taking a long time to come out.  Tiffany noticed the doctor becoming impatient and tugging on the umbilical cord.  “So I asked, ‘Gee, how long does it take to come out?’ I bought the mom time, about 45 minutes, because the doctor was pulling on the cord.”  Tiffany was concerned about possible postpartum complications if the doctor rushed something that Tiffany knew could normally take up to an hour.  She used her ‘dumb nurse voice’ to redirect the doctor’s awareness to the wide variation in ‘normal.’ In so doing, Tiffany felt that she ‘bought the mom time’ to hold and admire her newborn before the nursing staff took the baby for institutional processing such as measurements, bathing, and vitamin K shots.  This strategy of using ‘classic’ feminine wiles was often described by doulas when they asked a question of the nurse or doctor in front of the client in an attempt to introduce another viewpoint.

In the best nurse-doula scenario, both assist each other and work for the benefit of the laboring woman.

One doula remembered a nurse’s behavior while recounting a birth story about a long labor during which the client got an epidural and fell asleep:  “The nicest thing for me in that birth, I was sitting next to her, dozing, around 3am, and a nurse came in and put a warm blanket on me.  She was a doula to me, her intention was so sweet.”  Here, demonstrating personal attentive care is described as acting like a doula.

Doulas who stress the importance of establishing a ‘team’ approach with the nurse acknowledge that part of what the doula is there to accomplish infringes on some part of the nurse’s job description: providing labor support.  Doulas are aware, however, that individual nurses vary in the degree to which they embrace hands-on labor support aspect.  By making initial overtures to the nurse, the doula is able to assess the degree to which the nurse will be an ally with the doula and support the woman’s desires.

Another strategy doulas use to counter medical information or unhelpful attitudes from clinicians occurs during their access to ‘backstage’ time with their clients when no clinicians are present.  This strategy can utilize information obtained prenatally about the client’s fears and desires for her birth and agreed-upon techniques for managing a physician’s recommended intervention or change of course.  A doula described it best when she said:

Well, one thing that I try to do is when the doctor’s not in the room—I’ve encouraged my clients to say, ‘We’d like to think about it’—and they ask the doctor to leave and then come back so that we have a chance to talk in privacy.  What I’m finding is that the doctors have egos and the last doctor we were with said to the client, when she started asking a few very simple questions about artificial rupture, ‘I’ve done a couple more births than you probably have.  I’ve done about 4000.’  You know, totally demeaning.  And I wanted to say, ‘Yeah, but you haven’t had your baby.  You’re not the one who’s giving birth right now.’  He was totally insulted that she wanted to ask questions.

This backstage strategy can be an effective way to validate women’s feelings about the medical interaction or to sort out possible approaches to the particular situation at hand.  It is also used by doulas as a practical strategy for challenging and countering medical information, and providing more advocacy.

Roberta King is another doula who provides a concrete example of the backstage strategy to help her client achieve her goal of an unmedicated birth when the nurse actively disregarded this desire by her continued offers of pain medication:

Another thing I do is to be that buffer in between that medical staff and mom … because nurses will continually come in and say, ‘You know, you can get medication,’ and the mom says ‘No,’ and they’ll come back and say ‘You know, you can have medication…’ So that’s what I talk to the mom about [when the nurse leaves].  I don’t talk to medical staff, I don’t give them any decision.  [I tell the client] ‘When she [the nurse] comes back in, just let her know that you will ask for medication, and tell her ‘Do not ask me again.’  And she told them that way.  Because medical staff, that’s what they do, it’s nothing negative against them, they’re doing their job. Since we did it that way, it didn’t put pressure on them, because when you’re in the midst of a pain, (laughs) if someone can tell you ok, I can take you out of the pain, you know, it’s difficult, it’s difficult.

Roberta uses her continuous presence at her client’s side to offer advice on how to respond to the nurse’s continued offer of pain medication.  She effectively uses the backstage time with her client to construct a response to the nurse’s offer for medication that kept her, the doula, out of the interaction.  Roberta didn’t construe the nurses’ behavior with sinister motives; rather, she saw the offer of medication as ‘their job’ but acknowledged that this offer can be tempting to a woman in the midst of a painful contraction.

This use of backstage strategy is made possible by virtue of the doula’s continuous presence at the birth.  Nurses come and go but the doula remains in the room, privy to the woman’s reactions to a particular nurse and to her knowledge of the woman’s goals through her prenatal contact.  In cases where the backstage strategy isn’t applicable or doesn’t work, doulas adopt varying styles of direct communication with maternity care clinicians, whether to challenge information, suggest alternative practices, or to enlist them in helping the doula support the woman’s desires for her birth.


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Ann Douglas

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