Tag Archives: Doula

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.”

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?!

Elayne Clift: Volunteer Doula

2 Nov

Elayne Clift: Volunteer Doula

Birth Ambassadors co-author explains why she is a volunteer doula.

Posted: Friday, May 31, 2013 1:09 pm | Updated: 1:17 pm, Fri May 31, 2013.

By Elayne Clift

With the second annual World Doula Week having just ended, I’ve been reflecting once more on why I became a volunteer doula and what the work means to me.

I’m a baby freak, plain and simple. As a young candy-striper I routinely snuck into the pediatrics ward so I could rock sick kids. While my high school friends dated, I babysat. If I hadn’t been a product of the fifties, I might have considered becoming an obstetrician or a midwife.

Instead I followed the path that most girls my age did: I went to college for a liberal arts degree and then became a secretary – a medical secretary. My real career began when I became program director in 1979 for the National Women’s Health Network, a Washington, D.C.-based education and advocacy organization dedicated to humane, holistic, evidence-based, feminist approaches to women’s health care.

In 1985 I went to Nairobi for the final international conference of the United Nations Decade for Women. Inspired by that amazing event and armed with a master’s degree in health communication, I began working internationally on behalf of women and children, always trying to bring a gender lens to the table.

In the midst of all this, I gave birth twice. My children were born in the 1970s as the women’s health movement, and individual women, were beginning to advocate for natural childbirth and to resist the traumas of overly-medicalized birth experiences. We took Lamaze classes, learned about nursing, expected dads to be active in our deliveries.

I was lucky – not only were my labors quick and unremarkable, but the small community hospital where I delivered was sympathetic to the changes taking place in birthing. There were no monitors, no drugs “to take the edge off” if you didn’t want them, no enemas, no shaving and no macho-docs (although I couldn’t talk my doctor out of the episiotomy).

I labored with my nurse and my husband and when the time came to push, I watched my babies come into this world in total awe of what had just happened and what I had done.

Several years ago, I learned that my local hospital had a volunteer doula program. Signing up was a no-brainer and I’ve now had the honor of supporting dozens of women and their partners as they’ve done the hard work of delivering a baby. Not one of them has failed to say afterwards, “I couldn’t have done it without you!” (They could, but I’m glad to have eased their experience.)

One of the early births I attended stands out in my mind. It was a first pregnancy and the mom labored stoically for 36 hours, pushing for five, before her son was born. As the hours passed, I held her hand, wet her lips, wiped strands of matted hair from her eyes, rubbed her back.

“You can do this,” I whispered in her ear when she grew doubtful. “You’re doing a magnificent job! Soon your baby will be born.” As the baby finally crowned, wet, dark hair pressing urgently against her, I held the mother’s leg in my arm, her hand clenching my free wrist as she cried out with that guttural groan of a woman pushing her child to life outside the womb.

And suddenly, there he was, head emerging, wet and pinking up even as his perfect little body swam into being. Later, swaddled and nursing at his mother’s breast, his father, eyes wet, whispered across the bed to me, “Women’s bodies are so miraculous!”

“Yes,” I said, my own eyes filling, “Miraculous.” Always miraculous, no matter how many times you give witness, or weep yourself to see a woman giving birth.

Doula supported childbirth has been proven to reduce the incidence of c-sections, shorten the length of labor, reduce the number of medicated births, increase breastfeeding and provide higher satisfaction for mothers regarding their birth experience.

As one pediatrician put it, we are “the descendants of those millions of women who gathered at bedsides around the world” to help women through labor and delivery. “Someday we may again reach a point where women rely on the traditional circle of birth-experienced [women] to ease them through childbirth. … Until then, skilled, compassionate doulas will ably stand in for them.”

That is why I feel privileged to do this voluntary work. It is simply an honor to give witness to birth, and to offer as many women as possible the opportunity to have a birth that is supported, memorable, and full of joy.

Elayne Clift, of Saxtons River, Vt., is co-author with Christine Morton, of “Birth Ambassadors: Doulas and the Re-emergence of Woman-supported Childbirth in America,” forthcoming from Praeclarus Press. This essay is adapted from her preface to the book.


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