Tag Archives: Doulas

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?!

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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.

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.

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Birth Ambassadors Contributors

18 Oct

Birth Ambassadors Contributors

Birth Ambassadors, a New Book from Praeclarus Press, Describes Why Doulas Are the Ambassadors for the Midwifery Model of Care

2 Oct

Women who give birth the U.S. often find that it is very difficult, so many are hiring doulas to provide continuous labor support. A new book from Praeclarus Press, Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America, describes the work of doulas, the dilemmas they face, and why they have become the ambassadors for the midwifery model of care in the U.S.

An increasing number of American women are hiring doulas to attend them during labor and provide continuous labor support. For many women, this a way to counter the highly interventionist births they are likely to encounter in American hospitals. Rates of cesarean sections are at an all-time high. Almost half of American women described their recent childbirth experiences as “traumatic,” with 9% meeting full criteria for posttraumatic stress disorder.

Doulas provide individual attention, information, and support to their clients. But this role does not come without dilemmas, as Christine Morton and Elayne Clift describe in their forthcoming book, Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America, new from Praeclarus Press.

One dilemma doulas face is how to advocate for the woman in hospitals, where they may not be welcome. Another dilemma is what doulas should do when hospital policies or clinical practices violate their core beliefs that women have the right to plan for their birth, to be active participants in their care, and to be treated with dignity and respect. This core belief can be at odds with the structural care models currently in place at most U.S. hospitals. Thus, doulas sometimes find themselves in awkward and emotionally charged interactions with health care providers.

While egregious cases of obstetric maltreatment do occur, more common are cases in which a woman’s desire for an unmedicated birth is not respected, or when interventions are proposed without allowing for a full discussion of risks and benefits. Women may feel coerced into intervention because clinicians implicitly–or explicitly– convey the idea that if a woman does not comply, she will harm her baby. Knowing how to handle situations like these is often difficult for women working in hospitals as doulas.

Women often become doulas because they want to support women in childbirth. But to continue, they need to find ways to navigate the challenges inherent in their role. Birth Ambassadors summarizes results of the first scholarly study of the role of doulas and the dilemmas they face. It is a fascinating and readable volume destined to become a classic in women’s health.

Christine H. Morton, PhD is a research sociologist whose research has focused on women’s reproductive experiences and maternity care roles. Since 2008, she has been at Stanford University’s California Maternal Quality Care Collaborative, where she conducts research on maternal mortality and morbidity.

Elayne G. Clift, MA is a writer, journalist, and Humanities adjunct professor. She has worked internationally as a health communications and gender specialist, and is an educator/advocate on maternal and child health issues. A volunteer doula and Vermont Humanities Council Scholar, she has edited anthologies and published fiction and poetry collections, a novel, and a memoir.

Praeclarus Press is a small press founded by Dr. Kathleen Kendall-Tackett and specializing in women’s health. It features books, webinars, and products that support women’s health throughout the lifespan. Praeclarus Press is based in Amarillo, Texas, USA.Image

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