Tag Archives: Hospital Births

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.”

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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