September 10, 2002

More on Doulas

I am really glad that so many poeple have responded to my comments on doulas. I was going to add some feedback to the comments already posted, but since there are a number of things I wanted to say, I will put them in this new Diary entry.

Karen, Pip and Jaqueline - thank you for your thoughts. I agree that we are all striving for the same things, I guess my concern is how we go about it. See my comments below.

Tina, yes, we need to be careful that lactation consultants and childbirth educators are also not co-opted into the system. The place and role of lactation consultants is another interesting development and I will write about it another day. It seems these specialities develop in medical systems that are dehumanised and social systems that are fractured...... but more about this later.

Childbirth educators have a different function, as I see it, and that is to provide social settings in which parents can explore their experiences together. I ahve always seen this facilitation role as the most important reason for prenatal groups of all kinds. The giving of information is of secondary importance to my mind. Again, when health professionals (e.g. midwives employed by a hospital) take on this role, they are often coming from a different angle and see the information they give as the primary function of their programs. As a result, parents end up in huge classes with didactic teaching that revolves around the theme of "what will happen when you come in to have your baby in our unit". Choice is explained as "the services we offer (tolerate) here. I could go on, but let's leave this to another day as well.

Marilyn, thank you for your insights, especially about the system in the US, where my experience has been limited to facilitating workshops for a mixtureof midwives/nurses. I agree that if the system was perfect we wouldn't need doulas because there would be enough sensitive midwives (as opposed to burnt out or frustrated midwives) who could fulfil that role. Several years ago I was the keynote speaker at the Midwives Alliance of North America (MANA) Conference, whose theme was "Midwifery in the Mainstream". My message was to take the skills that the participants at this conference clearly had (most work in either independent practice or in birth centres) and get them into hospitals, so that the vast majority of women, and not just the priviledged few, could get better births. I was astounded to discover that in reality, MANA members didn't want to have anything to do with hospitals and that instead of being "mainstream" they wanted to stay on the fringes. I am not blaming them for taking that position, because they've been hounded by the system as it is, but I was surprised that they didn't see that this stance was elitist and that all women should have the right to midwifery care. They didn't know what to make of me - for a start I was wearing my "corporate type clothes" even though I sounded like one of them!

Beth, I think you have misunderstood me (or perhaps I haven't made my self clear). I would never question that women want to be suported by women at birth, it is very defintiely "women's business". If you have read what I have written in my books, you would know that most of what I know about birth has come from labouring women, those I have been honoured to support as a companion. Some of these were friends but most were women I met though my prenatal sessions and that I had come to know. I think there is an "art" to being a good support person - and that revolves around being invisible. The woman should not be aware of your presence and at the end of the day believes she did it all by herself. I am concerned that some women may choose to be a doula because it gives them a profile and they "need to be needed" - that's why I say you have to look at your own motives and innermost feelings before you take this role on.

In summary, I would say I have these major concerns about doulas:

1. The potential for undermining midwifery and midwives, especially when the system is under stress.

2. The commercialisation of social support. This is something you do because you care and not because you will be paid.

3. Friends and family should always be invited first, and openly, into the labour wards. We've been doing this readily in Australia for 20 years as part of our Active Birth approach and thus I question the need for an organised system of doulas.

4. Claims are being made for the necessity/usefulness of doulas on the basis of questionable research, sometimes as part of selling training courses etc.

Posted by andrea at September 10, 2002 06:08 PM

Comments

I must say that I believe doulas do have a role. However, coming from a South American context of living, I 'd say that I still expect a mother, a sister or a good friend (one who is in tune with the same philosophy of birth) should be the one at birth, besides the child's father, naturally.
In my case, if I opted for a doula, I'd feel I no longer have any of the extended family left to support me and/or I am in "need". In need to actually pay for a friend, because this is what my friends would do for me.
I will give birth in about 3 weeks from now, and a good friend will be there with us, as a doula-sister encouraging me and reminding me of my capabilities to give birth naturally. Let's hope I will not fall into the temptation of asking for (or accepting) any medical intervention this time. :))

Posted by: Jaqueline Marwick on September 11, 2002 04:25 AM

Comments

Hi Andrea: I just had to respond to your concerns:
1. re undermining midwifery: I really can't see how this can happen unless there is antagonism coming from either the doula, the midwife or both.I have been at births where the doula (be she family, friend, or paid support person) is a wonderful part of the birth team and I have been at a couple of births where the doulas (in both cases unpaid friends) had their own agendas for the birth and I had to wonder exactly what was going on. I think a good doula training would have been advantageous for both these ladies.

2. Commercialisation of social support: I agree is a very sad part of our culture, but I think it comes about because their is a deficit of caring, trusted, loving friends probably more now than in the past, but there have always been isolated people, people who didn't fit in, outcasts from the village. It is sad to pay for a friend, but in reality isn't that what many (not all) people see a psychologist/counsellor for: someone to talk to? And how many of us have been subject to spurious advice and support given by family and friends? Maybe enough to create job opportunities for professional supporters. I don't think that because people get paid for doing something caring (doulas, midwives, psychologists, social workers) it means they don't care.

3. Of course friends and family are invited first, and I think this has been the way in most of the USA since at least the 1980's (my third daughter was born in a birthing center in Chicago with nurse midwives in 1981 and her 2 sisters, grandparents and father were all present (as well as myself). I say most because I have a friend whose son was born in 1981 in Kansas and she had here hands strapped down alone for his birth, unbelievable.

4. I don't think the research is that questionable. I have re-read "Mothering the Mother" by Klaus and Klaus and though the 2 Guatemalan studies would fall into the developing countries category, the trial in Houston, Texas in a large public hospital could not at all be classified as in a developing country and since the trial in South Africa was prior to the removal of Apartheid I have no idea what category the hospital would fall into. The number of women in each of the 4 studies was relatively small (40,225,416,189)though large enough to calculate statistical significance of doula care on various outcomes. I think these studies clearly show the benefits of doula care. I am familiar with the comparison of trained and untrained doulas but could not find the reference, so I could not re read it. I think in all of the studies I have mentioned from Klaus and Klaus, the doulas had some training. While the numbers of women were small, as described by Klaus and Klaus on p. 33-36 the mothers were ethically informed of the option of doula care, given the choice to participate in the trial and then randomally assigned doula care or not doula care if they chose to participate. I don't think this research is that questionable.

Sadly, I don't think anyone would attend a friend's birth without hesitation: you and I would Andrea, and many people on this list and ozmid but not the average woman on the street, I don't really know in that I haven't done a survey, but given the responses I got when I was a doula, I would say not very likely.

And finally a quick (I hope) comment on the MANA midwives: they are a very diverse group but most (not all) would be strongly opposed to anything governmental/regulatory (hence hospitals and incidently nurse midwives too) check out the Midwifery Today website and the Forum section. They would never in a million years see their independent midwifery as elitist, it is a whole different way of thinking about government, individual rights and freedoms, a whole cultural phenomenon that I could never totally buy into, because I saw the elitism inherent in that approach. Certified Nurse Midwives however, have a strong history of public healthcare. Nevertheless, I studied as a direct entry midwife because I wanted experience in natural birth and that is difficult to get at any hospital but particularly at the university hospitals where most nurse midwives do their training. Incidently, some MANA midwives see Seattle Midwifery School together with the Nurse Midwifery Schools as elitist because of the emphasis on professionalism and university level education. Quite strange the lenses we look through.

Paid or unpaid, I think doulas support birthing, labouring, and postpartal women and their midwives, I really believe together we can make a difference.

marilyn

Posted by: Marilyn Kleidon on September 13, 2002 03:28 PM

Comments

Although I now live in NZ, I write from the perspective of working as both a voluntary and paid birth (and postnatal - which your article does not discuss) doula in the UK. I wonder, as some months have passed since you first raised these issues about birth doulas, whether your feelings have changed? I would like to make the following comments about your concerns:

1. The potential for undermining midwifery and midwives, especially when the system is under stress.

You use the term "undermining" - I do not see how doulas can undermine what has already been undermined by years of successive governments under-resourcing the health systems and placing birth and midwifery low down in its priority list. Your statement smacks of fear, and of a "threat" of some kind from doulas. This is misguided and saddening because I believe that ultimately we all want the same thing - a safe, positive, natural environment for women to birth into.

This type of environment does not always exist in our current health systems apart from where there is independent midwifery, or specialised hospital wings/units and birthing centres - this is why the need for doulas has arisen because of the "lacking" in the current birthing services available to women.

Unfortunately the need is *now* - there are birthing women in many countries who do not have a choice in the type of birth experience they have. By backing off, doulas are not going to lessen the stress on the system, instead there will be thousands of women around the world birthing with little or no support. Doulas are not the "threat". The situation is dire already in many countries and I believe that, aided by those in prominant positions in childbirth education, midwifery and health care, we require there to be an awakening of the powers that be to the need for better support for birthing and new parents.

If every midwife was allowed and enabled to offer the continuous one-to-one care that many of them entered into the midwifery profession to provide, then there would not be as great a need for birth doulas and I would be satisfied that my role was perhaps no longer needed, but sadly that is not the case.

I believe that instead of midwives and childbirth educators (especially one in your position whose comments are well-respected) speaking out against doulas or any other women who are offering support to pregnant/birthing women and new mums, we should be joining together with the rest of the women in the world and shouting about the fact that birth is not being taken seriously enough by our governments.

2. The commercialisation of social support. This is something you do because you care and not because you will be paid.

Whilst I agree with you that one's motives behind being a doula should be because you care not because you will be paid, your view that doulaing is a "commercialisation of social support" is a worrying one. In your diary entries it comes across very much as if you think that doulas should not be paid at all? Through lack of confidence and social conditioning I believe that the majority of women are already too inclined to devalue their roles within our world without someone as respected as you saying this type of thing. Women perform very important roles in our societies and yet often it is for little pay or no pay at all - I am not just talking here of unpaid housework or childcare, I am meaning more the lowly paid positions in health and social work, and just look at which gender contributes most to the voluntary sector!

It should be noted that many doulas do work for no pay, or just expenses, or in a bartering arrangement. If they receive money for their work it often barely covers expenses due to the time involved given in support before, during and after the birth. Many keep their day-to-day jobs or work part-time to support the doula work that they feel is their calling. In any occupation you will find individuals working in it only to get their pay cheque - however, those entering doulaing with that attitude will soon be disillusioned. Others who are trying to charge too much and are not in it for the love of supporting women in labour and birth will be "found out" and won't be around for long - word of mouth is how most doulas in my experience get their paid jobs.

Why should a doula feel that they have to stop this wonderful work because of their own need to support their family? Often doulas are away from their own partners and families for many many hours or days at a time offering birth support (just as midwives who are not shift-based are). That time cannot be replaced, but in today's society time has a monetary value and just as midwives and childbirth educators are paid for their work, why should doulas not get monetary reward for offering birth support? What makes their roles not worthy of that? They may have had to arrange paid childcare while they carry out their work just the same? You often find that doulas do have home situations where their partners are able to support the family so that being a doula does not cause financial hardship - but why should that have to be the case?!!

Women and their partners are willing to pay for doula support because they see it as valuable - in my personal experience they say it is money well spent and that they believe that the presence of a doula did make a positive difference.

Regarding your earlier comments about your concerns that some doulas take on the role to feel "needed", that may be the case for some and they also may come with issues from their own births that they have not yet worked through, however, *exactly* the same could be said of midwives - many women could choose to become a midwife because it gives them a profile and for their "need to be needed".

3. Friends and family should always be invited first......

I agree that friends and family should always be invited first if that is what the woman/couple want - if they choose that then - wonderful! However, there are women who feel that there is nobody within their family or friendship circle who they would want to play this important support role. Or there are women who are simply alone or who don't know who to turn to and feel overwhelmed and yet society dictates, keep quiet and accept what "happens" ...... "just get on with it"! Indeed I personally find it sad that professional doulas have arisen because that need existed, but that is the case, and because we now have many more nuclear families than extended, more single parents and more geographical separation of families, the support network for parents-to-be and new parents is severely limited in the westernised world we live in. There needs to be an organised system of doulas otherwise how else can a woman in this position find out where the doulas are who are willing to support her in this way?

As you state yourself Andrea in your diary entry for Sept 15th about the topic of Male Midwives; "Surely the most important qualities for a birth attendant of any kind are sensitivity, faith in the birth process and trust that women can give birth successfully. ..... At the end of the day, it is the woman who should choose the attendant to care for her during pregnacy and birth - only she will know who feels "right" during this most intimate and demanding time of her life. Choosing a caregiver is "the woman's business"."

If women (and their partners if applicable) choose to have a doula to support at the birth of their baby, there will be valid reasons for that decision and respect should be shown for their choice to do so. There can only be a handful (with money to spend) who are having a paid doula because it is the latest "trend" - and even then, should we judge that as wrong if they get to gain the benefits of the support of a professional doula?

4. Claims are being made for the necessity/usefulness of doulas on the basis of questionable research, sometimes as part of selling training courses etc.

Being present at the birth of another woman's baby is the most special thing in the world and something anyone would do, if asked, without hesitation. Let's keep it at the level of community service and not turn it into another business or allow it to be cooted by the health care system.
~~~
Regarding the "questionable research" about doulas, I would agree with Marilyn Kleidon's response to this point above. There are research papers undertaken by those in the medical field who are not promoting training courses that have found that doulas make a positive difference to the outcomes of labour and birth.

Being present at the birth of another woman's baby is a very special thing and women around the world have been supporting each other through pregnancy, birth and beyond for thousands of years and it is only natural that that instinct is still there in some shape or form. Doulas have that instinct and they see the need and that is why they work as doulas. If they cannot provide that for free, but have a gift to do so, who are we to say that they should not be valued enough to get paid for that. I also do not believe that that instinct is there for everyone as you are suggesting. I definitely do not think that "anyone" within a community would support at a birth without hesitation - often Mums and sisters of birthing women do not want to.

Having now read your subsequent diary entries "State of midwifery in Britain" (October 23rd 2002), "Are Midwives really "with women"?" (October 29th 2002) and " 'Us' and 'Them' attitude amongst midwives" (Jan 6th 2003), I wonder whether you now see why there is not just a *want* from the parents-to-be but a *need* for doulas. Do you not feel that in the system as it presently is the majority of midwives, although they may want to, simply cannot provide the supportive, one-to-one service that is the ideal for birthing women and this is where doulas can help in the "now" and bridge the gap and offer the support they can to make the birth experience a more satisfying one for the mother?

I agree that it does not solve the long-term crisis that midwifery is in, but then that is not up to doulas to resolve - midwives, childbirth educators, doulas, those in the medical profession and women everywhere need to come together as a powerful collective for change to be achieved.

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