Here are some musings of mine about the advent of the doula and the social context that led up to the emergence of this new birth-worker in the US:
I have to confess, as a midwife I really didn’t “get” the role of the doula for a while. I didn’t understand her profession. Was she really just a midwife wanna-be who didn’t have the ovaries to take on the responsibility and potential legal liability of being a full-fledged midwife? Or was she just another birth junkie who wanted to be in on the miraculously high energy of birth? More importantly, should I be threatened…or supportive of her? And was this new person really necessary?
It wasn’t until I was doing a book signing for Lady’s Hands, Lion’s Heart, A Midwife’s Saga in 2009 in New York City sponsored by Choices in Childbirth that I “got” the phenomenon of the doula trade. That night there must have been over 100 doulas in the hall and I watched as they responded to my reading, their eyes shining and glistening with pure joy for the birth stories. Yes, these women were the real thing—in love with birth with their bodies and their souls. Many were young, college-aged women who did not have children of their own (yet). But they were all clearly called to their profession, willing to fight alongside their sisters for autonomy in childbirth. What was going on?
Let me backtrack a little bit with my own personal herstory, as it does dovetail with all this. I was the first (modern) midwife practicing in NH. Because there were no other midwives to teach me, I was trained by an old country doctor who taught me the art and science of obstetrics. He was the only doctor still doing home births in the state. I didn’t even know I was a midwife for the first year of attending births with this wonderful doc. I just thought there was something wrong with me and that I was obsessed with birth.
By the mid-1970s, a spontaneous grassroots movement developed to “deinstitutionalize” maternity care and to “demedicalize” critical life events, such as childbirth. Many hospitals were still doing archaic practices such as strapping women down—a holdover technique from when women were drugged with Scopolamine. Childbearing women in the early 70s were refusing any pain medications but were still subjected to rote, unnecessary routines and sometimes dangerous practices.
The next logical step was to avoid going to the hospital for birth altogether. The interest in home births derived, at least in part, from a desire to escape unyielding medical dominance as well as from the sterile environment of the hospital. Women maintained that childbirth was not a disease and that normal deliveries were not a medical emergency and did not require the supervision of an obstetrician. There was a growing interest in childbirth education, breastfeeding, and natural childbirth. Consumers of hospital-based, mechanized maternity care began to rebel. Women and families who were pessimistic about their chances of having a safe and satisfying birth in the hospital began to explore the option of home births with midwives.
This consumer criticism of aggressive medical management of childbirth resulted in the advent of the “lay midwife,” the apprentice-trained midwife attending home births. Women began to stay home to birth their babes. I was created by these brave women. I was their response to the degrading and demeaning approach to birth in the hospitals. I caught my first baby when I was 24 years old. I was so blessed to be chosen by those families to help them. They sought me out, they taught me, and, eventually, I like to think that I actually knew what I was doing. I ended up attending 1,200 babies born safely in their own homes.
In those years, due to consumer demand, the pendulum swung to the side of pro-mother/baby practices. There were tremendous strides forward for active, upright birth. Even the hospitals jumped on the bandwagon of mother-baby friendly initiatives. Hospitals that didn’t adapt lost many women patients. Women were listened to and respected and it seemed like things would always remain sacred and sane.
Ahhh…but the heyday of natural, unfettered birth didn’t last. Since the 1990s, obstetrical practices have slid down a slippery slope of increasing medical interventions until childbirth in some institutions seems worse than the 1950s. VBACs have been prohibited in most smaller hospitals. Water births are extremely rare. Many OB residents state that they have never seen a birth that wasn’t induced with pitocin in all the years of their training. The current practice of routinely inducing women at 40 weeks makes me particularly nuts. Where are the studies that show that this improves outcomes? There aren’t any. All this does is increase the Cesarean section rate due to fetal distress from lengthy inductions on an unripe cervix. In some urban hospitals, the Cesarean section rate tops 50%. Most of these practices are driven by an overwhelming fear of malpractice litigation.
The pendulum has swung way backward, back to ignoring the needs and desires and, potentially, the safety of the women (think misoprostol inductions on a scarred uterus).
Enter the doula. (Here’s where they come in…finally, after all this rambling!) As I see it, the doula’s role is to prevent a tiny snowball from escalating into a full-blown avalanche. The doula needs to have a magician’s hat full of damage control and patience, as well as be a master manipulator. The doula actually has three clients:
First and foremost, the doula has the responsibility for the mother. The doula’s job is to create a bubble of safety and serenity around the laboring woman, to block out all the frenetic activity around her, so she can focus on her body and her baby without distractions—not a small feat in today’s “efficient” hospitals. The doula needs to protect the normalcy of birth, even in an abnormal environment, and make it look seamless and pleasant. She must protect the mother from an onslaught of unnecessary interventions. Studies have shown that just a doula’s reassuring touch and words alone have reduced the need for a cesarean section by 50%. And let’s not forget the magic and mystery of birth—most importantly, the doula is there to remind everyone of the sacredness of the moment.
Second, the doula has the father of the baby to gently guide and reassure that his partner is not going to die from the crushing tsunami of pain that is engulfing her at the moment. He may be overwhelmed by the power and the beauty of what he is witnessing. Or he may be terrified that his sweet beloved has just turned into Linda Blair in The Exorcist, vomiting vile green stuff. Either way, the doula has to talk him down from the ledge.
Last, but certainly not least, the doula must interact with and be the mediator with the birth attendant. It is truly an art to get an obstetrician to do what you want and then get him/her to think it was their idea in the first place. The doula must be skilled in negotiating for what is safe and sane without pissing anyone off. For some reason, most OBs have very fragile egos (I speak from experience here…I was married to one). The doula must be assertive but at the same time be savvy enough to forge a working communicative relationship. And then, when all are safely delivered earthside, she has to congratulate the obstetrician on a job well done.
In the case of a home birth, the postpartum doula can be a godsend. Home birth women tend to be Super Hero-types and often arrange for only minimal support in the postpartum period. The postpartum doula is invaluable for breastfeeding assistance and as well as helping with physical recovery and family chores to allow the new mother to rest and relax and focus solely on her newborn babe.
In short, the doula is a multi-tasking saint.
In 2012, the United States has the highest maternal mortality rate in the industrialized world. Cuba is ahead of us, for godsake! This is totally unacceptable. American women are not told when they are routinely scheduled for a C-section that there is a 4 times higher maternal mortality rate with this surgery. This is criminal.
It is precisely this backward swing of the pendulum that has caused the arrival of the doula. Just like the renaissance of the apprentice-trained midwife in the 1970s, the modern doula has been created to try to regain birthing equilibrium and normalcy. And just like the Suffragettes of the early 20th century, doulas are birth activists who are here to fight for the safety and dignity of their laboring sisters.
Yes, this new person is most definitely necessary. The doula is the bellwether of our broken maternity system—telling us it needs to be fixed.
~ Carol Leonard is a midwife and the author of the best-selling memoir LADY’S HANDS, LION’S HEART, A MIDWIFE’S SAGA, Bad Beaver Publishing, 2008.