Wednesday, January 12, 2011

A Doula's Path

"Doula" is not yet a common household word, though the importance of the role of a doula in modern maternity care is well documented in many studies. For those of you new to the concept, a doula is a woman who supports pregnant, birthing, and postpartum women and their families. The word is derived from the ancient Greek word for "slave" (I know, strange, right?), but has come to mean "in the service of women" in modern times. A doula supports women in their childbearing year by providing information about what she's going through and the choices she will face as pregnancy, birth, and mothering unfolds, offers comfort measures to ease the bumps along the journey, as well as reassures with constant emotional support.

If the mother has a partner, he or she also benefits from a doula's care, as the doula's support extends to them as well, ensuring they are well informed, prepared, and relieved of the stressful feelings many duties required of birth partners evoke. Many things concern the birth partner, such as knowing whether what the mother is experiencing is normal or not (if someone has never seen birth before, it may not be obvious that shaking, vomiting, and loud vocalizations are all very typical things labouring ladies do), having to press hospital staff for clarification surrounding medical interventions in birth, knowing what best techniques and methods to use to help the mother cope with the strong sensations and emotions that come up in birth, knowing how to deal with sore nipples during breastfeeding, etc....the list is vast. By being free of the burden of anxiety of having to know all the details of birth and how to advocate for the mother and help her deal with the challenging task of birth, not to mention at the same time being an emotionally invested, possibly nervous partner and co-parent, the partner can be fully present for the mother, holding her, encouraging her, and providing the intimate connection which gives so many women the strength they need to get the hard job of birthing done.

A question that commonly comes up is, "Is a doula the same as a midwife?" The answer to that is "no". Midwives, while also usually extremely supportive to the couple in their childbearing year, also usually have the responsibility of the mother's clinical care, meaning the midwife is the one who assesses and monitors the mother and baby's health throughout pregnancy and birth as well as the weeks following birth. She is usually a primary caregiver, and depending upon the laws of the country, province,state or county the midwife lives in, she "delivers" babies in a home, hospital, or birthing centre setting.

A doula's care is not clinical. Some doulas have midwifery skills, and if this is the case, they often, if where they live allows, work as "monitrices", meaning they provide the support of a doula, but monitor the mother's and baby's health at home until she feels it is time to move to the hospital for a doctor or midwife to take over clinical responsibility of the birth while she stays to support the couple. Because a doula is not responsible for a woman's or baby's health status, she is free to provide that information, comfort, and support the couple wants. That nuance was really brought home to me during the birth of my first child. My midwife arrived at my home when I felt like labour was good and strong. She listened to the baby's heart through my belly and examined my cervix. She said, "Everything is good. I'm going to go take my sleeping bag and have a nap in the other room so I can be fresh when the baby is born. My assistant will stay with you." I didn't know the assistant well, though she was very nice. She was not, however, particularly skilled at providing comfort or emotional support, and didn't really address my inexperienced anxiety at having dilated from 3 to only 4 centimetres in 18 hours of labour. It was my doula and my husband who kept me grounded and provided me with immense comfort, like massage for my sore back, whispered sweet nothings, and a real sense of emotional safety. Not that a midwife can't or doesn't do that very same thing, it's just that in my case, she was tired from having attended a lot of births, and was doing the responsible thing by ensuring she was fresh and awake when I gave birth so she could better use her clinical skills if they became necessary. When primary caregivers and doulas work together, the couple often feel they are getting the best of care, meaning a good clinical safety net should it become necessary, as well as continual supportive care.

I have been a doula in Montreal for over 17 years now. I have often been asked why I don't go on to become a midwife or a doctor. For one, I enjoy being "just" a doula. I am personally not interested in being responsible for important health decisions should they arise. I have much respect for those who are, and I prefer to let them do their thing while I remain continually emotionally present for pregnant, birthing, and postpartum women. If things go unexpectedly in birth, then clinical care is the priority of the primary caregiver, whereas the doula takes those scared parents-to-be by the hand, looks deeply into their eyes, weaves a web of calm around them and says, "Okay. Here we are..yes, in that very place you were scared to be. Breathe and stay." If things go normally, as they usually do, we simply remain available for what the parents need for comfort.

My favourite thing about being a doula is being a keeper of precious memories for parents, of moments of their love and brilliance told to them later on in our postpartum follow up visits. To witness a new father moments after birth as he anoints his baby with his tears of awe, or to hear those quiet, holy words of love whispered to a newborn by his enraptured mother is to hold the most beautiful and subtle threads of the tapestry of the story of this family's beginning, threads that are lovingly handed to them in the moments the parents are swept away on the roller coaster ride of the postpartum period. These bits of story connect them to their strength, serving as reminders that all of this experience, even the hard parts, is about love. The healing potential in these juicy bits of story could be so easily missed if we as doulas had to put our attention to the clinical details. We walk the halls with our couples while they labour, sit by them while they rest in the bathtub, just listening...with our ears, with our hearts, always striving to find the balance between being and doing.

As we are story keepers, so are we keepers of the gate between fear and confidence, distress and courage, panic and calm, empowerment and victimization. While we do not own the birth our clients experience, nor attempt to control birth or birth's caregivers, our belief in birth as a sacred journey, no matter how it unfolds, very much holds the potential to influence the process. Doulas strive at births to be our most grounded in the knowledge we have as well as open to the realms of intuition, which we look to when we need to know the best way to buffer a harsh environment, or to sooth away the ripples caused by an unconscious yet hurtful remark, so things that could otherwise potentially be perceived as trauma do not get a chance to anchor into the labouring woman's perception and be carried into motherhood with her. It is not always possible, but we try our best.

As a young doula I wanted to help women have natural births, no matter what. I felt like the epidural and I were in competition. I was easily wounded by the often shocking hospital environment, and felt like if a woman received an intervention, I had failed. It took time and experience to know on a cellular level that my job was not to rue every little intervention. I don't own another woman's birth. She is responsible for her choices. If she decides she must give birth in a hospital to feel safe, she will be subject to the environment. I do my best to buffer the harshness of the hospital environment and empower her as best I can so she is able to make choices suitable to her. If she chooses induction because she and her doctor feel this is best, it is not my business or my right to dissuade her. I ensure she has the best information I can give her at her fingertips with which to make an informed choice, and when she chooses, I support. Yeah, that ride may potentially prove to be really bumpy as all those risks she was hoping to avoid with induction become reality in her experience. And so it is. This is her story, her learning, and her own grappling with the tension that lies between trust in her body and fear of not doing the right thing for her baby. I have learned that my job is to support not always what I wish would be for someone, but what exists in the now.

I know many have contempt for doulas...the Medical Establishment (and I refer to an entity, not to individuals, whom I find are most often caring and have the best interest of the mother and baby at heart) for our illuminating the often gross shortcomings in the sometimes unconscious and unkind policies that are not at all supportive of a labouring woman, her baby, and her partner. There are as well those who think doulas are sell outs by trying to help women have more humane birth experiences within the hospital system, standing idly by as we meekly "allow" our clients to be brutalized. Again, I support what is, not just what I wish would be. Sure, I'd love us all to claim responsibility for our own births, birth at home humanely and lovingly, our experiences undisturbed, our babies born into optimal bonding environments with bodies, minds, and spirits intact. I am blessed to have had that experience three out of four times, and I want that as much for everyone as the next guy does. But if about 98% of women in North America are giving birth in the hospital, most with medical care, because they feel safe there or they feel it's the only option they have, this sense of safety and lack of options a product of a culture that is terrified of birth and death, do these women not need an incredible amount of support to have birth experiences they can look back on with a sense of power? I do not believe my trying to help a lady have a decent birth in spite of the hospital environment will make women go, "Oh, okay, it's all good, then," and lessen the minuscule percentages of those who choose home birth. I alone am not going to get those 98% to change their minds, regardless of all the stats which tend to support the idea that home birth is as safe or in many cases even safer than hospital birth. Many people may understand that their fears are overblown on an intellectual level. But the collective fear is so big, people still pack their bags and birth in the hospital with obstetricians anyway. And if that's where they feel safe, and that's where they want to be, that's where you'll find me. I'm not there to judge what makes someone feel safe. I'm just there to help when I can. And believe me, when things go awry, I'm very grateful for obstetricians and technology. I am not against hospital births or doctors or nurses at all. What I am challenged by are many of the policies and protocols which detract from the normalcy of most births. This is where change must happen, and I'm hoping it will grow from more positive hospital birth outcomes, which the presence of a doula is shown to increase.

Isn't every birth a woman looks upon with love and good memories a triumph, even if it isn't filled with the potential for "perfection" (meaning perfectly undisturbed, perfect environment, perfect bonding, etc.)? Isn't it good to have a few more women come out of the hospital feeling like strong and powerful mothers? Of course it happens that sometimes when a woman looks at her birth with fondness I am knotted up inside at the things she maybe didn't know looked heinous to me. But who am I to tear apart her birth experience because my vision of great birth isn't the same as hers? I WANT her happiness, and am thrilled for her triumph, and I have learned not to be attached to my version of "perfection" in birth. If something was really awful and she was unconscious of it at the time because she was all hopped up on her love and ecstasy hormones, adoring the nurse who was maybe actually quite impatient with her, and feeling bonded with the doctor who brought up emergency cases with the resident in front her of while she birthed, it will come up. It will sit in the back of her memory until it is ready to burble up to the surface for illumination. And when it does, I usually get a call, and then we process it. Often there are delayed reactions. If it never happens, fine...it is not for me to say what "should" traumatize someone.. but if it does, many of these women go on to choose different routes for their next birth experiences. There are many roads to empowerment.

My path as a doula has morphed from just wanting to see nice births to really trying to help improve maternity care in hospitals. Midwives are doing a great job tending to those families who feel happy birthing outside of the hospital, and God love 'em. There is a big movement right now that is shedding light on the some of the potential pitfalls of hospital birth and illuminating the beauty of homebirth and potential for the amazing strength women possess. Women are taking their experiences and using them for others to learn and gain courage from. One of my favourite examples is the scene in the The Business of Being Born where Ricki Lake gives birth in her bathtub. She is naked, hurting, and vulnerable, yet at the same time in her fullest power. She allows us to witness her bringing her child joyfully into the world, a generous and precious gift to our lost birth culture, an invitation to those who have maybe never thought about birth beyond how soon they can get an epidural, or had perhaps not even had an idea that homebirth was an option they could pursue for themselves. This is potent medicine.

We have had grassroots homebirth movements for some time, but to now reach out to the mainstream, to not just preach to the converted but to begin little by little to shift the collective consciousness from overwhelming fear and contempt of anything that questions what Medicine tells us to, to "I'm still afraid but somewhat curious...maybe some change is needed" is crucial. While the rising Cesarean rate and crazy induction and routine epidural epidemic continue to wreak havoc in North American hospital birth, this slight shift gives us a glimmer of hope that we have to nurture and help grow...hope that our birth wounds can begin to heal...slowly, little by little, decade by decade. Along with the work people do to raise awareness, consumers of medical care must also become aware of their responsibility in birth. As long as we put all the power in a doctor's hands to get our babies out, the pressure on them is enormous, and their fear of not doing everything possible to meet these expectations and maybe even the fear of litigation makes medical maternity care often very aggressive indeed. We cannot simply lay blame on Medicine...we have to look at areas where we may have abdicated our own responsibilities as well.

Doulas, with their belief that birth is usually normal and healthy, go into the hospital with a couple and try to keep them, within that environment of "what if" and "risk" and "danger", connected to their intuitive knowledge, their practical wisdom: their motherwit. I choose to do this as my part. This is my small contribution to what I hope is healing. One mother, father, and baby at a time.

The doula training I provide reflects this impetus to create healing within the system that often perpetrates great wounds (while honouring the many blessings it can also provide). Many doulas have contacted me over the years, feeling woefully unprepared for doing this crazy job within an environment that can be resistant and sometimes cruel. While I feel that my work as a doula has changed its shape over the years, I feel that training needs have changed too. I think we need a paradigm shift in what a good doula training constitutes. I do not believe a woman can take a 2 or 3 day training and do this job with enough skill and enough tools with which to protect herself emotionally. This approach doesn't gel well with this profession. This is why I believe wholeheartedly in the apprenticeship model of learning, and strive to promote it as a new standard of doula training. While many trainings are excellent given the time they're done in in terms of learning hands on labour support techniques and how to deal with challenges, a lot of the students are very focused on papers and credentials and sometimes arbitrary limitations that are as fear based as hospitals are, and I have not found those things to confer good doula skills. Yes, it is up to the doula to continue her education and be self motivated to study, but this kind of learning does not necessarily help develop wisdom.

I believe strongly in the value of having an experienced birth attendant doula the doula (yes, I am using "doula" as a verb) as she embarks upon this journey of birth healing, helping her build her skills, recognizing her vulnerabilities, being involved in her education and development. I like to bring her into the hospital with me so she can observe, without pressure, as birth unfolds, no matter how it is. It is good for my students to have to shift gears and prepare for the planned C-section they were hoping our client could avoid and bounce creative ideas of how to give the best support off someone experienced. It is good for them to call me in a shaky voice telling me they're not doing well emotionally because the birth they are at is really hard, the woman is losing it, barfing uncontrollably, and the novice doesn't know what to do to make her feel better, learning the lesson that sometimes you can't and you just have to keep trying and be present. It is good to get a call in the wee hours from a new doula who has witnessed something traumatic saying, "I am so angry and I don't know how to go back in there and do a good job" and have someone who has been through it talk her off the ledge and bring her back to her centre. It is good for them to miss a birth because it was so fast near the end and know clients were so happy because it went well and are grateful to her because they used all that good prenatal guidance they were given, and good to be able to call and ask, "they're not just trying to make me feel better, right?" It is good to have gatherings so the apprentices can build community with each other as well, and can vent and cry, laugh and muse, ask questions and come up with their own answers with encouragement. And it is good for me to learn from them too.

As I continue to support women in birth, and hopefully will continue to do for decades to come, I continually develop my approach to training new doulas. This is important work. We are striving to shift the pendulum, adding our voices and skills to those who are also working hard to illuminate, educate, and empower people about what birth has the potential to be. I am excited that my birth and postpartum doula trainings, as well as MotherWit doula mentor training workshop is sparking interest in student and experienced doulas around the globe who are realizing the potential they have to be a wealth of resource and support for parents to be and new doulas. Though I don't know if I'll see radical changes for the better in hospital maternity care in my life time (though being asked to give doula workshops to nurses and even medical residents has been a really pleasant surprise), I will remain steadfastly hopeful that doulas are making a difference not just to the individual families they serve, but to our culture as a whole.

This is my path, and I'm sticking to it.