Manifesto

MBC Doula School Manifesto

A doula is … a birth attendant, who provides many and varied resources for the family-to-be during the childbearing year. This was a common role from ancient times up until the 20^thcentury, when it died out when hospital birth became the norm. Before hospitals were the places where women went to give birth, a midwife would attend a birthing woman in her own house and there was usually another woman or two, or an apprentice midwife, who would help with the extra tasks like giving the woman a back rub, or fetching warm cloths, or cooking some food, or encouraging the birthing woman when she needed it.

Back in ancient times, in some cultures, there was a circle of women who attended the birth and cared for the birthing woman carefully and with love. In other cultures, however, women birthed alone in a solitary hut and sometimes things went well and sometimes not. Romancing the past is not a good thing when it comes to the history of maternity care: maternal and neonatal mortality and morbidity rates have decreased consistently over the centuries.

Starting only about 150 years ago in the industrialized world, women started to go to hospitals to give birth. This created all sorts of problems, not least of which was massive levels of infection because medicine hadn’t yet discovered the important role that hand-washing plays in preventing infection. Just as importantly, women were going to the hospital on their own, separated from their families, and were being cared for by people they had often never met. By the mid 20^thcentury, hospital birth had become the norm, or at least a sign of wealth, in many parts of the world.

But there were serious problems with this alienated way of giving birth, and these problems are increasing day by day. Birth in the industrialized world has become a mechanical event, monitored by machines. Increasing rates of surgical birth have led to health problems in children. The cost of birth is rising. When this model is transferred to parts of the world where the infrastructure is not sustainable, the results can be catastrophic.

In the industrialized world, those of us who bear children feel alienated from the process of birth. This alienation makes us reach out to others who can perhaps accompany us through the powerful process of giving birth. We know that the presence of another person in a birthing room, who is not emotionally connected to the birthing woman, decreases labor time, decreases requests for pain medication, and decrease the use of surgical and other interventions. This companionship gives the woman a sense of peace that enables her to look back on the experience with more satisfaction.

At the same time, in most of the industrialized world, midwives have become a very small part of the maternity care team, and the huge majority of women go to the hospital to give birth attended by medical doctors. The doula enters into this world as a companion, a guide, and an advocate but doulas do not provide maternity care for mother and baby. The doula sometimes finds herself in conflict with the recommendations put forward by the doctor or midwife, but she cannot voice her doubts. She is a companion, a vessel, an advocate.

In the early 1970’s, Klaus and Kennell were doing research on the moments after birth. They were wondering how mothers reacted to their newborns; what are the consequences of how a mother treats a baby when the baby is born. How does a mother attach to a newborn? How does the newborn react to the mother? Are there lasting effects from these few moments after birth?

Their research shed light on another interesting fact, and that was that the women who were being observed were actually affected by the presence of the observer, and if the observer was encouraging and present, the labor time was shorter and the birth was easier.

The modern doula was born. The term was appropriated from the Greek. It was a cultural appropriation that, as most linguistic borrowings are, was slightly inappropriate. The ancient Greek word that it appears to have been borrowed from means “female slave” or “handmaiden” as in “behold the Handmaiden of the lord.”

In 2003, I started a doula training program with another Montreal doula, Lesley Everest. We were already practising doulas, and we were noticing that there was a growing need for doulas in our city. Because of the particulars of maternity care in our area (large, multicultural metropolis, with a struggling infrastructure and poorly paid medical professionals), it was difficult to integrate doulas into the maternity care team. Birth abuse was common, and inexperienced doulas were often traumatized by their experiences. A short weekend workshop about normal birth, and an introduction to the basics of doula care were not enough for these doulas, and they were suffering.

Our course was an intense, comprehensive course that covered almost a full year, and included hours of class work and some shadowing opportunities.

Part of the students’ requirements included fourteen hours of volunteer time. Students started volunteering at the Montreal Diet Dispensary, which provides free food and other resources for mothers in need. They soon realized that these mothers also needed free doula services, and so the students started offering this service. Montreal Birth Companions grew from this small start.

Over the years, the partnership between Lesley and I dissolved, and I concentrated more on the volunteer organization. I was providing free training and mentorship for the volunteer doulas, as well as running a private practice. MBC grew over the years, and now provides doula care for over one hundred clients a year. That’s $100,000 at the average market price for doulas in Canada. I realized that I needed to provide a more comprehensive training for the volunteers, and I could provide MBC with eager, dedicated volunteers through\ the training program.

MBC Doula School grew from this idea. I started with a Level One doula training that provided students with the basics of doula care, enough to give them the skills to accompany a mother through her birth experience together with a partner doula. The Level One training also provided the opportunity for the students to shadow a more experienced doula, until they felt comfortable taking on a client with a partner.

Level Two is the next step, and it is much more comprehensive and gives students the skills they need to provide full care for a birthing mother throughout the childbearing year.

The next step was a natural progression that is in tune with my beliefs about education and knowledge. I provide doula students with much of my own beliefs, philosophies, and approach. They read my book and study for hours under my guidance. I wanted to open up their education by inviting other teachers and guides to provide a different voice, and more varied skills. To this end, I have invited high profile teachers from around the world, and I also invite local guest teachers who are active in the community to share their skills with the school.

I think my general philosophy about life informs my specific beliefs about birth, so I will touch on them briefly. Fundamentally, I do not believe that the particulars that make up our lives can be fully controlled by our desires or actions. As midwives say, meconium happens. However, I do strongly believe that we are responsible for our choices: it is up to us to inform ourselves, make decisions, and then live with the outcomes of those decisions in a conscious and responsible way. How does this reflect on my beliefs about birth? Essentially, I try my best to facilitate an excellent birth experience for a mother and family, and when I am the sole caregiver for that family, I take my responsibility for the safety of the mother and child very seriously. But I do not believe that the ultimate outcome is up to me. The buck does not stop with me. As the Muslims say, pray to Allah, but tie your camel to a tree. So, I interpret that to mean: do all you can, your very best, to ensure a good outcome for mother and baby, but know that all is not 100% in your hands.

Cutting-edge scientific research in the 21^stcentury is focussing more and more on the interconnectedness of things and forces, moving away from a trend that started in the 17^th century which attempted to break down the world around us into easily digestible units.

Unfortunately, modern medicine has not yet jumped into the 21^st century, so we are still burdened with an understanding of the human body that sees it as a collection of pieces that function well together, but are essentially separate. As professional physicians became more a part of our lives in the industrialized world, we also lost the sense of responsibility for our own health care and tend to shift that responsibility and power to our doctors. Add to this precarious mixture a culture that is based on fear, and that uses military metaphors even to sell yogurt (“the best defense”!), and we have a birth culture that is malfunctioning and hurting families. Mothers go into the doctor’s offices afraid of birth, worried that their bodies will not work properly, believing that the doctor knows more than them, and believing without question what the doctor suggests.

My fundamental belief about childbirth is that the human body is perfectly capable, in the vast majority of cases, to give birth to a child without much help, intervention, or trauma. I believe that birth is a physiologic event that is part of the normal function of the female human body. I believe that mothers do not need lessons or techniques to learn how to give birth, but rather, that they often need to be untaught fearful or pathology-based reactions so that the body is allowed to function normally.

I believe that there are ways that a normal birth can be prepared for by the mother and expectant family. These include:

v  Effective prenatal care, including nutritional counselling, a minimum of interventive testing, informed choices throughout the process of pregnancy, labor and birth

v  Prenatal education focusing on physiologic birth, made available for the mother and partner.

v  Community support and resources readily accessible and affordable for all families.

I believe that the control of women’s bodies has been one of the essential characteristics of human life for thousands of years. It may have originated in the disturbing fact that a male could never know exactly who impregnated whom, but that is not important now. The fact that remains, however, is that we live in a culture where the fear of birth and the birthing body is paramount. All over the world, birthing women are abused and violated, usually without their consent. I believe in the value of informed choice, but I am also aware of how the “informer” can bend that information to suit their own political will.

I believe that every single time a birth unfolds without violence, the world and human society is healed a little bit.

My approach to healing and medicine is holistic, in the fundamental sense. I appreciate that most of the tools we see used in maternity care are tools that have appropriate use. While most of them should not be used routinely for every pregnancy or birth, many of them save lives when used in the right way at the right time.

Many birth practitioners make the mistake of assuming that just because something is deemed “natural”, it is fine to use it in any situation with any mother. This is not the case. Neither is it the case that more interventive tools should be used routinely. Midwives and doctors certainly need to use certain tools to monitor a pregnancy and birth. Tape measures are useful in recording the healthy progress of a pregnancy. Hands are immensely useful at all stages of pregnancy, birth and postpartum as diagnostic and healing tools, as are our senses. And of course, there is equipment of all sorts that can and should be used, or at least made available, for every pregnancy and birth.

But we don’t need to use very much equipment or procedures at all if the pregnancy or birth is progressing well and we can see (or hear) the signs of health in the mother and baby.

Education is the most effective tool at our disposal. It is, obviously, what MBC Doula School is all about! But education is much bigger than a doula school. It is every birth story you read on the social media. It’s every conversation you have in the grocery store. It’s the gruelling education that physicians endure in medical school. It’s every one of us, throughout our lives, making choices.

I believe that knowledge is a public resource. It is a vibrant source that changes with each generation, and is constantly being added to and modified. Human knowledge is what makes us human.

As our birthright, it should be shared freely. Those in the business of sharing knowledge and skills, however, need to be paid for their work, and that places knowledge within structures that can be limiting.

Education itself can be limiting, when it is bound by hierarchical, fossilized power structures. Just as the doctor/patient relationship can be one of the powerful and the powerless, so can the teacher/student relationship. When this kind of educational dynamic is established, the student gives up responsibility for active learning and ceases to question, to challenge, and to learn.

MBC Doula School grew out of my thoughts about education and birth. I was teaching a successful three-level doula training. I freely shared everything I knew with my students, for a fee. I gave them practical training and mentorship for free, and for as long as they thought they needed it. I still have former students asking my advice for their clients.

But I am just one voice, one pool of knowledge, one history. There is a whole network, in our city and in the world, of teachers who are eager to share their knowledge and skills, and MBC Doula School is a forum where they can do just that.

MBC Doula School has many students who have gone through the training and then hope to start midwifery education. My advice to them is to attend as many volunteer births as they can. There is always more to learn. It is better if every single birth teaches you something about birth.Many of the MBC Doula School students are still young. Traditionally, midwives have been older, finished with the task of raising small children. I counsel patience to these young doulas. The more births they attend as doulas, the better midwives they will become.

MBC Doula School is the child of Montreal Birth Companions. I have seen that the experience the students gain from their volunteer work with MBC makes them better prepared to enter training for many other professions, from midwifery to medicine to social work, nursing, and more.

Specifically, for students hoping to become midwives, the task of accompanying marginalized families through the childbearing year gives the student exceptionally valuable preparation for a life in midwifery. It prepares them for a life of giving; it teaches them about the medicalization of childbirth; it shows them how to accompany a mother through labor and birth using the lowest technology available (doulas do not use high-tech equipment at all, so they have to rely on their hands, their senses, and some gentle tools); it teaches them humility and cultural sensitivity.

There is a lot of discussion these days about the benefits or ethical meaning of midwives, doulas, and students traveling to poorer countries and gaining experience in birth by providing their services to the families there. There are definitely ethical problems with this model. I believe that student doulas and midwives should look closer to their own communities and focus their volunteer efforts there. There is no need to go elsewhere looking for poor people to practice on. The issue for fully trained midwives is obviously a different one, and every midwife must chose for themselves how they choose to practice. If we start to see that the world is a living, breathing entity, then we will understand that the experiences we need are often just around the corner.

In a more specific sense, the extended family of people surrounding MBC Doula School and Montreal Birth Companions have a strong sense of community, and I strive to nurture that sense. Over the next few months (by June, 2015), we will be teaming up with the Caffe della Pace to provide a physical space where students, doulas, clients, people can meet and share their stories. This community, I am hoping, will be a source of fundamental change in the birth culture in our city and hopefully part of a worldwide movement.

We are now located at the Caffe della Pace, a home for good food, good vibes, and positive change. Please come by and join us!

Midwifery and Doula Work

I just found out that another student graduate of the MBC Doula School has been accepted into Ryerson midwifery school. She will make a wonderful midwife and I truly believe that the experience she has had volunteering for Montreal Birth Companions has given her the groundwork that she needs to start her midwifery education with confidence and compassion. I hope she can be inspired by my friend Robin whose midwife life is documented in this wonderful film:

I have been involved in maternity care since I was thirteen, which as my youngest son likes to point out, was a very long time ago! For years, when my four older children were small and I was running an organic subsistence farm, I studied Clara Hartley's "Apprentice Academics" long-distance midwifery courses, and so I gained my theoretical background for woman-centered care. When I returned to Canada, I chose to attend births as a doula and I continued to learn from every woman I accompanied, and from every professional I met.

I have been part of programs that offer midwifery internships to students in parts of the world where midwives is scarce and hospitals are under-equipped and expensive. This phenomenon morphed into programs in the southern US that provide midwife-based maternity care to Mexican women, and it also became a popular way for student midwives from the US to "get their numbers" for the Certified Professional Midwife program administered by NARM. This practice has now been discontinued because of ethical considerations, which makes it even more difficult for midwifery students from North America to have contact with women from cultures outside of their own. 

Midwifery programs in Canada are not apprentice-based, and the university programs that teach Canadian midwives do not expect students to go to the community to gather their birth experience. Practical experience is combined with theoretical study to provide the students with a grounding in midwifery in Canada. 

The requirements for graduation vary slightly from province to province, but generally a graduate midwife must have attended "a minimum of 60 births, acting as primary caregiver for at least 40 births in home and hospital settings." (http://www.ryerson.ca/midwifery/overview.html)

A student midwife can learn a lot from participating in the births of 60 babies. As every birth is different, the student will see, hear and learn about many variations to the tune of giving birth. If she is primary caregiver for 40 births, hopefully she will attend ten home births, and possibly have to transfer one of those to the hospital.

But I propose that prospective midwifery students in Canada and around the world can greatly benefit from a foundation of learning and experience that they will find by volunteering as doulas for needy women.

Why? 

First, volunteering as a doula can teach a midwifery student about an important aspect of midwifery, an aspect that is not taught in class and can only be learned in practice - and even better in doula practice! This is the art of sitting on your hands: "Don't just do something - sit there!" is one of the golden rules of being a true Birth Keeper. Doulas working in hospitals alongside medically trained professionals need to be able to keep their opinions to themselves. They need to learn how to act diplomatically in all sorts of situations. They need to learn how to comfort, how to heal, how to facilitate natural birth with only the lowest technologies. They learn how to measure cervical dilation with their eyes and ears. They can distinguish between normal pain in labor and suffering. They are adept at hearing the little catch in the breath at the peak of a contraction that means that a woman is nearing the pushing phase. They can sense the difference between the "6 cm rectal pressure" (when a woman probably just needs to have a poo); and the fully dilated deep pushing urge.

Why are these skills important for a midwife? Because the art of midwifery rests on a foundation of physiological childbirth. And the more a midwife knows about how NOT to disturb the birthing process, the easier her task will be. Then when she starts her midwifery classes, which teach her the skills that doulas are not trained in, she will already have the very basics of birth attendance.

Secondly, as a volunteer doula with an organization such as MBC, the midwife-to-be will come into contact with women from many backgrounds. She will witness birth experiences that will be as different from each other as every woman's story. She will find herself listening to women's stories from around the world, and she will learn about herself as a woman and as a birth companion. She will learn about professional boundaries, and about the challenges that women face when they are marginalized.

As a Birth Keeper, I have witnessed many births and I have been part of many more, as coordinator of MBC, as shoulder to cry on, as mentor. I have learned from books and from my teachers (Basia, Ibu Robin, Heather, and others). I have learned what NOT to do from other teachers - and those I won't name - but I have witnessed midwives, nurses and physicians who have treated birthing women with disrespect and brutality. 

But the most I have learned has been from the birthing women I have served. And this is why I believe that volunteering with an organization such as Montreal Birth Companions should not be an aid to midwifery school acceptance, but a requirement.

Women who want to be Doulas

Mamas, please let your babies grow up to be doulas.....

We started Level Two again two weeks ago - time is already flying - there's so much to teach and learn at every level! Two of the Level Two students are accompanying a birthing woman today, so they won't make it to class tonight.

I am so pleased to have met my new students. The group of women this year is very diverse, in age, background, experience... and yet we are all drawn by the desire to accompany women through the journey of childbirth.

I believe that all midwifery students should have to accompany at least fifty women through the birthing process (but even better one hundred or more), and that most of these should be in the hospital environment. Why is this?

Doulas learn to sit on their hands and let the birthing process unfold.
Doulas learn to keep their mouths zipped while they maintain a safe space for the woman.
Doulas learn respect.
They learn that the birthing process is unexpected. That it proceeds better when it is undisturbed, but that nature is pretty flexible with its rules.
They learn what NOT to do.
They learn humility, kindness, diplomacy, and they learn when to speak out and when not to.

We may all have our different ways of practice, just like we were all born slightly differently, just like we will birth differently. But we all practice companionship, which is the most important aspect of our care.

Learn to be a doula here.

Ethical Birth Work

I was an intern at a maternity clinic a quite few years ago and I had some interesting experiences there. One young woman came to get some experience as a midwife, so that she could decide if she wanted to make the jump from being a doula, or if she was going to move to physiotherapy instead. On her first afternoon, the clinic was very busy, and she was led to a room where found she was the only midwife (not even!). She became depressed over the six weeks I knew her, and she left miserable and feeling violated.

I was very interested in what was happening. I have had a dream all my life of returning to Uganda where I spent my first three years, and working alongside the TBAs there to provide maternity care. I am fascinated by how organizations work, and I love to see how particularly women's organizations unfold, and how we keep (or not) bullying and aggression out of the ring.
I have travelled to many places. I have so many memories of different places and different people. I remember being led up a rocky path in the mountains of Morocco when I was seventeen, by two young women. We found a stream and drank, and spoke with our eyes and hands. We laughed. I gave them my earrings.

In Africa, a few years later, a young woman ran to me carrying her baby. I knew he was dying. She thought I may be able to help because of the color of my skin. I couldn't.

I travelled on my own, avoiding danger or fleeing when necessary. I used my polite manner and my eyes and hands to communicate friendliness, and I was never hurt too badly.

Years and many experiences and chapters later, I decided to finally get my certification as a professional midwife. My visit to the maternity clinic was one step along the road. One night, at around three in the morning, I was in a birthing room at the clinic. I was not supposed to be "primary", but the woman who was on for that night was exhausted from a hard birth, so the head midwife told me to assist. The birth was difficult, and the head midwife told me to enter the woman and manipulate the baby's head so that he could be born. I had my hands in the woman, when the boss midwife entered the room, tapped me on the shoulder, indicated that I should leave, and she had another intern take my place.

She was having a power struggle with the head midwife. Her ego was too big to fit through her pelvis, that's for sure!

But what about the woman giving birth? How did she feel when my hands left her, there was a tense emotional moment, and a new person's hands went in? Did she feel violated?

I have no interest in manipulating baby's heads, actually, I believe they get born better if they're left alone. But I also believe that the epicentre of the birthing room HAS to be the mother who is birthing her baby. A birthing room is no place for politics to unfold. Aggression and rudeness do not belong there. Love belongs. Peace belongs. Honor and respect belong.

There is a wider discussion going on right now in the midwifery world, about how this plays out in the bigger world picture of midwifery today. Student midwives from North America are traveling to poorer countries to earn their qualifying numbers so that they can become certified as professional midwives. Is this right or wrong? How can we accept a student midwife's desire to do good, and screen out the "number whores" (these are the students who travel to other countries simply to get their qualifying numbers, giving little thought to the women they are working with or for).

There are many small clinics all over the world where courageous, passionate, dedicated and professional midwives work every hour of every day to improve maternity care for the women they serve. Let's not throw the baby out with the bath water! For many of these clinics, paying volunteers from rich countries are one of the few ways they manage to stay solvent. But we do not need students to travel to other places so that they can experience a woman dying...birth is not reality television.

I believe the answer is within. If you go into every birthing room with love in your heart, respecting the other people in that room and honoring the birthing mother, then you will find yourself unable to use a birthing mother as a number, a statistic, or an educational tool. Women who give birth are worthy of the greatest respect. Let our politics play out elsewhere, away from the new baby, away from the birthing mother, away from the birth room.