Doula Love and Accountability

I have raised a lot of eyebrows with yesterday's post so I would like to go back and comment and try to clarify. One message I was sent was this:
"Doulas don't cause Cesareans. Emphatically. Doctors, emergencies, and women's choices do."
Yes!! Absolutely! And we, as doulas, need to remember this. It is ALWAYS the woman's birth, and not the doula's. No matter where the path leads, it is the doula's mission to follow, and to respect and nurture the woman she is accompanying.

Another message went like this:
"When I'm at a difficult birth, even though I've only been practicing for a few months, I know that I am providing something that no one else can, and that is unconditional support. I know that I'm not responsible for the outcome of the birth, and I hope you realize that inexperienced doulas may take your words seriously."

Still another:
"Yes, we need to take responsibility for what we do - and if a woman in my care has an unnecesarian, I take responsibility, I try to work through it to improve my care."

Wow! Please comment on my blog. I appreciate your messages but I would like to make this discussion public.

To clarify, I would like to publicly apologize to any young/inexperienced doula who was hurt by my words. That is the last thing I wanted to do. I would like to engage in an ongoing discussion about responsibility and transparency. How do you feel when your client has an unexpected outcome? How do you feel when you have a feeling she will end up in surgery, even though she is planning a natural birth? Do you change your practice? Do you call in a more experienced or differently trained doula? What do you do when you are at a birth and things start going haywire? Do you reach out to other doulas?

Whenever I am at a birth that ends in an unexpected c-section, I always look back at my actions and the prenatal and labor process to see if I could have worked differently. Sometimes I know I did everything possible. Other times I know I could have done more. I know as doulas we are not held accountable, as medical professionals are. We form associations and collectives but we are accountable, in the end, only to ourselves. I know I am very hard on myself, always wanting to do better, and I would do good to accept that meconium happens.

To all of you, keep up the good work, and keep on loving.

Owning Our Practice

When we are working with such an elemental and mysterious thing as birth, it is often hard to tell where the lines that define ourselves and others can or should be drawn. I was speaking with another very experienced doula the other day who took exception to something I said. I suggested that inexperienced doulas may not be as successful at preventing unnecessary cesareans as a doula who has had years of experience working in a hospital environment with many diverse clients.
She countered, and rightly so, that the essential role of the doula is to offer companionship and respect, and those qualities will triumph, whatever the outcome.

I agree. To a point. Love works wonders. But a combination of things are at play, especially in a busy hospital that may or may not have a sensible approach to natural birth. A younger, less experienced doula may not know quite how to respond when a resident reaches for the amniotomy hook as she is doing a vaginal exam and prepares to do an amniotomy, all without saying anything to the laboring woman. Although we don't like to admit it, it is true that even the presence of a more experienced doula will help doctors to exercise caution. A less experienced doula will not know the policies and protocols of the various hospitals as well as a more experienced one. She will not have built relationships with the medical staff she is working alongside. All these elements can and sometimes do lead to the inexperienced doula accompanying a woman along a very different path than the one they had hoped.

That said, is that not our ultimate mandate? To accompany? To be a companion as the woman makes her journey? If we are beside a woman and her partner as they are becoming parents, and we are there to support, to love and respect, as the woman moves through labor, is that not sufficient?

Yes, if the environment she is birthing in is a sane and healthy one. Definitely. But what if a woman is birthing in an environment where the professionals are overworked, the infrastructure is crumbling, the focus is on risk instead of health, statistics are distributed as freely as narcotics, and the emotional and spiritual side of bringing a child into this world are more or less ignored? Then, possibly, a birthing woman needs more than a companion in love. She needs a watcher, a guardian. Experience, skill, humility, and an open heart are the foundation blocks that a doula can build her practice upon. And one important rule is: never stop learning. When you have a chance to change your mind, change it. When you feel you know enough, know you are wrong. The responsibility is great, the stakes are high. Ego should not take part in the miracle of birth.

Natural Birth

Here in Montreal, a woman has a few choices when it comes to giving birth:

We have several large hospitals, most of which have maternity centers. If you are birthing in a hospital, you will be followed either by a family physician or by an obstetrician. Because doctors here in Montreal get paid less, are more overworked, and have to work under worse conditions than in the rest of the country, there is a real problem of access and availability. This means that a woman may not find a doctor who necessarily agrees with  her approach to childbirth. The larger hospitals are also teaching units, so women in labor are under the care of several people other than the doctor she is officially being followed by.

There are three midwife-run birthing centers in Montreal. Two of these offer women a choice to birth either at the center or at home. The third provides home-birth midwives to eligible women. Demand for these provincially registered midwives is high, and the eligibility requirements are strict.

There are women in Montreal who do not want to follow the provincial rules, and these women have two choices. Some hire "lay midwives", who have been trained elsewhere and are not registered with the Quebec college. Still others give birth on their own or with their partner or a friend.

For years I was getting swamped with requests from women who were desperate about their chance of having a natural birth. The conversation would go something like this:
 "I was on the waiting list for the Birthing Center but I know I have a very slim chance. So I've decided to go with Doctor x at y hospital, because I have heard they have a more natural approach. I would like to give birth at home with a midwife but I do not feel comfortable with an unassisted childbirth, and my husband is not happy about hiring a lay midwife. So we feel our best choice is to hire a doula."

Yes, the presence of a doula can reduce interventions. Yes, my c-section statistics (6%) compare well with most of the Montreal hospitals' statistics (25-30%). Yes, birth can take unexpected turns and you are well advised to have a trained attendant. But to be able to stay in your own bed after giving birth, and bring your child into an environment that is your own means a great deal not only to the mother, but also to the newborn.

And my concern is, I am not getting those phone calls any more. The calls are still about hiring a doula, but they are usually not from women who are serious about natural birth. The women who are on the midwives' waiting lists are actually getting in to the birthing centers. They are not hiring lay midwives, and they are not giving birth unassisted. I know that the birthing centers are not working at over capacity; they have rules about how many they can take on. So my conclusion can only be that the desire for a midwife-assisted birth is becoming more rare, and this makes me wonder. Is the doula-accompanied birth in the hospital the way of the future?

A Peek into the Doula's Year

… you are assisting at someone else’s birth. Do good without show or fuss. Facilitate what is happening rather than what you think ought to be happening. If you must take the lead, lead so that the mother is helped, yet still free and in charge. When the baby is born, the mother will rightly say: “We did it ourselves.” Tao Te Ching

January 23 … I make myself comfortable on the couch in the living room … they have the lights on low and there is a sweaty, earthy smell in the air. The cat hovers around my ankles. I hear another contraction coming and going. Its 3 a.m. and I have been here for two hours. In the morning, we will go to the hospital, driving on the highway at dawn. The baby will be born by breakfast time. Everything is good.

March 16 … I am sitting in the Jacuzzi room, kneeling quietly next to the bath as I splash water on her back.

July 3 … She wants to dance during contractions, back and forth across the small room, keeping me moving as she holds my hands.

October 1 … I speak gently to the father-to-be, explaining that her pain is normal and his anxiety is perfectly natural.

December 23 … She calls me at home at 2 a.m. I awaken and answer the phone quietly. She says she is in labor and wants me to come to her. I hear from her voice that she is not ready so I speak to her for a while through a few contractions and suggest that she tries to sleep. She calls me at 7 a.m., after sleeping for four hours. She was woken by stronger contractions and she calls me to find out if it is time to go to the hospital. I reassure her that she is coping very well and I talk her through a couple of contractions over the phone. As she is still able to talk through them, I know that I will be able to start my day as planned. She calls me after lunch to say that she has lost a pinkish mucus plug and that she can no longer speak through contractions. I reassure her that everything is going well. At 9 p.m. her husband calls and I can hear her moaning in the background: they want me to meet them at the hospital. We arrive together and the doctor finds her cervix is seven centimeters dilated. She is given a room and she continues to labor well. Her back is hurting and I use St John’s Wort oil to relieve the pain. Her husband is by her side, letting her know that she is doing a great job. She turns to me and says that she needs pain relief. I tell her that this intensity of pain probably means that the baby is almost here. With her next contraction she starts to push. The nurse comes into the room and notices that she is pushing and calls the doctor. As the doctor arrives, it is clear that the lady is pushing and her baby will be born soon. The doctor greets her patient and as the nurse prepares everything on the delivery cart, there is silence and peace as the woman relaxes in between her contractions. As she gets ready to push again, her husband gently wipes her face as he murmurs words of encouragement. I know that with this contraction, the baby will be born. And he is. The doctor tells her patient to reach down to take her child; as she does, her husband bursts into tears. The nurse helps her to place the baby on her chest and covers them both with a warm blanket. I look at the doctor and we smile at each other, happy with the team effort.

Viagra?

I was listening to our national radio the other day in the car. There was a rather lame comedy show that took the place of a mock debate, with canned laughter and all. The debate was supposed to be about the perils of Big Pharma.
With a half an ear on the radio, one eighth of my attention on the road, and the rest of my thoughts on the woman I had just visited, I waited for a laugh - there must be some gags you can get out of the idea of drugs and the common man.
Into my consciousness blurted the voice of a youngish man, explaining the increase in Viagra's popularity over the past few years. In a ham-handed way, he was attempting to turn the problem around, and according to him, the reason why a 65 year old man couldn't get it up was because - oh, when he looks at his wrinkled, saggy, old 65 year old wife, what's there to turn him on?
I quote almost verbatim.
I was shocked. This is national radio! How can he be allowed to present older women, and older men, in such a light? Whoever talks about a long marriage with such disrespect? And how's it anyone's business anyway?
Then I remembered, of course, this is the 21st century. My 9 year old watches hockey games, where men are getting their necks broken by other men (I thought the game was about shooting a puck at a net?), and during the commercial breaks, he learns about Viagra, and imagines it is a pill you take when you are tired of going on walks.
In our drug-happy, Pharma-controlled society, little wonder that women do not expect to give birth without pharmacological pain relief. Men and women cannot maintain a long marriage without Viagra. Children cannot be controlled without Ritalin. For every mild ailment there is a pill. You can take a pill if you are shy, if you are sad, if you are scared.
But why not go through the real emotion? If you look at your old lover's body and see all the scars and lumps that were not there when you met, wouldn't that fill you with love? And if the love isn't Viagra love, so be it.

Volunteer Doulas

Imagine you were alone. Imagine you were new to a country where everything was different - the climate (cold), the language (confusing), the way people act towards each other (are they angry?), the system....
Imagine your country was at war, and imagine that no one in your family could be found.
Imagine, now, that after experiencing violence and abuse at the hands of strangers, that you found yourself pregnant.
We are very lucky, us Canadians. We live in a place where you can have your baby in a safe place, where you can get medical care if you need it, where people have the luxury, the possibility, to help others. And though there are problems, and though we don't all get the birth experience we always dreamed of, we are fortunate.
Montreal Birth Companions accompany women in need through their pregnancy, labor and birth. A volunteer doula will be on call and available for questions day or night, before a woman goes into labor. She will be by the woman's side as she labors, and she will share in the joy when the baby is born.
The Montreal Birth Companions doulas and administrator (yours truly) having been working on a shoestring since 2004. We are dreaming of growing, and for real growth to occur, we need cash.

Dining for Social Change is putting on a gourmet dinner tomorrow night. People will join together to eat good food, have fun, and the proceeds will go towards providing a doula for every woman in need.
I love having things fit together - and this event is one of those times. It is the hormone oxytocin that stimulates the woman's uterus to contract so that the baby can be born. This hormone is also important in breastfeeding. It is called the "love hormone". And it is produced when people are eating together.

So, a toast to all of you! Life, love and happiness to the women we serve, to our volunteers, and to our joyful diners!

Birth Conspiracy?

I remember seeing a medical student who was attending his first birth. It was a normal, natural hospital birth. The woman was on the bed, her husband was by her side, I was next to him, there was an intern helping with the delivery, a nurse, the physician in charge, and a young medical student. The baby came out, everyone was happy, the new parents were exhilarated and crying, and then the medical student exclaimed loudly: “Look! Look! Look at its little toes! Look! They’re like real toes. They’re just like real toes!”
The attending physician looked at him and whispered: “Philip, get a grip!”, but I was hoping that that simple amazement and wonder would stay with him throughout his career.
For some people, this story may be full of problems and issues. What do I mean by a “normal, natural hospital birth”? Can a woman have a natural birth in a hospital? I remember hearing from an obstetrician that among some women in our city a “natural” birth was when you didn’t wear much makeup when you gave birth. What is a normal birth? If a hospital has a 90% epidural rate, does that mean getting an epidural is normal?
And certainly, we can’t have trained professionals going gaga over newborn’s toes, can we?

We are living in an age when we are terribly concerned with our health, yet it is an age when human life expectancy is at its highest. We worry and fret endlessly about our children, but have difficulty finding time to spend with them. We are living a life that is far from nature, yet we yearn for the “natural” and the “green”. We are so divorced from our own bodies that a surprising number of pregnant women do not know where their cervix is or how a baby is supposed to come out.
In our world, human life has become so complicated that every simple activity has a huge structure built up around it. This structure is built upon a foundation of information supplied by an army of experts. Simple processes such as eating, healing, making love, giving birth, breastfeeding, caring for children, have all become complicated and institutionalized. When a woman decides she wants to have a child, one of the first things she will encounter is the structure we have built up around birth. She will be met with a mountain of information and much of it will be conflicting.
In the birth world everyone wants to have a little piece of the birth experience. The birth practitioner wants a piece of even the most physical and elemental. Here is an example: It is often very tempting to do a vaginal exam. Why? We want to know what’s going on; if the baby is moving down, if the cervix is opening, where the baby’s head is positioned. What most practitioners will not admit is that this intimate physical connection with a woman is important to them: it is an amazing thing, to feel a baby’s head coming down the birth canal! But how often is it really necessary? Does the laboring woman actually want to have so many exams? How many vaginal exams are done for the sake of the birthing woman, and how many are done for the attendant?
The birth practitioner, or any birth “expert”, also wants a little piece of the bigger picture: we want the woman to have a natural birth, with no epidural and no interventions. Or perhaps we want her to have an epidural so that she can be more comfortable. Or we are convinced that surgery will be less risky. Either way, we want to convince her that we know best. In fact, we do know best: we are more educated, we have seen more births, we have seen more pregnant women and we know what to do.
Or do we?
The Birth Conspiracy is this: It is an understanding, created by all of us, that we cannot function without experts. We cannot give birth without birth experts. We cannot labor without assistance, without classes and checklists. We cannot make our own decisions, or accept consequences for our own actions. It is a way we can avoid responsibility for our lives. Those of us who are experts want and need to control the process. It is very hard to sit on your hands and wait while a woman labors. It is much easier to interfere, to preach, to suggest, and to control.

Interested? You can order your copy of The Birth Conspiracy soon - watch this space!