Trends in pregnancy and birth sometimes seem peculiar — placenta eating, umbilical cord saving, partying to reveal the gender (or sex, to get specific) of the unborn.
What a woman chooses for her pregnancy, and how she chooses, during this, one of the most significant times of her life, is personal and precious, and to advocates of choice, it’s the woman’s right to birth however she pleases.
Because today’s pregnancy trends include getting educated, women are seeking insights as to how to best serve their bodies and babies. And although not many folks will argue that arming oneself with knowledge and understanding is a mere frivolity of hip birthing, there are certain movements in the world of pregnancy challenging the norms in birth medicine.
Recent publicity, and documentaries like The Business of Being Born, brought to the mainstream that which women in the know have long understood: birthing in the U.S. is a business, a sometimes strange and complicated business.
Navigating that business — not to mention the sundry bodily goings-on that occur during pregnancy, birth and postpartum — can be challenging for women and their partners.
That, according to Dalia Abrams, director of the nonprofit BirthWell Partners, is where a doula comes in handy.
A doula’s role
A doula (pronounced “dew-lah”), whose etymology is derivative of the Greek for “a woman who serves,” is a woman whose purpose is just that — to serve and support an expectant mom.
“Generally, women who hire doulas are upper-middle class who can dole out $300 to $600, and their goal is to have very little intervention — not have a C-section or induction, but have a natural birth or water birth and all that pretty stuff,” Abrams said.
During pregnancy, the doula assists the parents-to-be in plotting a birth plan — natural? epidural? induction? — and provides the parents with resources to understand those choices.
“We’re not diagnosing or dispensing advice. We’re providing information,” said Susan Petrus, executive director of business operations for BirthWell Partners.
According to Lynn Jeter, the obstetrics nurse educator at Brookwood Medical center who serves as a liaison between the doula community, nurses and physicians, the use of doulas is on the rise because, “The percentage of expectant moms who attempt unmedicated childbirth is on the rise, and the two seem to go hand-in-hand. Modern women are more likely to research the risks, benefits and alternatives of medical procedures.”
Abrams said “doulas are available in Birmingham for everybody. It’s not about natural birth; it’s about support and care.” Both the women of BirthWell and Jeter agree that the goal of a doula is not to force natural birth on a woman, but to guide a woman in finding the option right for her and reminding her of that choice when labor arrives.
When labor does indeed begin, the doula meets her client, either at her home or the hospital, and supports her throughout birth. What type of support is provided varies birth to birth, woman to woman.
“One mom has said, ‘I went through a traumatic birth experience with my first and this needs to be a redemptive process,’” said Lauren Little, who volunteers with BirthWell Partners. “Another mom will say, ‘I want that epidural quick, and I want to have a party. I just want to have fun.’ Those are clearly two different roles that I’ll play in the labor room — whether I’ll be advocating for the women or videotaping and making sure they’re having fun.”
“Sometimes it’s as simple as parking the car so that the husband can stay with his wife,” said Allison Miller, a local doula who’s volunteered with BirthWell Partners. “I’m there to make sure the partner best serves the laboring woman and to make sure that woman knows how strong and powerful she is, to remind her of the choices she’s made and the planning she’s done to get to this moment.”
Abrams pointed out that while nurses are provided to laboring women for support, their attentions are often required elsewhere. “OBs are barely in there at all. Nurses — some spend more time than others. Some give a lot of support, but they have a huge time requirement to chart everything so they can’t be as hands-on as a doula can be,” Abrams said.
“The role of the doula is focused on emotional and physical support of the mom and family,” said Jeter. “The nurse provides this same support and also has additional professional responsibilities.” Jeter believes fostering a more collaborative partnership between nurses and doulas can only result in a more satisfying birth experience for women.
Becoming a doula
That satisfaction is what Abrams strives to create for clients in her doula practice. “No one had ever said this would be the most amazing, powerful experience,” Abrams said of the birth of her first child. “When I was pregnant with my first kid, my sister gave me a book called A Good Birth, A Safe Birth. I was like everyone else, ‘Of course I want an epidural. Why would I want to suffer?’
“I read that book and started thinking about birth in a new way. I took a Bradley [natural birth method] class. I knew from the reading I had done that I didn’t want to have medical interventions because of the effects on the baby.”
General medical interventions include inducing labor, administering an epidural or pain medications, undergoing Cesarean section, receiving an episiotomy, or requiring the use of a vacuum extractor or forceps.
“I had this amazing, intervention-free birth that was empowering,” said Abrams. “The doctor said, ‘Would you like to lift your baby up?’ and I actually pulled him up to my stomach. And I thought, ‘Oh, my gosh. This is amazing.’”
Not every woman’s birth story is a tale of liberation and strength. “I went to a birth with a girlfriend to help,” said Abrams. “She had a disempowering experience where they pulled the baby out with a vacuum, and she let out this primal scream. I realized what I had was unique and that not everyone gets to have that experience.”
Abrams quit a PhD program in the mid-1990s to pursue “empowering women.” She trained as a childbirth educator in Israel then as a certified breast-feeding counselor. When her family moved to Birmingham, she began leading birthing classes in her basement before realizing “that [her] real goal was to get women to hire a doula.”
But as the Oz of Birmingham doula-ing, Abrams understands the need for due diligence on the part of parents when making their selection. “You could walk outside tomorrow and put up a sign that says, ‘I’m a doula.’ It’s up to the parents to make sure you’re legitimate,” said Abrams.
Becoming a certified doula requires the completion of a nationally recognized training program. BirthWell holds training in Birmingham twice a year.
None of the women interviewed for this report had ever met a male doula. “Theoretically, you could have a male doula, but it’s a matter of trust,” Petrus said.
“Historically,” said Abrams, “men have never been in labor delivery until recently. And, that’s probably as it should be. Your partner, with whom you have a strong relationship, is in a different situation. … Most of them need someone there to show them how. It’s not intuitive for most men. Partners do the best job supporting when they have support — from a doula or an amazing nurse.”
Abrams and Petrus started BirthWell Partners to offer services to a broader population of women in Birmingham. The nonprofit exists “to make doulas available to those who can’t pay. Those folks can take Birthwell Birmingham classes at a lower cost or for free,” said Abrams. Their partner company, BirthWell Birmingham, serves the population of mothers that Jeter and others consider the “modern, educated mom.”
In addition to classes, BirthWell offers a number of services including parenting workshops, doula workshops, breastfeeding support, fertility and prenatal yoga, placental encapsulation and birth tub rental.
Individual hospitals offer childbirth classes and breastfeeding courses, varying in time commitment and scope. Other providers in the community offer support both pre- and post-birth. Understanding those offerings and comparing what local resources are available is tough for women with hectic lives who are from harder backgrounds, according to the doulas who volunteer their services.
Like Abrams, the women who enter this profession do so with hopes of increasing the number of positive birthing experiences through connecting women with those support services. Little said, “I wanted to work in some women advocacy role for a long time. And so in Alabama, this is something that’s a clear choice — if you want to advocate for women. We have some real birth issues that we can work to correct.”
According to a 2008 Alabama Department of Health report, 40 percent of births at Brookwood Medical Center ended in C-section. The lowest C-section rate in Jefferson County was at Cooper Green Hospital (21.1 percent), and the highest was at Trinity Medical (45.6 percent).
In Jefferson County, 10 percent of pregnancies end in infant mortality.
These and other issues will be examined further in a future Weld feature on birthing in Birmingham.
For Miller, a stint abroad in Nicaragua while completing an internship for her Masters in Public Health led her to recognize an inherent need for support. There, she witnessed young women bedded head to toe with other laboring women — or girls — unable to communicate with doctors because of language barriers or because they lacked the confidence to do so.
That lack of confidence exists here in the States as well, said Miller and Little, but it’s lessened when an advocate is present.
“If you went into a birth right now without any training…by offering love and support, you’ll make a difference. Number one, how she feels for herself. It affects your pain level when you feel support. She’ll better be able to speak up for what she needs,” said Abrams.
By using a doula, Abrams said, “Research shows that women have higher self-esteem and lower likelihood of postpartum depression. They’re likely to breastfeed longer. When we go in to get healthcare, just by the fact that that person is a doctor, there’s a power difference. Add to that, many times, this person is a man, and you’re a woman. You’re wearing a gown with nothing under it. He’s fully dressed. You’re lying down.
“You could add to that you’re an African-American; he’s not. You’re a teen mom. Maybe your partner isn’t your husband; he’s your baby daddy, or maybe you don’t have a man with you. All that increases the power differential. Even with a wonderful OB, the mom may not feel empowered to ask for what she wants.”
That feeling of empowerment manifests in hard stats. According to research conducted at the University of Toronto in 2011, “Continuous support during labor has clinically meaningful benefits for women and infants and no known harm.” The research, published in the US National Library of Medicine, reports that for the women receiving doula support, “their labors were shorter; they were less likely to have a Caesarean.”
Doula or not?
If having someone in your corner championing your birthing efforts will only increase the likelihood of you having a successful birth, then why not? Who would say no to the use of a doula?
“The healthcare team and the doulas share a common goal, but sometimes the way to accomplish that goal is not always agreed upon,” Jeter said. “According to [the Journal of Obstetric Gynecologic and Neonatal Nursing]… the doula may, at times, attempt to work outside of her scope of practice, giving medical advice and asserting her own opinions and desires. But mostly the roles are that of a working relationship for the benefit of the patient. Doula care can definitely enhance the birth experience. ”
“I’ve heard people say a doula drives a wedge between a doctor and a woman. We have OBs who love working with doulas and those who don’t. We have nurses who love it, and nurses who feel threatened,” said Abrams.
“With families, too, sometimes a woman’s mother feels like it’s her duty to be there with the daughter,” Petrus said. “There’s a big change once they’re all in the room and realize that doulas enhance the support and experience for all. Doulas don’t replace anyone.”
During delivery, if a doula does intervene in any way, medical personnel may ask her to leave.
“It’s my job to advocate for those women when we get in the room by reminding her of her options. Only a woman or her husband are able to speak for her. So I’m never able to speak for a woman, but there are a lot of ways you can advocate,” said Little. “Not to sound too cynical, but doctors and nurses have a way of coming in and using certain phrases…”
“Like ‘harming the baby,’” added Miller. “You think, ‘Surely, they know. Surely they’re not just saying that you’re harming your baby.’”
“No mom is going to make a decision where she harms her baby,” Little said, who remembered a story of a mom who was told birthing in a tub would be harmful. “I was in a birth at [a local hospital] last December. The woman’s mother was a midwife in France; she’d gone to births all her life. She’d given birth once. She started pushing in the tub, and the nurse told her to get out of the tub and in the bed — the tub is for laboring, not birthing. The mom didn’t even look at her; she was so intense. She responded when I touched her, but she told me later, ‘That woman was crazy, I couldn’t listen to her. I was so focused.’ She delivered in the tub. She was fine. She pulled her own baby up.”
Jenna Lambert, a client of BirthWell Partners who planned to birth naturally, knows the woes of navigating an intense birth. “We went to this doctor, and she said, ‘Your baby is going to be close to 10 pounds, and if you give birth to him naturally, he’ll die.’ My mouth hit the floor.”
Lambert, who did ultimately have a C-section, said, “If it wasn’t for [my doula], I wouldn’t have been able to get through it. My husband was so nervous that he had to leave the room to go find some meds. … When he was in there, he was helpful, but without her, I don’t know what I would have done.”