What does 'support' in childbirth really mean?

I have been thinking about the use of the word 'support' in relation to childbirth and wondering if it is not just being paid lip-service to lately, a bit like 'natural' childbirth.

Folk say "Yes, of course support is important' but do they understand what this really means?  What kind of support we are talking about? Or why it can make a difference?

My wise doula sister BB tells me that Michel Odent is not a fan of the use of the word 'support' which perhaps suggests there is something to this discussion. Yet what term are we to use instead?

For me, this poem by Anonymous, really sums up what I mean when I talk about childbirth support, or any kind of emotional support I suppose:

What is Support? 

Support is unconditional 

It is listening
Not judging, not telling your own story
Support is not offering advice …

It is offering a handkerchief, a touch, a hug … caring. 

We are here to help women discover what they are feeling … not to make the feelings go away. 

We are here to help a woman identify her options … not to tell her which options to choose. 

We are here to discuss steps with a woman … not to take the steps for her. 

We are here to help a woman discover her own strength … not to rescue her and to leave her still vulnerable. 

We are here to help a woman discover she can help herself … not to take that responsibility for her. We are here to help a woman learn to choose … not to make it unnecessary for her to make difficult choices.

Anonymous

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Although written as if for mothers, if we replace the word 'women' for 'men', it becomes a poem for fathers too.

So let's be mindful of how we use the word 'support', let's notice when and where we use it and what we really mean by it, and if we hear it being paid lip service to, let's feel proud to quantify the true value of its existence.

'Birth Aunties'

I was fortunate to have been invited to the annual 'Gala Evening' fundraiser event for our university campus, last week.






It was a 'black tie' do and I found myself seated between a Professor (our host) and a Doctor of Education who I had not previously met, both highly intelligent, interesting and interested men.


Inevitably the moment came when I was invited (by said Dr) to define a doula.

"But surely that's the same thing as a midwife?" he responded, "What's the difference?"








So, after reiterating the emotional, social and practical - rather than the clinical - support bit, I tried something new:

"Kind of like a birth auntie!"



The conversation then changed to another subject. However, some fine wine and a good dinner later in the evening, as we paused between Raffle and Auction, the delightful Dr reflected this term back at me in perfect context.

Yay, he so got it! I was so impressed! And it made me reflect on the possibility of using 'Birth Auntie' as a way of describing the doula more often ...

Against the professionalisation of doulas - where next?

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The role of the doula has been formalised in the UK for ten years now and I sense that the doula community and what we stand for may be standing at a threshold. My recent blogposts challenging the case for professionalisation of doulas have been met with some interesting feedback from both sides of the pond. 

There seems to be a general consensus that doulas work in a 'professional' way - we do what we say we are going to do when we say we are going to do it and we work with respect and integrity towards our clients as well as health professionals - but that we are not 'trained professionals' in the same sense that a midwife or a teacher is. And I do believe that the majority of doulas, including myself, would concur with this theory.

However, I also believe that there is MUCH more we could do in the way of giving a consistent message to the public and to health professionals by avoiding the use of the word 'professional' altogether. In essence, Doula UK's Philosophy has traditionally promoted the doula as a lay person:

"The doula role, we believe, is a way of "being" not "doing". A "training" implies completion and it is not useful to believe that a woman can attend a two or three day workshop or ... course and believe that she is a doula. Doulas are learners, they are explorers, they are guides, friends, sharers, it goes on and on. Without an open approach to self development and human growth it is impossible to be available to enable others. Within a doula’s education there must be a deep concentration and focus on self awareness and ... a lot of time reflecting." "We do not want doulas to add another layer of ‘professionalism’ to an already overloaded maternity system."

  

yet terms like 'training', 'trainee', 'profession' and 'continuous professional development' still feature in the organisation's vocabulary. There is perhaps room for adjustment here therefore, a replacement of such professionalised terms for others that are more in keeping with the lay role perhaps, such as 'preparation course', 'new doula', 'doula work/doulaing' and 'ongoing learning'.

      

During the doula preparation course too, much work can be done by course leaders and facilitators to remind new doulas that our role is not a professional one. Terms such as 'qualified' and 'certified' simply suggest that doulas have some special 'professional' status which in fact we do not. Why not 'attended an information session' or 'completed a preparation course'? If all doula course leaders were consistent in perpetuating the use of lay language, our students would carry this with them on out into their work.  

In any occupation, jargon particular to that line of work may be found, jargon that is relayed initially to new workers via their educators or supervisors - so why not doulaing too?   

As we stand on this threshold where an awareness of our role has reached a wider public, where more mothers and fathers are choosing to enlist a doula during childbirth and more maternity health professionals are beginning to take the value of lay support seriously, we can surely step forward from here and make ourselves what we want to be.    

I believe that now is the moment to commit to our principles and fuse the definition of our role into how we want it to represent us into the future, for if we do not, I fear we will miss the moment, and possibly miss the greatest opportunity UK doulas will ever have to unite as one voice.

Against the professionalisation of doulas - why?

Having recently stuck my head above the parapet for challenging some of the principles raised during the process of Doula UK's imminent Board changeover - and got it nipped (!) - I feel an urge to further elaborate on why I disagree with the professionalisation of doulas.

Admittedly much of the literature written on doulas does apply words such as 'qualified',   'professionally trained' and 'certified' to the lay childbirth companion, but this is because the vast majority of these texts are American. And the way American English is used to describe the US doula does, in many ways, make her a different entity to the UK doula. 

The reason for this difference however, is because midwifery practice in the US is also very different to that in the UK. And it is the midwife-doula relationship that lies at the heart of my argument against the professionalisation of doulas.

There has always been discussion among the doula community - as the newcomers to the UK childbirth arena - about how to creatively build bridges with midwives, in the belief that this can only help towards sensitively and effectively supporting women and birthing families. While the doula's first allegiance is to the mother and father she is working with, she is also mindful that her positive relationship with the attending midwife can play a key part in ensuring the protection of an undisturbed birth environment.  

Equally, there is concern among the midwifery community regarding the increasing number of birthing mothers and couples who are enlisting doula support and how, hand in hand with Government cuts, the presence of doulas may be aiding the erosion of the role of the midwife. Why, if the UK midwife autonomously provides physical, emotional as well as spiritual care to the birthing family, should there be a need for any additional support? What can a doula provide that women and couples are not already offered by their midwife?

I make no excuse in refraining from attempting to respond to these questions here, for to remotely adequately comment on this sensitive issue deserves an evidence based paper written for another time and place. My point is not about what the doula or the midwife does or does not do in any case. Rather to suggest how insulting it might feel for the midwife, who is a professionally trained, qualified and registered practitioner, to contend not only with another figure in the childbirth arena who potentially threatens her very existence, but also with one who - further to having undertaken a course comprising of just a few days as opposed to years - deigns to describe herself as a 'professionally trained' or 'qualified' practitioner. 

This is my point against the professionalisation of doulas.

I have to admit that I just do not understand why some doulas and doula organisations choose to use this terminology at all. Does it stem from the need to big-up the doula role, to make it more acceptable, more accountable, more credible? Does it come from a place of lack of confidence in the right to 'be' there as a non-professional support person? Or is it down to people simply not thinking through what they are saying, not considering the implications behind the words they are using? Perhaps not fully understanding the role of the midwife too?

As part of the doula community's commitment to building bridges with midwives and maintaining harmony in the way that birthing families are supported in the longterm, I would so welcome an 'outing' of this issue. And I would so like to hear Doula UK, as the leading voice for UK doulas, take a much stronger position against the use of professionalised language in reference to doulas for all the reasons I outline in this post. 

To end on a positive note however, much to encourage and support the coming together of doulas and midwives, to share learning, skills and knowledge of our not dis-similar yet in many ways very different roles, is already unfolding. Meetings, MSLCs, workshops and study days are providing forums for discussion and exchange, to build on understanding and to air concerns regarding each other's roles. And I applaud those who are instigating these opportunities. Let's keep working on it!

The Doula-Midwife Relationship 1 - training & boundaries

I am in the unusual position of being a trained midwife (no longer practising) as well as a currently working doula and doula trainer (or 'course leader' as I prefer to say) at Mindful Doulas. This has given me much cause for reflection lately regarding the issue of boundaries between the two roles and how this is being presented to student doulas during their 'training' course.
 

Although I have always supported the idea that doula courses are most appropriately led by working doulas, for we are lay people and do not require to be 'trained' in the same way as a midwife, I guess this is because I do have the experience of having been a practising midwife. I do therefore fully understand the working boundaries between the two roles. 

How can a doula, generally speaking, be in a position to comment from a truly informed position on the midwife's role? How can she fully understand the way the midwife is bound by policies and the pressure to conform to a system of care, or how if she steps out of the box, she can be ostracised from her own professional community? Or how the boundaries of this 'box' can vary so drastically between trusts/units, with much depending on the support the midwife receives from her senior colleagues?

This is not a failing of the doula, simply a fact that doulaing and midwifery are different roles. And therefore, I believe that, rather than focusing on any 'bad midwife' or 'unsupportive NHS' stories, it is more relevant and useful for the doula course leader to keep clarifying with her students the working boundaries of the doula, to reiterate that while she is there to protect the mother's birthing environment, a part of this includes striving to ensure a harmonious relationship with the attending midwife. 

So perhaps there is a place for inviting a midwife speaker in to the doula course, as some already do, to share exactly what her working boundaries are? Working together does require respect and integrity between us, but I believe this is helped hugely if we are well informed about and have had a good experience of each other's role.
 

Regardless of whether she had completed a course or not, a doula may be very experienced in supporting birthing families as a lay companion. And yes, her role is to protect and promote normal physiology, but often the reason why the doula is enlisted in the first place is because the mother feels her voice was not heard during a traumatic birth experience the last time round. The doula develops a close trusting relationship with the mother and her partner through pregnancy and works on sharing resources with the parents to enable them to make their own informed choices about the maternity care that feels right for them.

If things start to deviate from the norm during labour, the birth doula can only be led by the parents on how best to support them and the midwife's advice will also enter this equation. However, the doula also knows (or should know) that sometimes, disturbance of the birth space (through noise, lack of privacy, stressed or fearful supporters, strangers entering the room) can be the very reason why the birth process starts to deviate from the norm in the first place. If the parents also understand this and have prepared well to minimise the risk of this, then it is likely that in view of her own role in supporting the couple's wishes, the attending midwife will be mindful of limiting disturbance in the birthing room too. 

Indeed, many doulas and midwives are working amicably and effectively together in this way to support normal physiology right now - for example, supporting a mother to birth her twins in water!

In the same way that the midwife may feel caught between her employer's rules and regulations and the choices of mother or couple she is attending, the doula may feel caught between her client's wishes and medical advice. Of course it is not her role to defy professional opinion, but it is the doula's role to support the mother if the mother chooses not to accept medical intervention. 

Since the biggest impact on the doula/midwife relationship is likely to be established in the clinical area, and since the doula may be perceived as the ‘newcomer’ on the scene, I feel we have a responsibility to take the initiative towards establishing a harmonious working relationship. However, this does not mean that I would encourage a doula to coerce with the midwife if the mother's wishes were not being heard. And let's face it, despite the best will in the world, there is evidence to show that this does happen, as indeed there are doulas who equally inappropriately cross their working boundaries.

We are all only human, but one thing we do all have in common is a passion for supporting women, men and families to enjoy the best birth and early parenting experience possible. I believe that if we both, as doulas and midwives, truly have the mother or couple and their baby's best interests at heart, most times we will do our utmost get it right between us, and doula course leaders can do much to mindfully promote this good intention.

Homegrown doulas, great resources

Developing Doulas

This year, we celebrate Doula UK's 10th birthday and I have been reflecting on how many of the really great doula resources available to us now originate from the UK, as well as from around Europe. It is understandable that our first reaction when looking for a doula reference may previously have been to turn to our US sisters who set the precedent for the role of the modern doula, yet I am thinking that it could be time for UK doulas to mindfully keep their eyes wide open closer to home.

We have UK doulas blogging, speaking, building bridges with midwives, writing, running courses abroad, we have Maddie McMahon's Birth Hub, Nicola Goodall's Wysewomen, Paula Gallardo's Mamaheaven, Olivia Seck's Birthing Wisdom, the film Doula! and much more. A wealth of rich and relevant experience and exciting discourse to tap into at our finger tips! Not forgetting our links with our sisters in mainland Europe, the Doulas de France, the ongoing development of the European Doula Network and the doulas at Da-a-luz in Spain.

Da-a-luz

I say 'relevant' because my feeling is that the doula culture in any particular country must to a certain extent evolve in direct response to local midwifery practice. For example, in the UK midwives are autonomous professional practitioners and therefore it makes sense that doulas remain as lay workers; it somehow validates our role as the mother or couple's chosen support person, rather than presenting as a kind of para-professional which could suggest links to the maternity care system and its politics. In the US, where hospital midwives are much less autonomous, interestingly, the doula role is more professionalised and has been known to include undertaking vaginal examinations! The French doulas on the other hand are not permitted to support their clients in the absence of a midwife, for fear they are practising underground midwifery. Doulas can act as apprentices to lay midwives in Spain, where it is assumed that all women will give birth in hospital attended by obstetric nurses and doctors, but for the few who choose not to, attendants who have not completed any formal training are accepted. Conversely, many of us will be aware of the harrowing story of Agnes Gereb, the Hungarian obstetrician/midwife who was imprisoned for supporting mothers to birth at home, yet even in that country, doulas are gathering.

Debra's DVD

There is little doubt that we owe much to the US pioneers of the modern doula role, to Dana Raphael for reminding us of the Greek women who supported the mother so that she could breastfeed, to Ina May Gaskin for sharing her inspiring journey from doula to community midwife, to Penny Simkin and her founder colleagues at DONA International for establishing a premise for doula education and peer support , and to Debra Pascali Bonaro who continues to bring DONA's courses to the rest of the world today. However, it is clear that the American doula has her own way of working, her own guidelines and boundaries which can differ considerably from the way that doulas work elsewhere.

As one of my favourite North American sister bloggers Molly Remer of Talk Birth comments: 

"I hadn’t realized how ethnocentric my own perceptions were about the role and history of doulas and I previously assumed that the “doula movement” was essentially synonymous with the “doula profession in the US.” Not so!"

Birth Space, Safe Place: emotional wellbeing through pregnancy and birth

Written for mothers and fathers-to-be, my new book reflects ways of protecting gentle birth. It tells of the role of doula (childbirth companion) and the benefits of lay support. It supports you to discover your birth journey in the way that is right for you.

"Every decision to be made during your pregnancy is yours to make. You are always entitled to ask for and pursue the care that you feel is right for you. If at any point you do not have all the facts with which to make a fully informed choice, you can take more time to find out further information before making your final decision."

"Essentially, your doula is someone you know and trust to uphold your philosophy of birth and parenting, to protect your memories of your birth experience and to assist you in your transition to parenthood in the way that is right for you and your partner. She may also help facilitate communications between you and other caregivers."

Available from Findhorn Press or Amazon.