The Doula Paradox

Revitalizing Midwifery: Reimagining the Doula’s Role

(originally published in Midwifery Today, Summer 2019, Issue 130)

I observe the comfort of warm bodies hugging one another as sterile tools are wheeled into the room. My role, the role of the doula, weighs heavily on my mind—through a decade of late night calls, the cycling of Styrofoam cups of cold coffee, the oscillating moans and whimpers of laborious evenings, the incessant chirping of monitors, of clattering metal tools on trays, the long exhalation of relief as a newcomer takes its first gurgling breath amidst gloved hands, glistening foreheads, and stark fluorescent heavens. 

Most quiet nights spent in humming hospital rooms of sleeping mothers are spent imagining labors at home, with families in bed, bellies in bathtubs, and births cradled by gentle hands. Filled with yawns, a nurse emerges to check the monitors surrounding another sleeping mother whose epidural is clearly working. My eyes fall to the book in my lap. I trace the edges with my fingertips, briefly feeling defeated, guilty, mind in quicksand. Knowing it’s one of my last labors as a doula, memories of past births begin resurfacing: memories of sweetness, of strength, but also of grief and disillusionment. 

The bureaucracy of birth is wrought with trauma and healing. We find ourselves, as doulas, midwives, and advocates, deep in the thicket of institution, navigating and balancing patient and protocol. Hospitals, like most social institutions, function as a disciplinary force for social control. While some may deny this, many of us cannot. Ultimately, we are wholly appreciative for life-saving technologies, yet we still must analyze and critique those same technologies, for they can and do cause irreversible harm. 

Obstetric violence is a relatively new term for events that have an extensive and complex history, spanning land, culture, generations, and bodies. Obstetric violence, first defined in Venezuelan legal texts in 2007, is “the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, [and/or] an abuse of medication to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women” (Pérez 2010, 201). More simply, obstetric violence is a violation of human rights, and these violations exist at the intersection of violence against women and structural violence. 

At the crux of a shift from fragmentation to holism, from transition to crowning, it is a pressing imperative in reproductive justice work that we recognize that the doula’s role exists at the intersection of dissent and the maintenance of the established order. There is no denying that doulas are restricted to a role of subservience within the institution; the doula is forced to assimilate and comply in order. Ask yourself, how can the doula accurately symbolize the birthing body’s reassertion of decisional authority while simultaneously being restricted to a role of subservience? 

While still maintaining an unwavering reverence for the work and service of doulas, we may begin to describe this phenomenon as a paradox or anomaly. Doulas are forever on the frontlines, working tirelessly in the shadows of bureaucracy, holding space for families and communities, weaving together threads of light and hope for future generations—as are midwives. However, while this romanticization of doula work can be rightfully encouraging and validating—comforting even—it is our right and our duty to critique its capacity to effect real and lasting change. 

The insertion of the doula’s presence into the hospital is a form of docile protest. It is docile because we must operate within the confines of institutional rules and regulations. Doula-supported hospital birth is considerably safer from interventions than unsupported hospital birth, but we cannot ignore the fact that, with positive outcomes being the goal, the vast majority of births need not occur within a medical setting at all (Wagner 2001). From this perspective, I believe it’s safe to acknowledge that the doula is both protest and retreat in the same gesture (Foucault 1975). Rather than a full reclamation of autonomy through holistic or humanistic care, hospital doulas are both an impetus to change and a continued expression of oppressive social conditions simply by their continual reinforcement of the normalization of hospital birth. 

This piece is clearly an oversimplification of a very complex issue. It is clear that a shift from obstetrics back to midwifery care will take decades. As a now-30-year-old who was once a teenaged mother on Medicaid, the awareness of midwifery care being unaffordable and, oftentimes, geographically inaccessible, is not lost on me. In the here and now, doulas serve an undeniably critical role in the improvement of birth outcomes. This we know for certain. Doula work seeks to defend and protect physiologic birth—yet, by failing to directly support midwifery, we reinforce that which we protest: medicalization. The doula cannot be a symbol of radical resistance if the current role involves subservience within the socio-medical hierarchy. Doulas fill a major social gap in care, but the functioning of that role should be temporary, as a shift to midwifery is ultimately the key to sustainability in care. 

Obstetric violence is one of the major reasons for the growing grassroots emergence of doulas in the health care system. Women saw a need for social care—a gap in the medical model—and they did not hesitate to rise and step in. Doula work is unregulated and autonomous, and it fills a need that would otherwise remain unaddressed. Doulas not only provide emotional and physical support, but they reduce the risk of medical intervention by encouraging families to question their providers and demand productive communication with hospital staff—of course this is easier said than done. Although doulas contribute to the reintegration of the social model of care, the service is clearly reformist, not revolutionary. 

We have been trained since birth to look outside ourselves for safety, to look to technocracy, a capitalist patriarchal power structure, as savior. Upon deeper inspection, we don’t need saving, we need liberation. Doulas frequently and naturally contribute to a dialogue of reducing harm, both with clients and within the broader birth community. However, I believe eradication rather than reduction should be the end goal; that can only happen when we actively inform others about midwifery options. 

In her ethnography of doulas, sociologist Bari Meltzer Norman concludes that doulas are largely “apolitical” and “passive,” and that “in trying to make quiet waves, doulas ultimately help along the current medicalized system of birth” (Norman 2007, 280). Monica Basile poses an important question in her PhD dissertation, “Reproductive Justice and Childbirth Reform”: [T]o what extent are doulas capable of creating institutional change in order to improve birth experiences and outcomes? (Basile 2012). 

If a pregnant woman says that she would prefer to avoid all unnecessary intervention, then why, as doulas, are we omitting information about homebirth? Along with educating families and communities, we must address barriers to care, along with legislative efforts, policy-making, establishment of accessible midwifery education, and expansion of insurance coverage. It is undeniable that the normalization of hospital birth is being perpetuated by doula care—but, in our defense, what options do we have? It’s a double-edged sword. Our in-hospital support is undoubtedly proven effective; we provide evidence-based care that lowers the risk of most routine interventions and supports healthier outcomes. But to what extent, really? 

What role do doulas play in the reclamation of bodily autonomy? Is the role revolutionary or reformist? Do doulas seek to liberate or perpetuate the limitations of our birthing freedoms? How do doulas participate in and perpetuate gender-based oppression in maternity care? Journalist Jennifer Block said, “By supplementing the hand-holding and informed consent conversations that nurses and doctors should be doing, and by buffering the level of intervention, [doulas] are perpetuating the very system they are in the business of changing” (Block 2007). 

It is one thing if a client chooses hospital birth because she desires pain medication and is comforted by technology; it is another to have a client who wishes to avoid medicalization altogether, yet is left unaware of alternative options. To fail to inform an individual that homebirth with a midwife is safe and attainable is to reinforce and normalize the cultural assumption that hospital birth is the best and safest option. At what point is withholding this information considered negligence on our part? At what point does a person’s uninformed decision to birth in the hospital become our personal failure as informants? 

Like many doulas, I find myself expanding my doula work beyond the prescribed role. Most of our political engagement happens outside the birth space, because it must. With individual cases, much of the informative work happens before the birth. Emotional and informational support generally happens prenatally, so that the woman is better prepared for the various institutional politics faced during labor. Why is it that we encourage clients to create a birth plan, an ideal anti-interventionist vision of their birth, only to sit back and watch silently as they intentionally hire a trained surgeon whose pathologized view of their body will naturally lead to active management? Once they step inside the hospital room, it is no longer up to them what happens to their body—and the fascinating part of this is: it’s considered cognitive dissonance. 

Doulas use catch-phrases like “informed birth” or “empowered birth,” which are merely half-truths since we often fail to mention homebirth as an option. The midwifery and homebirth movements may seem parallel to the doula movement, but “doula care often represents a more accommodating variety of childbirth reform, most often seeking to improve women’s birth experiences within the hospital setting, where 99% of births take place” (Basile 2012). This statistic is an interesting one given the knowledge that “70 percent of all birthing women in America, if given adequate prenatal care, could deliver their babies normally and without need of medical intervention at all. Another 20 percent may have complications that require extra prenatal care and some special attention, but these mothers, too, could give birth normally, again, without need for medical interference. This means that at least 90 percent of all birthing mothers can have normal, spontaneous births and have healthy babies” (Arms 1975, 56). 

We can now see a shift in culture happening, beginning with the recent discussions sparked by a NY Times article, “New York to Expand Doulas to Reduce Childbirth Deaths,” published in April 2018. The article describes a plan for a series of initiatives aimed at addressing maternal mortality in New York, where the mortality rate for black mothers is alarmingly high. The plan, according to the author, includes “a pilot program that will expand Medicaid coverage for doulas” (Ferré-Sadurní 2018). The announcement immediately created an uproar in the NYC doula community and beyond. Some celebrated it, while others, including me, expressed deep criticism and skepticism. With the widespread acceptance and push for standardization of doula support in the medical setting, it seems we are choosing to maintain medicalization rather than to revitalize midwifery. 

Let us consider where our allegiance truly lies: Is it with institution, or with women? If it is with women, we should inarguably be promoting a shift to midwifery care in home and birth center settings for women with uncomplicated pregnancies. Our focus would be supported and encouraged with an agenda to establish accessible midwifery education in every state, fund midwifery campaigns, and encourage insurance coverage for traditional midwifery care. 

A WHO publication states: 

It is important to remember that it has never been scientifically proven that the hospital is a safer place than the home for a woman who has had an uncomplicated pregnancy to have her baby. Studies of planned home birth in developed countries with women who have had uncomplicated pregnancies have shown morbidity and mortality rates for the mother and baby equal to or better than hospital birth statistics for women with uncomplicated pregnancies. These studies have also found significantly fewer interventions used in home birth than in hospital births. (World Health Organization 1985, 86–87) 

This is important to note, especially when considering that most postpartum trauma, including postnatal post-traumatic stress disorder (PTSD), can be prevented with appropriate social care and, even more easily, by choosing to birth outside a medical setting. According to The Birth Trauma Association, the leading cause for birth trauma is the type of delivery. The factors include labor induction, feelings of loss of control, high levels of medical intervention, cesarean section, impersonal treatment, being ignored or neglected, conflict with hospital staff, lack of information and/or explanation of procedures, lack of privacy and dignity, iatrogenic harm to baby, and poor postpartum care (The Birth Trauma Association 2004). While a few of these factors are caused by technological intervention, many are undoubtedly due to lack of social support. With this in mind, the solution seems simple: support midwifery. 

I stir from my daydream when the nurse exclaims, “It’s time to push!” Still wiping the sleep from her eyes, the quiet mother rolls toward me, reaching for her cup of ice chips. I stand and spoon-feed her as the nurse adjusts the stirrups on the bed. The room smells of bergamot and mint tea, thanks to my open doula bag. I take a few long gulps of cold coffee from a Styrofoam cup. Golden orange hues peek around the edges of closed curtains, evidence of a new day dawning as she takes a deep breath and starts to push. This last birth as a doula was marked by trauma and overwhelming defeatism. The mother’s sobs filled the room. She shook, gripping my hands, repeating her fear of cesarean over and over. The obstetrician stood over her, her words insensitive and sharp, “It's not your fault you were born with this body.” 

A flash of internal rage overwhelmed my thoughts. How dare she? How dare this doctor, a fellow woman, tell this mother her body is broken? Internalized misogyny runs deep. The institution's denial of nourishment in addition to the continuous drip of Pitocin was to blame. Her body is not broken, the system in which she is caught is broken. Denied sustenance in labor for 24 hours, only to be told it was her fault. 

I quieted my rage and softened as I turned to the mother. As her doula, I was there to soothe her, comfort her, remind her of her strength. Her sobs slowed into deep sighs as I removed the wet cloth from her forehead and told her she is so strong. I watched as she was wheeled off to the 

OR, silently affirming I can no longer bear witness to these obstetric abuses. When looking toward our own stories as doulas, births we’ve attended, abuses we’ve witnessed, it is easy to see the conventional doula’s role is indeed a form of pathological protest—a metaphorical band-aid (emotional support) for a systemic infection (obstetric violence and the medicalization of birth). This is no easy task since, as I have acknowledged before, each doula has a vision of what her work means—whether political or apolitical. Even an apolitical doula can be labeled an activist simply for existing in the medical space and offering emotional support that would otherwise be absent without her presence. That being said, my work as a doula is intentionally and unapologetically politicized, and even though I would love to see a radical shift in the doula’s role, I admire doulas who—even without an intent to dismantle the system—simply choose to hold space for women in their most vulnerable states. It makes a difference in the lives of so many. 

For the doulas whose work is intentionally political, Basile shares: “Doulas working in the reproductive justice model are shaping new directions in the priorities of birth workers and forging connections between birth workers and activists for causes such as LGBT rights, abortion rights, prisoners’ rights, and economic and racial justice.” Basile also discusses the emergence of the doula movement as part of the broader women’s health movement: “Many of the goals of doula care run parallel to feminist principles: expanding the range of reproductive choices for women, centralizing embodied knowledge, and promoting self-help and solidarity among mothers” (Basile 2012, 5). 

What can a doula do? 

· Doulas can easily support midwifery by dispelling myths about homebirth and by sharing information about the safety and benefits of midwifery care. If a client says she wants to avoid medicalization, it is the perfect time to discuss options. Most pregnant women are unaware of evidence-based practices involving the safety of birthing at home. 

· Many times clients aren’t aware of local midwives or birth centers in their state. Doulas can carry an up-to-date list of midwifery-related resources for discussion during prenatal meetings while a client is still deciding on a care provider. Having these conversations with clients is key to providing optimal support. 

· Networking with other doulas, midwives, and birth centers is an important part of the work. Not only does it provide the best options for pregnant clients, but it aids in the revitalization of midwifery. It is also important to mention that even if a client decides on midwifery support, the support of a doula at home is still just as beneficial as it is in the hospital—not to mention it can relieve the midwife of some of her duties so that she may be more 
attentive to clinical aspects, like assessing labor progress or catching the baby. 

Each individual and her collective life experience is unique and, as doulas, we always support informed decision-making, whether that includes an elective surgical delivery at the hands of a skilled obstetrician, or a freebirth in which the act of resistance is full rejection of all assistance other than the birther’s own instinctive hands. Neither is wrong or right, as long as basic dignity and respect are practiced and intact. This is what reproductive justice is all about: total liberation and autonomy. In Jessica Gonzalez-Rojas’ and Kierra Johnson’s words: 

To be clear, reproductive justice is not a label—it’s a mission. It describes our collective vision: a world where all people have the social, political, and economic power and resources to make healthy decisions about gender, bodies, sexuality, reproduction, and families for themselves and their communities. And it provides an inclusive, intersectional framework for bringing that dream into being. Reproductive justice is visionary, it’s complex, it doesn’t fit neatly on a bumper sticker, and it has a lot to teach us about how to be successful in a changed and changing world. 

In closing, let us be reminded of the primacy of practice over belief. It is simply not enough for us, as doulas, to believe in the safety and normalcy of physiologic birth; we must also learn the principles of feminist praxis and remain constant in our advocacy. It is simply not enough for us to be well-intentioned; we must also embody our knowledge. Our actions must be in alignment with our visions. We must resist docility. We must socialize birth by de-medicalizing it. We must assist midwives in the revitalization of midwifery, for these actions are paramount to creating a future and culture of health equity and optimal care. 

For a complete list of references, please check out Midwifery Today’s Summer 2019 issue here.