WHY IS CHILDBIRTH SUCH A PAIN ?
We can say that the ability to conceive and bear children is the last frontier of gender equality; it is possibly the least contested arena & the best illustration of the words of the Edward Koren cartoon in the New Yorker ‘Despite my best efforts you’re still the man and I’m still the woman’.
Despite a few, rare exceptions where intersex individuals are reported to have given birth, women have still cornered the market in this activity.
This poses a challenge for many an educated ,egalitarian woman: should she maximize this unique possibility for personal fulfilment and self-expression (and risk being accused of essentialist clinging to the old binary certainties); or play the whole thing down as All- In- A- Day’s- Work. Probably most women fall somewhere between the two, and whilst prepared to go into intensive training for the event ...through rigorous exercise, carefully calibrated diet, ‘comfortable shoes’.....would like to hand over actual ‘event- management’ to the professionals. It is the risky... and oh yes, painful... element which prompts a great many women who, luckily, have the option to opt for a less-than-natural birth.
Global statistics on maternal mortality confirm that childbirth is still a risky business despite it having been around for a while & in defiance of the rosy fiction often purveyed that in developing countries women deliver children without breaking stride. With 28 maternal deaths per 100,000 live births the US ranks 50th in maternal mortality globally which puts it on a par with sanctions-hit Iran, and gives American women a four times higher risk of dying in child-birth than German women (only 7 maternal deaths per 100,000 live births). And the US figures may be rising in contrast with most developed and developing countries. This is due to a complex range of factors on the health supply and health demand side which are raised but deserve to be more fully explored in the book under discussion.
This book ... ‘Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America’... examines the role of the doula in the midwifery model of childbirth...this model in principle and to the extent possible eschews medical intervention . It is argued that the services and presence of a doula enables a woman to have the best possible birth experience from an emotional, physical and spiritual perspective, and furthermore actually reduces the incidence of intrusive practices such as anaesthetic, epidurals, and caesarean sections. ‘Doula care is an interactional accomplishment of labour support by non-medically-trained women during childbirth. Doulas enter medical institutions with the goals of emphasizing emotional over technological triumphs and affirming the woman’s act of giving birth rather than the physician’s role in delivering the baby. Doulas articulate the need for triumph in a medicalized system overly focused on institutional routines’, including numerous procedures which doulas often describe as ‘non-medically indicated interventions’ - intravenous fluid lines, continuous electronic foetal monitoring and so forth. The doula is also there as a kind of one-person Greek chorus to frame the events surrounding the birth in the most positive light, and her skill in ‘ telling the story’ are expected to influence forever the way the women and their partners remember the birth.
Currently only between 3% and 6% of childbirths in America are assisted by a doula ; doulas are engaged predominantly by white, educated, middle class women most of whom will give birth in hospital .
So what does a doula do? Doulas are most simply defined as women supporting other birthing women, and their re-emergence in the States harks back to a simpler time when childbirth was handled at home in the community rather than in a hospitals or nursing homes and was regarded as a natural event.
The international development community for several decades (particularly UNICEF & WHO)has been working in the developing world to upgrade the clinical skills of doulas often known as Traditional Birth Attendants in ‘under-resourced settings’ in order to improve the level of cleanliness and safety of deliveries, typically equipping them with better knowledge of peri-natal care and some simple medical equipment , as well as knowledge of referral to MCH services in the event those are needed. It might be said that TBAs in some communities have evolved in a para-medical direction.
In contrast, the four-day doula training provides no medical or paramedical skills – though it is stressed that doulas keep abreast of the latest advances by reading medical journals . Usually the ‘good doula’ is at pains to stress her lack of interest in encroaching upon the territory of the medical staff in attendance. Doulas are there as ‘birth ambassadors’ (or ‘birth junkies’ as one doula confesses) though it is against the doula code to actually speak for or represent the mother in labour but only to remind her gently, preferably when the doctors and nurses are absent, that she needs to be faithful to her ‘birth plan’ and should avoid accepting medical interventions that in the heat of the moment may look increasingly seductive. One of the book’s few (darkly) comic moments occurs when the labouring woman goes off-message and shouts, over the doula’s demur, for an episiotomy “Oh I don’t care, get this baby out!”
With the medical staff in attendance it seems, not surprisingly, that ‘geisha-doula’ is more in evidence than ‘ambassador-doula’ as in her ‘doula voice’ she tries to suggest that doctors do the right thing and allow nature to take its course rather than giving in to the presumably more lucrative and time-efficient practices in their arsenal...induced labour, ‘elective’ c-sections, epidurals etc.
Whilst traditional doulas tend to operate ‘where there is no doctor’ American doulas attempt to re-balance towards the interests of the mother, a system where there may be too many doctors pushing their expensive agendas.
The data shows that the continuity of attention and care provided by the doula throughout the process is very important to the experience of the client giving birth ... and may be crucial to the mother’s well-being where ‘much of the nursing role is devoted to documenting data that can be used as a legal defense for the physician and the hospital’.....the presence of a doula is also demonstrated to have a positive effect in reducing ‘unnecessary’ procedures which have become routine.
Whilst the book...by its cover and elsewhere... tells us that it is very much pro-doula...the thorough qualitative research allows ambivalence to seep in. Are doulas just a band-aid on a system that is not friendly to the empowerment of women before, during and after child-birth or the thin end of a wedge of real health care reform? Many doulas - perhaps younger & more educated- appear to regard their role as a stepping stone to something better beyond doula-dom, - even in ‘allied child-birth fields’ -that is to say as a way of entering into rather than changing the system.
Interestingly enough the chapters based on the actual study are much more nuanced and less ‘gung-ho’ for doulas than the chapters which provide “personal stories” from doula-assisted mothers .All the women who provide testimonials in these chapters report glowingly on their doula experience.
And a male paediatrician provides an erudite appreciation of vaginal birth as depicted on the Temple of Hathor in the Ptolemaic Period 323-330 B.C.
This is a good book which carries within it the seeds of several better books. Especially for non-American readers it would have been helpful to have some more contextual information about the health- care system which gave birth to the doula. It would also be good to hear more from the medical personnel , and the health insurers about the pressures they experience, and the relative rewards pecuniary and other. A doula may earn as little as a few hundred dollars for her services before, during and after delivery or may even provide her support pro bono.
The study and the advocacy it underpins would also have been enriched if we had heard some more nuanced evidence... from a father who had wanted to take more or less of a role but had been cajoled by a doula; from a nurse or midwife who found the doula role less than useful; from a woman who had encountered a ‘bad doula’ who ‘knows what’s best for everybody”. And indeed from a ‘bad doula’ herself. The fact that this stereotype exists suggests there may be quite a few.
It would be interesting to see some cross-country and cross-cultural studies over time which would start to untangle the interplay of the different dimensions... maternal mortality rates; the status of women overall and in the health sector as professionals, para-professionals and doulas; the proportion of the health care budget allocated to maternal care; the country’s GDP....
Has the US, in trying to go back to the old simplicities, introduced even more complication. In the longer term can the theatre of American childbirth really bear yet another character in the cast, all of whom have different agendas and approaches ;childbirth educators, nurses, midwives, anaesthetists ,obstetricians, gynaecologists- not to mention fathers and other partners; and now doulas, doula networks & organizations and doula therapists. Is there any wonder that some women shout “Cut it out! (and bring on the Twilight Sleep whilst you’re about it)”.
Don’t (yet) say: A doula not a doctor; no contest.
Do say: I may just tear up my birth plan & still bond.... if I want to OR don’t underestimate the staying power of a band-aid.
For more on the joys of motherhood from gendercentric please visit http://gendercentric.org/16-newsflash/86-the-unkindest-cutharmful-cultur... and http://www.nyjournalofbooks.com/book-review/motherhood-rescheduled
 The maternal mortality rate is the annual number of women who die during pregnancy and childbirth per 100,000 live births. See http://databank.worldbank.org/data/home.aspx and http://www.who.int/gho/maternal_health/countries/en/
 Birth Ambassadors- Doulas and the Re-Emergence of Woman-Supported Birth in America – Christine H. Morton with Elayne G.Clift, Praeclarus Press,LLC (2014) Available as a Kindle e-book
 See for example http://www.healthynewbornnetwork.org/blog/traditional-birth-attendants-a...
 See http://hesperian.org/wp-content/uploads/pdf/en_wtnd_2013/en_wtnd_2013_fm...