Thursday, June 24, 2010

You Can't Take the Effect and Make it the Cause

"You can't take the effect and make it the cause," is a saying I quite like, immortalized in a song by The White Stripes.

I have thought a lot lately about the prejudice that exists towards doulas in general. A friend and I were having a discussion with a nice lady who happens to be an OB nurse. I don't want to make people think badly of her or anything, so please don't be reactive...but while my friend and I were making points about some medical practices studies suggested warranted more research by parents-to-be before they made decisions about their care, she responded, "Well, you know everything, then. It must be written in stone because the doulas say so," She at some point in the conversation claimed that if something wasn't medically proven, it was not knowledge. Yeah, yeah, I know, but this isn't the tangent I want to take now.

Please don't demonize this woman, who is a good person...it happens that people get defensive about their positions. If you've worked one way for a long time, believing it's the very best, safest, medically validated way, then it's not fun to have a couple of hussies come along and rock your world with stuff seemingly plucked from the air.

The thing is, we DON'T pluck things out of the air.

Doulas have been around since the beginning of time, doing our warm-fuzzy bit for birthing women and new moms. But in the last few decades, this role has become far more political. Now we are also called upon to be advocates. As the doula profession grows stronger and stronger as more and more women request our services, we are becoming more scrutinzed, criticized, and even ridiculed by many medical professionals, despite most of our clients' excellent outcomes, both clinical and experiential.

Consider this: our modern role developed BECAUSE loads of women weren't enjoying their obstetric experiences. Women were coming away from delivery rooms feeling confused and traumatized about what went down. You've all heard about Twilight Sleep and all babies being yanked out with forceps. It was the women who said, "We need to figure out whether this debilitating treatment of us in birth is actually needed! Were we not born capable of figuring most of this out on our own like those women we hear about who squat in fields? What's wrong with us that we need to be knocked out and cut and without our husbands?" And as the women looked for more gentleness in birth, their concerns being picked up and validated by compassionate medical people, they realized that in the throes of intense labour sensations, they may not have the power to communicate their worries, and were terrified of getting caught in a cascade of interventions they didn't need or want.

Wonderful people, such as Klaus and Kennel, noticed how much better women felt about themselves and their birth experiences when they decided to take another woman with them into the birthing room. Even just the presence of another woman contributed great things to the birth experience, never mind a female who also knew how to provide great emotional support, communication of the mother's needs (not decided for her BY the support person, but translated to the medical staff FOR her if the labouring woman couldn't speak herself), and soothing comfort measures. These researchers took the time to conduct some well known and well documented studies which confirmed their observations. Lo and behold, the presence of a non-medical, nurturing woman in the birthing room drastically reduces the need for medical interventions, as well as the desire for pain relief from labour sensations.

I can kind of imagine how medical people, who have busted their humps to get through the gruelling hell that is medical school, becoming skilled at diagnosing complications and executing amazing feats to spare mothers and babies from death, might scratch their heads and go, "Say what?" when a friendly woman NOT in scrubs asks them, because the labouring couple are clearly very focused on the work of dealing with huge contractions, "if it's not truly necessary to stay lying down, this lady would enjoy walking around to help soothe her labour pain. She would like to have a natural labour if this is how things work out, and being upright seems to help her a lot. Would this be okay with you?" If that doula/mother/partner team do all kinds of strange things together, like slow dance, everyone massaging and murmuring sweet nothings to the mom, who drapes herself in unfamiliar positions chanting oddities like "oooopen!" and even yelling out tension releasing expressions of pain that would fill the uninitiated with fear, you might feel extremely wary. If you as the doctor are simply not comfortable with these shenannigans, having learned a way of managing labour that you are secure with and within your knowledge base and experience keeps your patients safe, you might, if you're not actually impressed by the birth unfolding naturally, feel odd. You may feel usurped. You may feel resentful that the couple seemed to respond emotionally far better to the person with the strange smelling back of doula tricks than to you, who is the one ensuring their safety, for Pete's sake! You may feel downright angry that some chick with her essential oils and hippie talk of breathing away tension came into your delivery room and messed around with your sense of rightness, in your own place of work no less!

We get that. I think it would probably be quite a normal human reaction, considering the doctor is the one in the room who bears all the clinical responsibility. But the thing is, our strange ministrations to these women ALONG with excellent clinical care actually create more favourable outcomes, for doctors, mothers, babies, and partners (fathers or other mothers). Even if medical people want to look at doulas sideways, believing we are puppet masters who pull our clients' strings to make them carry out our evil plots of undermining medical authority, it's important to take a breath and get some perspective.

Doulas do NOT attempt to assume medical care of a client (decent, run of the mill doulas don't, anyway). It may seem like it to a doctor or nurse if a mom is being yelled at to get angry and PUSH while we're smiling at her silently, not joining that enthusiastic cheering squad. It might irk nurses to hear us say, "your body is amazing! It knows how to birth that baby. You know how to do this." Please know this is not a covert attempt to undermine anyone's medical authority, but to execute the wishes of the mother, made known to us in advance. She has spent her pregnancy reading up, figuring out how she wants things in her birthing environment if things go reasonably normally, and discussing those things with us. We open their eyes to other possibilities they may not have learned in their hospital based childbirth education classes, yes, but if a mom is not interested in something, we don't go there. If our clients have different ideas from what is typically done in a hospital, it is our job to lead them to resources that will help them make decisions about their care...we don't tell them what to do, we make sure they've informed themselves from several different sources, so as to better make choices for themselves from an empowered place. We absolutely encourage them to discuss their wishes with their caregivers. Then we support what they want. If their ideas are not sympatico with typical hospital protocols, it is important for medical people not to assume their patients are weak minded, malleable creatures whose minds were warped by the likes of doulas. Patients need more credit than that. In fact, that's probably why we're here, because even up to the latter part of the last century, birth practices were still pretty barbaric in many ways..and women became fed up.

We are not accusing the medical system of being barbaric now, or ignorant as to how to deal with perfectly normal births (though you may find that some women who feel victimized and traumatized by their births and treatment would vehemently disagree). But it is important to understand that the modern doula profession was born from the effect of medical practices that made women feel disempowered.

You can't take this effect, and make us the cause. Good doulas are emphatically not the cause of patients seeking empowerment, looking to birth on their own terms, even if those terms make medical staff feel uncomfortable. Media jokes about doulas a lot. We get many snide remarks from some hospital staff members, like "The DOULA told her to lift her leg while lying on her side, yeah, like THAT'S going to get a first baby out!" Or "There's a DOULA here...I guess now we're going to have to speak in dulcet tones." Or, one of the ones that hurts most, is, "Honey, you don't HAVE to suffer with labour pain! Just because your doula told you epidurals are bad doesn't mean she's right. She can't know that because she's not a medical professional." It hurts because we wouldn't say, "epidurals are bad," and we would never keep a mom from an epidural if that was her wish. It may not be realized by staff that mothers tell us in advance of labour that they'd like to avoid an epidural, and we have ways of communicating with each other so we'll know when she's serious about changing her mind. While the staff may think their ire is aimed at us, in reality, comments like these completely disrespect their patient's wishes, based upon gathering information and making choices for herself that make her feel safe and happy. To take the effect of a mother's choices (to hire a doula to help her birth naturally) and to make us the cause (of her "suffering" in labour), is not acceptable, or logical. Many birthing women here are told, "if you want to birth in that position, you should have given birth at home!" and this is cruel. Do you know how many women in Montreal want to birth at home and cannot because of the unavailability of midwifery care? Some of our clients want to birth in hospital, on their own terms, and some feel stuck with medical care they wish they didn't have to have. Don't point fingers at doulas for those women feeling uncomfortable with the hospital institution.

We're often treated as if we just waltzed into the hospital, having attached ourselves to an unsuspecting couple, just to wreak havoc in the obstetric ward. In reality, we are sought out, requested, paid for, turned to for emotional support and bouncing ideas off, and at the end the relationship are very often told, "we couldn't have had this experience without you." This does not mean our clients were not grateful for their medical care. It just means they are so glad they got that saline lock instead of an IV with a pole so they could be mobile (which often is not offered...it's asked for by us or our clients), or that when everyone was telling them they should have an epidural, our voice illuminated the possibility of getting to the end on their own steam. The medical procedures that occur with a woman who wanted a natural birth are usually secondary in a new mother's experience to how she felt she was treated.

I try hard in my doula career to come into the birthing room as clear as possible every time, letting go of past traumas and challenges. I try to always let bygones be bygones, and stay focused on the task at hand to help the woman I'm with according to HER needs. If a doctor or nurse has in the past been burned by bad doula behaviour, I would appreciate not having that effect turn me into the cause of this particular patient's "non-compliance". I do not take past TERRIBLE things I may have seen and hate the medical system for it. My gratitude for Medicine to diagnose and intervene with complications is profound, and the bad behaviour of some of its practitioners will not kill my respect for it nor the women who choose this institution within which to give birth.

The truth is that doulas and medical practitioners working together represent to most women in our North American birth culture the best of both worlds for their birth experience. It behooves us to foster respect and compassion for each other.

If you'd like a little entertainment, check out the actual song I'm referring to, just for fun!

"Effect and Cause" The White Stripes