HOLDING THE SPACE: THE REEMERGING ROLE OF THE DOULA

A thesis submitted to the faculty of San Francisco State University In partial fulfillment of the requirements for A5 the Degree

Master of Arts

In

Anthropology

by

Jessica Rae Schmonsky

San Francisco, California

Spring 2016 Copyright by Jessica Rae Schmonsky 2016 CERTIFICATION OF APPROVAL

I certify that I have read Holding the Space: the Reemerging Role of the Doula by Jessica

Rae Schmonsky, and that in my opinion this work meets the criteria for approving a thesis submitted in partial fulfillment of the requirement for the degree (Master of Arts:

Anthropology at San Francisco State University.

res Quesada, PhD Professor of Anthropology

Mark Griffin, PhD Professor of Anthropology HOLDING THE SPACE: THE REEMERGING ROLE OF THE DOULA

Jessica Rae Schmonsky San Francisco, California 2016

With the ongoing medicalization of birth in the United States, many are not receiving the kind of care they should be afforded. Despite the large amount of money the United

States spends on healthcare, birth outcomes are suboptimal in comparison to other industrialized countries. In addition to health disparities based on class, race, ethnicity, language barriers, gender and sexual orientation, the reason for poor birth outcomes in the US has to do with the highly technological rigor with which medicine is practiced which has created a social or emotional absence within obstetrics. Doulas, non medically trained birth companions, are helping to fill this void because the nature of their work involves emotional, social, physical, support, before, during and after birth. I argue that in filling this void, doulas act as agents of social change in that they are ushering in a new way to “do” birth while also being concerned with feminist issues, reproductive rights, and hindrances in accessibility to good quality care.

I certify that the abstract is a correct representation of the content of this thesis PREFACE AND/OR ACKNOWLEDGEMENTS

I would like to express my sincere appreciation to my thesis advisor, Dr. James Quesada, and committee member Dr. Mark Griffin for their input and guidance throughout this process, as well as the San Francisco State Anthropology department for granting me the opportunity to complete this degree, and graduate studies for their patience. I would especially like to acknowledge all of the doulas and doula clients who took the time to sit down with me to be interviewed.

When I began this process I knew next to nothing about childbirth, but in encountering various individuals, communities and resources, I now hold and cherish a very important and relevant breadth of knowledge. I continue to be blown away by the tenacity, grace and empathy that birth workers constantly maintain and feel humbled to have been a minute part of this ongoing process to transform birth and maternal healthcare. TABLE OF CONTENTS

Introduction: Understanding Mainstream American Births...... 1

Chapter 1: The doula: the Professionalization of an Ancient Practice...... 8

Chapter 2: The Medicalization of Birth: Foundations and Formations...... 19

Chapter 3: “Standard Care”: Birth Outcomes With Medicalizaed Birth...... 41

Chapter 4: Birth as a Biosocial Event: the Evolutions of Alternative Birth Models...... 65

Chapter 5: Birth Outcomes with Continuous Social and Emotional Support in Labor.... 83

Chapter 6: Doulas as Agents of Social Change: Expanding to a Reproductive Justice Model...... 101

Chapter 7: Discussion: Birth as Symbol for Society, Identifying Potential Problems with Doula work, Questions for Further Study...... 112

Bibliography...... 117 1

INTRODUCTION: UNDERSTANDING MAINSTREAM AMERICAN BIRTH

In 2014,1 went to a doula training and was surrounded by like-minded women who shared in both a curiosity of the body and birth processes as well as a concerned interest in the political and social underpinnings to maternal health. I took the training for educational purposes, but found myself personally and emotionally affected by what I learned. I also felt inspired in learning about the kind of work that many birth workers employ. In learning about actual physiological perspectives, standard hospital practices as well as alternative methods, I was better able to understand the harsh realities that women giving birth in the United States often face. Even women who can afford the best in- hospital care still might have traumatic experiences or suboptimal birth outcomes. I discovered many injustices and asked myself, how could so many professional, educated experts be disinclined to stop practices that have been proven to have poor outcomes for women? And why didn’t these experts seem to listen to women’s opinions and grievances?’

Societal mainstream views towards childbirth in the United States generally adhere to highly scientific and technocratic values. Birth is medicalized, or pathologized like a disease in dire need of intervention. This outlook has over time led to the prevalence of invasive procedures that can often lead to negative birth outcomes, both physically and emotionally. In Robbie Davis Floyd’s book, Birth an American Rite of

Passage (2003), she outlines “standard obstetrical procedures” from when a laboring woman first enters a hospital, to after her baby is bom. She mentions over 10 procedures 2

that commonly occur during birth in hospitals, ranging from being consistently hooked up to an IV, to an epidural. While these tests and medical procedures are important in emergency situations, not every birth is an emergency, and births often become emergencies needlessly because of a lack of care to women’s emotional states.

Often these standard procedures snowball, from one intervention leading to another. Of the most well-known and invasive procedures are Cesarean deliveries and epidurals. While the existence of either technology should not be taken for granted because of their life saving capabilities, the staggering increase in their usage is alarming.

In 2008,61 percent of women who had a vaginal delivery received an epidural (Osterman and Martin 2011) and a 2006 study concluded that epidural usage resulted in a higher instance of Cesarean deliveries, as well as being known to cause increased labor, fever, and serious perineal tears (Klein 2006). Cesarean delivery was the most frequently performed surgical procedure in U.S. hospitals in 2006, and the rate of Cesarean delivery rose by 53% from 1996 to 2007, more than any other industrialized country (Menacaker and Hamilton 2010).

Essentially, there is a systematized overuse of medical and technological practices, which could be referred to as medicalization, or a bio-technological model for care. Within this model there is a lack of attention paid to the impacts of emotional and social aspects of care, as well as a devaluing of women’s own bodily knowledge, all of which is the result of an overarching cultural narrative. Monica Campo (2010) explains:

Childbirth therefore, has been conceptualized within a biomedical framework of risk and

pathology and perceived as best overseen by experts in hospitals where the emotional and 3

psychological process of birth, and women's embodied knowledge, is devalued in favor of a

professionally managed mass-production system compatible with industrial capitalist culture”

(Campo 2010: 22).

According to a 2010 Amnesty International study, titled “Deadly Delivery,” the United

States spends more on healthcare than any other country in the world, and hospitalizations related to childbirth make up the highest hospitalization costs of any area of medicine (Amnesty 2010: 1). Despite these high costs and advances in medicine, giving birth in the United States falls short of global standards, as evidenced by complications and maternal mortality rates: “more than a third of all women who give birth in the U.S. experience some type of complication that has an adverse effect on their health” while “maternal mortality ratios have increased from 6.6 deaths per 100,000 live births in 1987 to 13.3 deaths per 100,000 live births in 2006 (Amnesty 2010:1). The

Amnesty study focuses specifically on how maternal health has suffered over the years by emphasizing health disparities based on race, class or ethnicity, when, for instance,

African-American women are four times more likely to die from complications during childbirth than white women (Amnesty 2010:1).

More and more studies are linking social and emotional support with more positive birth outcomes. As such, continuous labor support has been widely recognized to be beneficial to women by reducing instances of Cesarean deliveries, the length of labor, 4

the need for epidurals, and raising Apgar scores1 (Beets 2014:1). Furthermore, these outcomes have been seen to be the most beneficial when continuous labor support is given by someone whose only role is to provide labor support (someone other than a nurse or midwife) and someone who is not in the woman’s social network, and has some experience and training (Beets 2014: 1). In the United States this person is known as a doula. Doulas seek to “hold the space” - a common term I learned in my doula training, which means creating an intimate and comfortable environment for women giving birth.

Doula tend to birthing women’s emotional and physical needs, while also helping to support her partner and/or family, helping her navigate the healthcare system and acting as an advocate.

Focus and Methods

The focus of this research is on doulas that practice in hospitals, as the majority of women in the U.S. now give birth in hospitals and are therefore more vulnerable to a technocratic model of birth involving invasive procedures and lack of emotional, social and physical support. Labor units in hospitals can be seen as a site for potential harm and disempowerment. However, this can be mitigated with the presence of doulas, serving not only as labor companions but also agents of social change (Basile 2012). Doulas are shifting the way birth is regarded as well as ushering in safer and more satisfying

1 Apgar is a term for assessment made after the baby is bom to determine how healthy the baby is and if there is need for additional medical assistance. It is an acronym for Appearance, Pulse, Grimace, Activity, and Respiration. 5

alternatives for in-hospital births, bridging popular ideologies that include more “natural” approaches to birth while also utilizing modem medical interventions if necessary.

Pregnant women and new mothers are also ushering in changes, as there has been a burgeoning demand for this kind of care. In fact, women, as consumers and activists, have long been shaping the childbirth landscape (Morton 2002: 83-85). The use of doulas has been proliferating across the globe in the last few years (Steel 2014: 2), but the San

Francisco Bay Area is an interesting and revealing region for this kind of study because doulas here are ubiquitous compared to other areas in the country. When I sought to do doula training, I found many options across the entire Bay Area, with courses filling up fast. The trainings, while ubiquitous, cost upwards to $500 dollars.

This leads to some interesting questions pertaining to accessibility and knowledge about doulas in the first place. Since women likely would want doulas that are part of their community and share their language, ideas or motivations, what does it mean if only some women can be trained as doulas? Who gets to benefit from this kind of birth work and why? And what does the growing emergence of doula care in hospital settings reveal about the current state of obstetrics as well as shifting cultural views towards childbirth in the United States? In a country that is so wealthy and technologically advanced, why do we continue to see disparaging statistics and conditions for childbirth? How are doulas successfully or unsuccessfully changing these conditions? How do factors like race, class, immigration status or language barriers, age, sexual orientation, and geographic locales contribute to barriers in care? I will argue that while doulas are filling this social and 6

emotional void within obstetrics, being valuable assets to childbirth communities across the country and challenging entrenched norms, the scope of their practice is currently shaped by socio-cultural, economic and bureaucratic forces.

Methodology and Organization o f Research

The literature on the use of doulas has mainly pertained to identifying positive birth outcomes with the use of doulas (Sosa et. al. 1980, Pascali-Bonaro and Kroeger

2004, McGrath and Kennell 2008, Hunter 2012, Beets 2014), pointing to how they should be a welcomed addition to the medical institution. Research has also focused on how doulas can act as agents of social change (Basile 2012), as educators and advocates

(Hunter 2007, Morton 2002), as well as the more economic aspects of doula work (Torres

2012). However, the majority of ethnographic research that is specific to doula work has been limited to focusing on doulas experiences (Morton 2002, Basile 2012). My research incorporates the struggles and experiences doulas have with client experiences and reflections, in order to paint a fuller picture of the role of the doula, the benefits of doula work, as well as presenting social, cultural and economic limitations or challenges to the future of doula work.

Building off of existing literature, my research is based on my participant observation in a San Francisco Bay Area doula training and interviews. Doulas and clients are not recruited as dyads. I conducted informal, semi-structured interviews with six doulas that practice in hospitals around the Bay Area as well as six doula clients who 7

had at least one birth with a doula in a hospital. I recruited doulas and clients by sending out recruitment letters to various organizations, social media groups and list serves. The participants, both doulas and clients, were mostly white, middle class, educated women and were practicing or birthing all across the San Francisco Bay Area, reflecting a relative homogeneity within the Bay Area doula network. One doula was a person of color; one doula client was lower income. Two people were both doula and client: one was recruited as a client and it was revealed she was beginning her certification process; one was recruited as a doula that was also pregnant and intended to use a doula.

Doula clients tended to be well educated and were all knowledgeable about birth and standard hospital procedures, along with critiques or concerns of said procedures. In other words, all wanted less invasive births, indicating that they had sufficient access to this information about the potential problems of medicalized birth through their own research, occupations or education, connections, childbirth education classes or other resources. Many of the clients interviewed had expressed that they chose a doula either because of a previous negative experience, or a preconceived fear, that prompted them to look into alternatives, or because it had been recommended by a friend or family member.

In Chapter One, I will more fully outline the role of a doula, chronicling the history of the role, leading into doula roles and a doula typology. Chapter Two outlines the medicalization of birth. I start with the scientific revolution to draw on key themes within Western views towards the body and medicine, drawing on the mind-body split, as 8

well as discussing the capitalistic underpinnings of the American medical system, specifically obstetrics. I also outline the role of midwifery within a modem birthing context elucidating how political values are wrapped up in how birth is perceived.

Chapter Three goes on to present the literature on birth outcomes with medicalized birth, pointing to both empirical studies and ethnographic studies, which draw on emotional and physical outcomes. Chapter Four presents the history and evolution of alternative birth models. I open this chapter by describing how employing a biosocial perspective

(Jordan 1997) of birth can allow for more nuanced perspectives, which have led to various waves of feminist and childbirth discourse in the past. I also discuss the production of knowledge within these discourses. Chapter Five describes, empirically and ethnographically, what the birth outcomes are with this kind of model, drawing heavily on my own research. Chapter Six discusses the expanded role of the doula as an agent of social change, discussing feminism, intersectionality and community organizations.

Chapter Seven concludes my research by discussing potential problems and areas for future discussion and research.

CHAPTER ONE: THE DOULA: PROFESSIONALIZING AN ANCIENT PRACTICE

In Greek doula means woman caregiver (DONA International 2012:1.1), but the word is now used to describe a labor companion who provides the laboring woman and her partner with continuous emotional and physical support as well as helping them to find information necessary to make informed decisions before, during and after birth. A 9

doula does not perform clinical tasks like a midwife or obstetrician, whose role is to safely help deliver the baby. Instead, a doula’s role is to be beside the woman to support and comfort her, no matter what ends up happening. Doulas are supposed to remain

“neutral” in that they do not make decisions for their clients, they do not project their opinions, values or ideas onto the laboring woman.

While, historically women have been taken care of by other women throughout the whole childbirth experience, usually by friends or family members, the use of doulas as a formally constructed role has been proliferating in the last few decades as women have begun challenging and questioning childbirth practices within hospitals. In 1973, an

American anthropologist named Dana Raphael coined the term doula in her book,

Tender Gift: Breastfeeding, to mean a woman who provides postnatal care

(Koumoutizes-Douvia 2006: 34). Her definition of a doula was “one or more individuals, often female, who give psychological encouragement and physical assistance to the newly delivered baby and mother” (Basile 2012: 22). This definition expanded after pediatricians Marshall Klaus and John Kennell were researching mother-infant bonding and quite accidently discovered that having a doula, or support person in the room not only improved mother-infant bonding but also contributed to a decrease in complications

(Sosa et. al. 1980).

Accordingly, doula began to be colloquially referred to as someone who supported women before, during and after labor. As Kennell and Klaus continued their research, women who had been already been attending births as helpers or educators 10

began to find definition for their work (Basile 2012: 22). Subsequently, in 1988, Penny

Simkin, who trained doulas and published a book called Birth Partner (1989), formed the Pacific Association for Labor Support (PALS). Both Penny and her book continue to make significant contributions to doula trainings across North America. In

1992, Doulas of North America (DONA) became the first certifying organization for doulas with many more having been established since then2.

Doulas practice across the whole childbirth spectrum, being present both at homebirths with midwives and hospitals with obstetricians and nurses (and now for abortions, which I will detail in Chapter six). In general, doulas either work independently or in partnerships or collectives, in which they set their own fees

(sometimes on a sliding scale, or with payment plan options) or are part of a hospital/community doula program, which are typically on a volunteer basis. New doulas often work in volunteer hospital programs to gain experience and complete their training; many then go on to become fee-for-service doulas. There are few insurance companies that might reimburse doula care, but this is a very new phenomenon and is not at all standard for typical doula care, which tends not to be institutionally compensated work.

Doula trainings typically involve intense weekend long events where doulas learn about the physiology of childbirth itself, learn about and practicing comfort techniques, as well as ethics, responsibilities, and the business aspects of their endeavors. After their trainings there is a series of requirements to become fully certified which, depending on

2 Though, some doulas consider themselves as doulas, and practice as doulas, without ever getting certification. These doulas were not considered for this study. 11

the certifying institution includes: a reading list with five books, completion of the basic knowledge assessment tool, completion of a breastfeeding education course, a childbirth education class (or prior experience working with midwives or in labor and delivery), birth support to at least 3 clients (after attending a training), submitted copies of good evaluations from 3 mothers, and 3 primary care providers, documentation of said births, the production of a resource list with at least 45 resources for clients, a 500-1000 word essay, and two character references (DONA 2012:2.13).

Doulas meet with clients prenatally to discuss their client’s options, preferences or concerns, and then once labor begins the doula is called when the woman or her partners asks. The doula stays with her clients until after the birth and follows up with a post partum visit weeks later (there are also post partum doulas whose sole role is to help the new mother and her family adapt by bringing food, helping with any lactation issues and guiding family members on etiquette; the birth doula's post partum role is less extensive).

Obviously this means that the doula could be awakened during the middle of the night needing to get to a hospital immediately. This also means that during this time, doulas cannot vacation, drink much alcohol or “party”, and have to be willing to miss their loved one’s birthday parties, sporting events or anniversaries. This can have an effect on doulas’ ability to care for themselves (or others in their family), since they can potentially work 24 hour plus shifts. Often doulas will work intensely like this for months on end, taking long vacations if they can in between. Because of the unexpected nature of life, 12

with illness and family emergencies, some doulas have “back up” doulas that can step in, in case a doula had another birth to attend or a personal manner to attend to.

As I outline in the next chapter, doulas often struggle to set wages that are both fair for them and their clients. And, since they work independently, separate from hospitals or institutions, they often don’t have the ability to accept health insurance coverage plans. In the San Francisco Bay Area, a doula can expect to be paid anywhere from $500 to $2,500 for their services. As well, doula trainings themselves are often costly, limiting who gets to become a doula. In other words, because of how the system currently functions, becoming a doula may not be an equal opportunity endeavor as trainings and setting up your business as a doula would require time and money up front, not to mention the intense commitment doulas have to make in terms of being on call.

These factors, and others, making becoming a doula problematic and will be fleshed out throughout this thesis.

Who arethe Doulas?

In 2002, Christine Morton wrote her dissertation on the reemerging role of doulas in the United States, presenting the typical doula as white, married, with children, likely to have a college degree, is “passionate about how birth can be an empowering and positive experience for women”, and “may or may not be a self-declared feminist”

(Morton 2002:188). Most of the doulas in my study were white women with some degree of higher education. Many of the women both in my research and in my doula 13

training were young women, which I think is indicative of a larger trend amongst newer generations towards reproductive justice issues, the reemergence of women’s movements, as well as the glamorization or popularization of identifying as a feminist within popular culture.

Sister friend, Mama Bear, Science Doula and the Radical Doula

Many people, upon hearing what I was researching, assumed that doulas were like midwives, and/or that midwives and therefore doulas, are hippie-witch-goddesses, chanting barefoot while dispensing magical elixirs to naked laboring women. While certainly some women might wish to birth like that, the alternative childbirth movement has come a long way since its associations with “natural” birth and hippie-goddess connotations. Doulas, like their clients, are of varying “types”. It was interesting to have doulas themselves lay out a sort of typology in our interviews.

When I talked to Lauren, who actually filled in for her mom, a doula, when she could not be interviewed at the time, she self identified as a “sister-friend” kind of doula, when I asked her to elaborate she explained:

3 Many influential celebrities, like Beyonce, Emma Watson and Taylor Swift, have popularized “feminist” and the term is used ubiquitously in popular culture as of late. In 2014 TIME magazine posted a list of words that should be banned in 2015 because of their overuse, and feminist was on it. The point they tried to make was that the word was overused and that it may have been used in non-accurate or non-genuine ways due to pop culture associations. They have since included an editor’s note: TIME apologizes for the execution of this poll; the word ‘feminist’ should not have been included in a list of words to ban. While we meant to invite debate about some ways the word was used this year, that nuance was lost, and we regret that its inclusion has become a distraction from the important debate over equality and justice. 14

Most of my clients are first time moms, who are of course excited but also just a little nervous and

want some validation... and so, I think that, that kind of sister-ffiend role, but with good

experience, can kind of help serve that purpose... the sister friend role is maybe a little bit more

practical, and less ooey gooey, less motherly, and that is my personality style too, I’m not, like,

super hippie-earth-goddess (laughs), so I think I tend to attract those kind of clients as well, which

might be a little more different than a super motherly type.

Interestingly, Lauren contrasted her doula style with her mom, Cynthia, by saying that she was more of a “mama-bear” type of doula: “some women are looking for more of a mother figure, and I’m not really going to suit that, but my mom, she’s perfect for that, she’s got that vibe completely; me, not so much.” She described her role not only in terms of her personality but what she thought she could realistically provide her potential clients. Being young and childless, she implied that she literally could not take on the

“mama bear” role. Her mentioning of attracting clients that want more of a “sister-ffiend” or “practical” approach to birth, to me implies a growing trend in doula care: to appeal to all women, not just women who want an “ooey gooey”, “natural” kind of birth, which is often associated with “alternative” birth models.

Other types of doulas, in the same vein, are moving away from this “hippie goddess” association. I interviewed Courtney, who was very much into science, earning three associates degrees in social and behavioral science, science and math, and science and biological science; she is also a certified EMT. She was a doula client that had become so inspired that she decided to become a doula as well. When we spoke she was pretty far along in her certification. To her, science was very much wrapped up in her 15

approach to doula work, and during her birth experience as well, as she was able to track her own biological processes. When I asked her what the most important roles or qualities of a doula were she said:

Number one is education. My husband jokingly calls me the science doula... there are a few doula

stereotypes one being the super hippie and the other being the super science geek, and I sadly, just

fit that stereotype. I’m not usually all about stereotypes but if you provide education, you explain,

you know, this is what happens in these stages, then you can help mitigate some fear.

While most doulas are focused solely on their craft, educating themselves and supporting mothers, other doulas are more political and may think of themselves as “radical doulas”.

My first interview was with Jo, who identified as a Latin@4, and who did birth work with queer people and people of color. Jo mentioned that most of the doulas Jo worked with are diverse and more politically minded. Jo was very passionate about being focused on the importance of accessibility, and doulas working with women they can relate to. In describing Jo’s doula training, Jo said:

When you talk about access, and getting access to doulas, most doulas are going to be sort of this,

white volunteer person, who has the time and access and capability to be a doula.

Here Jo is describing again how most doulas are white and middle to upper income, with an ability to spend the time and money that is needed to become certified. They also tend to serve women of a similar socioeconomic status. Jo goes on to relay how important diversity is in order to reach the whole birthing population:

...And its super important for your doula to look like you, talk like you; speak your language and

all of that. They’re there for your really intimate moments and you want them to connect with you

4 Latin@ is a gender-neutral term for people with Latin American roots. 16

like that. And so what’s also really powerful about the training, is that we have mainly black folks,

a couple Latinas, quite a few queer folks, and one trans identified person3, and that like, just that

hodge-podge of people is super important to all the type of folks that are giving birth.

When I asked Jo if it was an obstacle that not all birth workers were so social justice oriented:

I don’t know, I guess, I wish everyone was social justice oriented, whether they’re a doula or

not... I feel like there is a responsibility and accountability that you as a person need to understand

when you’re embarking on something like this. [...] I think it’s really important for people who

have privilege to be really curious and forthcoming with finding answers.

Jo’s point of view as a doula is very much guided by intersectionalist issues that concern race, gender, class, sexuality and ethnicity. In this way Jo incorporates social justice issues into birth work, however, Jo does not self-identify as a radical doula as many other doulas might. I will outline more in Chapter Six the various ways doulas work towards social change to varying degrees.

“Bag of Tricks Doula Roles and Techniques

Doulas take on various roles before, during and after birth. Prenatally, doulas act as educators and “translators” as they educate women about their choices and help them break down hospital jargon. As far as their tasks during labor, they are vast and depend on the woman in need. Some women don’t really want to be touched, some women don’t really want noise or some women might want to learn and practice different breathing

5 It should be noted that while I recognize that not all people who give birth self-identify as women, for the purposes of this research I will use gendered words like women, female, and mother to denote pregnant and parturient (laboring) persons. 17

methods. During birth, all doulas act as advocates for laboring women and support them in anyway they can, physically and emotionally. Doulas have a vast “bag of tricks,” or a multitude of props or techniques that they apply.

The DONA International Birth Doula Manual (2012) lists components to emotional care that doulas should provide, they include: continuous uninterrupted presence, knowledge and understanding of emotions and physiology of labor, experience with other laboring women, ability to remain calm/objective, perspective on problems and options, advocacy of mother’s wishes or goals, freedom from obligations, other patients, tasks, clinical management, hospital/MD practices and knowledge of comfort measures (DONA 2012 1.2).

Comfort measures that are physical, social and emotional can include: massage, aromatherapy, hot and cold packs, acupressure, emotional support by way of verbal reassurance (“you’re doing great”), music, different positioning or reminding client to ask questions about a procedure that differs from her wishes. Doulas also refer clients to resources on general information regarding questions, reminding a client tactfully if their birth plan might need to change, and requesting help or advice from medical staff if need be (DONA 2012: 2.8).

Doulas have to understand when and how to suggest things. For instance, a doula should never put music on or use aromatherapy unless they first ask the woman/couple.

Doulas might disagree on different techniques but each doula over time will figure out what has and has not worked and will adjust. For instance, some come ready with music 18

machines, essential oils, snacks, birth balls, fans, etc. Many doulas have a designated doula bag, which already has everything they need so that when a birth occurs they are ready. This includes things like a change of clothing, cell phone charger, and toothbrush, to name a few, given that doulas often work long and unpredictable shifts, and also require a relative amount of self care to stay alert and supportive for their clients. For long labors, doulas will often, with the permission of their clients, find a quiet place to rest or nap in the hospital while the mother does the same.

Postnatal visits might require a need for social support, as far as explaining to loved ones what might be appropriate and what might be helpful for new parents. Post partum visits might also include helping the family with their children so that they can rest, bringing nourishing foods, or recommending a lactation consultant for breastfeeding issues or a specialist to deal with post partum depression if need be. Many doulas do placenta encapsulation as well, which involves cooking, dehydrating and encapsulating the placenta, which many within the community feel is beneficial. However, this is a contentious issue and some doulas I spoke with mentioned having to “smuggle” placentas out of hospitals for their clients. Sometimes there are conflicts with hospital staff, while other times doulas and hospital staff work very well together.

Overall, a doula’s main goal is to provide continuous support throughout the whole birth process so that the laboring and new mother can comfortably and confidently take on this huge, life altering transition. Doulas act as advocates and educators through their emotionally and socially supportive roles. 19

CHAPTER TWO: THE MEDICALIZATION OF BIRTH: FOUNDATIONS AND FORMATIONS

Medical anthropologists, sociologists and historians have long chronicled the ways in which our everyday lives have become medicalized. Medicalization can be described as a process by which problems that were once seen as nonmedical are now defined and treated as medical problems (Conrad 1992: 210). Sociologist K.K. Barker refers to Western medicine as having “cultural authority,” and she explains, “medicine’s cultural authority is not dependent on efficacy alone, but on the ability to reconceptualize a phenomenon as ‘medical’ and an acceptance of that conceptualization by the public”

(Barker 1998: 1067). With this acceptance, social and political agendas can thrive under the guise of scientific universalism (Barker 1998). In terms of childbirth, medicalization means that childbirth itself is always seen as a medical event (even with a healthy pregnancy), that women’s bodily knowledge is not as “useful” or “important” as a trained professional’s knowledge, and that women’s emotional and mental state is separate from physical birth outcomes. These themes are deeply rooted in Western intellectual history.

The Scientific Revolution and the Mind-Body Split

Inherent within medicalization is a split between the mind and body. This can come as no surprise as many of America’s values stem from worldviews established during the Scientific Revolution when developments in the math and sciences proliferated. Most notably, during that time Rene Descartes ushered in a new way of 20

thinking in which internal processes like thinking, feeling, experience, spirit and consciousness, were separate from the external world of matter, objects and the physical body. Cultural historian Richard Tamas states: . .all objects of the physical world lack subjective awareness, purpose, or spirit...Rather, as purely material objects, all physical phenomena can in essence be comprehended as machines” (Tamas 1991:278). As bodies, separate from the human spirit, began to be seen as machines, the spirit, or the mind, was seen as being prone to error or fantastical illusions. The physical and measurable world became a beacon for understanding the universe’s greatest mysteries, and Descartes thought the most assured way to understanding the universe was the use of mathematics (Tamas 1991: 278). To back up his metaphysics and epistemology,

Descartes concluded that no scientist should focus on qualities that appeal only to sense perception, which could be distorted by the human mind, and instead they should focus on objective qualities that could be analyzed in quantitative terms such as shape, size, duration, number (Tamas 1991:279). Authority then became more closely associated with human reason as opposed to Holy Scripture, and science flourished as a means of analyzing the world separate from God, untainted by subjective, spiritual qualities.

Today, we see this Cartesian legacy mirrored in many facets of our everyday lives, including biomedicine. In Nancy Scheper-Hughes and Margaret Lock’s (1987)

“The Mindful Body” they chronicle this dualism in Western biomedicine by pointing to common viewpoints among clinicians. In one example, when medical students were presented with a woman who was suffering from chronic headaches, while also learning 21

that she had been suffering from domestic abuse, as well as other sources of stress at home, the students were sympathetic but still puzzled. One student demanded to know what the real cause of her headaches was:

“The medical student, like many of her classmates, interpreted the stream of social information as

extraneous and irrelevant to the real biomedical diagnosis. She wanted information on the neuro­

chemical changes, which she understood as constituting the true casual explanation. This kind of

radically materialist thinking, characteristic of clinical biomedicine, is the product of a Western

epistemology extending as far back as Aristotle’s starkly biological view of the human soul in De

Anima.” (Scheper-Hughes, 1987: 8)

Despite the sciences eventually coming around to partially reuniting the mind and body through psychological and social sciences, biomedicine still struggles to break free of this

Cartesian legacy, namely with an inability to treat the whole person, or to see the issues they study in wholes.

In an effort to be objective, biomedicine misses a world of opportunity to more fully understand a given situation while often times ignoring political and social intersections that innately underlie the words, actions or even symptoms of everyone. The assumption that a highly quantified maneuvering of realities is the only way to understand what’s real does a disservice to doctors and patients alike. As Claire

Wendland states in “Vanishing Mother,” “objective or “neutral” knowledge is dominant knowledge disguised” (Wendland 2007:226) and “only when our vaunted scientific objectivity is critically reconfigured as a powerful, valuable, fallible, and partial contributor to medical knowledge can the imagined neutrality of medical research be 22

confronted effectively, allowing other suppressed evidence to be brought to light”

(Wendland 2007: 227). Therefore, in paying mind to how knowledge is produced and how it is wrapped up in systems of power, allows for more critical awareness of how these authoritative structures can shape childbirth practices.

Authoritative Knowledge and Control

Brigitte Jordan (1997), an anthropologist and one of the first to write about childbirth discusses systems of power and knowledge in an essay “Authoritative

Knowledge and its Construction.” She explains that within any given domain, several knowledge systems exist, though some carry more weight than others in two primary ways: “they can explain the state of the world better for the purposes at hand (efficacy)” or “they are associated with a stronger power base (structural superiority)”, but usually its both (Jordan 1997: 56). In this way, we can see how knowledge is produced in terms of power relations.

Jordan recounts Paul Starr’s account of the historical transformation of authoritative knowledge within medicine in the US. Well into the 20th century, medicine was embedded within a pluralistic system in which the knowledge of folk healers of various kinds, midwives and other empirically founded practitioners was given authority by different parts of the population. Though eventually, allopathic professional knowledge became the dominant form of knowledge, giving this newly formed medical profession cultural authority (Jordan 1997: 57). Authoritative knowledge is just what it 23

sounds like: knowledge that is construed as having authority or power over individual actions and choices. So in essence, this trust in a particular knowledge isn’t based on objective knowledge, or “facts” but on culture, though it is seen as “natural, legitimate, and in the best interest of all parties,” what Bourdieu and Passeron (1977) refer to as

“misrecognition” (Jordan 1997: 57). Jordan continues:

Authoritative knowledge is persuasive because it seems natural, reasonable and consensually

constructed. For the same reason it also carries the possibility of powerful sanctions, ranging from

exclusions from the social group to physical coerciveness. Generally however, people do not only

accept authoritative knowledge but also are actively and unselfconsciously engaged in its routine

production and reproduction.

It is important to realize that to identify a body of knowledge as authoritative speaks, for us as

analysts, in no way to the correctness of that knowledge. Rather, the label “authoritative” is

intended to draw attention to its status within a particular social group and to the work it does in

maintaining the group’s definition of morality and rationality. The power o f authoritative

knowledge is not that it is correct but that it counts

In childbirth, authoritative knowledge is wrapped up in American values of technology and science, and often a hierarchy is created in which doctors and professionals, mostly male, are the authority, and women’s bodily knowledge is disregarded as well as their right to informed decision making. I will discuss authoritative knowledge in more detail in the next chapter, highlighting women’s personal experiences from my interviews. 24

Biopower and W o m e n ’sBodies as Machines

The medicalization of birth, stemming from a mind-body dualism, has resulted in the creation of a risk-based discourse that values rationality and control and manipulation of natural functions, so that physicians and the institutions they inhabit, have the ultimate authority. Through this “medical gaze,” a term coined by Michel Foucault to denote the gaze a physician has upon their patients, which is devoid of identity or personhood as knowledge is acquired based solely on physiology (Foucault 1975). Through this gaze, social or cultural influences are ignored. The patient is not being measured or observed based on the totality of their being, but in the totality of a collection of the patient’s quantified states. In other words, patients are treated more in terms of preexisting quantitative information that has been measured over time, as opposed to being treated more in terms of what is happening on all levels at that time in the patient’s life, i.e. psychological or social conditions in addition to physical ailments.

The medical gaze positions the patient in terms of what is normal or average based off of medical histories: “but its support was not the perception of the patient in his singularity, but a collective consciousness, with all the information that intersects in it,

growing in a complex, ever-proliferating way until it finally achieves the dimensions of a history, a geography, a state” (Foucault 1975: 29). Essentially, through this medical gaze, not only is subjective (and therefore undervalued) knowledge lost, but patients’ bodies are controlled and turned into the kind of body society wants, one that is institutionalized,

since this institutionalization is obviously beneficial for institutions and the people who 25

wield power within them (Goodman 2007: 619). Through this gaze, childbirth specifically, can be seen as a disease, a pathological abnormality that must be monitored and intervened upon.

Going back again through history, as Robbie Davis Floyd (2003) has pointed out, this medicalized worldview that began to take shape during the Scientific Revolution, aligned perfectly with our already existing belief in our right to dominate nature (written in Genesis), and the human body soon became viewed like a machine “composed of interchangeable atomized parts” that could be fixed or replaced from the outside (Davis-

Floyd 2003 44). Western medicine thusly became mechanistic and the tendency to dominate, control or suppress nature (to include human bodies) still resonates.

In her essay, Isfemale to male as nature is to culture? Sherry Ortner draws the link between women as embodying nature, and men embodying culture;

Woman’s body seems to doom her to mere reproduction of life; the male, in contrast, lacking

natural creative functions, must (or has the opportunity to) assert his creativity externally,

“artificially,” through the medium of technology and symbols. In doing so, he creates relatively

lasting, eternal, transcendent objects, while the woman creates only perishables—human beings”

(Ortner 1974:337).

In pointing to what she calls a “universal devaluation of women” Ortner shows how women are symbolically linked to nature or biology because of their reproductive roles, and since “it has always been culture’s project to subsume and transcend nature” women would therefore be considered part of nature, where culture would subordinate them

(Ortner 1974: 351). With this view, women’s bodies are vulnerable to domination and 26

control. Specifically in terms of childbirth, the female body on its own is seen as unable to be trusted (like nature) and must be mitigated by cultural, technological and symbolically male interventions that are valued over natural biological processes. In turn, the female body is especially primed for the body as machine metaphor, to be surveyed and controlled.

An additional view of the body as machine, male/female, nature/culture nexus is that not only is the human body rendered machine like, and women’s body inferior, but that the male body is the prototype machine and that “from the male standard, the female body was regarded as abnormal, inherently defective and dangerously under the influence of nature, which due to its unpredictability and its occasional monstrosities, was itself regarded as inherently defective and in need of constant manipulation by man (Davis

Floyd 2003: 51). Obstetrics then became geared towards the control and manipulation of the process of birth.

This idea of control and manipulation of bodies is part of another Foucauldian concept termed biopower, which can broadly be defined as a source of power that uses techniques or technologies for achieving the subjugation of bodies and the control and regulation of populations (Foucault 1990). In contrast to more overt forms of oppression gleaned throughout history such as medieval systems of rule, the formation of biopower situates oppression within the mechanisms of everyday life with the intention of propagating a certain norm, or way of life. As opposed to power built on the threat of ending lives, biopower, as an invisible socially constructed force, controls lives. It is the 27

modem democratic form of control in which a hegemonic way of life is sought to preserve overall health and prosperity for the population, while typically only serving elites or those in positions of power.

Biopower is essential for the development of capitalism. Since biopower is a means for controlling and sustaining lives, it lends itself to capitalist aims in that it turns the human body (specifically the female body) into a machine for production and the population at large into a machine for reproduction. Thus, women’s bodies, because of their reproductive functions, can be manipulated by social norms to uphold systems of power that enable certain people to make profits off of these actions. Childbirth much like everything else in the U.S. has become inextricably linked to capitalist values.

The Childbirth Industrial Complex: Commodification and Commercialization o f Care

These mechanistic themes of control were drawn out during the Scientific

Revolution and they were intensified during the Industrial Revolution, as the extended family was replaced by the nuclear family, in turn narrowing women’s spheres of activity

(Davis-Floyd 2003: 219). With this familial breakdown poorer women were limited to work in factories while upper class women were limited to their homes (Davis-Floyd

2003,219). Therefore, built-in supportive and care roles indicative of an extended family structure, were commodified and outsourced, placing limitations on the kind of care women could receive, especially poorer women. 28

Jennifer Torres (2014) succinctly outlines not only how care has been commercialized but how the kind of care received over time has changed, as well as how there is a “care crisis,” with more people needing care than giving care. Torres also highlights how care work is gendered. She explains that with industrialization and urbanization, families are “largely cut off from kinship circles and communities” with little help from the state, resulting in a “care gap” which we have used the market to fill

(Torres 2014: 2). This commercialization is part of a larger trend of commodifying labor.

While productive labor of goods moved into the market with the advent of industrialization, reproductive labor like care work remained in the home, to be given freely, until the second half of the 20th century (Torres 2014:2).

So while care work has been outsourced, it still remains relatively undervalued since it is gendered and for a long time thought to be “free” or taken for granted work.

With scientific and technological advances, specialized roles and “expert” knowledge

(authoritative knowledge), the meaning of good care has transformed so that the care provided in hospitals and by physicians is different from what was once provided in the home (Torres 2014: 2). This kind of care is seen as superior, and the norm. This commodification and commercialization of care was made possible with the medicalization of care (and specifically childbirth).

With the commercialization of care, institutions and businesses can dictate what kind of care is received and who receives it, as care is dependent on market forces.

Hospitals especially are big business; in 2008, hospitals were 5% of GDP (Thomasson 29

2008: 77). Many nations have universal health care but the US has left health care up to the market, which Goodman (2007) explains causes problems since “health care does not conform to traditional economic theories in the same way as non health related markets because of issues relating to information, authority, power, wealth and control. Health care markets are further complicated by the fact that consumers are dependent, vulnerable, naive and often unformed when it comes to their health” (Goodman 2007:

612). It therefore becomes easy for dominant groups to influence the state of healthcare for their own social, economic or political advancement.

Having care roles heavily dependent on capitalistic forces complicates the exchanges from caregiver to receiver, especially in terms of birth, and especially working outside of established institutions (like a doula would). For instance, some of the doulas I interviewed had difficulties trying to provide the care they wanted to, while also being compensated accordingly. Most doulas were flexible in setting their fees and tried to work within their client’s financial limitations, sometimes at their own detriment.

When I interviewed Cynthia, she spoke heavily about her difficulties with the business side of her work. She relayed that while she wanted to provide the best care she could to clients, while also making it affordable, she had to think about her needs as well, making things complicated, if not uncomfortable. At the time we spoke she was working out a fee system. Because of the unpredictability of labor, she wanted to set a bottom rate of $500 for a birth at or below 15 hours and a $1000 fee for births higher than 15 hours.

She had one couple that really wanted to hire her but they were unsure about the fee. 30

They didn’t want to have to worry, during labor, about staying below 15 hours. Cynthia emphatically understood:

I totally agreed. I wouldn’t want to be adding to that stress. But on the other hand I feel like I

have to respect myself and value my time, enough to not just be, like, giving it away for ten bucks

an hour. That’s really not reasonable. I don’t know, its kind of funky. People expect doulas to

work for nothing.

She expressed frustration, not towards her clients themselves, but with attempting to be fair to her clients and herself:

... I’m not begrudging it, just trying to respect myself. I didn’t come away feeling irritated or

angry, but I also feel like, because I’m in a healing, caring, compassionate field, doesn’t mean that

I’m only worth 10 dollars an hour? And I feel like that’s kind of disrespectful. Here I am talking to

women all day about valuing themselves, ya know, and being empowered by this experience, and

yet if I’m doing it in such a way that isn’t valuing and respecting myself and my own sense of

empowerment, right, that is just, I think that that kind of inconsistency is, I don’t know, it erodes

at your authenticity in a way.

Here Cynthia speaks not only to the delicate balance doulas have to maintain in being both business-minded and compassionate, but how care work in general is regarded. In an interview with another doula and midwife apprentice, Katelyn addressed similar issues.

We started talking about setting fees and the business aspects to the work and she explained how there is an online support group for local doulas and the most asked question is what doula fees should be: “its like, are they under valuing themselves because its their passion? Because of course they would do it for free.” 31

Katelyn does do payment plans and said that while she never lowers her rates, she will work with clients to pay what they can when they can. This comes along with another set of complications, namely doulas not getting their fees at all:

So I have a client who, it’s been a couple years, and she finally paid it off. And I know some

doulas that won’t attend births unless you’re paid in full, which I get, because I’ve had people

blow me off.

Somewhat shocked by this I asked what she had done in that situation, she said that since

“you have signed a contract, you could technically take them to a small claims court” but she just cuts her loses and moves on.

The same difficulties could be had for many other care provider roles that do work within institutions or businesses, such as day care workers, in which caregivers are paid very low wages but literally have children’s lives and wellbeing in their hands.

Riane Eisler (2007) aptly states in her book “The Real Wealth of Nations,” that the way care work is treated within our economy is pathological: “Not only is the work of care giving— without which there would be no workforce—given little support in the economic policy when its done in the home, [but] work that entails care giving is paid substandard wages in the market economy”.. .“people think nothing of paying plumbers, the people to whom we entrust our pipes $50-$60 per hour, but child care workers, the people to whom we entrust our children, are paid an average of $10 an hour according to the US

Department of Labor” (Eisler 2007:16).

Building on Viviana Zelizer’s (2005) observations, Torres attributes these complications to the “separate spheres ideologies” that construct dichotomies of 32

sentiment/rationality and intimacy/economy (Torres 2014: 4). Accordingly Torres comments on how gender is mapped onto these dichotomies as they are overlaid with private/public, woman/man and unskilled/skilled (Torres 2014:4). Care work is seen as belonging in the private sphere, which is also linked to femininity. So despite the fact that care work has been commodified, there is still an underlying expectation that this kind of work should be unpaid or that it is unskilled or lowly work, innately tied to women.

The crossing of economy and intimacy, a major condition of the medicalization of birth, not only creates a difficult situation for birth workers, but it also contributes to unequal access in care. I identify two major issues in terms of accessibility. The first has to do with healthcare in general in the United States in which many women (specifically women of color, poorer women, immigrant women, etc.) are simply not afforded care at all because of a lack of insurance, lack of transportation, lack of education or language or cultural barriers, which can lead to fear and misunderstanding (Amnesty International

2010). The other factor is the mainstream obstetrical model in general, which places limitations on the kind of care that is provided. Even women afforded a higher socioeconomic status often struggle to receive care in which their full consent is given.

This model is built within a system that values profit and efficiency above all else. The midwifery model (in which the doula is closely aligned) in contrast “supports women’s rights to self determination and encourages women to be active participants in decision making processes of pregnancy and birth” (Goodman 2007: 611). Thus this model can serve as a threat to an overarching system built on capitalist and patriarchal values. As 33

such, a deliberate exile of midwives was brought on giving rise to the dominance of the hospital and the physician.

The Rise o f the Hospital and Marginalization o f the Midwife

Like many other facets of society, the landscape for giving birth in the US has changed tremendously over the years. Prior to 1750, medical intervention dining childbirth was practically unheard of, as most women were assisted at home with midwives and close friends. This all changed when male physicians trained in Europe came back to the US with medicine and technologies like forceps and eventually ether and chloroform (Thomasson 2008: 79). In 1900, only 5% of births took place in hospitals but this percentage leapt to about 50% in 1935, with over half of births taking place in hospitals, reflecting the rise of hospital usage in general (Thomasson 2008: 77). The assumption could be drawn that this spike in popularity was because hospitals offered superior medical care. However, maternal mortality rates did not decline with the increase in hospital births, and some historians attribute maternal mortality in hospitals to increased operative intervention (Thomasson 2008: 77).

General practitioners became eager to deliver babies as they saw this as a great way to build up their practice (Thomasson 2008: 79). However, initially, practitioners still practiced in homes, not in hospitals. A common perception throughout the 19th century was that poor health was association with a poor moral character. So hospitals were seen as charity sites that were more concerned with bettering one’s character than 34

achieving medical advances (Thomasson 2008: 79). Mainly poor and immigrant families used hospitals (or midwives) since “respectable” people were cared for in their homes by physicians (Thomasson 2008: 79). This began to change after 1900 as hospitals began to make reforms in medical education while hospital size and number began to increase; the number of hospital beds doubled between 1909 and 1940 (Thomasson 2008: 80).

Another shift occurred which rendered hospitals acceptable for those of a higher socioeconomic status as physicians began to prefer practicing in hospitals. There were many reasons why this was the case, most of them having to do with what is convenient for physicians and their institution. First, physicians were trained in hospitals, so keeping physicians all in one place made sense for educational reasons. Second, hospitals allowed physicians to use technologies that might be more difficult at home such as anesthesia or a birthing bed. Third, there was an increasing awareness about the importance of a germ free environment. And fourth, essentially it was easier on the physician to work from a hospital since they wouldn’t have to carry their equipment (like forceps) across town.

Thus their business would be more lucrative as they could see more patients at a time, they could have nurses and other doctors to help them, and hospitals allowed them to do more complicated (and more expensive) procedures (Thomasson 2008: 82).

Some researchers have found that physicians performed procedures based on

“supplier induced demand”. That is, there was a correlation with how frequently a physician would perform a procedure and the income of their clients. For example,

Cesarean rates were a low 1.4% for poorer families compared to 3.7% with wealthier 35

families (Thomasson 2008: 82). More shocking is that episiotomies, a procedure in which the perineum is cut, were at 25% for poorer women and up to 50% for wealthier women

(Thomasson 2008: 82). These correlations point to how wealth affected (and still does affect) the kind of care people received.

Physicians were able to successfully perform these procedures often because there was an intense fear of childbirth during the early 20th century. Many women were afraid of giving birth and rightfully so, as childbirth caused more deaths among women 15-44 years old than any other disease except tuberculosis from 1900 to 1940 (Thomassen

2008: 82). Women wanted a less intimating and less painful birth experience and advertisements touted the safety and ease that came along with hospital births

(Thomasson 2008: 82). By the 1930s, giving birth at home began to be viewed as a risky endeavor and by the end of the decade obstetricians had convinced most women (and themselves) that giving birth in a hospital would be safer (Haire 1998:27). Families were banned from labor wards and the drugs to relieve the expectant mother’s anxiety and pain began to replace the comfort of family support and adequate nursing care (Haire 1998:

27).

A popular intervention included “twilight sleep,” the administration of the

amnesiac scopolamine, which didn’t stop pain but stopped women from remembering the pain (Thomasson 2008: 83). The use of twilight sleep often led to other interventions.

Because twilight sleep incapacitated women mid slowed labor, a drug similar to Pitocin

(used to induce labor) had to be administered, as well as the use of forceps, and often 36

women would have to be strapped to their beds, all of which make the hospital and ideal site for the administration of twilight sleep (Thomasson 2008: 83). Despite these drawbacks, which also included infant respiratory depression, wealthy women still demanded its use (Thomasson 2008: 83).

Obstetrics began to be legitimized and systematized while more and more middle class women chose physicians to trust with their pregnancies. By 1920, a physician named Joseph DeLee advocated a new definition of “normal” birth as a highly medicalized one: “the woman should be sedated and the baby extracted with forceps”

(Simonsen 2015:137). Ultimately, as new technologies existed, a consumer demand proliferated with a fear of and desire to control childbirth. This attitude in turn legitimated a medicalized view of birth as the standard for birth, rendering only trained professionals as sources of knowledge and authority. Because hospitals and physicians resonate feelings of safety and control, it is easy for these models to be upheld, as women obviously want the safest options available and trust that their physicians can provide that. This biomedical hegemony is what birth workers and activists, including midwives and doulas, have been reacting to and fighting against.

The Marginalization and Regulation o f Midwives

As the demand grew for physicians to deliver babies, women who depended on midwives were left with limited options as midwives declined; midwives fell from 50% in 1900 to 12.5% in 1935 (Thomasson 2008: 83). Midwives were pushed out because of 37

the rise of the hospital, with its medical and technological advancements, but their

livelihood also suffered because of a deliberate campaign against them. The marginalization of midwives is unique to the United States when compared to other nations since the medical profession has successfully exiled midwifery from mainstream medicine since the 1900s (Goodman 2007:612). Whereas many other industrialized nations incorporate midwifery into their mainstream models for care.

The marginalization of midwifery happened because of two major factors: the combinations of racism and xenophobia, and the sociopolitical aims to institute or professionalize a cohesive field of obstetrics and nursing, namely nurse-midwifery. So while midwives were being marginalized, their profession was simultaneously being absorbed into the professionalized field of nursing. Lacking this legitimization outright, many midwives were vulnerable to attacks. In the 20th century, medical, public health and nursing journals published articles accusing immigrant and African American midwives of being ignorant, dirty and dangerous, descriptions that were taken as fact and published up until the 1980s (Dawley 2003: 87). The campaign was bom of out the long discredited theory of eugenics, which posits that qualities such as intelligence, cleanliness and honesty were racially inherited, and that non-white persons therefore inherited these qualities (Dawley 2003: 87). This discrimination narrowed the scope of midwifery services to their own communities.

Simultaneously, nurses, specifically public health nurses, were concerned about the lack of maternity care services in some communities and sought to bring midwifery 38

into nursing (Reed 2000: 131). This idea became solidified under the Sheppard Towner

Act of 1921, which authorized public health nurses to oversee the practice of midwives in their areas, and by 1925 the first midwifery service in the US was established (Reed

2000:131). Now there are numerous nurse-midwifery schools and trainings, as well as numerous limitations for “lay midwifery” which utilizes older, apprentice based educational methods. Midwifery has been professionalized, but at what cost? Despite midwifery’s good track record, they are still a minority and many women still do not have access to the care they need. In some states, apprentice midwifery, or direct entry midwives, are illegal, and many laws have been enacted that set limitations on what kind of care midwives can provide. This is all testimony to medicalization and medical institutional hegemonization.

According to the World Health Organization (WHO): 70-80 percent of births are normal and uncomplicated, meaning that they are unlikely to require medical interventions. Midwife attended births result in much lower Cesarean rates, less low birth weights and lower infant and neonatal mortality rates (Goodman 2007: 611).

Nonetheless, midwives are only present at 7.45% of births (however this is up from 1% in 1976) (Goodman 2007: 611). In countries where midwives attend 50-75% of births, lower infant mortality rates are reported as well as lower costs (Goodman 2007: 611).

Despite the benefits to midwifery, which often involves a more biosocial perspective on childbirth than standard obstetrical practices, midwifery use is not the standard in the U.S. What has happened over time is a devaluation of true caring, namely 39

social and emotional support, which has been slowly replaced by a model that highly values efficiency, profit, and is built upon a fear based narrative of birth. In reaction, many now feel doula care should be more ubiquitous, offered by more insurance plans and/or in hospitals, however, there is also concern of what this professionalization or

“bureaucratization” of doula care within (or outside of) hospitals would mean, especially

in considering the histoiy of midwifery.

Katelyn, a doula, but also a midwifery apprentice, explained to me that laws in

California restrict her from “wearing two hats at once,” or in other words, prohibit her to provide care for a woman within a certain capacity, for example:

There are very strict rules that we can not doula with a homebirth client (as a midwife’s

apprentice) because then you get into situations where, say I show up early because I’m the doula

and then the baby is bom, but I’m also a midwifery student, so did I just deliver a baby without a

license?

In terms of midwifery, Katelyn also brought up how changes in legislation have been bitter sweet. She said that while it used to be illegal to attend homebirths at all, now they can attend homebirths, but there are limitations: they can’t deliver multiples or breeches at home and they’re only allowed to attend to pregnant women at 37-42 weeks, such that a woman giving birth before or after, has to be transferred to a hospital, “so we can transfer without fear at least,” she said, referring to how in the past midwives would just drop women off at the hospital and leave for fear of chastisement or worse.

Cynthia seemed to be optimistic about doulas working in hospitals, pointing out that each hospital has a different model within it, so why would it be any different if they 40

employed doulas? I asked if she felt like if she was employed by a hospital she would

still be able to maintain a sense of autonomy:

Yeah, I think so. There’s a lot of different models that exist now within hospitals, just in terms of

standard of care, so like, if you had doulas on staff, even the way the hospital provides doctors is

different, so I would think the way hospitals provided doulas would be different too.

What she was implying was that there wouldn’t be one homogenous way for doulas to perform their tasks, even with more regulation and employment through hospital institutions, just as different hospitals have different policies allowing for different kinds of care.

Birth as ritual, symbol for society

While childbirth may not be colloquially recognized as ritual, it is nonetheless ritualized in the sense that there are proscribed and controlled procedures as well as formal beliefs surrounding childbirth. In viewing childbirth as a form of ritual, the subliminal sentiments regarding technology and women’s agency resound. As Douglas argues, “the more personal and intimate the source of ritual symbolism, the more telling its message. The more the symbol is drawn from the common fund of human experience, the more wide and certain its reception” (Douglas 1966:441). Given the intimate and widespread experience of giving birth, an analysis of die symbolism of such experiences uncovers certain beliefs about cultural hegemonic knowledge surrounding conceptions of gender, class and authority. 41

Robbie Davis Floyd (2003) points to how many within the medical profession may deem the ritualistic aspects of birth as a thing of the past, now seeing birth as merely a “physiological reality” (Davis-Floyd 2003:2). However what I have aimed to show, and what Davis-Floyd has written extensively about is that birth is indeed ritualized or standardized, reflecting cultural values. These dominant American values are namely technology and profit, built upon a patriarchal, bureaucratic and capitalist framework that believes in the superiority of technology over nature, and institution over individual. The hegemonic nature of these values conceals the damaging effects that this technocratic view undertakes. Consequently, many women experience physical and emotional trauma, as well as dealing with hefty hospital bills or limited choices in care.

CHAPTER THREE: “STANDARD CARE”: BIRTH OUTCOMES WITH

MEDICALIZAED BIRTH

So far, I have sought to establish how the medicalization of birth began and how it has proliferated in the United States to become the standard way of having a baby in

North America. I will now detail outcomes of the medicalization of birth based on empirical and ethnographic data. It is my belief that, given the technological capacities and wealth in the U.S the current state of obstetrics has been failing women. The proliferation of the use of doulas is indicative of this failing, or this social and emotional void within obstetrics; women having babies desire more emotional and social support, before, during and after birth, and numerous studies support the effectiveness of this kind 42

of care (Sosa et al. 1980, Pascali-Bonaro and Kroeger 2004, McGrath and Kennell 2008).

Despite this, actual changes within institutions have been slow or altogether stagnant.

Doulas more effectively assert changes in care by being juxtaposed within and outside of these institutions.

First I should make clear again that medical technologies alone are not problematic. In fact, many of these technologies save lives. Women and children in less industrious countries could absolutely benefit from the use of these technologies that many benefit from here. What is being discussed has to do with the use, or overuse, of these technologies. Additionally, my intent is not to denigrate physicians, as they are abundant sources of knowledge and dedicate their lives to helping others. What is of issue has more to do with the institutional system within which the majority of physicians operate that is guided by pedagogical elements perpetuated by technology, efficiency, and fear-based cultural values. Childbirth outcomes are influenced not only by physiological elements but by emotional and social elements as well, including difficulties in navigating a complex healthcare system.

Since the medical establishment upholds their practices based on evidence-based research, I will draw heavily upon empirical studies to show that the practices that have become standard might not necessarily be right. I will also include some ethnographic data as a way to help frame the state of birthing in America today in a more holistic manner, elucidating the way in which knowledge production and what is deemed the

“best” evidence can be problematic. By this I mean that power dynamics and biases are at 43

play, leading to faulty research as well as disempowerment through devaluation of certain kinds of information or knowledge. Empirical evidence aside, how much weight does a birthing women’s opinion have in the medical industry? I will draw this out further in the following and subsequent chapters, discussing alternative childbirth movements and birth outcomes with doula care while highlighting the lengths birth workers and activist have gone to in attempting to bring their voice into mainstream biomedicine, namely by

“speak[ing] to biomedicine in its own language” (Basile 2012: 77).

A Standard American Birth in Hospital: Practices and Procedures

As I briefly stated in the introduction, Robbie Davis Floyd (2003), in her book

Birth as an American Rite o f Passage, details what she terms “standard procedures for normal birth.” While some of the procedures she mentions may be used less frequently since 2003, many of the procedures are discussed in interviews I conducted, as well as other ethnographies. Surprisingly, as I will mention, some of these procedures have become the norm before there was sufficient evidence indicating their efficacy, pointing again to how knowledge operates within a praxis of authority that is supposedly upheld by empirical data, which is not always the case. While women’s experiences and opinions are more difficult to quantify, the information they provide is nonetheless what is missing in terms of contributing to the empirical data, which could ultimately lead to a better understanding of birth processes. Doulas help in bridging this gap in that they can give women options through information, ultimately allowing them to better advocate for 44

themselves, which can help empower women to have a greater voice during their childbirth experiences.

I draw from Davis-Floyd because she succinctly outlines these procedures, as well as the official rationale, symbolic inferences and physiological effects. I also draw on more recent analysis, as well as incorporating views from doula clients I interviewed.

I’ve chosen the most common and potentially damaging procedures to outline.

The Bed and the Supine Position

After a woman is admitted to the hospital in labor (likely in a wheel chair), she is ushered into her room where she is instructed to stay in a bed, in an upright sitting position (supine position). This has been considered a standard position since its introduction into the Western world, without there ever being evidence of its advantage over other positions (Jonge et al 2008). As Robbie Davis Floyd explains, under a technocratic model, laboring women are seen as weak, in danger of falling or tiring themselves (Davis Floyd 2003: 86). Women are advised to not be up and walking around, and often nurses complain about keeping track of their “ambulating” patients (Davis

Floyd 2003: 86). Thus, lying in bed, primarily in the supine position is essentially for practitioners to keep track of their patients’ whereabouts as well for easy vaginal examinations and for the ease of electronic monitoring and the administration of intravenous fluids. Essentially, these suggestions allow staff members to better monitor and assess pregnant women. This need to manage and control labors is demonstrative of a 45

larger structure that values and strives for efficacy and profit, as well as an avoidance of litigation, sometimes at the detriment of patients and their families.

Studies have concluded overwhelmingly that upright; nonmoving positions can be dangerous as it can reduce the mother’s cardiac output leading to fetal distress which can lead to a Cesarean delivery (Davis Floyd 2003: 86). Standing positions can thus be more efficacious for labor, and numerous studies support walking or standing as a way to shorten labors and to reduce the need for pain medications (Davis Floyd 2003: 87). A

2014 study found that vertical positions in the first stage of labor were associated with less pain, reduced labor length, and reduced use of analgesia, ultimately leading to more comfort and satisfaction after birth (Gizzo et al 2014). This could be because mothers are often uncomfortable lying down, so their labor slows and they are more likely to request analgesia or need pitocin6 (Davis Floyd 2003: 87). One of the main things most doulas will do is to encourage and help a laboring woman try different positions that might include, walking, squatting, or going into a shower.

Fasting

Many women are expected to abstain from food and drink throughout their labors, despite little research pointing to the benefits or need to do this. The rationale is that if a women should need urgent general anesthetic, the risk of inhaling undigested food if they vomit during anesthesia is minimized, thus minimizing risk of choking and aspiration of acidic gastric juices, leading to pulmonary edema and a partial collapsed lung, a rare

6 Pitocin is a synthetic form of a naturally occurring hormone called oxytocin, it is used to induce labor. 46

complication known as Mendelson’s syndrome (Davis Floyd 2003: 89). Robbie Davis

Floyd refers to this as a “medical myth” which in turn denies many women of nourishment during labor (Davis Floyd 2003: 89). In reality, Mendelson’s syndrome is extremely rare; a 2010 study found that “pulmonary aspiration among women experiencing a Cesarean birth is so rare that a randomized clinical trial to see if oral intake is related to maternal mortality is not even feasible” because there are not enough people to collect the data from. (Sharts-Hopoko 2010:198). Interestingly official recommendations on the matter are split, the World Health Organization (WHO) recommends not interfering with the intake of food or liquid, while the American College of Nurse-Midwives recommends self determination if at low risk, while the American

Congress of Obstetricians and Gynecologists recommends clear liquids only (Sharts-

Hopoko 2010:199).

In an interview with Crissy, a client who was having her first child, she relayed how she did really great throughout her labor, until she had to push, when she said she

“kind of lost it.” During that difficult time, her doula had a squeeze bottle of what she remembered as applesauce, that she would squeeze into Crissy’s mouth: “that gave me a little boost, a little bit of sugar, it was really, really helpful.” She also went on to say that she’s heard of a lot more hospitals in the Bay Area allowing women to eat if they are low risk, and that her choice in hospital was heavily guided by their acceptance of these shifts that allow for more personal preference and adherence to more evidence-based practices. 47

Courtney grew up very poor, and not being able to eat triggered memories from her childhood. She didn’t disclose this information to her doula prenatally, but said it ended up being one of her biggest triggers during her birth, especially because she asked for a food tray, they brought one, but then a nurse came in and said she was a diabetic so they took it away:

As a diabetic they don’t feed you. Like at ail. So that was hugely triggering. And I still think I

have issues from that. Even if I’m not hungry, if there’s food in front of me I’ll eat And I think

that comes from subconsciously being afraid that someone will take my food away again.

Here is where the snow balling begins: pulmonary edema seems more likely with fasting since the gastric juices in the stomach are more acidic so if vomit is inhaled it would be more harmful to lung tissues. In addition, needing to be in the supine position to administer anesthesia increases risk of gastric inhalation. The risk increases further when practitioners apply fundal pressure7 to the abdomen to speed up birth (Davis Floyd 2003:

89). Fasting during labor can also increase chances of ketosis, a condition that weakens muscle cells and alters blood chemistry (Davis Floyd 2003: 90), resulting in decreased energy levels and hydration (Waller-Wise 2013: 32), which can ultimately lead to exhaustion, necessitating more interventions such as labor induction through pitocin. In fact, carbohydrate intake, in either liquid or solid form, decreases maternal ketosis during labor. It should be noted that while women who eat during labor may vomit more than women who don’t eat, there is no association with eating and unfavorable birth outcomes

7 Fundal pressure is pressure applied to a woman’s abdomen during labor to help move the baby out. 48

(Waller-Wise 2013: 32). Additionally, and perhaps obviously, fasting can also be harmful as it puts laboring women in a state of stress, which can lead to complications as well as dissatisfaction and trauma. In 1986, Penny Simkin evaluated 159 women’s feelings of stressfulness during childbirth and found that 27% of women found lack of food intake to be moderately to very stressful while 57% found the lack of oral fluid intake to be moderately to very stressful (Simkin 1986).

Intravenous Feeding (the IV)

Considering laboring women are not supposed to consume food or fluid, an IV is inserted in her arm to compensate for the food and drink she is unable to have. The other purpose of this is for emergent situations in which the vein would need to be immediately available. Not only are women essentially immobilized because they are attached to a plastic IV bag, but the fluids themselves can cause problems, as well as what is eventually put into the IV, such as pitocin.

In an interview with Vanessa, she was explaining how one of her births was supposed to be at home but they had to go to the hospital because of some complications with her blood pressure and protein in her mine. She was especially critical of medical interventions because she wanted a more natural birth and had had a homebirth before.

Though she said that she was ok with the interventions because she displayed all these symptoms and wasn’t feeling well, she was nonetheless frustrated: “they hook you up to 49

an IV, that you drag around with you, which gets, ya know, it can get in the way of laboring.”

IV solutions contains dextrose, a refined sugar which can rapidly raise blood sugar levels resulting in an eventual crash in energy as blood sugar levels plummet, ultimately leading to exhaustion (Davis Floyd 2003: 93). Even in I Vs with glucose, patients often suffer from a fluid overload (Davis Floyd 2003: 93). Additional problems include the IV solution not having any protein to replace what is expended during labor, as well as a correlation in more infant problems such as hypoglycemia resulting from excess insulin production generated in response to the drop in blood pressure (Davis

Floyd 2003: 94).

Pitocin: “the pit drip ”

Pitocin is one of the drugs that can be administered through the IV. It is a synthetic form of oxytocin, a hormone that can start or speed up delivery. It is usually mixed with intravenous fluids in a continuous drip (hence, “pit drip”) (Simkin 2008:

226). Often pitocin is administered if a woman’s waters have been broken for a long time

(and often physicians manually break the waters, called amniotomy) and labor hasn’t progressed (thus the potential for infection, though largely infection has to do with hospital interventions) (Davis Floyd 2003: 96). Pitocin might also be used if pregnancy is 50

prolonged past 38 weeks.8 Induction rates have doubled from 1990 (10%) to 2010 (23%), estimated to be at around 57% of the entire US population (Bell et all 2014). Davis Floyd points to how pitocin fits into the rubric of a medicalized or technocratic model in that labor isn’t understood as something that stops and starts, “so any slowing of labor is interpreted as abnormal or dysfunctional necessitating intervention” (Davis Floyd 2003:

96).

The physiological effects of pitocin, for both mother and baby, are quite well known and disheartening. While pitocin does speed up labor and can be beneficial, it must be used carefully. According to Davis Floyd, Williams Obstetrics, a leading obstetrical reference, recommends that the drug should be administered minimally and that the mother, once the drip is administered, should never be left alone (Davis Floyd

2003:97). The risks to the mother include uterine rupture from tetanic contractions

(sustained muscle contractions), as well as severe stress and anxiety as the contractions are often back to back with little rest in between, which then can lead to requests for more pain medications (Davis Floyd 2003: 97). Complications can also include water intoxication in combination with IV fluids, further increasing risk of pulmonary edema in cases of gastric aspiration (Davis Floyd 2003:97). Risks to the baby include a lack of oxygen supply from the increased pressure of the contractions (Davis Floyd 2003: 96-

97). A recent study concluded that pitocin usage may be associated with higher neonatal

8 Since due dates are set by practitioners based on the last day of a woman’s period, dates are often inaccurate, more accurate due dates can be determined based off of ovulation dates which can be determined by women themselves through fertility awareness practices. 51

intensive care unit (NICU) admission rates and lowered Apgar scores (Gillian 2013).

Many researchers are now urging a higher adherence to pre administration checklists before pitocin is given (Wojnar et al 2014).

Vanessa’s doctors had induced her labor with pitocin and she said that it was really painful at the end and her midwife told her that could happen with pitocin. She also expressed concerns about how much she had been given:

They kept me going on pitocin until the baby was bom... and I never thought to ask them to stop

or lower the dose... and I think for me I kind of give up my own, I give something up when I’m in

the hospital and I’m not feeling great [...] we said no to many things but I trusted that if there was

no longer a need for pitocin they would stop it, but I think that once they started it, they didn’t

have much intention of lowering it.

Amniotomy: Breaking the Waters

An amniotomy is an artificial rupturing of the membranes or “the waters” by inserting an instrument through the cervix to break the amniotic sac. If labor needs to be sped up, often the membranes will be ruptured, or if the physician needs to insert an electronic fetal monitor. Occasionally, if fetal blood samples need to be taken or if physicians need to know if meconium (fetal bowel movement) is present which is considered to indicate fetal stress, then an amniotomy is considered (Davis Floyd 2003:

102).

Amniotomies may speed up labor, but they also leave women vulnerable to infections from vaginal exams (which can be taken care of with antibiotics but which 52

results in discomfort and lengthier hospital stays) (Davis Floyd 2003:103). If false labor is mistaken for real labor, an amniotomy will be performed needlessly, which could lead to the need for pitocin (since it is customary in hospitals that after 24 hours of the water breaking women must be induced), women are also at risk of more perineum tears, as there is more pressure on the perineum without the amniotic sac (Davis Floyd 2003: 103).

Furthermore, amniotomies can harm babies in that their head is subject to greater pressure from contractions without the protection of the amniotic sac, as well as being at risk for cord prolapse (Davis Floyd 2003:103). A 2013 review of 15 studies involving over 5,000 women supported notroutinely breaking the waters for the reasons indicated

(Smyth, Markham & Dowswell 2013).

Internal and External Fetal Monitoring

The baby’s heartbeat during labor generally reflects the baby’s condition; during contractions the heart rate is slow, speeding up after contractions. Monitoring the fetal heartbeat is important since fluctuations in this pattern could indicate serious problems in need of immediate intervention. Prior to electronic monitoring being invented in the

1950s, practitioners would place a stethoscope onto the mother’s abdomen. Electronic fetal monitoring, in contrast, can be administered both externally and internally. External monitoring involves a large belt strapped around the abdomen while the internal method involves placing an electrode (needle) through the birth canal and onto the baby’s head

(as previously mentioned, this thus requires the amniotic sac to already be broken or to be 53

ruptured artificially). While external monitoring is less invasive, it is not as accurate as internal fetal monitoring.

To return to Vanessa’s interview, she recounted how after her IV she had an external monitor on her stomach to register her unborn son’s heartbeat and her contractions: . .and you know, we were in, like.. .we spent a whole pregnancy with no technical instruments, our midwife just used an old fashioned stethoscope, and then you go to the hospital and within an hour, you’re hooked up.”

Physiological effects for external monitoring have mostly to do with how it can set up the need for further interventions, needlessly, and that many of the factors that could lead to fetal distress are brought about or made more dangerous by the hospital. For instance, as Davis Floyd points out: “fetal infections commonly result from too many vaginal exams; where cord compression often results from improper maternal positioning and/or the administration of pitocin; and where drugs are often pressed on laboring women who otherwise might choose to do without” (Davis Floyd 2003:105). Ironically, as Davis Floyd goes on to point out, the physician and inventor of the external monitor,

Dr. Edward Hon, was quoted saying: “if you mess around with a process that works well

98% of the time, there is much more potential for harm.. .[Most women in labor may be] much better off at home [than in the hospital with the electronic fetal monitor]” (Davis

Floyd 2003:105).

Internal monitoring presents even more risks: fetal infection rate for internal monitors is nearly double that of an external monitor (Davis Floyd 2003:110). This 54

points to how once again, many of these interventions were introduced without much research, and yet, many traditional midwifery practices are questioned constantly for their supposed lack of empirical data. As far back as 1986, Penny Simkin (whom I mentioned earlier as one of the forerunners to the doula movement), established research on stress during labor recognizing that some stress is normal and that often, fetal distress is unrelated to neonatal distress. Most importantly she proves that often this stress occurs by the surroundings in the hospital such as intimidating technological procedures and unfamiliar hospital staff (Simkin 1986). More recently, in 2011, editor of the Journal of

Obstetric, Gynecologist and Neonatal Nursing, Nancy K. Lowe, published an editorial drawing off a 2006 study which found that Electronic Fetal Monitoring bears no long term benefits to babies and increases the need for Cesarean and operative vaginal deliveries. In thinking about whether this new evidence would change anything for women, she stated: “Unfortunately, I doubt it because EFM is a cultural phenomenon, not merely an invalid medical screening test. It is part of the technological, interventionalist, and litigious culture that dominates maternity care in the United States” (Lowe 2011).

Epidural

The epidural is a common form of regional anesthesia that takes away the pain for a laboring woman without incapacitating her so that she can be conscious for her birth.

The administration process is complex, involving a catheter in the spine; the whole process takes around 20 minutes. 55

The effects of epidurals can vary from woman to woman and can depend on how it is administered. Successful epidurals reduce pain while also not interfering with the woman’s ability or urge to push, while unsuccessful epidurals can “completely deaden the woman’s sensations” increasing the likelihood of forceps and Cesarean delivery

(Davis Floyd 2003:113). If an epidural is administered before active labor (5-6 centimeters dilated), a slowing of labor can result, once again leading to increased need for the use of forceps for delivery (Davis Floyd 2003:114) or vacuum extraction, and can also lead to fetal distress (Osterman and Martin 2011:2). In 2008,61% of women who had vaginal births in the US received an epidural (Osterman and Martin 2011: 2).

Interestingly, a 2008 study showed that women in the US were more likely to receive an epidural if that had received prenatal care during the first 3 months of pregnancy

(Osterman and Martin 2011:4), indicating possible effects of authoritative knowledge within the technocratic model, when women’s choices are heavily influenced by institutions and their doctors. Additionally, there is a strong correlation between epidural use and Cesarean rates: epidural given before the active phase of labor (which was until recently considered only 4 centimeters dilated) more than doubles the chance of receiving a Cesarean (Klein 2006: 419).

Episiotomy

An episiotomy is essentially a manual cutting of a woman’s perineum with sterile scissors, when the baby’s head is 3-4 centimeters outside of the vagina. Its purpose is to 56

enlarge the vaginal opening to make it easier for the baby to come out. Again looking at

Davis Floyd’s (2003) research, most of the physicians in her study genuinely believed that episiotomy shortened the pushing phase making it less likely the baby will suffer from oxygen deprivation, this belief is held so strongly that many physicians she interviewed were never even trained to deliver babies without performing one (Davis

Floyd 2003:128). Additional reasons given for episiotomy include “to maintain vaginal tightness for enhanced pleasure of a sexual partner” (Davis Floyd 2003:128). At the time of Davis Floyd’s research in 2003, over 90 percent of first time mothers had episiotomies compared to only 8 percent at the time in the Netherlands (Davis Floyd 2003:129).

Despite ACOG’s (American Congress of Obstetricians and Gynecologists) recommendations (as well as the WHO and the International Childbirth Education

Association (ICEA) to limit the use of episiotomy, they are still performed at high rates

(The Leapfrog Group 2015).

In an interview with a doula client named Tricia, she spoke highly of her obstetrician. Her and her partner had wanted to get a midwife but because of insurance reasons they couldn’t find one so they opted for the most low-tech doctor that they could find. Prenatally and leading up to labor, she said he didn’t perform any invasive procedures and instead would focus on how she was feeling. On top of that they really liked his personality. However, despite his low tech approach, Tricia still unexpectedly had an episiotomy: “he gave me an episiotomy the first time and didn’t tell me, and I was irritated, but he was like ya know, we didn’t have a lot of time.” He went on to explain 57

that they needed to do a vacuum extraction that was unsuccessful and that the baby’s head was turned, so in his eyes, the only way to get the baby out immediately was to do an episiotomy. So while Tricia was overall pleased with her doctor and felt that he was relatively low tech, she still endured an episiotomy without knowing it. While I can’t speak to whether this was a medical emergency or not, nonetheless, this procedure is performed amongst even “low tech” doctors and women do not often get a choice.

Despite so-called evidence supporting episiotomy, research has shown perineal tearing was the lowest in women without episiotomy (Davis Floyd 2003:129). New research as of 2012 continues to back this up when vaginal deliveries with episiotomy had statistically higher rates of 3rd or 4th degree perineal tears than those without episiotomy (Steiner et. al. 2012).

Cesarean Delivery

Cesarean delivery is perhaps the most well known medical procedure related to childbirth, as well as the number one indication of medicalization trends. It involves opening up a woman’s womb, through surgery on her abdomen, to safely extract the baby. Cesarean delivery is truly a life saving procedure and has revolutionized life saving capabilities for birth. However, its increasing overuse is what is disconcerting. Since

2009, Cesarean rates have hovered around 32% of all births in the US (Joyce et.al. 2015), about 20% more than WHO recommendations (a 10%-15% rate, however before 1970 it was around 5% (Davis Floyd 2003: 131), which saw rates higher than 10% as having no 58

association with reductions to maternal and newborn mortality rates. In some teaching hospitals these rates can be over 50% and in Brazil rates are as high as 65-95% (Davis

Floyd 2003: 131).

Cesarean delivery goes beyond its obvious physiological effects and is indicative of a larger trend used in a technocratic model of childbirth delivery, namely that of efficiency as well as profit. It is major abdominal surgery, which is associated with higher rates of complications including the need for re-hospitalization or the need for NICU care, but equally important, the price compared to vaginal delivery is nearly twice the cost (Menacker 2010). Back in 1987 a report showed that at least half of the 934,000

Cesareans performed in the US were unnecessary, costing the public an additional $1 billion with “uncalculated increases in maternal morbidity, with no discernible benefit to neonatal outcome” (Davis Floyd 2003:131); rates have only gone up since then.

However, studies show that continuous labor support has been correlated with lower

Cesarean rates (Pascali Bonaro 2004).

After birth: Apgar Scores, Washing the Baby, and Bonding

Once the baby is bom, there are standard procedures performed that further demonstrate technocratic values. While not as invasive and physiologically damaging, these procedures reflect the devaluing of the mother’s knowledge or ability in caring for her newborn. Apgar is a scoring system so that physicians can assess the newborn’s condition. It is based on a ten point system, two points for each category: skin color, 59

muscle tone, breathing attempts, heartbeat, and response to stimulus (Davis Floyd 2003:

135). Women are reported to feel proud of their baby’s high scores, or feel serious anxiety for lower scores, as Davis Floyd puts it: “The apgar score is but the first in a long series of ratings that society will give its new member; scoring the baby at birth sets up the mother to respect and rely on society’s rating system to judge her baby by for the rest o f‘its’ life” (Davis Floyd 2003:135). Women also have expressed a feeling that after birth, once the baby is out, the hospital staff stops paying as much attention to new moms. Vanessa explained that during labor she was given special diabetic meals because of her complications, but then after the baby came out, her meals went back to normal.

When the baby emerges from the womb it is covered in various substances that are then washed off, again reflecting the need to deter unseemly natural processes; since the baby came out “dirty” there is a need to wash it, immediately after birth, even before the mother gets to hold her baby. This is despite the fact that the there is a protective layer called the vemix which helps the baby’s skin from getting too dry (Davis Floyd

2003:136). There are also many emerging studies on the importance of skin to skin contact after birth (Rogers 2013), as well as positive outcomes when the umbilical cord is not immediately cut, even allowing it to fall of naturally (ACOG 2012)

Tricia’s experience with her baby included additional testing. Because her baby was very large, after he was bom they would come in to her room and measure his glucose levels by pricking his foot After a while she got frustrated and told them to stop:

...and I’m fine with them doing it once or twice, but they did it like three times to my son and we

couldn’t get him to sleep, he would try to rest and the nurse would come in again, I was like, 60

“you’re not gonna prick his heel again, his blood sugar is fine, he is fine, there is nothing wrong

with him you need to stop.” He was showing no signs of anything else. Its really kind of, its like

the whole person somehow gets missed, like, with everything else that’s going on.

After she said no, the nurse stopped but came back with a form that she had to sign. This points to not only how pervasive and normalized procedures are, but it also highlights how litigated medicine is and especially as it relates to labor and delivery.

All of these practices and procedures: the supine position, fasting, intravenous feeding, pitocin, amniotomy, fetal monitoring, epidural, episiotomy, Cesarean deliveries, as well as apgar scoring and washing, are not necessarily done at every single hospital birth in the U.S (and there are also many other procedures), but are common procedures that are administered at varying degrees depending on geographic location, the hospital itself and obviously patient desires and/or the use of doulas might affect those outcomes.

Many doulas I interviewed had their preference for hospitals based on how open they were to change or the use (or lack of use) of less standard practices. Doulas provide a way for women to be in the safety of a hospital while helping to avoid unnecessaiy procedures, as well as providing physical comfort that goes beyond standard hospital care

(i.e. massage, different positioning, breathing, music, etc). Doulas also help to mitigate any emotional traumas that can come about with feelings of mistrust, pressure, and a general lack of confidence in their ability, that come with the overall medicalized mindset towards birth and the accompanying authority. Essentially doulas help conquer authoritative knowledge by educating women and giving them ability to have informed consent. 61

Authoritative Knowledge: the Social, Emotional and Bureaucratic

As I briefly introduced in the first chapter, authoritative knowledge is knowledge that is produced not necessarily based on efficacy, but acquires its authority based on systems of power that bestows a specific hegemonic form of authoritative knowledge. In

2010, Monica Campo wrote on feelings of trust and agency within childbirth. She interviewed several heterosexual, middle-income women, most of whom expressed a lack of trust in their own bodies because they had put their trust instead in the hands of their doctors. She argues that “women in medical systems of maternity care are not ‘passive dupes’ of obstetric hegemony but their autonomy is nonetheless constrained by their relationship with their obstetrician and an increasing normalization of medical birth

(Campo 2010: 3).

In her interviews with women who experienced a hospital birth, Campo depicts women’s attitudes towards this dominant obstetric model. In an interview with a woman named Jenna, she describes her physician:

He's someone who's specialized and done 10 years of research and I'm figuring it out as 1 go a

long so yeah. I'm big on subject matter experts and he knows more than me about these things, so I

trust him (Campo 2010: 22).

Similarly, another woman named Kim explains:

I feel more comfortable being in the care of a specialist obstetrician as well. And my obstetrician

is the head obstetrician of the hospital and he's a professor of obstetrics as well. I feel way more

comfortable with this guy knowing that the buck stops with him and if anything ever goes wrong it

always goes straight back to him anyway and if I've got him looking after me, I can't have anyone

better on my side (Campo 2010:22) 62

Trust is of apparent importance for expecting mothers. Jenna and Kim’s complete trust in their obstetricians reveals the lack of trust they have in her own abilities, unearthing the unequal relationship between physician and patient. Moreover, patients often put their full trust in their doctors, relying on them for support, when the support is usually not given. Another interview with Gabriella illustrates the distracted presence that obstetricians can maintain:

...yeah what happened was, the obstetrician, in that whole time I was in the hospital from 1:30 in

the morning till the OB got there at about 10:20 that night to do die caesarean, other than then, the

only time I saw the ob was about 1 o’clock in the afternoon for about 2 minutes...she told me that

she'd be back between 6 and 7 but she never came ... I only saw her for a total of 20 minutes, not

including the caesarean (Campo 2010: 23)

Pregnant women often “go along with” the medicalization of birth through picking up on social norms. They are also often downright ignored, belittled or doubted by obstetricians and practitioners. In Monica Campo’s same research she describes the various women’s experiences:

Three women described how their doctors dismissed their birth plan anyway - this was even from

the supposedly "low intervention doctors”. For example Sandra's doctor told her to "forget it” in

response to a question about a birth plan and that as far as he was concerned the "plan is to get the

baby out”. Jasmine's obstetrician told her "only women who don’t trust us use birth plans [and

doulas]". Jasmine, a health professional in the maternity field, claimed that she'd often seen

obstetricians "scoff' mockingly at "silty women's" birth plans, so she knew that even if she wrote

one it "would mean nothing". Sally, pregnant with her first baby, wrote a birth plan however she

says her doctor "didn't even look at it" telling her to "give it to the midwife". In this way, medical

authority is reinforced and women's autonomy is undermined (Campo 2010: 23) 63

Going back to my interview with Vanessa, when I asked her if she had a choice to be hooked up to an IV, she said, “Well I don’t know, they don’t act like you have a choice.

And this wasn’t a time for me that I wanted to be in conflict with the people I was trusting to take care of me,” reflecting how, while she knew she might be able to protest what was happening, she didn’t want to create any waves that might be detrimental to her care. Earlier in our conversation she went on to talk about how in her opinion hospital environments were very fear-based:

...because the idea is that if you don’t do these things you’re putting your baby in danger, but

really it makes it easier for them in some way because they don’t have to tend to you as much,

because they’re sitting at the nurses station able to see if there’s a problem, whereas if someone is

attending to you the whole time, they might be able to avoid interventions, but again, its not a big

deal to them, they don’t see [the interventions] as a problem.”

The experiences of these women highlight the asymmetrical power dynamic at play, but their statements also express the ways in which the medicalized, technological version of birth is being perpetuated. This results in symbolic (or literal) male dominance as well as reflecting capitalist, science-driven values, as the medical model for birth becomes an expensive and profitable enterprise. Furthermore, the women Campo interviewed for her study were relatively well off, educated women in heterosexual partnerships, signaling that these women should be in positions of relative authority and wealth. It leads one to wonder how different conditions would be given a lower socio-economic status. 64

In 1994, Ellen Lazarus did her research on choice, control and class, in respect to childbirth. Being one of the first to draw on issues of class, Lazarus describes biomedicine as having structures of power in place:

Medical knowledge, like most knowledge, is inseparable from social relationships and social

experiences [...] because the doctor-patient relationship is asymmetrical, power becomes

domination; one actor is more autonomous, the other dependent. This power disparity is further

widened by social class. Thus, there is an interdependence between knowledge, ones ability to act

on such knowledge, the social institutions that constrain actions, and one’s positions in the large

structure of society (Lazarus 1994: 30).

Considering the medical system is difficult for women with many resources to manage, women with fewer resources would likely have an even more difficult time in terms of choice and control. For instance, in Amnesty International’s study “Deadly Delivery”

(2010) they cite many barriers to women receiving maternal health care services at all in the U.S These include: lack of insurance, discriminatory practices, poverty and homelessness, bureaucracy, language barriers, or even just having difficulty getting to and from appointments or hospitals (Amnesty International 2010). Excerpts from the study provide personal accounts of women’s stories demonstrating the severity of these issues: for instance, one woman, an undocumented immigrant who spoke little English, was initially turned away from a private hospital. They eventually allowed her to stay but left her in a wheelchair alone until her doctor showed up the next morning, she told

Amnesty that during this time nurses told her to “shut up!” “Everyone can hear you, shut up or we’ll throw you out.” (Amnesty 2012: 21). 65

Doulas can help lower income women receive more equitable care by offering their services with flexible fees. Additionally, doulas can help navigate healthcare environments for their clients starting with prenatal visits, first by discussing their choice for care provider, their birth plan, as well as helping to prepare for what might happen during a hospital birth. Monica Basile refers to doulas as “translators” in a chapter of her research by explaining that doulas can make hospital jargon more understandable to women in labor making the “muddy waters” of hospital birth more navigable (Basile

2012: 121).

CHAPTER FOUR: BIRTH AS A BIOSOCIAL EVENT: THE EVOLUTION OF

ALTERNATIVE BIRTH MODELS

What I’ve attempted to argue thus far is that while medicalized birth is the standard for obstetrics in the U.S., often this medical rigor does not benefit mother and baby. Evidence supporting these procedures has been contentious, leading researchers, birth workers and women themselves to challenge much of how we are made to understand birth (Davis-Floyd 2003, Campo 2010, McGrath and Kennel 2008, Menacker and Hamilton 2010, Torres 2014, Wendland 2007, Simkin 2014). Doula work involves birth work that is a departure from standard obstetrics, and similar to midwifery it continues to challenge how we view birth with many constituents demanding more evidence based birthing practices as well as more patient centered care. As I found during my training and interviews, many doulas are in support of avoiding unnecessary 66

interventions, and facilitating more empowering births, but they do not push any agendas onto their clients. In other words, a doula’s main concern is with mother and child’s health and happiness. Doula care is more in line with a view of birth outcomes as not purely physiological, taking into account how social and emotional realities frame birth experiences.

Taking a look at birth models cross culturally can help elucidate how other industrialized countries are incorporating technology into birth, as well as help to deconstruct how certain kinds of knowledge can become authoritative and should therefore be looked at with a more critical eye. Looking at multiple birth systems provides a more nuanced perspective of birth within the US that allows for a departure from viewing birth as a purely physiological event in need of constant intervention by highlighting socio-cultural particularities.

Birth workers engaging in alternative discourses have been drawing on evidence- based research against interventions for decades, to no avail. For instance, in 1986 Penny

Simkin critiqued the use of Electronic Fetal Monitoring by reviewing the evidence-based literature at the time in an editorial called: “Is Anyone Listening? The Clinical Impact of

Randomized Controlled Trials of Electronic Fetal Monitoring.” In the editorial she questions how, despite the lack of scientific evidence in support of fetal monitoring, its use is not only pervasive but it is inconsistent, varying from hospital to hospital, pointing to its ubiquity and haphazard use: “why the confusion? Why have the best-designed EFM trials had so little impact on clinical practice? Clearly, policies on the use of EFM are 67

based on considerations other than scientific evidence” (Simkin 1986: 216). Despite her efforts to point to how there are many other factors that determine EFM use (such as nurse staffing and economics), electronic fetal monitoring is still pervasive to this day and is practiced under the guise of scientific authority. This one example is indicative of larger trends in the U.S pointing to how more holistic perspectives should be incorporated, calling attention to how social, economic, political and cultural factors underlie standard procedures, not necessarily scientific evidence.

Cross Cultural Perspectives and the Production o f Knowledge

Bridgette Jordan (1993) writes about birth in four cultures in her book of the same name, Birth in Four Cultures. She frames birth as a biosocial phenomenon meaning that birth is produced by (universal) biology and (particular) society (Jordan 1993: 3). She argues that without cross cultural analysis from a biosocial perspective, less changes will occur within a given system, as deviations from the status quo could be considered unethical. As such “experimentation within any system is always hazardous and quite frequently impossible” (Jordan 1993: 5). In other words, knowledge and authority are produced in such a way that there is a moral association attached to dominant or standard practices, and going against dominant knowledge can be seen as unethical or amoral, even dangerous. Bolstering this argument later in the book, Jordan points out that if systems are stable then they are experienced as appropriate from within and it becomes hard to separate physiological necessity from social production. Going off of Jordan’s 68

theory, I would argue that obstetrics has become less stable, and based on my interviews it seems less and less appropriate to those experiencing it and subjecting themselves to its primacy; the burgeoning use of doula care, which incorporates both physical and social realities, is an indicator of a disrupted system, where those operating within it are seeking change.

This calls into question what is deemed as appropriate evidence in studies surrounding birth. Which evidence is best? Often the studies on emotional and social support are neglected because they are not “objective” enough to be valued or to be proven efficacious. In exploring “evidence-based obstetrics,” Claire Wendland (2007) explains that recently obstetricians have embraced a new paradigm that explicitly seeks out evidence-based analysis, as opposed to relying on “...experience, tradition, intuition, or the recommendations of medical authorities, the clinician, trying to practice in an evidence-based way, seeks to identify and evaluate the best studies available on the issue in question and make clinical decisions based on the outcomes shown in such studies”

(Wendland 2007: 218). This is akin to the point I made previously about physicians not treating the whole person in front of them, but rather generalizing the person, comparing them to the whole of society. In other words physicians make decisions about care based on what is “normal” according to medical evidence, not with what they are presented with at hand. Many birth workers proclaim that there really is no normal when it comes 69

to pregnancy and birth9 and that the word normal is problematic because it can make women feel insecure or panicked if they’re not progressing “normally”.

Wendland also claims that medical knowledge is hierarchically ranked with this new epistemology of “evidenced based medicine” which is based on aggregate data rather than clinical experience; she questions how apolitical and objective these studies truly are (Wendland 2007). This presents a problem for obstetrics in my view, since a whole breadth of knowledge is left out of medical decision making that has to do with factors like a person’s psychology or socioeconomic background. In terms of birth, so- called objectivity seems impossible if we are to understand it as a biosocial event. This dilemma is presented within the field of anthropology as well, and many anthropologists have been addressing the virtues of identifying and actually incorporating emotion into their ethnographic analysis. A perhaps classic example is Renato Rosaldo’s (1980) research on the Ilongot headhunter’s rage, when he was only able to really understand their rage after he lost his wife and experienced similar emotions (Rosaldo 1980: 537-

551). Across the sciences, it is important to identify the problems in striving for absolute objectivity: “Because “reality” tends to unfold in response to the particular set of methods by which it is studied, our formal understandings of the “real” are always somewhat bound by the limits of the methods we employ” (Davies 2010: 13).

9 Of course there are emergency situations that occur during labor, and there are “at-risk” pregnancies, which might not be “normal”, but every pregnancy and labor is going to look different. In reality, a “normal” or a “standard” birth, is too broadly based to offer any usefulness in terms of coming to a conclusion about what eveiy birth should look like. Its use is charged with associations of good or bad: normal or abnormal. 70

Additionally, often what is considered evidence-based, is considered as such because of pre existing beliefs, reflecting a general tendency towards confirmation bias.

As Basile (2012) points out:

Often, doulas call attention to the gap between what medical literature seems to support as best

practice, and the way in which childbirth is managed in the hospital. It becomes clear from looking

at the research, they argue, that many of the routine protocols of obstetric practice have been

undertaken or continued to practice not on an empirical demonstration of their efficacy but instead

on specific culture of practice (Basile 2012: 82).

Basile goes on to demonstrate these discrepancies by chronicling a scene from a documentary called “Bom In the USA” (Jarmel 2000), which depicts obstetric nurses and physicians in a meeting about a patient:

As one nurse justifies artificially rupturing a woman’s bag of waters by stating that “there is

evidence that the release of fluid causes dilation to occur more quickly,” she is quickly corrected

by a high-ranking physician, who quips, “every obstetrician believes that, but there aren’t a lot of

good data to support it.” Another obstetrician joins in, “we do a lot of things there aren’t a lot of

good data to support,” and the room erupts in laughter. The group goes on to acknowledge that the

Cesarean section the mother in question underwent was most likely unnecessary and caused by the

routine induction of her labor. But instead of recommending that labor not be induced routinely at

40 weeks, the physicians agree that since the woman was aware that Cesarean section is a risk of

induction, they were ultimately not responsible. In other words, they chose to preserve the

continuance of routine practices, regardless of the fact that they may be scientifically unjustified or

harmful (Basile 2012: 82).

Therefore, stepping outside of the dominant framework that exists in the US, and taking a look at another dominant framework in a country with similar access to technology and 71

resources, can uncover these biases while also helping to dismantle our highly “rational” and technocratic views of birth. Taking a brief look at the birth model in Holland, which some argue is the vanguard for the future of obstetrics; there are many differences when compared to the U.S. model. What stands out is their Obstetric Indications List which defines what “healthy” is, by distinguishing which pregnancies are normal risks

(“physiological”) and which are high risks (“pathological”)10 (R. De Vries et. al. 2009:

13). By distinguishing pregnancies this way, women who are high risk seek obstetrical care because they may need emergency interventions, whereas midwives tend to women with low or normal risk pregnancies, often at home. This is in high contrast to how birth is modeled in the US in which all pregnancies are regarded pathologically and treated as high risk.

This dual-system, one that doesn’t neglect either the “natural” homebirth model, or the technological/emergency model, could be compared to the work doulas do in the

U.S. in which the ultimate goal isn’t the kind of birth that is had, but the overall health and wellbeing of the mother and baby. That is, every woman’s pregnancy and labor is approached on an individual level, measuring physiological risks and making decisions based on those alone, as opposed to treating every pregnancy the same, as an emergency situation. Doulas, similar to the Dutch obstetrical system, evaluate patients (or clients) on an individual level. Doulas support any kind of birth (medication free birth, hospital birth,

10 According to De Vries et al., the Dutch prefer to use their screening system to identify physiological or pathological in contrast to high-risk or low-risk as referred to in the US, to avoid the assumption that all births should be defined in terms of risk (De Vries 2009: 13). 72

Cesarean birth, home birth, etc.) as long as the mother is included in the decision-making and is supported throughout the process, emotionally, socially and physically.

The Roots o f the Alternative Childbirth Movement

The evolution of childbirth has been driven greatly by feminism, particularly in terms of women wanting control over their bodies and how they experience pain. There were various feminist “waves” throughout history that spotlighted reproductive issues.

These waves are more dialectical than I present them, as not every woman fell in line with the burgeoning thought at the time11.

The first wave started in the early 1900s when women demanded pain free births.

The second wave was in the 1940s in reaction to the first one; when women wanted control over their bodies again. The last wave could be seen more recently with feminists critiquing the second wave in terms of idealizing “natural” birth. The first wave could be seen as arising with the start of medicalization, at a time when midwives were being disparaged and new medical technologies were being ushered in amidst painful and fearful representations of birth. Doulas, in the modem colloquial sense, could be seen as growing out of the second wave: the alternative or “natural” childbirth movement, along with many modem midwives, in that they want to see women have control over their lives and bodies. This viewpoint has evolved to incorporate a reproductive justice model

11 These waves were defined more in terms of middle class white feminist concerns, this section does not critically explore birth options and concerns for lower income or women of color. 73

for some doulas (Zoila-Perez 2012), which will be explored more in Chapter Six.

Reproductive justice models parallel issues of choice and control with forms of structural violence like institutionalized racism.

The first feminist wave is heavily associated with the advent of ‘Twilight Sleep’, a powerful pain reliever composed of morphine and scopolamine (Skowronski 2015:26).

Women at the time were demanding pain free births. Twilight Sleep not only made childbirth pain free, but women could not recall the experience of labor at all. Twilight sleep became increasingly adopted in the United States despite expressed concerns on behalf of American physicians, and women were encouraged to fight for pain free birth and to fight for their “sex” (Skowronski 2015:26). Its use started to wane with the second feminist and natural childbirth wave, which was helped along with maternal deaths associated with the twilight sleep12.

The second wave grew in reaction to the first wave, in that in demanding pain free births through the advent of twilight sleep, women were losing control of their bodies:

“the obvious paradox of the ‘first wave’ feminists was that in fighting for the right to choose and control their own childbirth experience, they opted to be rendered unconscious and to surrender their care to the medical profession” (Skowronski 2015:

27). Like twilight sleep with the first wave, the second wave is closely associated with

Namely women were dying from “aspiration of stomach contents” which is part of why women are now encouraged to fast during childbirth, though as I laid out in Chapter two, this seems unnecessary and appears to be the product of out dated information. (Sleutal 1999: 508). Though, the American Society for Anesthesiologists has recently recommended that women no longer need to fast during labor. 74

the introduction to Dick Read’s Childbirth Without Fear (1944) and then later, Thank you, Dr Lamaze (1959) by Maijorie Karmel, and Robert Bradley’s Husband-Coached

Childbirth (1965), which circulated among doctors and lay persons alike (Simonsen

2015). None of these resources were inherently feminist by any means (though they were used by feminists at the time), and in fact these authors were all male obstetricians

(including Fernand Lamaze whom Maijorie Karmel is referencing). Essentially this second wave is characterized by advocating for “natural” childbirth. In contrast to the first wave, “natural” birth was desired, and defined not necessarily in terms of a lack of medical intervention but preparedness and participation. Acceptance during this time amongst educated middle and upper classes allowed for midwifery to “resurface with a new respectability” in addition to an attempt to reduce medical authority (Judson 1995:

48).

The Third Wave: “Primitive” Births and Moral Associations with the Term “Natural”

The third, most recent wave, coming out of the 1990s, is built on a criticism of the second wave’s advocacy of “natural” birth. Namely, feminist scholars have been critiquing many issues including: “othering” by race, ethnicity and economic class, the subjugation of women based on perceived gender differences, women as being seen as close to nature (and as such women should only tend to “natural” processes), false consciousness (the idea that women choosing technological births don’t know what they’re doing), as well as questioning the idea within the alternative childbirth movement 75

that the home is the ideal place for childbirth (Skowronski 2015). The last three factors both attribute to women’s feelings of inadequacy if they don’t achieve an “ideal”

“natural” birth, as they were “designed” to do, sentiments iterated in the second wave

(Skowronski 2015:27).

Dick-Read, one of the main advocates for natural birth, argued that, “ ‘civilized’

Western women had become weak, nervous and pain-intolerant by comparison with their

‘primitive’ counterparts whom he claimed experienced little in the way of pain or fear”

(Skowronski 2015: 27). Namely, he argued that pain was in the imaginations of laboring

Western women while romanticizing visions of “primitive” women squatting in a field the world over. Dick-Read even made spiritual connections to motherhood in highlighting the reverence Roman Catholics have for the Madonna and Child (Davis

Floyd 2003: 165). And many women in my interviews, both doulas and clients, reflected this “earth goddess” caricature in association with perceptions associated with natural birth or midwifery and doula care.

The construction of “hysteria” is also tied closely to ideas about “nervous birthing,” as Monica Basile (2012) has pointed out, “hysteria was intimately tied to ideas about race, femininity, civilization and motherhood. Constructed as a disease in the uterus, hysteria’s symptoms were often said to manifest in birthing rooms as long, difficult painful labors.” Women of a lower class with darker skin were considered more robust and less nervous, and therefore less feminine and civilized. Though, similar to 76

now, women who were disadvantaged socio-economically tended to have more difficult births (Basile 2012: 54).

Jane Simonsen (2015) addresses these tropes in her research: “Neither ‘Baby

Factories’ Nor Squatting ‘Primitives’: Defining Women Workers Through Alternative

Childbirth Methods in the United States” by addressing Bradley’s observations of the

“prim secretary” and the “boat women in India” (Simonsen 2015:135): “one white, nervous and plagued by weakness; the other racialized, colonized and hardy” (Simonsen

2015:138). Simonsen parallels women’s reproductive labor to women’s productive labor by drawing out tropes asserted by Dick-Read and Bradley at the time which contrasted the medicalized Western birth and the modem working woman, with the “pain-free” birth and hard working “primitive” woman, drawing out how a “gendered rift between productive and reproductive work was a hallmark of “civilized” culture” (Simonsen

2015: 138). Coincidentally (or not), Dick-Read’s book Childbirth Without Fear was published around the same time that many World War II veterans were “reclaiming industrial work from women war workers” (Simonsen 2015: 140), suggesting that male proponents at this time like Dick-Read, wanted to maintain male superiority, and reclaim their role within the workforce by convincing women that childbirth and motherhood were valuable (while also revealing racialized sentiments at the time). During this second wave, proponents of “natural” childbirth argued that:

Maternity was women’s primary source of power, framing childbirth as the defining experience

of womanhood. They argued that women had an innate capability to bear children and stressed 77

prepared, un-medicated childbirth as the best way to access their inner power and triumph over the

rigors and anxieties of parturition” (Simonsen 2015: 138).

Obstetricians, other practitioners, and academics heavily weighed in on the issues, but feminists and childbearing women themselves were participating in and shaping the process. As such, the romanticization of “natural” childbirth models and the othering of

“the primitive,” on behalf of white American feminists were similarly troubling to views of male obstetricians of the time, revealing how gender, or “femininity” collided with ethnicity, class and race. Basile (2012) locates these themes within feminism as far back as 1889 when she quotes suffragist Elizabeth Cady Stanton: “We know that among

Indians the squaws do not suffer in childbirth. They will step aside from the ranks, even on the march, and return in a short time bearing with them the newborn child” (Basile

2012: 57).

Johnson (2008) explores white women’s rejection of medical care during childbirth as privilege, showing that privileged women in industrial nations tend to request less medical intervention, while vulnerable women in both industrial and nonindustrial nations request more (Johnson 2008: 890). This line of thinking is directly correlated with critiques on medicalization and desires for “natural” birth, which seems to be heavily guided by social and economic factors.

The Natural Childbirth Ideal

During the 1970s and 1980s, many women in America sought “natural” births, which was connected to, as Davis-Floyd describes, “ the away from technology and back 78

to nature movement” of previous decades (Davis Floyd 2003:174). The natural paradigm can be equally problematic to that of a strictly medical model in that sometimes, underlying assumptions about what is “natural” subsume a sense of objectivity or universality, when there is no singular purely “natural” way to give birth. In other words, just as women might feel that they are pressured into having a medicalized birth, they can also feel pressure to have a natural birth. Often striving for a natural ideal birth leaves women feeling inadequate as they feel they have not succeeded in their natural motherly duties. In framing “natural” as the only way, or the best way, when women undergo medicalized births based on educated choices, they can be seen, or be made to feel, as though they have been “duped” or that they have stupidly allowed an institution to dictate their birth.

Different people define “natural” childbirth in different ways. Some define the term as a birth without painkillers, while some argue that only births with no medical interventions at all qualify (Elmer 2013: 7). Mansfield (2007) analyzed various natural childbirth books and concluded three factors that are integral to natural birth: activity during birth, preparation before birth, and social support (individually and in a broader societal sense) (Mansfield 2007). In 1994 Lazarus quoted a New York Times article in her research, which stated that “natural childbirth is alive and well but it has become a marriage of biology and technology”, and that doctors have changed the definition of natural childbirth “to include any birth in which the mother is awake and delivers vaginally” (Lazarus 1994:27). 79

While exact definitions might vary, what is more important is how the term is internalized in a way that can be harmful to expectant mothers. Many feminists argue that the term is essentializing, and in spite of critiques of the medicalized model, argue that the natural childbirth movement “can be morally oppressive since some women may experience the natural childbirth movement’s strong promotion of medication free birth as disciplining and controlling rather than empowering (Boulton and Malcrida 2012:

749). Boulton and Malcrida also posit the idea that “sacrifice and pain are normatively understood to be part of birthing and ideal womanhood” (Boulton and Malcrida 2012:

752). They also draw forth conflicts women have in coming to terms with “competing ideals of motherhood” set forth by societal values, which make them feel the need to be both asexual parturient martyrs (dedicated, selfless mothers) as well as “heteronormative sites of pleasure and sexuality”13 (Boulton and Malcrida 2012: 753).

In interviewing 40 women in 1999, Fox and Worts revealed that women had varying opinions about natural and medicalized births. One woman, Tanya, who was planning on having a “natural” birth, ended up needing more medical interventions than anticipated but still had a positive experience: “I really felt a lot of control all the way through, and I think one of my biggest fears about hospitals was not being in control... I felt like I was making the decisions” (Fox and Worts 1999: 335). In contrast, another

13 Many women struggle with coming to terms with how their bodies will change after a birth, and special attention is given to the effects of vaginal births. A 2012 Salon article called “My Awesome C-section” chronicled the experience of a woman who felt shame in not wanting a natural birth as she “was supposed to”. She wanted a cesarean because of fears about her vagina: “My pristine vagina was about to be blown to smithereens.” 80

woman, Trish, was seen to be suffering from postpartum depression because of the pain she had to endure (Fox and Worts 1999: 335). Additionally, many other women in their study described the intense amount of pain they encountered and were very thankful for the interventions that were available.

These experiences highlight how medical intervention can sometimes be the best option for individuals and that women can in fact chose to take on these interventions knowing full well what they might entail, and they might actually enjoy their medicalized births. In more recent interviews, Malcrida and Boulton (2012) spoke with new mothers and found that some women questioned their abilities after “failing” to have an intervention free birth. One mother, Katherine, had to get an unplanned Cesarean her first birth and had a planned one for her second. In recalling her births she stated: “part of me wonders... is there something wrong with me in that my body didn’t progress in labor naturally... Maybe I’m not supposed to have babies, maybe I’m not supposed to be a mom” (Malcrida and Boulton 2012: 760). The same sentiment resounds in an interview with Tanya:

I failed in the birthing arena.. .My friends are all intelligent women who are in really good shape

and they are just such natural moms. Like, they’re breastfeeders, and they just make it look so

easy. And I think, I’m the overweight one who had the C-section. It’s hard not to compare

yourself but it makes me feel sort of inferior to them (Malcrida and Boulton 2012: 760).

These interviews highlight the unintended consequences that can occur when women feel pressure to have an ideal “natural” birth, since anything can happen during birth, regardless of measures mothers may or may not take. 81

Davis Floyd (2003) found that while in the 1960s and 1970s practitioners were trying to find ways to teach “natural” childbirth education without making waves within the medical community, the “mainstream postmodern” childbirth educator’s dilemma is trying to retain some of the connections to the natural childbirth movement while still serving technocratic clientele (Davis Floyd 2003: 174). In other words, the trend towards

“natural” childbirth has declined since the 1990s. This could be in part due to romanticized, as opposed to realistic, notions of what a natural birth could look like within a technocratic society. In turn, what has been created is a polarization of birthing models with the technocratic at one end and the natural at the other. Though I will argue that doulas are helping to bring the two poles together, therefore creating a spectrum.

So while the natural childbirth movement opened up a new way of thinking about birth more in line with a biosocial perspective by emphasizing the role of culture, Dick-

Read and feminists alike brought on the contentious impetus for the third wave, in which the term “natural” continues to be a very charged (if not passe) term when it comes to childbirth.

Mardorossian (2003) quotes Naomi Wolf in saying that “natural” childbirth is incongruent with an institutional hospital setting: “what most parents-to-be don’t realize until it is too late is how little effect on pain [natural childbirth techniques] are likely to have in the hospital setting: such... techniques were not designed for high tech hospitals that place time limits on labor and seek to speed up contractions” (Mardorossian 2003:

113). Similarly Davis Floyd views the Dick-Read approach, or “natural” birth, as 82

unsuccessful in mainstream America because women were not prepared for the social conditions they would face during labor in a hospital (Davis Floyd 2003: 163). She argues that the Dick-Read approach was “far too radical a philosophical departure from the technocratic model to be in any way conceptually tenable within the hospital” (Davis

Floyd 2003: 163). While women were attempting natural births in hospitals, they were situated within an environment where they would hear screams and constant invitations for pain medications in shared rooms with other women, making it difficult to maintain a natural birth (Davis Floyd 2003: 163).

I would argue that “natural” (or medication and surgery free) childbirth within a hospital setting is indeed obtainable with the use of a doula, because the doula acts as an advocate in educating and supporting their client, in turn helping to mitigate obstacles to achieving natural birth. In other words, doulas are the missing link in achieving a more natural birth within the hospital setting, or more importantly, they are instrumental in helping women to feel more confident about their births, regardless of the outcomes. As I will argue in Chapter 5, doulas act as agents of social change not only by being supportive during birth and bridging medical/technocratic models with “natural” models, therefore providing more options for women, but some doulas are also taking on issues of race, class, ethnicity, gender, sexuality, prisoner’s rights and even abortion, in turn adhering to a reproductive justice model that challenges many facets of society that interfere with women getting the care they need. At a foundational level, doula care takes 83

on emotional and social aspects of birth, the effectiveness of which is now beginning to be empirically and ethnographically verified.

CHAPTER FIVE: BIRTH OURCOMES WITH CONTINUOUS SOCIAL AND

EMOTIONAL SUPPORT IN LABOR

As mentioned in Chapters Two and Three, we should be critical about how knowledge is produced, especially in terms of a biosocial event such as birth (and other bodily or health related processes as well). Monica Basile (2012), found that doulas in her study, similar to their bridging of different birthing models, try to bridge connections between scientific and embodied epistemologies, rather than presenting both epistemologies in opposition to one another (Basile 2012: 78). In an effort to see real changes within obstetrics and in knowing that “the language of science carries significant authoritative power in our culture”, proponents of alternative childbirth in the US have been calling on those within maternal health to administer more evidenced based care to women (Basile 2012: 77). Though, there is also disagreement within the alternative childbirth community as to whether scientific studies of birth practices are “relevant measures of desirable care” and therefore non-scientific sources of knowledge are equally applied to discussions with clients and with the public (Basile 2012: 77-78). In this chapter I will attempt to make the connections between empirical and embodied or ethnographic information. 84

Biomedicine: Evidence Based Research

As far back as 1980, doctors throughout the world have observed the benefits of labor support. As I mentioned in the introduction, doctors John Kennel and Marshall

Klaus, somewhat accidentally discovered possible benefits of continuous labor support in their study with Guatemalan women. Their 1980 findings demonstrated that human companionship was important for labor and delivery, finding that “the likelihood of development of certain problems that require intervention during labor and delivery was lower for mothers who had a supportive companion” (Kennel, Klaus, et al 1980: 599).

In 2004, Debra Pascali-Bonaro, reviewed various scientific studies that pointed to positive outcomes for continuous female companionship during childbirth. To briefly lay out her findings, after Kennel and Klaus’ study, she draws on a South African study done in 1991, then a 1998 study in Mexico, as well as a 2003 systematic review on behalf of the Cochrane Library which reviewed 15 studies summarizing the births of 12,791 women (Pascali-Bonaro 2004). All of the studies she mentioned support the efficacy of labor support using randomized trials (Pascali-Bonaro 2004: 21-22).

The South African study highlighted issues of who labor companions are, by pointing out that while doulas were previously unknown to the laboring women, they were not affiliated with the hospital and were members of the local community, therefore having similar values to laboring women, including the ability to communicate effectively (Pascali-Bonaro 2004: 21). Women in the doula group were reported by investigators to have more confidence after birth, leading to increased breastfeeding, 85

which they point out, is “literally a matter of life and death” in communities with a lack of other feeding resources (Pascali-Bonaro 2004: 22).

The Mexico study was similar in that the authors thought that community doulas would be more effective than nurses, as the trial included doula care in one group and

“routine care” (with nurses) in another group (Pascali-Bonaro 2004: 22). In the Cochrane study, Pascali summarized that women with continuous labor support, as opposed to no support, were 36% less likely to report dissatisfaction, 28% less likely to receive analgesia or anesthesia, 26% less likely to require a Cesarean delivery, and 41% less likely to need the use of vacuum extraction of forceps (Pascali Bonaro 2004:22). These studies highlight the efficacy or doula work in general and especially for low income or disenfranchised women.

Susan McGrath and John Kennel did another randomized trial in Ohio in 2008 for middle income women who would be birthing with male partners, building off of previous studies demonstrating the positive effects of labor support for poor women with no family members present. The participants in the study were all middle to upper income women, 78% were white and 88% were married, 57% had a college degree, the control group received standard care from private obstetricians with a male labor companion (their partner), while the other group was birthed with a doula (McGrath and

Kennell 2008: 94). The results concluded that doulas had a positive effect, as Cesarean delivery occurred significantly less in the doula group. They discuss the role of fathers within birthing in contrast to doulas: 86

Results from this study demonstrated that the support provided by male partners does not have the

same positive impact on perinatal outcomes as does that of experienced doulas. Doulas come to a

labor with a specific and well-defined role, and their relationship with the laboring woman ends

soon after the birth. In contrast, a father-to-be may attend his infant’s birth for a variety of reasons,

and his role is far from clear. Although some new fathers have attended childbirth education

classes or have been exposed to childbirth in the media, they typically have had little or no direct

experience with labor and delivery (McGrath and Kennell 2008: 96).

The authors go on to discuss how the emotional attachment male partners might have could interfere with their ability to remain calm and objective during birth, thus pointing to how not only is labor companionship important, but that doula care specifically is important because of their defined, objective roles and their training.

Vanessa said in our interviews, that after her first birth when she realized that her midwife wouldn’t be around during the whole birth, for her next birth she wanted a doula because she felt her husband might be too emotionally invested to support her alone: “my husband was great, I needed him there and wanted him there, but I needed something more, more objectivity... I needed something more maternal.” Additionally, doulas can be helpful in helping partners be supportive as well. Many women in my interviews brought up how beneficial their doula was for their husbands.

Cynthia, a doula, recalled the absolute gratitude husbands expressed towards her:

“women are appreciative and grateful but men are shocked... because I think they realize so much of what I did they couldn’t have done.” Additionally, when I asked Tricia, a client, if she felt she had to have a doula she responded by saying that it was more for her husband so that he could sleep or go to the bathroom knowing that someone was there to 87

care for her, their doula also helped with giving him suggestions, all of which took the pressure off of him which made Tricia feel more at ease.

However, Marshall Klaus, John Kennell and Phyllis Klaus, published the third edition of “The Doula Book,” in 2012, and in one of the chapters they reveal a study based on the use of lay doulas, or female relatives and friends that served as doula. The mothers-to-be were asked to chose a close female relative or friend, who were then instructed to provide “anticipatory guidance, praise, and reassurance, and they were also instructed in comfort measures, including suggestions for positions and movements for labor and pushing, and relaxation techniques such as massage and imagery” (Klaus et al

2012:156). The study showed essentially, that any doula care is better than none, because women with lay doulas had shorter labors and higher apgar scores for babies (though differences in Cesarean delivery rates were not significant) and new mothers in the doula group reported more satisfaction with their births (Klaus et al 2012:157).

W om en’s Experiences with Doulas and Doula Experiences with Hospitals and Clients

Ethnographic studies often involve in-depth interviewing. Using this kind of data goes beyond observation and number crunching, and reveals the lived or embodied experiences of people, in their own words. I find this kind of information useful

(especially in conjunction with quantitative studies) in terms of childbirth because it allows for women to have a voice, and in doing so, allows women to shape a system of which they are a part. 88

While studies involving women’s experiences with doulas are relatively abundant, with questionnaires, observations, and statistical analysis being the dominant method for inquiry, I have had a difficult time finding a lot of anthropological research done on doulas, but more specifically in relation to women’s opinions or experiences with them.

Childbirth as an anthropological topic has been popular for a while (Jordan 1993,1997), as well as the effects of medicalization on childbirth (Davis-Floyd 2003), and women’s experiences with a medicalized childbirth (Lazarus 1994, Campo 2010). However, I think there is a dearth of information on women’s experiences with doulas within the anthropological literature because doulas are only fairly recently becoming a sought after, sometimes contested, often beloved, service. The research reflects the newness and contention involved in doula work as some argue that current studies are insufficient

(Steel 2014). Therefore, my interviews with doula clients will be what I predominantly draw from in this section.

Intimacy, Encouragement and Reassurance

Cheryl Hunter (2012) did her research chronicling women’s experiences birthing with doulas in hospitals. She interviewed nine doulas and nine mothers, all white women and mostly educated and married (Hunter 2012: 317). One of the major themes she presents is intimacy and the doula’s ability to “hold the space,” or in other words create a supportive environment (as mentioned in the introduction). One mother, Paige, described 89

how she felt just having a doula be with her and described the experience in relation to control:

It was so wonderful to have her there with me, her just being there. There is something special

about having her there... But we don’t regard it that way when it comes to the birthing

process... then all of a sudden birth becomes this other person’s domain. My doula and I were just

talking about how the woman is supposed to surrender herself to the process. Of course that is

right, but that means surrender herself to her process, not someone else’s or what some else is

supposed to think how her process should go. She gets managed by this other person. It’s like

being a puppet. It’s your body but someone else is pulling the strings” (Hunter 2012: 322).

Hunter goes on to analyze this passage in describing how doulas help women maintain control over their own bodies or processes, and that the doula and mother “share one common voice in labor, the voice of the mother, which represents a high level of personal intimacy” (Hunter 2012: 322).

The most common themes throughout my interviews had to do with “holding the space” in which doulas reassure and encourage their clients through the intimate space they create. Vanessa spoke a lot about the calming effect her doula had:

From the second she walked in the door she was just so containing, and so, like, motherly, just

taking charge, so supportive, and like right next to me the whole time, and calm. And not bothered

by what I was going through where ya know, I felt like my husband might have sympathy for me

that I was going through pain and I didn’t want sympathy, I feel like sympathy makes me weaker

in some way, so I wanted the objectivity of like this is just normal, normal birth pain, you’re fine,

its all going really well.. And the doula she was right there, doing that.

Later in the interviews Vanessa reiterated this sentiment by saying that, when the doula got to the hospital: 90

I was feeling disparaged, I think because I had gone from what felt like pretty normal pregnancy,

but at the hospital they were like “you have this, you have this, you have this...” and so I was

telling her, they’re telling me that I have all these things wrong with me, and she just looks at me

and says “you have nothing wrong with you, you are totally fine and you’re giving birth to this

baby”... and I was like oh, ok. And she was just so reassuring.

She went on to describe later, how when it was time to push, it was such a strange sensation and she became worried, but her doula was right by her side: “And she was just so right there and really like, caring, ‘this is absolutely normal, this is what its supposed to feel like, you’re almost done.’ I don’t know if I would have felt free enough to let myself be vulnerable in that way with hospital staff, whom I didn’t have a relationship with.

Clients also expressed the importance of an experienced and objective labor partner. Vanessa had both her husband and a friend in labor with her and while she appreciate their presence she felt it wasn’t enough in reassuring here:

My husband and friend were great but they had never attended a birth before, they had no idea

what the impact would be like, they were reassuring, but its really different to be reassured by

someone who has seen a hundred births compared to someone who has seen none.

Vanessa felt that because of a doula’s experience, their reassurances held more weight because in the confidence they garnered from past birth experiences.

Brittany, who ended up with two doulas, echoed this sentiment as well. Brittany was all about having as close to an intervention free birth as possible, and wanted a homebirth. But because of her experience being a pediatric nurse for ten plus years, she was very aware of what could go wrong in labor and delivery. She was also taking 91

anticoagulants during her pregnancy, so she was concerned about complications. She labored at home with and without her doulas as long as possible before going to the hospital. Explaining her desire for knowledgeable reassurance she said:

While I can eyeball a kid at any age from across the room and tell you if that kid is “normal” or

not, I had no idea what a normal labor and delivery would feel like, and I wanted someone there

who had seen many, many labors and deliveries who would be able to tell me if what I was

experiencing would be normal, cause I knew that my husband would be just as clueless as I would,

and I knew that it wasn’t going to feel normal, if I wanted to do natural childbirth, and I just

wanted someone there to say: “yes I know it feels like you’re dying but you’re ok”, so that I could

just move on, or, somebody that would say “you know what this doesn’t look good we need to call

911”. I just wanted to have that confidence and comfort. And I knew I wanted to have natural

childbirth, natural delivery, and I knew I just couldn’t do it on my own.

Brittany, because of her experience as a nurse working in hospitals, also brought up how she knew that she wouldn’t get that kind of support from staff at the hospital, but that she still wanted to birth in the safety of the hospital, because of her anticoagulants, in case of an emergency:

I’m a nurse, and I know what its like to be a nurse, and I know that labor and delivery nurses, I

wouldn’t be their only patient, they’re in and out, they’re here, they’re there... not there by my

side the whole time. [But] I wanted to be in a hospital setting when I gave birth just so I could

have that saline lock in my hand, IV access, not hooked up but just have the access so that if

something went wrong they could take emergency measures.

With doulas, women don’t have to choose to either have a “natural” homebirth with a midwife, or a highly medicalized birth with an obstetrician. Instead, women can give birth in hospitals, where they can take comfort in the accessibility of intervention, but 92

only if necessary. In this way, more women can come closer to achieving their ideal birth. Crissy had similar thoughts, when I asked her if she would want to give birth in a hospital she said:

Yes, I felt like having a doula and midwife in the hospital was kind of the best of both worlds

because hospitals are a large reason why mortality rates associated with birth are drastically lower

this days, so that’s not something I wanted to risk, but at the same time I like to do things as

naturally as possible, with as little intervention as possible because there’s so many negative

effects with interventions, so for me the perfect mix is having a support group and a medical

professional that prefers all natural.

Tricia had a similar feeling, and she said that initially, she didn’t even plan on ever having kids and didn’t think much about interventions: “I was like, can I be unconscious?

Just hand me the baby afterwards.” But after she became pregnant and began doing research, she realized that wasn’t what she wanted. She was inspired to get a doula to help her and her partner be a “buffer” between her and the hospital.

Similar to Brittany, Courtney, was type two diabetic and despite her desires to give birth at home, she wasn’t able to. She shared with me her initial thoughts upon learning she was pregnant:

When I found out I was pregnant I was like oh my god, I’m going to have my baby at home in my

kitchen, its gonna be awesome, I’m not gonna deal with doctors in the hospital. And then I went to

a doctor’s appointment because I still want prenatal care and I found out that as a type 2 diabetic

you are risked out of midwifery care, you’re risked out of homebirths and you must go to the

hospital and in my case the doctor I first went to wanted to induce at 38 weeks, when the baby

didn’t have a heartbeat yet. So I was like, um, I don’t really understand, what’s wrong with my 93

vagina. And he was like, well, its just protocol. And so, those words “its just protocol” made me

stop in my tracks and think, “I do not want this kind of care.”

So I went home, and I googled: “diabetic, how to avoid c section,” because of, kind of the road he

was on. And so I found support, and supportive doctors that did work for me. But I had never

heard of a doula, so one of the first results that came up, I think it was on “evidence based birth”,

it said doulas can help to reduce c section rates and a whole host of other benefits so I thought ok

lets look into this.

So while some women might chose a doula to bridge the gap in care, some women don’t

really have a choice but to birth in a hospital, whether because they might be considered high risk like Courtney where the state will not allow a homebirth, or where they might perceive an potential emergency like Brittany. And of course, other women might go to a hospital because that is all they know, want, or can afford. In creating an intimate space

within a hospital setting, doulas can make a bridge between different philosophies of

birth.

This experience of intimacy is in contrast to what many women would experience with “standard care”. Many women assume that nurses will take on this role of

comforting and caring for women, though often because of the rounds they have to make,

or tests they have to run, nurses simply do not have the time to give good quality intimate

care.

When I asked Vanessa about her experience with hospital staff, she was

understanding but altogether underwhelmed by their support: “the nurses in the hospital, they’re nice but they’re not very warm and super engaged, they’re more clinical.” She 94

went on to point out that you just cant get the level of intimacy with hospital staff that

you could with a doula:

They’re super attentive, they're like, trying to meet your needs even before you necessarily have

them, and your just not gonna get that, as far as I can see, from a hospital staff. They also seem

more fearful about following their protocol cause you know they’re worried about consequences,

so you feel like they’re just following protocol and not engaged in the sense that they’re

supporting your making decisions, so they’re not there in a way that a doula (or midwife14) are.”

Interactions with hospital staff and doulas are varied and every doula seemed to have a

different perspective when I asked them. Jo was told in her doula training that sucking up

to the hospital staff might be a good thing, like bringing them cookies, but she didn’t

think it was necessary and ultimately always had positive experiences regardless.

Whereas Katelyn, had some run-ins with nurses where she felt that they must have had

bad experiences with doulas in the past, because they wouldn’t act warmly towards her.

Aileen, another doula, took issue not with staff, but with some doulas, especially

young doulas who bring on interventions of their own without communicating with

hospital staff. She was the only doula I spoke with to address this issue. Being a seasoned

post partum doula, when I asked her if she thought that it was a problem that new doulas

don’t know as much about the clinical side as birth she responded by saying:

Um, I don’t think it’s a serious problem, but I think there are serious problems when, and I’m not

going to be too clear about what they are, but when clinical practitioners and we’ll say, naive

14 In this section, Vanessa paralleled the care she got from both her doula and midwife, though the midwife she was describing was the one she had used for her homebirths, not the midwife at the hospital, although she didn’t have a problem with her hospital midwife. 95

doulas, who are very wedded to natural childbirth and/or natural outcome, don’t understand each

other... and aren’t willing to learn from each other.

I think that’s a problem, and its too bad because its just a learning experience, it really could be

very straight forward if there was a teachable moment that people were willing to teach in and

learn in, as opposed to “no, no, no, no, my client doesn’t want this or that, that’s bad this isn’t

good” and clinical people on the other side are saying, “this is how we do it”. You know, “you’re

just stepping in our way”, or whatever. And it’s political but its more than political, we’re talking

about a mother and child who are trying to make a major life transition.

This is when doula approaches might differ the greatest, and when there could be problems as far as bridging these “two worlds” successfully. Many doulas don’t feel comfortable engaging in any sort of conflict with hospital staff, nor do they wish to impose too many of their own opinions onto clients or staff, whereas, it is also not uncommon to find doulas doing just that. During my doula training, my trainer spoke about the importance of not getting too political, and also warned us about potential conflicts, and suggested that being clear and respectful in speaking with staff was the best option. But she also emphasized encouraging clients to speak up for themselves. To my knowledge, most doula certifying organizations, like DONA, instruct doulas not to speak for clients. This is when advocacy roles might get blurred, especially if doulas have strong opinions or political assertions.

Doulas learn to advocate in other ways that may be contrary to legal or political understandings of the role of an advocate as a “representative or defender of another person” (Basile 2012: 101). Instead of speaking on their client’s behalf to ensure that something happens or doesn’t happen, doulas might make small requests, ask questions, 96

or make suggestions. For instance, Brittany’s doula asked hospital staff if they might be able to get a nurse who is comfortable with natural childbirth. However, some doulas might not even go to that length, and may instead encourage their clients to ask questions.

Courtney described how at one point she felt the staff was being mean to her and trying to pressure her into breaking her waters, and that she was scared. So she called her doula and her doula encouraged her to speak up:

She said, ‘What do you want?’ I said, ‘I don’t want them to break my waters.’ She said, ‘Ok, you

need to tell them that. You need to use your words, I can’t say it for you.’ And so I told them, ‘I

don’t want to break my water’ And she was like, ‘OK you don’t have to’, so I felt really supported

in that.

Cynthia said in our interview that she tells clients right off the bat that she doesn’t feel comfortable advocating for them in that way, and that it is not her job to speak for them.

Though, she feels strongly that her advocate role shines during prenatal visits in which

she can equip her clients with the resources they need during birth so that they actually can speak up for themselves.

Education and Informed Consent

In educating women throughout their childbirth process, doulas help support women in making their own informed decisions. Therefore, it is not the doula or the hospital staff who are encouraging or dictating what the laboring woman should do, but

that, the woman, equipped with an abundance of information, decides what she wants to do. This is accomplished most commonly prenatally but also postpartum, when women 97

would essentially get no care, and have no contact with hospital staff, until several weeks after birth.

Cynthia expressed how she sets the tone for a birth within a prenatal visit, by encouraging and inspiring women while also being informative. She felt she often went beyond what might be expected of her in her interviews or prenatal visit, and recollected an experience with a woman who didn’t even end up being her client:

I had this lady call me, and I won’t do phone interviews. Because I think you have to feel the

personal connections [...] but my daughter tells me all the time. My interviews are like an hour

long, hers are about 20 minutes. I’m giving a lot more information, and personal care, even in the

interview, than what some doulas do. Um, but this lady called, and, I spent an hour and 40 minutes

on the phone with her, after telling her I didn’t want to do the phone interview with her and saying

ya know I really need to go.

Through prenatal visits, doulas can not only establish birth plans and client’s visions or hopes, but doulas and clients can discuss options. After discussing her positive experience with her doula, Courtney relayed the importance of education, throughout the whole birthing process to instill a sense of confidence. She said that part of why she

wanted to become a doula herself was so she could help women feel confident through

being informed (as well as through a supportive presence). She felt her doula gave her

many options and resources during her pregnancy, labor and post partum and on more than one occasion astutely summarized the power of information by saying: “if you don’t

know your options you don’t have any”. She went on to describe her relative unease and

confusion and eventual reassurance after speaking with her doula after a doctor’s visit: 98

I think she did two prenatals, she gave me a lot more resources early on. When I was probably,

well after the anatomy scan at around 20ish weeks, I noticed some yellow discharge on my breast

and was like oh my god, what is this? In the Midwest you don’t see people breastfeed. It wasn’t

until I talked to my doula that I even realized my daughter was going to nurse.

Her doula subsequently recommended a breastfeeding support group where she obtained support and guidance for breastfeeding and milk storage. Courtney then went on to describe how her doula provided education and resources for postnatal concerns as well:

At one of my prenatal appointments I mentioned that I thought regular disposable diapers are so

wasteful. She was like actually, you can use cloth diapers. And I was like, really? And so at the

second prenatal visit she brought some of her infant cloth diapers and an infant sized doll to show

me how you could do it. I was like, that’s awesome. And I asked her where I could find this, and

she told me. So I looked it up and they were really expensive. So I asked her if she knew where I

could find them used. And she was like are you really interested in cloth diapering? And I said

yeah I think so. And she said well I was going to sell some of mine. SO she sold me some her

prefolds for a really good price and all I had to do was get covers. And then I turned around and

sold them to someone else when we were done with them.

Vanessa also had some concerns with breastfeeding. After giving birth she was worried about mastitis, a common infection of the nipple. She said it was so great to just text her doula and ask her what she should do? Her doula provided her with resources to deal with the problem before it developed into anything major. Her doula also encouraged her and her husband to think about food after birth.

She said, do you have food in your freezer?... she really encouraged us to get food set up and the

first two weeks after the birth we had people bringing us food almost everyday. She was great that

way. She was constantly texting. She must have come the next day or the day after. 99

Aileen, a post partum doula15, was obviously very adamant about the importance of post partum care, and she felt that many women and families, as well as some doulas, don’t even realize how much support will be needed after the baby comes. So while some doulas like Cynthia, or Courtney’s doula, might provide the most support before and during labor, Aileen’s concerns were primarily with post partum care, namely because of her own personal experiences. She was pregnant at 17 but still wanted a natural birth at home, and her mom was supportive of it. However her difficulties came later:

Now when I was 18 and had just given birth, and was good, all that, piece of cake, had a

wonderful midwife but wasn’t doing well and wasn’t thriving and was struggling with being a new

mom. I wondered why this was so challenging. I wondered what was wrong with me and I

wondered where the support was. And I remember having conversations with women who

described a doula. A doula wasn’t a birth attendant, they were post partum attendants. 1 think it

would be nice if we hadn’t allowed the term to be absconded with birth, because there’s perfectly

great terms for birth attendants, doula means post partum care16. And when I learned that at the

age of 18,1 thought, that is what is missing. Even those, us cool hippie ladies who think we’ve got

it all going on, who think we’re so alternative. We’re not being taken care of, or taking care of

each other after having babies. And that’s because it was ripped right out of our culture. And

replaced with, women are supposed to get up out of their hospitals beds after a week or two and go

home to the suburbs and cook and clean and bottle feed.

15 Post partum doulas specifically support women and their families after birth. They will meet with clients before birth, but do not attend births. 16 As mentioned in previous chapters, ‘doula’ was initially referred to as a post partum care provider and the definition was expanded after Kennell and Klaus’ research. 100

Physical Comfort Measures: Breathing, Massage and Positioning

In addition to emotional and social support, doulas often work to physically comfort women through various movements or techniques. And similar to their emotional and social roles, doulas have to gauge what their clients might want, and when. Much of this is guided by what is discussed in prenatal visits.

Crissy recalled how her doula comforted her physically by applying a calming touch:

We had established in the prenatal visits that I loved to be touched, always, and anyway (laughs).

So my husband and her were just stroking my hair, or massaging my feet. My husband put a lot of

pressure on my lower back. We also did a lot of walking, and either her or my husband would hold

me and we would kind of sway during contractions.

As Crissy described, doulas often encourage movement, something hospitals don’t encourage, but are becoming less strict about. Vanessa described, how her doulas always kept things moving, and in doing so she didn’t have much time to feel negatively:

It felt like it (labor) was always moving along, so I never really felt like lost or unguided, I didn’t

really have any negative feelings about the process, they were so good at shifting the energy, like,

why don’t you try this, why not get a shower? And they’re always with you, standing with you in

the shower, talking to you.

Brittany had a similar experience as far as feeling like her doulas were working around her to keep things moving, while also speaking to the subtle ways doulas might make requests on behalf of their clients:

I think it was pretty seamless. The doulas just orchestrated everything around me so I didn’t have

to do anything or think about anything. One thing they were actually kind of... when it was time 101

to push, they specifically asked for certain equipment, they asked for the squat bar, and asked for a

sheet, so 1 could pull myself up to a squat at the edge of the table. And that was all them, the

doulas just did it. The only person I looked at in the face and spoke to during labor was my doula.

Breathing techniques are also implied to help calm laboring women. Many women are encouraged to focus on breathing. Vanessa described this as, breathing into the contractions, like waves.

Essentially, through education, advocacy, and social, emotional, and physical support, doulas are helping women to become empowered during their experiences, in turn shaping how birth is perceived and handled within hospitals.

CHAPTER SIX: DOULAS AS AGENTS OF SOCIAL CHANGE: EXPANDING TO A

REPRODUCTIVE JUSTICE MODEL

In addition to physical and emotional support that can lead to more positive birth outcomes, both psychologically and physically, doulas can act as agents of social change.

Some operate within a reproductive justice model, taking on feminist issues often with an

intersectionalist perspective involving race, class, ethnicity and sexuality or gender orientation, as well as focusing on prisoner’s rights or abortion. Many doulas actively take on this role in the radical political sense, but the nature of the work of a doula can lend itself to social change in that doulas are shaping what kind of care is accessible to women. Doulas are bringing childbirth choices into the larger discussion on reproductive justice issues; they are bringing a “new political consciousness into birth work” by taking 102

on issues that go beyond medicalization (which has tended to mostly affect middle to upper class white, educated women) (Basile 201: v)

Feminism at the base o fDoula work: Empowerment and Advocacy

At the base of doula work is a committed effort to empower women so that they can have better birth outcomes. So while not every doula might self-identify as feminist, the nature of the work values bodily autonomy, or helping women have control over the choices made during birth, as well as women gaining better access to reproductive care.

Looking again at Christine Morton’s (2002) work, the doulas in her study, defined doula discourse as being aligned with liberal and materialist feminism:

Doula discourse, as articulated by doulas themselves, is aligned with liberal and material feminist

discourses in so far as it acknowledges the institutional and economic frameworks in which most

women’s reproductive “choices” are constrained. [...] The putative goal of providing

unconditional support to women’s own choices regarding pain medication recognizes the validity

of personal decision-making and female autonomy. They also realize that women’s views have

been shaped by the larger cultural influences about birth, from advice books to television

talk/reality shows and their social networks. Their personal experiences and knowledge from

attending births as doulas also provides them with an awareness of various structural factors

affecting labor and birth experiences. [...] They have read about the scientific literature showing

how one intervention can lead to more, resulting in what is called a cascade of interventions.

(Morton 2002: 304).

Doulas in my interview had similar sentiments, in terms of recognizing how social or cultural resonances affect women, and wanting to change that through their support. In 103

my interviews, I asked Katelyn, a doula, how she got to be interested in birth. She explained how she first went into nursing then ended up in a doula training. She described her doula training with 15 other women in which her trainer asked everyone to go around and say why they wanted to become a doula. She said that everyone had pretty much the same answer: “I had a really traumatic birth experience and I want to make sure nobody went through what I went through.” Although she didn’t share their experience, and went into the field because of a desire to help people and a love for babies, her reflection nonetheless illustrates doulas’ motivations in shifting how birth is handled.

When I interviewed Robyn I asked why she decided to become a doula. She said recounted the childbirth environment at the time, 1992, indicating that there was a lot of fear around birth:

“I don’t know why, but I felt like, there was a, a thing in our country, that, um, an idea among

women in our country, that birth was near impossible. Women were very afraid to give birth and

so I wanted to try to help give them confidence and quell some of that fear. I thought the best way

to do that would be to become a childbirth educator, and so, I started looking into that, and when I

started observing births for that certification, I recognized that nurses and doctors couldn’t really

be in the room the whole time, and I felt frustrated. So I came home to my husband [a doctor] and

said, ‘Well whose job is it to be with them and let them know that they can in fact do this?’ And

one of his professors was Dr. John Kennell [see Chapter One], so he was in medical school at the

time, and Dr. Kennel had been doing research on doulas. So he came back from class one day and

said, ‘Well there’s this thing called the doula, maybe that’s your job, to take care of these people

in labor.’ 104

Robyn’s passage highlights what many doulas have expressed: feeling a need or desire to

support women during labor, recognizing that there is a lack of social or emotional care within obstetrics. That their work has proliferated producing good birth outcomes, proves that doulas are helping to shift the social and political landscape surrounding birth.

While Morton goes on to say that doula ideology can be very individualistic, in that attention and concern is concentrated on one particular woman, and that “larger goals for widespread social change in childbirth practices or hospital policy are supposed to take a back seat to the task of labor support” (Morton 305), I would argue that even doulas who remain relatively apolitical can effect social changes through the promotion of alterative birth solutions that bridge different approaches, with the ultimate goal of simply providing continuous support. While the foundation of doula care can be viewed as evolving out of a feminist framework (See Chapter Five), this framework sought most exclusively to take on medicalized birth and to empower women, mostly white women with access to resources. By doing so, doulas have helped to challenge cultural values of technology and control. Doula care continues to challenge these norms, and more and more doulas are aligning themselves with reproductive justice aims, evolving beyond medicalization.

The Radical Doula: Reproductive Justice, I n te r

In 2012, Miriam Zoila Perez printed “The Radical Doula Guide”, which she describes as “a resource for doulas that addresses the political context of supporting 105

people during pregnancy and childbirth.” Perez outlines how aspects of doula care can be

a seen as a form of activism, while also recognizing how far doula work has to go.

Drawing on her experiences being a doula for seven years in which she noticed that

issues of race, class and sexual orientation were not addressed much, if at all, in doula

trainings, she highlights how these issues intersect with birth work in important ways.

Accessibility: the Sliding Scale and Volunteer Doulas

Perez succinctly states in her doula guide that working with a sliding scale as a

doula is a form of activism:

Approaching our douia work as activism is about making our services accessible to people who

wouldn’t otherwise have access. It’s about reaching people who couldn’t afford a doula or

wouldn’t even know that doula care was an option. Providing services to someone who can’t

afford to pay for them is a form of activism. Providing doula care on a sliding scale, low cost or

through a barter agreement is a form of activism. All of these examples are about filling a need,

about reaching people who wouldn’t otherwise be reached (Perez 2012: 7).

In this way, doula care in general could be seen as a form of activism in that doulas

mostly work in hospitals, where most women are giving birth. Therefore, they are

changing how a large part of the birthing population comes to see and experience birth.

However, there are obviously limitations, since many women can’t afford these services

despite their burgeoning presence and working with price can often mitigate these

barriers. 106

Courtney, a lower income client and now doula, explained that her doula’s ability to work with her on price was tremendously helpful:

It’s just, so embarrassing, there’s such a stigma of being poor, it’s a struggle to be understood.

And so, the fact that she was willing to help us with a discount and she was willing to support us,

was really a light in the darkness.

Though, as mentioned in other doula interviews, namely with Cynthia, sometimes this can have a negative impact on doulas themselves who may not be able to afford to accept lower wages, or who may feel undervalued in doing so. Often doulas feel tension in

setting fees since they want to help everyone, but also need to support themselves.

Another way doulas reach lower income communities is through volunteer programs, which vary across the country, but tend to work in partnership with a hospital or clinic. These programs are especially typical for newer doulas that want to finish their certification but might feel uncomfortable charging fees with little experience. Doulas in these programs sign up for shifts and the clients they work with might not know what a doula is, or they might not have the opportunity to meet their client until they are in labor, meaning that no relationship can be developed before birth.

There are also doula programs that work with prison populations, helping women to have better births while they are incarcerated. There is a plethora of issues that radical doulas and activists are currently addressing. What has gained the most attention is how prisoners are shackled, as prison policy, during birth, as well as for appointments and procedures. Though as Perez (2012) points out, the problems don’t stop there: women face routine post partum isolation, inadequate nutrition and prenatal care, mistreatment 107

from prison officials and separation from infants immediately after birth (Perez 2012:

41).

Overall, efforts to reach marginalized populations are plentiful, yet obstacles still remain. While doulas can provide their services for free, or at a lower price for women

who especially might need their support, the weight of their efforts might be limited

because of a lack of bonding or a lack of social solidarity. Radical doulas are helping to

draw out how accessibility to their care, and the type of care they provide, are guided by various political identifies or personal experiences.

Intersectionality: Bodies, Systems and Power

Considering how intimate of an experience birth is, many are concerned about the

quality of care within volunteer programs when the impacts might be greater if women received care from someone they met before hand or could relate to. Hearkening back to

Jo’s statements in the introduction, it is important for doulas to “look like you, talk like

you, speak your language and all of that.” Issues of race, ethnicity, sexuality, gender and

class, and more, should be considered and discussed within birth work, and especially

birth activism. In Perez’s radical doula guide, she outlines the politics of pregnancy and

birth and divides the section into Bodies, Systems and Power, to outline how people

might be affected by various political contexts.

Within a bodily context, childbirth experiences can be affected by race, ethnicity,

sexuality and gender, ability, and age. In a systemic context, we see issues of 108

incarceration, immigration status or language barriers. With issues of power, we see how

class, violence or past trauma can affect birth experiences. Of course, these factors are not discrete categories for political identity or analysis, many of these issues overlap,

influencing one another or relying on one another—many of these issues intersect.

Framing experiences in terms of intersectionality is therefore a productive way to discuss

social justice issues and birth work.

Khiara Bridges (2012) in her work Pregnancy, Medicaid, State Regulation and

Legal Subjection, looks at women birthing at a major public hospital in New York City,

revealing that women’s bodies (specifically poor women, women of color and

undocumented women) are supervised and regulated by the state, making them more

vulnerable to hardships, whether physical, emotional or financial. Bridges draws heavily upon Foucauldian theory by positing that control of bodies on behalf of the state has

shifted from “the classical era scaffold” which demonstrated sovereign power by

destroying the body of a prisoner, to “the modem era prison- the consummate vehicle for

acting on the heart, thoughts, will and inclinations of a prisoner” (Bridges 2012: 347). In

other words, as opposed to physically taking prisoners and controlling lives, people are in

essence prisoners by constant surveillance and moralistic associations that might guide

their behaviors. In the modem age, the “prisoner” whose body is “always capable of

being seen, bears this knowledge and, in turn, becomes the agent of his own discipline

and oppression” (Bridges 2012: 347): 109

Thus, bodies incarcerated in penal institutions are not the only bodies subjected to constant

surveillance and management, performed with the intent to “correct” the desires of the subject;

rather, all bodies caught within the “carceral net”—frequently indigent, disenfranchised, and,

importantly for the purposes of this study, female—are thus subjected. The observation that the

bodies that tend to be caught within “carceral nets” have specific racial, class, and gender

ascriptions may require an amendment to Foucauldian theory, which arguably speaks at a broad

societal and historical level without concerning itself too much with social distinctions (Bridges

2012: 348).

Bridges points out that marginalized bodies especially, are under constant surveillance and in her research this is embedded within pregnancy and childbirth experiences for

women who have to rely on the state for their care. Racism is alive and well within the

healthcare system and women of color have less birthing options because of it. Perez points out that while, between 2004 and 2009 there was a 29 percent increase in home births, 90 percent of that increase was from non-Hispanic white women (Perez 2012; 26).

She goes on to point out that many Latina immigrants she has worked with come from a

place where midwifery care is stigmatized, and that when hospital births first became

popular, African American women were excluded. In other words, she points to how the

hospital is seen as a place that people with wealth and privilege go to give birth, so many

women want what they perceive as the best quality care, but might also feel the impacts

of institutionalized racism or xenophobia.

Native American women, as women of color, experience similar issues albeit with

different cultural and historical underpinnings. Perez calls on us to remember that while

we often group ‘people of color’ into one community, or one terminology, we should not 110

erase differences amongst people of color. Because of marginalization and displacement,

many Native American women experience unsafe or uncomfortable situations. Perez

shares an excerpt from a Native American woman:

Enter Western patriarchy. Native women were subjected to horrors manifested in all aspects of

bodily harm. Our ancestors were kidnapped, gang raped and fed to war dogs. Eaten for

entertainment in circus-like manner. Forced to marry white men and birth babies alone, without

the help of their beloved Sisters. Traditional knowledge of menstruation, pregnancy and birth, and

breastfeeding were lost, and Native women today still pay the price. Of all ethnicities in the US,

Native women suffer the most when it comes to birth. We have some of the highest teen

pregnancy rates, pre term birth rates and maternal and neonatal morbidity rates, and some of the

lowest breastfeeding rates (Perez 2012: 27-28).

Gender and sexual orientation can also contribute to the kind of care people receive as

well. Often a feminine wisdom or intuition is associated with birth, most especially amongst natural childbirth discourse. As I’ve detailed in this paper, this was a response to

sexism within the field of obstetrics; women wanted to reclaim their bodily knowledge.

However, as Perez points out, we are fighting gender essentialism with more gender

essentialism (Perez 201:2 31). Some people giving birth don’t identify as woman at all, and many might not fit into heteronormative expectations of their gender and sexuality.

Factors such as size, disability or age, can also be physically seen, leading to

stereotypes and prejudice. Perez recalls a situation in which a woman was considered

“high risk” because of the medications she was on for her mental health, and how obese

people often face higher Cesarean rates due to biases about their weight and safety of a vaginal delivery. Perez also explains how age factors into care as young women and older I ll

women alike have to face stigmas and may even be considered “high risk” (Perez 2012:

35). Though, some factors cannot be seen. Physical violence or trauma, including sexual violence, may guide how a woman experiences birth, factors that doulas can help in supporting.

The Full Spectrum doula: Abortion, Adoption and Miscarriage

Full spectrum doulas support people beyond giving birth, and often help them with abortion, adoption or miscarriage. Perez considers “Full Spectrum Doula” a fairly new term, and first heard the concept of an abortion doula in 2007 from an OB-GYN working in a Boston hospital where they were training doulas to support others in second trimester abortions (Perez 2012:12).

For abortion support, doulas encourage breathing and relaxation, and sometimes distraction. Doulas may also support others at home through medication or herbally induced abortions. Miscarriage support is similar, as it often involving procedures in the hospital to deal with incomplete miscarriages. Though as Perez points out, many women who receive abortions might feel a sense of relief when its over, while those not choosing to terminate their pregnancy may feel overwhelming grief, in need of a different kind of support (Perez 2012: 15).

Adoption is also an area in which doulas are slowly entering. Perez points out that while many doulas might encourage or help to support more intervention free practices during birth, women who choose to put their child up for adoption may not want to remember or experience pain during childbirth (Perez 2012:16). Additionally, hospital 112

staff might not be aware of a clients adoption plan, in turn making assumptions that could be challenging and harmful.

Doulas can play a key role in helping to ensure that any person, regardless of their identity, socioeconomic position or choices, can have a more positive experience. Doulas in general impact social changes on a level of accessibility and empowerment. Radical doulas are moving beyond those issues and embarking on issues that challenge how certain bodies and bodily experiences can further impede receiving quality care.

CHAPTER SEVEN: DISCUSSION: BIRTH AS SYMBOL FOR SOCIETY, IDENTIFYING POTENTIAL PROBLEMS WITH DOULA WORK, QUESTIONS FOR FURTHER STUDY In following with the themes in this thesis, we can see how birth can be viewed as a symbol for society, reflecting patriarchal and technocratic values. Underlying these patriarchal and technocratic values are capitalist values which innately function through bureaucratic or free market initiatives that have over time contributed to the break down of familial and social support structures, rendering care work as a commodified yet underpaid and undervalued skill or attribute. Caring in general can be seen as a weakness, and is often linked with femininity. Additionally, like many other facets of society, childbirth reveals cultural attitudes towards people of various socioeconomic positions, reflecting obstacles inherent within a system that valorizes a homogenous identity: a white, middle to upper class, heteronormative identity. If even women within this homogenous identity struggle to get quality care, what does that mean for those who fall outside of it? 113

Given the complicated nexus that childbirth is situated within, how can activist or birth workers like doulas impact change? Since the efficacy of doula care is starting to be acknowledged, will more affordable and accessible doula care be something we see in our futures? How much does it matter if a doula is someone you know, or can relate to?

Doulas have been successful thus far in paving the way for a more empowering and nuanced perspective on birth, but will their ongoing professionalization have the same consequences as midwifery? That is, will doulas be limited in the scope of their work with more professionalization, standardization or bureaucratization? What would things look like if doulas were covered under insurance coverage plans everywhere in the

United States? Are doulas better off working within a free market economy? Are families better off this way?

In answering these questions, it’s important to look at how much authority certain individuals or institutions possess. Doulas and birth workers have been screaming from the rooftops for decades, demanding more evidenced based practices as well as appealing to women’s voices and bodily knowledge. The medical community seems to be catching up, but at what cost?

In an interview with Robyn, a veteran doula, she recalled how things have changed over the years. One example she mentioned is symbolic of the changing times.

When she first started, it was not uncommon for nurses and doctors within hospitals to question or be weary of birthing balls, which are big bouncy balls for laboring women to try different positions in. According to Robyn, nurses often used to worry about the 114

hygiene of these balls or worried that women might fall off of them. Now, she says, birthing balls are not at all uncommon, and she recalled how she has started to notice that these balls now display pharmaceutical company logos on them. Birthing balls are now more ubiquitous and previous concerns have melted away as pharmaceutical companies are selling them. What brought on this change? Do these changes have more to do with women’s demands and evidenced based research, or capitalistic forces? Both? How much does it matter?

When it comes to health and bodily processes, how can we balance scientific knowledge, which can often be biased or incomplete, with “ancient wisdom”, or bodily intuition that can often be too romanticized, or not easily quantified? Will social and emotional aspects to care ever be regarded? Can medicine ever come full circle to focus on more holistic approaches to health?

Because of how authoritative knowledge is dispensed, many people feel compelled to put absolute trust in the “experts”. I am reminded of the old food pyramid.

For decades it is what we all were told to look to for nutritional guidance. You could see posters plastered in classrooms and cafeterias everywhere, with bright colors and attractive visuals. While various organizations and nutritionists challenged the 1992 pyramid, it wasn’t changed until 2010. Most importantly, throughout the modification process many people on revision committees were called out for inappropriate financial ties to meat, dairy and egg industries (Petre 2012:66). The 1992 pyramid had whole grains and carbohydrates at the base, meaning that that is what was recommended for the 115

bulk of an individual’s diet. Now, nutrition trends have swung in the opposite direction,

casting aside grains to appeal to more “gluten free” or “paleo” diets. Just like childbirth, nutrition can be specific to individual needs. How can there be way to eat? One way to birth? How can we know what to trust if the “experts” have financial ties to various

industries and the science is constantly evolving?

When it comes to our own bodies and well-being, how much control do we really

have? Childbirth as a symbol for cultural values is a productive way to frame how much

control and choice we have. As an intimate, gendered experience, we can reflect on how

bodies are regarded and controlled. Women’s bodies are especially vulnerable, people of

color, lower income, undocumented or gender nonconforming people, are vulnerable as

well.

Viewing birth cross culturally helps us to understand how overarching cultural

values can impact how babies are bom. Going further, viewing birth from a biosocial

perspective allows for a more balanced perspective on how intersections based on gender,

race or class can impact birth outcomes (Jordan 1997). Many birth workers like doulas

have embraced these perspectives and incorporate change through their work. Other

doulas have chosen to take on a more explicit politicized role taking on social justice

issues, and specifically reproductive justice issues.

Because of their new or re-emerging and commodified role, we have yet to see in

which direction doula care will evolve since the scope of their practice is dependent on

capitalist and bureaucratic forces, which rest upon engrained cultural values like 116

patriarchy, control, and technology, which are difficult to challenge. It is my hope, that in drawing out the often unseen forces that guide childbirth practices, like social, cultural and political forces, the United States will eventually produce better outcomes for women and their families. I believe that doulas are uniquely positioned to impact change in this way because they are currently operating outside of, but also with institutions, in turn helping to transform them. To varying degrees doulas are succeeding in changing how birth is perceived and performed.

The conundrum at this point is confronting issues of accessibility: since doula care is not provided under most insurance coverage plans and doula trainings are costly, the demography of both doulas and clients is limited, and many women do not get to benefit from this impactful service. However, if doulas did become more accessible, through insurance coverage or having doulas employed by hospitals, the profession might risk the potential for a change in the scope of their practice with a more standardized, professionalized vocation. Nevertheless, for more quality obstetrical care in the United

States, social and emotional considerations should be more researched and incorporated within obstetrics, and medicine at large. 117

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