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