A Doula's Manifesto

An Interview In Honor of Women's History Month
Cross posted at: Health and Happiness Club
Julia Mannes is a is a professional birth consultant and doula certified by DONA International. She provides down-to-earth support throughout prenatal planning, labor, delivery, and the postpartum period. Julia is also a vinyasa yoga instructor specializing in prenatal and parent-baby yoga. She is skilled in acupressure, massage, photography, babycare, and bringing ritual to lifecycle events. Julia teaches workshops in babywearing, alternative newborn care, and yoga for labor and delivery. A native New Yorker who has traveled and lived in Israel, Morocco, Australia, and Europe, she received her Bachelor of Arts in Psychology at Vassar College and worked in the music business for many years. But it was close to home in Brooklyn where she answered the calling to serve pregnant women and new families in NYC. Julia served as Marketing Director for Coalition for Improving Maternity Services (CIMS') The Birth Survey, and Ambassador with Choices In Childbirth, helping with distribution for the New York Guide to a Healthy Birth. She is currently volunteering her services in Jerusalem, Israel and returns to NYC in June of this year. Learn more at www.juliamannes.com and www.juliamannes.blogspot.com.

1) What is a doula?
The word "doula" comes from the ancient Greek meaning "a woman who serves." Doulas provide physical, emotional, and educational support to families before, during, and following their birth. The doula’s role is to stay with a woman throughout her entire labor, delivery and immediate postpartum period – this continuous support is the hallmark of a doula’s care. A doula is distinct from a doctor or midwife - a doula does not attend to the medical aspects of your birth.

2) What drew you to this career choice and how did you get started?
During my primary yoga training in NYC, I was drawn to prenatal yoga. I started teaching prenatal and parent baby yoga classes for my mentor who was also a doula. I learned the rhythms of the call to birth from the times she needed me to sub, and when I completed my doula training I was completely compelled. I had felt a distinct lack of a "calling" in my life but around the topic of birth, something clicked. When I learned a bit about the politics of birth in the United States, I became an activist dedicated to supporting pregnant women and new families learn their birth options.

3) Why is a doula so important for a woman who is considering starting a family to connect with?
In days of old, a doula wouldn't be so important. But today women often haven't seen a birth, or breastfeeding, or even held an infant until their own. Families are spread further apart or just wouldn't dream of attending another family member in labor. But women have given birth with the support of other women throughout human history. It is helpful to have someone minimize bright lights and distractions, massage a sore spot, and keep you focused on productive activities - kind of like a sister or good friend with a few tricks up her sleeve. It is helpful to have someone knowledgeable about birth and skilled at active listening nurture your trust in the process. A partner alone with a woman may (lovingly) ask, "are you ok?," while a doula can emphatically say to the laboring woman "This is within the range of normal. You ARE (or will be) ok." Women are built to birth, but they are laboring under conditions markedly different than the women who came before them. Doulas help women learn how to navigate those conditions, change them when appropriate, and simply bear witness.

Studies have shown that when doulas attend birth, women rate their experience more positively, labors are shorter with fewer complications, and babies are healthier and breastfeed more easily.

4) What do you think are the main issues concerning women's health in the obstetrics field today?
Around the world, the great injustice in birth is the lack of access to basic medical techniques that would improve birth outcomes for both mothers and babies. Unfortunately the great injustice in the United States is the over-access to medical interventions that haven't improved birth outcomes. In 2010 the US ranked 41st in the world for mothers' deaths in childbirth, last among all other industrialized nations. The United States has more neonatologists and neonatal intensive care beds per person than Australia, Canada and the United Kingdom, but its newborn death rate is higher than any of those countries. The countries that have the lowest newborn and maternal mortality and morbidity rates are the countries where the majority of births are overseen by highly trained and skilled modern midwives.
As a society we are much more aware of our choices regarding an unwanted pregnancy than our options for how to birth. A lot of the feminist talk about birth mid-century was focused on a woman's right to pain medication. This is still a hot topic, but many feminists today focus on a woman's right to control the interventions she receives, to stay off her back and remain physically mobile in labor, and on returning to the women-centered midwifery model of care. Some people think avoiding an epidural is about being tough - but a choice to forgo pharmaceuticals unless urgent is most often about protecting your body and minimizing pain in the long run. It is also helpful for naturalists and allopaths alike to think less about avoiding the epidural and more about "how can we make this experience pleasant and functional enough that the epidural is not the main topic?"

5) Why do you think the U.S. has among the highest rate of c-sections in the western world?
If you ask me, it is because the majority of births are overseen by surgeons. An OB/GYN is a trained surgeon who we are lucky to have when truly needed. Since they attend the majority of US births, you will see more surgical births. Midwives are expert in physiological birth, and in cultures where they attend the majority of births, there are more vaginal births. You can read this for a more thorough explanation of this complex issue.
People often say they want an OB "just in case" something goes wrong and I agree! But to oversee the entire pregnancy and birth is not "just in case" behavior. Preventing that "just in case" becomes the focus of institutionalized practice more than the physiological and emotional ways to support a laboring woman. For example, all women naturally vary in their labor time - just like leaves fall from a tree at their own pace in autumn. Averages should give us a rough understanding of labor more than a mandate for each woman. Yet standard practice is to administer a synthetic form of oxytocin if labor is not progressing at 1cm per hour, which causes much stronger contractions and requires women to be immobilized and hooked up to a variety of intravenous drips and machines (and does not always speed labor as intended). Some babies do not tolerate these more intense contractions well, and a cesarean is suggested.
It would be like hiring a pediatrician to babysit your children. Not only might it be overkill, but it is a different skill set. The pediatrician may know about every childhood illness, but you'd want to be sure they know the basics of fixing a meal and connecting with your child.
The World Health Organization recommends the cesarean rate be about 10%. From a public health perspective, some say numbers much lower can result in avoidable natural trauma, and much higher numbers result in avoidable medicalized traumas. The rate in the United States is 32% and has steadily increased for 12 years straight - that is 1 in 3 births. Yet famous midwife Ina May Gaskin who started the birth community at The Farm in Tennessee has a 1.5% cesarean rate and better overall birth outcomes with fewer interventions than the national average.
People often ask me "what would a midwife do if the baby's cord is wrapped around its neck?" and I think to myself "at least give me a harder question!" A person trained in physiological birth should be even more skilled than a surgeon with a manual manipulation such as this - she would unwrap it with her hands. Her expertise is not limited to manual adjustments - a modern midwife has a lot more medical training than most people realize - but part of what makes birth with a midwife safe is that she will transfer care to an obstetrician when medically necessary. I've heard some convincing arguments that lack of faith in midwives is a form of chauvinism, in the sense that we're really saying we only trust the male-oriented medical system.
I have a dream of teaching "Birth and Babies 101" to teenagers because we need to know about birth way before we intend to conceive - it is empowering to better understand how our bodies work, distinguish the "choice" and "chance" aspects of birth, and increase comfort with this topic. TV shows like ER can make you feel like birth is an emergency where things go south at a moment's notice - in fact at most births there is a lot of waiting around, and most problems, when they do occur, have early signals. Movies with birth scenes lead you to believe that you're not in labor until your water breaks and when it does you need to be rushed to a hospital, get in a wheelchair, and be on your back until the baby comes out. In fact labor can start many different ways, often quiet and calm. Unless something is amiss when your water breaks, you are better off staying at home to labor for as long as possible. Put your bags in the wheelchair and push it yourself, if you are going to a hospital at all.

6) What role do you play on the day of delivery?
Doulas can support women at a birth center, hospital, or at home, and have proven helpful whether or not the client chooses or needs an epidural in the end.
The techniques I use include counterpressure, acupressure, massage, aromatherapy, hydrotherapy, use of hot and cold, suggestions for positioning to help speed labor and make you more comfortable, guided relaxation, and breathing exercises. You don't need all these techniques and there's no one best way to breath or move.
I am alerted as soon as my client starts laboring, and I typically offer suggestions and await another call until I am needed more. I often help couples figure out how to get some sleep to conserve their energy at this stage. Once I arrive it is my job to nurture a "rhythm, relaxation, ritual" triangle - helping women remember to move rhythmically, manage just one contraction (or surge, or rush) at a time, stay focused on the techniques that are working for as long as possible, yet help take decisive action to change what is not working, and facilitate communication between partners. We avoid getting caught in a "fear, tension, pain" triangle - fear causing tension, tension making the body more rigid, ridigity reducing comfort, and less comfort triangling back to increasing fear.
I take extra care to be courteous and unobtrusive with maternity-care providers (even if I believe the provider is not offering the best evidence-based care), because I have helped clients learn about their options prenatally and I have subtle ways to remind clients how to advocate for themselves during the birth.
It can be hard to understand the magnitude of why a doula is so helpful before you've been in labor, but when the minutes of labor feel like hours and the time you spend laboring stretches from hours into days, the need for a guide or coach becomes more clear, as much for partners as for the woman - in fact it may be unfair to ask a partner to not only learn all about birth but to also master support techniques and perform them for hours on end when they too are in the midst of the emotionally and physically consuming process of being reborn as parents.
My role actually increases the privacy and intimacy at births. Even though I am an extra body in the room, I minimize distracting intrusions and help clients advocate for their own preferences.

7) What role do you play after delivery?
I help establish initial breastfeeding, and there are many other things I do. After the baby is born I stay by the mother's side even though there is a lot of attention turned to the baby - she still needs to deliver the placenta and may need stitches, she may need support cleaning up, getting out of a tub, changing position, getting some food into her system, or processing her emotions. She may be hot or cold, high, low, or shaky. I do my best to make her comfortable. I also can help minimize separation from the baby, make the room cozier, or navigate the family in the waiting room. I speak to my clients on the phone at least once or twice in the day and days following the birth to make sure all is going well. I can offer support before an issue becomes acute. I visit clients at home a week or 2 after the birth to answer questions, help process the birth, and receive feedback about my role. This can all be very helpful since typical birth protocol involves discharge from the hospital with no follow-up until 6 weeks.
All the above pertains to my labor clients. I am also a postpartum doula, and for these clients I help with household tasks like shopping, laundry, and dishes, light meal preparation, registry/thank yous, and practical baby- and parent-care including breastfeeding, diapering, babywearing, yoga, and postpartum healing. I also remind people that if birth doesn't go as expected all is not lost and we can recover from setbacks.

8) Because of your career choice, you have a very intimate relationship with a woman looking to start a family. How does that make you feel?
It is fulfilling. Different women have taught me different things. I had one woman tell me that she's not into all this "hand holdy" stuff, and low and behold, she's the only client who ever asked me to hold her hand while laboring! You can't know which aspects of yourself will be most present during your birth, and I am always struck by the beauty of what manifests in the moment. I feel honored to attend each birth, and birth is never humdrum.

9) Anything else you want to add?
I suggest you interview a few different types of care provider – hospital or birth-center based midwives, family practice doctors, home birth midwives (read some reasearch about the safety of homebirth here, and obstetricians. Even if you love your current provider personality-wise, make sure you also jive philosophy-wise. Even if they are close to your home, think of other places you are willing to travel, such as your job. Interview others even if you are a little further down the line in your pregnancy (it is rarely too late to change care provider - and if you're concerned about offending them, try canceling your next appointment and see if you even get a follow-up phone call). See who answers your questions about safety and comfort best. People spend more time researching a car they’re going to buy, picking a wedding venue, even picking baby clothes, than they do researching the right care provider for their birth. And time and again, women rate their births as the most memorable events of their lives – so how do you want to remember your experience?

A final word - I loved my birth! It is helpful to know people have had positive birth experiences. Try to inform your psyche with positive stories. My daughter was born at home 17 months ago.