From Childbirth Educator to Doula and Back Again: Trends in the History of Birth Advocacy and Education
The ever-evolving history of the childbirth reform movement has new developments, which need to be incorporated into the older story which documents the shift from home to hospital birth; and the paradigm clash of midwifery and medical models of birth reflecting holistic and technocratic values, respectively. We need to incorporate the story of the doula, which I argue, is one of many efforts to bridge the divide – to provide, as Robbie Davis-Floyd has called it, humanistic care in birth, which is what most women desire.
History is happening now. In addition to the emergence of the doula in the past thirty years, more recently, we see efforts underway in maternal health policy (Childbirth Connections’ Transforming Maternity Care), among physician and nursing professionals (most especially around maternal quality measures, and maternity quality improvement) and resurgence among, for lack of a better word, ‘consumers’ or childbearing women, who seek greater access to vaginal birth after cesarean (VBAC). What are the goals of each stakeholder; how do they intersect and overlap, and come into conflict with one another? This is a big story, and we need to tell it!
I take a small slice of this larger historical backdrop to consider the interconnected history of childbirth educators and doulas, which will be the subject of my research presentation at the Lamaze-ICEA Mega Conference in Milwaukee.
To back up a bit, when I embarked on my sociological investigation of the doula role, I was interested in many aspects of this innovative approach to childbirth advocacy and support. What strategies and mechanisms enabled women with no medical training to insert themselves at the site where medical care is delivered to a patient in a hospital, and enact their self-defined role? Why did women become doulas and what did the work mean for those who were able to sustain a regular practice over time? How were doulas utilizing and leveraging the corpus of evidence based research which suggested their impact was as great, if not greater, than that of the physician, the culture of the obstetric unit, or the labor and delivery nurse? Where did doulas come from? What, in the history of childbirth reform, or childbirth education, or labor/delivery nursing, could help me understand how doulas emerged at this point in time in U.S. history?
Later, after learning that there were limited histories of childbirth education (by non-childbirth educators), and little research on the history of obstetric nursing, I had to take a step back and consider these factors as well. Why was the work and perspectives of women who support other women during childbirth an overlooked piece of historical research? Why did histories of women’s health reform efforts largely exclude childbirth reform? Why had there been no history of the women who were involved in childbirth education; in labor and delivery nursing; in the mainstream arena of birth care in the US? So as not to be accused of ignoring the scholarship that does exist in this area, I acknowledge my debt to Margot Edwards and Mary Waldorf; to Judith Walzer Leavitt, to Barbara Katz Rothman, Robbie Davis-Floyd, Margarete Sandelowski, Deborah Sullivan and Rose Weitz, Judith Rooks and Richard and Dorothy Wertz (I can make my full bibliography available to those interested). I have been inspired by these histories but they focused less on the women (childbirth educators) who were making history, and more on the larger cultural shifts in beliefs about medicine, technology, women’s bodies and reproduction.
When childbirth education per se was a topic of inquiry, the research focus tended to be on the primary sources of the male physician champions – Grantly Dick-Read, whose work informed the natural birth movement, and Ferdinand Lamaze (and his US counterparts – Thank you Dr. Lamaze author Marjorie Karmel, Elisabeth Bing) who formulated a method for accomplishing unmedicated, awake and aware childbirth. However, most of this scholarship makes unsubstantiated generalizations about what particular childbirth educators (of various philosophies /organizations) believed, and how they taught. There is surprisingly little in the way of empirical research – few scholars interviewed childbirth educators or conducted systematic observation of their classes over time.
So after completing my dissertation on the emergence of the doula role, I had the great opportunity to continue with my research interest through a research grant from Lamaze International to conduct an ethnographic investigation of childbirth education, with my colleague, medical anthropologist Clarissa Hsu. We talked to educators, observed their classes and analyzed our data.
We found that educators who were actively practicing doulas drew heavily on their direct labor support experiences as authoritative resources for stories and examples that supplemented the material they taught. Actively practicing doulas also included more curricular content on early labor than educators without such experience. Having real births to draw upon provided doula-educators a different type of credibility and authority than educators without such current labor support experience. These educators relied on other mechanisms to establish their authority, such as knowledge of the latest research on birth and use of more authoritarian teaching styles.
We found that the intersection of doula practice and childbirth education has significantly affected how childbirth preparation classes are taught, and this new infusion of practice and ideology is worth exploring. I encourage you to explore this with us, and welcome your thoughts.
Christine H. Morton, PhD, is a research sociologist at the California Maternal Quality Care Collaborative an organization working to improve maternal quality care and reduce preventable maternal death and injury. Her research and publications have focused on women’s reproductive experiences and maternity care advocacy roles, including the doula and childbirth educator. She is the founder of an online listserv for social scientists studying reproduction, ReproNetwork.org. She lives with her husband, two school age children, and two dogs in the San Francisco Bay Area.