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.

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  1. September 27th, 2010 at 23:57 | #1

    Sounds very interesting Christine! looking forward to seeing you at the Mega Conference!

  2. September 28th, 2010 at 08:47 | #2

    I know that the Bradley Method has become the ugly step-child of the childbirth education movement, and it makes me sad. I hope that as you research you can find a way to separate the teachers and their classes from the institution the Hathaways have built. Although all Bradley classes are *supposed* to be the same, they are not.

    Sounds like a great project, and I look forward to hearing more about it!

  3. September 28th, 2010 at 12:28 | #3

    Wish I could be there to hear everything you have to share at the Conference Christine…miss you and would love give you a hug! Thanks for all you are doing to continue the momentum of this paradigm shift!

  4. September 28th, 2010 at 18:41 | #4

    “…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.”

    I was most struck by this recently on viewing the British doula movie “Doula! The ideal birth companion”. The movie seemed to me to be a massive indictment of govt funded homebirth as women and doulas expressed reasons for having a doula and they were mostly around the lack of continuity and the likelihood of shift change even in a woman’s home! Hiring someone to make up for shortfalls in another careprovider says to me that we’ve hired the wrong careprovider in the first place and need to find someone who matches our needs and expectations way better.

    Doulas shouldn’t be protectors or stop gap measures. Anyone at a birth should only be there because of the positive influence they will bring to the birth space not because another body at the birth is potentially threatening or lacking. Clearly a lot of midwifery is no longer fulfilling these needs for women and I think we need to have a good hard look at why this might be. Hiring doulas to protect ourselves in the hospital seems to be a really sad example of how we don’t challenge ourselves to think outside the box. I won’t birth anywhere I feel like I need protecting or that the team I have is insufficient. It saddens me that women make the leap to “I’ll hire a doula for the nurturing I deserve” which is a keen and useful observation but many of us are unable, or unwilling, to take that to the logical conclusion “Hmmm I don’t think I’m safe with this model of care how about I look for a new one?” Does doula care which normalises hospital birth support this status quo? I think it does. Does this help women? I think not.

    Some of the doula community who now support “women’s choices” by blanding all “choices” into some postmodernist “all choices are equal” nonsense are simply supporting the status quo and enabling doctors and midwives to keep on with the anti-woman, anti-birth policies of the system. That’s not serving women or serving birth but it is serving the obstetric machine and goddess knows, it hardly needs any more support to wreak its havoc on women’s bodies and psyches. I think we all need to be challenged more about what we do to support that machine since it is but a reflection of our society.

  5. September 28th, 2010 at 20:33 | #5

    I’m interested in your research, Christine. I am an independent midwife in Melbourne Australia having studied nursing and then midwifery, graduating in 1972. I gave birth to my first three children in Lansing MI in the 1970s. Prior to the birth of my first child I went to Lamaze childbirth classes in Lansing, and learnt Lamaze breathing and psychoprophylaxis, which I thought at the time I used quite successfully.
    Upon returning to Melbourne I became a childbirth educator, and began teaching Lamaze classes in 1979. In 1980 I gave birth again, and I was starting to doubt the rigid strategies I had learnt. I think that in the process of experiencing spontaneous birthing I had in fact learnt to minimise neocortical stimulation, and work in harmony with my body in labour and birth.
    I returned to midwifery practice in hospital, and as I applied my intuitive knowledge from my birthing experiences I learnt more about being ‘with woman’. I am, of course, still learning. Today I do not encourage women in my care to go to any childbirth education classes. My practice is based on partnership and trust between the woman, and me, throughout the pregnancy-birth-pn continuum.

  6. September 29th, 2010 at 11:56 | #6

    Thank you for your comments, Janet. You write, “Hiring someone to make up for shortfalls in another careprovider says to me that we’ve hired the wrong careprovider in the first place and need to find someone who matches our needs and expectations way better. Doulas shouldn’t be protectors or stop gap measures.”

    In my analysis of how/why the doula emerged in US maternity care when it did – I argued that it had a lot to do with changes in the role of the L&D nurse and the increasing responsibilities in that role to monitor technology (EFM in particular) and engage in documentation tasks. Many occupations have seen a progressive ‘outsourcing’ if you will, in the area of emotion work – which is seen as less skilled, requires less training, and subsequently, less pay. I saw this happening in the US labor rooms — nurses wanting to gain professional prestige (or forced by hospital policy) sought new skills and responsibilities around technology. I agree with you that doulas emerged in this space largely in response to the gaps left by this shift — who will lay hands on the woman, talk to her on her own terms, and mediate the information she is receiving from an ever changing roster of medical/nursing personnel? Even her partner (if she has one) or family member, was deemed not up to the task. Where I would like to debate you is whether this “SHOULD” be the case. As a sociologist, I don’t see my role to impose a moral or evaluative judgment on the social practices that emerge in a changing world. I do see my role as one where I observe and analyze the costs/benefits or unintended consequences of these practices. My sense is that doulas are still a very small part of US childbirth, yet their very presence is indeed a critique of the current system. It’s easy to say women “should” look for a different model of care rather than hire a doula to provide that emotional/informational buffer between the ‘patient’ and the ‘model of care’ – yet this presumes choices and resources, which are not equal for all women in the US. Finally, in reading about patient safety issues throughout the US health care system, I think it is wise for anyone to bring a patient advocate with them to the hospital – while health care workers try their best and work hard to give good care, the systems in which they work sometimes prevent this. Doulas are an interesting ‘fix’ to a broken maternity care system. I agree with you this is not the only or best solution, but I would argue that it is an important first step. In dialogue, Christine

  7. September 29th, 2010 at 12:07 | #7

    @Joy Johnston
    Hi Joy, thank you for sharing your experience of the early days of Lamaze and your journey to independent midwifery. It seems reasonable to me that women planning an out of hospital birth with a midwife like yourself has less need for a typical childbirth education class – by that I mean one which goes through an ‘ideal-typical’ lecture of physiological birth, signs and stages of labor, etc. This core curriculum hasn’t changed much since the beginning, and can be very context neutral – which I think is problematic in terms of helping women/couples understand how to navigate both the physical/emotional aspects of birth but also the structural aspects of their birth location. However, in our study, we did observe classes where the instructors explicitly encouraged group interaction and community building as well as taught labor support techniques designed to be employed in a variety of settings (and in front of various people who might be in those settings). It takes a lot of skill and energy and insight to offer a class like this and it certainly isn’t the ‘typical’ childbirth class. We found most women seek a class that fits their schedules; and perhaps were not aware that selecting a class can involve other substantive criteria about how and what is taught.

  8. avatar
    September 29th, 2010 at 15:49 | #8

    I’ve been a (part-time doula) for the last 10 years and am now teaching childbirth classes at an area hospital, having previously taught some independent classes. I’m curious if there is a way to assess whether these differences in approach in childbirth classes translate to different birth outcomes for those in the class. Seems a bit challenging to try to tease this out, but it would be quite helpful to know.

  9. September 29th, 2010 at 16:26 | #9

    @Christine Morton
    Having worked as both a nurse and a doula, I can attest to the difficulty it is in fullfilling both roles. Sometimes I can do both, but often my work as a nurse makes such that I cannot stay by the woman’s side all the time to offer emotional support or help with labor. I’m not sure there is any hospital, that could offer a complete birth with just the nurse offering both medical care and labor support. In home births, there is even doula’s present, which attests to the fact that sometimes there needs to be someone there just for labor support. Thus, I don’t see doula’s as a fix to a broken system necessarily.(Though I do agree it is broken). Labor support was something that has for the most part been a part of birth until it was taken out of the home. Now it’s just finding it’s way back.

  10. avatar
    Ruth Williams
    December 29th, 2010 at 18:39 | #10

    I view Doulas as family advocates who speak out for best practices and encourage self advocacy for the mom. Good ones will use a strength based approach. Doulas can help to translate jargon as a trusted person by the mother’s side in order to help make a decision she is comfortable with. The U.S. is one of the highest Cesarean happy countries in the world and in my opinion the business of giving birth can shadow a very natural positive experience. If a mother chooses to use a Doula it will statistically reduce the need for a cesarean saving money, emotional drain, and a healthier outcome overall. As with Doctors, Nurses, finding a good match is crucial for one of your most vulnerable times in your life.

  1. October 3rd, 2010 at 21:36 | #1
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