Chapter 1 Excerpt from Birth Ambassadors

The following is an excerpt of Chapter One: The Birth of Doulas: A Social History from the forthcoming book, Birth Ambassadors: Doulas and the Re-Emergence of Woman-Supported Birth in America, by Christine H Morton & Elayne G Clift, from Praeclarus Press.

Doula care – encompassing the use of medical, herbal, and technological interventions, the social provision of physical assistance, and the culturally shared meanings attached to childbirth and mothering – has emerged as a unique response to the changing social and medical contexts of childbirth support in the United States.

While throughout history and across cultures, human societies have had childbirth support systems that addressed the issues inherent in facing the unknown, encountering fear, pain and possibly death as they awaited a birth, the nature and manner of childbirth support has gradually been altered in the U.S.  As last as the 1930s, childbirth support was concentrated within women’s social networks.  Since the 1960s, however, it has become distributed among a variety of social actors, technologies and locations.  In particular, labor support—the provision of emotional, physical and information support—became a specific role in the form of the doula.

As social childbirth practices changed from 1930 to 1960, the fragmentation of childbirth support began, with medical experts claiming authority over pregnant women’s health and childbirth outcomes, and moving birth to the hospital.  Subsequent decades saw the emergence of various political, professional and consumer negotiations around childbirth practices, which called for women to be ‘awake and aware,’ and take an active role in their birth experiences.

In the past forty years there has been increasing accommodation to medicalized childbirth support, as well as renewed interest in merging holistic and medical approaches.  It is in this period we see the emergence of the doula as a particular, specialized role in providing non-medical (emotional, physical and informational) support to birthing women.

As the shift to hospital births became more widespread across the country, the traditional form of childbirth support radically changed.  Now the technologies, physical support and meanings given to birth were incorporated into increasingly medicalized and professionalized arrangements.  Physicians, holding out the promise of safety and sterility, moved to adopt practices and technologies that quickly became rigid and lacking in compassion for women’s subjective experience of birth.

Obstetric nurses emerged as a distinctly American version of their European counterpart—trained midwives—without the title and without challenging physician’s leadership.  The nurse’s role was to support and augment but not replace the physician, in responsibility or authority.   Physicians depended on nurses to attend to patients, but were afraid of their potential for dislodging them from their preeminent place in maternity care both by virtue of their experiential authority but also by their emotional connection to women.  Nurses then, as today, supported and cared for laboring women both emotionally and medically, managing the administration of medications, monitoring the health of the woman and her baby, and knowing when to call the physician.

By the late 1940s, however, as nursing historian Margarete Sandelowski described, “nurses began to appear less like sisterly companions in labor and more like unfeeling robots.” Birthing women were now surrounded by and subject to the authority of professional medical and nursing staff in hospitals with new, ‘scientific’ ideas about birth and child care rather than among a community of like-minded women. Nursing care gradually shifted from a model of one-on-one to one-on-many over this period.  Hospitals largely replaced home as the site of most births and kept women hospitalized for two weeks after birth, distancing them from their social support networks, and establishing institutional authority over proper infant care.  Into this milieu came the first rumblings of discontent, with natural childbirth philosophies and methods imported from England and France.

The modern period of social childbirth practices changed how various components of childbirth support had been structured, leaving patients dissatisfied with high tech incursions into the social provision of physical support.  Although women eagerly sought some intervention to address their fears and compensate for the loss of social support networks, there were real costs.  The dehumanizing practices embedded in the application of technologies (being strapped down, routine enemas and pubic shaves), and long periods of separation from their newborns had physically and emotionally traumatic affects on women, and their families.

In the midst of increasing debate, childbirth reform activists began to organize and teach natural childbirth methods.  Reform efforts, none of which challenged the authority of the physician, focused on educating women about the process of childbirth, granting fathers permission to be present at births, and helping women through childbirth.

Various political, professional and consumer advocacy groups emerged to contest the medicalized aspects of childbirth support.  Their critiques focused on women’s experience of being restrained and rendered unconscious. The alternative was for women to be ‘awake and aware,’ and to take an active role in the birth.  Concerns were raised about the physical and psychological impacts of medicalized childbirth on infants, as well.  Research on mother-infant bonding provided scientific legitimacy to some consumer demands.

This period also saw a resurgence of licensed and nurse midwifery while childbirth education, begun with the goals to educate and empower women, became quickly incorporated into hospital practice, thus losing its independence. Gradually, it became clear to childbirth reformers that hospitals and doctors were not going to alter their practices around the assumption of ‘normal’ birth.

Enter Ferdinand Lamaze, a French physician who had been influenced by the idea of conditioning the mind to influence the bodily experience of pain while observing Russian obstetric wards using this method. Lamaze developed the technique further, publishing his results in Painless Childbirth in 1956. Marjorie Karmel introduced this method in 1959 to the United States, in her book, Thank you Dr. Lamaze: a Mother’s Experience with Painless Childbirth, which detailed her experiences in Paris.

Lamaze helped give credence to the view that women’s emotional needs in labor were related to childbirth outcomes and childbirth educators made it the cornerstone of their curriculum. Childbirth educators and midwifery advocates increasingly emphasized that how women feel during childbirth is critical to their experience of that birth, and to their subsequent transition to motherhood.

Labor support as a stand-alone service developed when childbirth educators began attending births of their students, who were committed to natural childbirth, but who had no other support person available.  Those women who wanted to try ‘natural childbirth’ brought a support person with them, usually the father of the baby.  Writings from this time indicate that many women were successful in achieving natural childbirth, but were still considered to be on the ‘fringe’ of normal.

Another birth story of the doula comes from the ongoing practice of women attending births during the 1970s, when the childbirth movement gained momentum from similar sorts of advocacy also underway in women’s health, patient rights and alternative medicine.  During this time, many birth activists, childbirth educators, and partners, friends and family members accompanied women during birth.  Many women claim they had been doulas before it was called that, ‘before it had a name.’  These were women who said they were always the one in their social network to attend the births of family members or friends, who had no special interest in midwifery or nursing, but ‘found themselves’ going to births frequently.

The articulation of the ‘doula as professional labor support’ encompassed years of work as several women, together and individually, developed, elaborated and communicated the particular way ‘traditions’ would or could be adapted to ‘modern’ childbirth support.  The idea of turning labor support into a specialized service niche that would complement but not overtly threaten or question ongoing medical management of childbirth support proved to be successful in attracting women who wished to provide this type of support, as well as women who wished to receive it.

Doulas, as embodiment of the humanistic element of supportive care within childbirth, have the potential, as Robbie Davis-Floyd has written, to ‘open the technocratic system, from the inside, to the possibility of widespread reform.’ Thus, the emergence of doulas as a defined role within maternity care is more than a mere extension of what ‘women have always done.’

Changes in pain management, obstetric technology and professional roles in maternity care over the past 100 years have created a unique space for the role of the doula.  She (doulas are usually female) provides a personal guide through advice and information surrounding pregnancy and childbirth and support during the birth experience itself.  Today, doulas portray their role in maternity care within a historical framework that highlights the universality and particularity of woman-to-woman support during childbirth.  Through this framework, they collectively construct an ideology that revalues care, as well as an innovative model for accomplishing that care in the current context of childbearing in the U.S.  This model articulates an important social aspect of birth:  Caring for and about women’s emotional experience of childbirth results in greater benefits to that woman, her relationship to that child and her partner, and by extension, to society as a whole.