Chapter 3 Excerpt from Birth Ambassadors

Trained Professional or Caring Woman? Doula Dilemmas

A doula applies a cool cloth to a laboring woman as the nurse looks on
A doula applies a cool cloth to a laboring woman as the nurse looks on

Doulas assert specialized knowledge of the complex intersection of emotional, physical and medical aspects of childbirth, yet simultaneously, portray themselves as kind, caring women with a natural, intuitive ability to improve clinical outcomes in medicalized settings.  These claims are complicated by several factors.  First, a profession is technically defined as a group that controls entry into its own ranks and possesses specialized knowledge verified through credentialing and licensing. So admission to the profession is strictly controlled through organizational means. But anyone can call themselves a doula – as yet, an unlicensed occupation.   Further, the doula’s claim to specialized knowledge is largely experiential, and rests on the constructed, collective experience as women who have birthed socially, among women, since ‘the beginning’.

The dilemmas posed by this juxtaposition create challenges for individual doulas and their organizations.  Further, the effect of these viewpoints is that they obscure the real skills, talents and value of what doulas do accomplish. 

Midwife and author Pam England, creator of Birthing from Within, a Zen-inspired revisioning of childbirth education, argues that current childbirth education focuses too much on rational information and not enough on women’s intuitive knowledge of how to give birth.  Her prescription for this problem is to encourage doulas to come to births “empty-handed and open-hearted,” adopting a mindset she calls “birthing in awareness.”

Christine Morton’s research on the history and experiences of doulas in the United States shows how doulas respond to what they learn in training and later, from their doula experiences. One doula she interviewed (all names are pseudonyms), Maisy, is typical of new doulas who feel anxious and uncertain in their abilities to provide labor support while also aware of author and doula trainer Penny Simkin’s research on women’s long term memories of labor.  Maisy was referred to her first client, an Ethiopian Muslim woman, by an experienced doula needing back-up.  When she met the client prenatally, it seemed to Maisy that the mom-to-be “wasn’t interested in childbirth, she didn’t really care.” At this visit, Maisy mentioned that her care would involve touching the woman’s body wherever she saw tension, and the woman should then just concentrate on getting rid of tension in those places.  But the doula had little time to worry; she was called to the hospital soon after this visit.  She later recalled her feelings:

I was really nervous before I got there but it was good that I didn’t have a lot of warning because I just had to go and do it.  I remembered what they said at training was ‘All you need to do is be there—if you are just there it improves the outcome, anything you add on top of that is just a plus.’  Fine, I thought, I can be there.

Her dilemma about what she would do as a first-time doula gets at the heart of the contradictions within doula care.  The training is brief, there is no supervised student learning, the mode of care can be merely touching a body but the outcomes are said to be medically and emotionally consequential for the laboring woman.  Maisy made the commitment to just ‘be there’ and she described the birth as being very satisfactory for her client.  She labored after a Pitocin induction and gave birth to her first child without any pain medications. “Yeah, she did it,” the doula said. “She had no drugs, did the whole thing naturally, and I was amazed.  She thought it was great and she said she’d never in her life been as relaxed as she was in labor!”

Doula Lorie Nelson identifies the requirements of a good doula this way:   Unconditional love. You know, willingness to work with whatever judgment comes up inside of them. I think that is the key factor in a really good doula because I believe that exhibiting caring and respect for the woman regardless of what she’s going through or what she’s choosing is a validating force that that can change her perception of herself in a difficult situation.  It’s the most challenging thing for many us. It takes great physical stamina to be a doula.  I think …it also takes a high level of sensitivity/perception/ intuition to continually track the energy of the room, of the parties present, and what the woman’s needing.

Another doula in the study, Tiffany, sounds a cautionary note in terms of who is a ‘good doula.’  She stressed the importance of technical knowledge and education.  She considers it essential for a ‘good doula’ to know ‘one’s own strengths and weaknesses as a person and boundaries as a doula.’

Perhaps the greatest contradiction of the doula role is the leveling of expertise necessary for quality labor support to one common denominator:  being a kind caring woman.  The gendered dimension of this role is explicit.  Although there are some men who have certified as doulas, their numbers are low.  Doula trainers explicitly contrast women’s and men’s knowledge and behaviors at birth:  “We all know this intuitively, men don’t.”

Doula practice is explicitly considered ‘women’s work.’  The term doula is itself gendered, coming from the Greek meaning ‘woman serving woman.’  Although the term is often reframed to be more gender-neutral, (‘experienced labor companion’ or ‘labor support person’) in cases where a pronoun is called for, the feminine is used.  Doulas themselves see the work as uniquely female.

Although there are some situations that are unrewarding, doulas believe their job is to cope the best they can, knowing they are there, above anything else, to help this woman to the best of her ability.  The emotional support provided by doulas during labor is seen as one of the most fulfilling and rewarding aspects of the role. After her first birth as a doula, Christine wrote in her field notes:

I came away feeling so incredibly HIGH and exhilarated.  I don’t know how doctors or nurses can do this and do it so impersonally.  To me, birth is sacred.  There is a story surrounding each new life—connecting the story to the lives that will be responsible for this new one for some time.  I am in awe of the incredible leap of faith that goes into having a baby.  I felt like I passed the test.  I am a doula.  I can do this.

Still, receiving rebukes while at a birth from either the client or obstetric clinicians can be devastating to a doula’s sense of competency and personal worth.  At a doula retreat organized by local trainers, many women disclosed their own unexpected discovery that they felt unprepared to do the emotional support required of doulas.  It was, however, a revelation for them to share their feelings with others, and give it a label, “doula doubt.”  Many factors contribute to doula vulnerability: personal issues with birth, an insecure role within the medical hierarchy, and lack of experience are implicated in how individual doulas respond to the interactional demands placed on them to provide doula care, when it doesn’t come naturally.

Work that is defined as “caring” has been a rich source of feminist analyses that attempt to balance the humanistic underpinning of such caregiving with the economic devaluation of the work itself.  Caregiving work embedded within reproductive contexts also poses interesting challenges for theorists who explore work, gender and emotional labor.  Doula practice provides us with a unique case study to examine how the gendered and emotional meanings of work are “simultaneously expected and rendered invisible” in a newly emerging occupation.  It is especially important for examining how the emotional component of intense caregiving work can be seen not merely as an example of economic exploitation as well as an exploration of gender, but also as a motivating factor for the work, in its own right.

The caregiving dimensions of doula practice can be compared with the contradictions and tensions emerging in other types of care work, paid and unpaid.   Doulas experience this clash of value systems when the central definition of what it means to be a competent, effective doula also includes a personal identity as a caring, nurturing woman.  Contradictions around being ‘selfless’ and ‘of value’ are heightened at a time of socially recognized, ritualized vulnerability—childbirth.

Published by Christine Morton

Christine H. Morton, PhD is a medical sociologist whose research has focused on women’s reproductive experiences and maternity care roles. Since 2008, she has been at Stanford University’s California Maternal Quality Care Collaborative, where she conducts research on maternal mortality and morbidity.

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