A Doula’s Role in a Medicalized Birth and the Danger of Glorifying Natural Birth as Ideal
By: Sophia Pekowsky
Tags: Doula, Womens Health, Feminism, Birth, Reproductive Justice

Illustration by Sophia Pekowsky 2018

In the popular imagination, doulas are associated with natural birth. A doula is kneeling with someone in labor; swaying with them over a birth ball, applying compression, and helping them work through the physical pain of labor. In a hospital setting, doulas can be perceived as a protective shield from the horrors of an overly medicalized birth and uncompassionate doctors. In fact, one of the main arguments for hiring doulas in hospitals is that their continued support leads to fewer medical interventions. What then, is a doula’s role in a birth that involves multiple medical procedures? When someone is hooked up to a fetal monitoring system and must stay on their back? When someone has received an epidural and does not feel any physical pain? If a C-section is necessary, has the doula “failed”?

As both a researcher and a doula, I straddle the fascinating and sometimes messy grey area between theory and practice.

Most people who study birth agree that there is a huge problem with the over medicalization of birth in the US. The C-section rate, as of 2016, was 31.29%, which means that one in every three women* will have a C-section. This is more than twice the World Health Organization’s suggested 10 to 15%, and many people report unsatisfying and even traumatizing birth experiences in hospitals relating to C-sections and other medical interventions.

In her book Birth as an American Rite of Passage, anthropologist Robbie Davis-Floyd outlines the technological model of birth that exists in most American hospitals. Within this model, birth is thought of as an illness, something that needs to be treated, monitored, and cured, rather than a normal and healthy process that sometimes has complications. She describes how many medical interventions in hospital births are in fact unnecessary, caused by a need to hurry labor along, to fit the unpredictable phenomenon of birth into a fixed schedule. In a subsequent book, Birth Models That Work, Davis-Floyd uses the latest scientific evidence to argue that birth models that produce the best outcomes for both the child and parents are those that actively seek to use medical intervention only when necessary.

As a researcher, my hope is to conduct studies that influence policy, to advocate for “birth models that work”, that promote cultural awareness in birth practices and avoid unnecessary and potentially harmful medical interventions during labor. However, as a doula working in a hospital, my job is not to push the person I am supporting towards a natural birth, nor is it to fight with doctors and nurses. My job is to be there in labor with the person I am supporting in that moment, to stand with them and help them understand what is happening around them, whether they’re getting a C-section in an operating room or laboring in a bathtub at home.

*While not all people that give birth identify as women, the most accurate statistics use this language. When I am describing specific research, or examples where birthing people do identify as women, I will mirror this language, but I will generally try and use gender neutral language to acknowledge trans and nonbinary people who give birth.

One of the most powerful moments of my doula training was an exercise in controlling our judgment.

We watched a video that followed four different birth stories, each on radically different ends of the natural-medical spectrum. One of these women had scheduled a C-section to have the most control possible over her birth. My instinct was to judge her, for thwarting the natural labor process and for unnecessarily undergoing an intense and potentially harmful surgery. But upon further questioning, there were more profound reasons for her need for control. She had experienced multiple miscarriages and each one had torn her apart emotionally. Her husband was distant and cold. She needed her birth to be predictable and scheduled, and she was terrified that it would once again end in loss.

“Who do you think needs the most support?” the trainer asked us at the end of the video. The other women in the video were planning natural births- one even went as far as to request no medical personnel beside her. But most of us in the workshop agreed that the woman who was getting the C-section needed a doula the most. Even though she would be immobile, and potentially unconscious, the presence of a trained and supportive person to calm her, to hold her hand during the operation, and to debrief with her afterwards would be vital in how she processed the experience- this could affect not only her emotional health but also how she bonded chemically with the baby.

Despite the proven benefits of limited medical intervention in births, glorifying natural delivery as the “ideal” way to give birth ignores the reality of who can have a natural birth, which in the US, is deeply linked to race.

Studies show that health complications such as gestational diabetes and high blood pressure are more likely to appear in Black women. This is due, in part, to a wide range of systemic injustices that limit access to healthy food and prenatal education for marginalized people. However, even among wealthy Black women with access to these resources, the statistics don’t drastically change. In her article “Why America’s Black Mothers and Babies Are in a Life or Death Crisis”, Linda Villarosa explains,

“For black women in America, an inescapable atmosphere of societal and systemic racism can create a kind of toxic physiological stress, resulting in conditions — including hypertension and pre-eclampsia — that lead directly to higher rates of infant and maternal death. And that societal racism is further expressed in a pervasive, longstanding racial bias in health care — including the dismissal of legitimate concerns and symptoms — that can help explain poor birth outcomes even in the case of black women with the most advantages.”

In pregnancies where these types of complications are involved, medical interventions such as C-sections can be life saving. When doulas are conceptualized as useful in natural births alone, they can end up ignoring people most affected by systemic injustice, creating a self-perpetuating cycle where people with more resources receive more support.

A doula’s role in a medicalized birth can be equally as important, if not more so, than in a natural birth.

In an induced birth, for example, the doula provides emotional support more so than physical support. Induction of labor usually requires a constant attachment to a fetal monitoring system, which often renders the birthing person immobile. Induction also tends to be more painful, and this combination of increased pain and limited mobility can lead to the use of epidurals. In this situation, a doula’s job is varied. It can look like checking in with someone as they drift in and out of sleep, making sure they’re drinking water, talking and laughing with them, explaining the medical jargon when the doctors don’t do so thoroughly enough. A doula will also help process the experience after the birth, making sure the birthing person continues to feel validated and taken care of after they have left the hospital.

The founders of The Doula Project describe their work as “a quiet form of activism, an advocacy of compassion, a watchful eye on the medical industrial complex.” The present tense support that doulas provide is, in my eyes, equally as important as long-term advocacy that challenges the over medicalization of birth and ingrained racism in medical spaces. In an unjust and violent world with so much that needs to be changed, it’s easy to overlook the seemingly simple act of companionship and continued support, especially in hospital settings where medical interventions are involved.

During a highly medicalized birth, I see a doula’s role as creating opportunities for agency in situations of limited control.

When someone is tied up to four different machines, not allowed to eat or drink, and has their cervix poked and prodded at every other hour, it’s easy to begin to feel like a vessel for a baby instead of a whole person. Within this context, the option of a choice as small as adjusting the temperature of the room, removing or adding blankets, or even changing the channel on the television can bring back someone’s sense of self in the birthing process, creating comfort and confidence that is intrinsically linked to hormones that improve birth outcomes and decrease chances of postpartum depression.

It’s important that hospitals, birth workers, and prospective parents value doulas beyond their ability to reduce medical interventions and instead focus on the long-term effects that doulas can provide even in situations where medical intervention is necessary. Additionally, I implore birth workers that conceptualize natural birth as the “ideal” and “correct” way to give birth shift their thinking to include the varied and complex reasons why a more medical birth might be the best or necessary option for someone. Instead, birth workers can brainstorm ways to facilitate connection, empathy, compassion, and care into medical practices that often seek to mechanize the unarguably emotional experience of giving birth.