Science and Sensibility. Lamaze speaks out.

From Childbirth Educator to Doula and Back Again: Trends in the History of Birth Advocacy and Education

September 27th, 2010 by Christine Morton

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.

Learn to Use Relaxation for Labor

Giving birth will flow if women learn to go with the powerful contractions that bring her baby into the world. Fear and/or fatigue tense muscles and may make her body work against itself delaying birth. It is important to prepare for the upcoming birth by learning how to relax and to ease tense muscles. This article helps to explain.

Since relaxation holds the key to managing pain in labor, it is important that you take the necessary time to learn and master techniques to relax your body, and to keep it relaxed during contractions. Relaxing through pain takes practice. Even if you have tried relaxation methods in the past, chances are your first response to pain (headaches, muscle cramps, stubbing your toe) is to tense the offending part of your body.

The information contained in this page is meant to help you learn to relax. Do not rush this process. Try each exercise for a week or more before moving on to the next. Practice in various situations, in different positions. Try it when you have a headache or other pain to see if you are able to concentrate enough to relax through the pain.

Start slow. Active muscular relaxation takes practice. If you are the average American woman, sitting still for five minutes will be a difficult task for you, as we are constantly on the go. Gradually increase the amount of time you spend in relaxation daily until you have the concentration necessary to relax for at least half an hour. During labor, your contractions will be 60 to 90 seconds long at their most intense, but you may desire to continue relaxation between contractions when the labor nears transition.

Learn What Tension Feels Like

Your first job will be to learn to recognize tension in your body. Quite possibly your body is carrying a lot of tension right now, only you are so used to feeling it that you don't even recognize that you are tense! Understanding the difference between a tensed and a relaxed muscle is key to being able to relax on demand.

Begin this exercise by assuming a comfortable position lying on your side, whichever side is most comfortable to you, with the top leg bent forward reaching past the bottom leg. The actual position you choose will be personal to you and your bodies intricacies. For some women, a pillow under the knee of the top leg will improve comfort. For other women, a pillow under the head. Do not be too concerned about the placement of your arms, do what feels comfortable.

This side-lying position will be the basis for most of your relaxation exercises. That is because it is one of only two positions that allow you to relax every muscle in your body as much as possible. You see, every muscle in your body has an opposing muscle so that you can move the parts of your body in many different directions. When one muscle is fully relaxed, its opposing muscle is fully tensed! For that reason, straight legs and arms should be an indication to you that your muscles are not as relaxed as they should be.

Lying on your side will allow you to bend your joints half way, without putting too much pressure on any muscle group. Allowing your muscles to be as relaxed as possible to start helps you achieve the most relaxation possible.

In your comfortable side-lying position, choose a part of your body and tense it as much as possible. For example, if you chose your shoulders, lift them high to your ears really crunching your neck. Feel the discomfort and tightness in these muscles. Recognize how the tightness carries to neighboring muscles.

Then, after holding that tension for about ten seconds, release the muscles, letting the body part go limp or get soft. Remember not to take the muscles into the opposite tensed position yet, we are trying to learn the difference between tensed and relaxed, not between the two possible tensions for each body part. Feel the looseness in the muscle, and the difference in comfort. Repeat the tensing and relaxing a few more times, trying to achieve a deeper relaxation of the muscle each time.

After you have tensed and relaxed that muscle group in one direction a few times, switch to the other direction. For the shoulder example, you will now press your shoulders down toward your waist, as if you were trying to stretch your arms to reach something low without bending over. Feel the tension that is created by the muscle this way, and the difference between the tensed position and the relaxed position.

There may be other directions you can try with certain muscle groups. For example the shoulders can be tensed forward or backward, each time tensing a different set of muscles. Become as familiar as possible with the feeling of tension in your muscles. Once you have explored all possibilities with a muscle group, move on to a different group. Don't forget to do your face and neck, back and buttocks, chest and stomach.

What you will find during the week or two that you practice this exercise is that some muscles will come under your control very easily, and you will be able to relax them without tensing them first. That is good, in fact that is what you ultimately want to achieve. You will also find that there are muscles that seem resistant to your desire to have them relax. That is ok, you need to know what muscles you need help relaxing so your coaches will know where to concentrate efforts.

Many women find that doing these exercises before they go to bed helps them achieve a more restful nights sleep. That should not be surprising to us, as experts have been telling us that stress in our lives affects our sleep for years. Relaxation is a way to alleviate some of the stress your body is feeling. It will not remove the source of your stress, but it can help you manage it more effectively.

source: Birthing Naturally

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