A Comment on DONA

Okay I can’t resist writing about the recent issue of DONA posting a highly insensitive image. I can’t say I feel quite gleeful or even a bit of Schadenfreude (thought it’s tempting) because this controversy comes at the expense of black folks who are at a particular crossroads of hatred and invisibility in our current environment, but critiques of the establishment neck of DONA are long overdue. I’ve had personal and professional beef with them as an organization since before I was even trained as a doula, and this has only grown over the years. This recent nonsense takes the cake, though.

I’m not going to repost the image. If you haven’t already seen it, DONA posted (for the second time in less than two years) an image of a white woman wearing an afro wig and looking dumbfounded in an advertising campaign. It’s an inappropriate and frankly just bad and nonsensical photo. It didn’t need to exist. The afro serves no particular plot purpose and beyond that, of course it’s offensive when there has to be policy action taken AGAINST the notion that you can deny someone work or access because of their black hair styles. DONA should have known better to begin with, but especially after they were already called out for using this photo, they should have known better than to reuse it.

Now, it is also worth taking this mantle up so that black women, already having to engage in these ridiculous battles to HAVE HAIR and you know…not die in childbirth, can take a nap or drink a beer or play with their kids or do their jobs without having to pause to fight these battles in the first place. And where I am exhausted as a liberally minded person by the constant in circle fighting and purity testing, this is an issue that is just so damn petty and annoying and caused only because people at the top of the biggest doula training organization seem to so constantly have their horse blinders on that I feel like this is something as a policy-oriented doula and a doula who recognizes the shameful truth of the disparities in care within an already failing system that I can’t just roll my eyes and wait quietly for it to pass.


So let’s be clear, I am a WHHHHHHHHHHHite WHOOOOOOOoman. Like, Nordic and Celtic, see-through skin, made of potato and flakey white fish, born in a pile of lily white snow white woman. I’m listening to Philip Glass as rage music right now sort of white woman. I inherited the blonde hair and high arched eye brows of my mother that seem to serve as catnip for older white ladies to come up to me out of the blue and say crazy racist things at my face. I can’t tell you how many Birkenstock wearing older white ladies have approached me on the street in downtown Oakland after I walk out of my front door with my pitbull to ask me if I have this dog because I’m afraid of the black folks on my block. I truly, deeply, wish that I could chalk this up to me being a pathological liar vying for click bait, but trust me, this has happened to me on numerous occasions. It happens to me in line at the Trader Joe’s and Whole Foods — older “progressive” white women commenting on “the hood” where these stores are located (in now highly gentrified parts of the city) to commend or chastise me for my supposed “bravery” at living in such a supposedly threatening area. I wish I could tell you that I turned and screamed at them “I’M NOT ON YOUR TEAM, LADY!” but honestly, I’ve managed to be a bit more subtle in my rebuttal and for that, I am ashamed.

I see these same sorts of comments online regarding this and other issues around the black maternal health crisis. White women, most trained by DONA and CAPPA and the more “establishment” organizations, jumping into the comments to wag their fingers at more radical activists for voicing their anger. This isn’t the exhausting circular infighting that impedes some radical activism. No, this is a symptom of a strain of birth work that is all too accepting of the status quo not wanting to feel threatened by colleagues pointing out systemic problems and demanding action from the organizations that are supposed to represent doulas and help lend legitimacy and protect our livelihood. If DONA and the other major training organizations and their circle of piranhas online can’t see their blindspots, it affects ALL of us in this practice, but particularly the most underserved and undervalued of us — Black women.

Black women are 4x more likely than white women to die in childbirth in this country. We know that statistic by heart by now. We know it because it has finally crossed into the national dialogue. We know it because non-establishment black women yelled, cried, wrote, showed up, pushed forward for decades until this became a statistic we memorized. And let’s be absolutely clear — this statistic is an embarrassment. Our healthcare system is a huge and expensive joke and getting worse, but this particular component of our failing system is a particular offense and there is not a second more we can waste ignoring its causes. As indirect as it may appear, when racism runs so systematically deep that the problem with this image was overlooked TWICE when this offensive image is being used to represent literally tens of thousands of doulas, it is absolutely part of the problem. It cannot rest on the emotional and physical labor of black women alone to redirect this course.

We need to continue to push against initiatives that block access to our already difficult to access yet important work through means disguised as advancement.

With great privilege comes great responsibility and that is something that the directors of DONA can stand to hear repeated lately as bills like Senate Bill S3344B in the New York State Senate begin to dictate to doulas matters of certification and what is deemed, to “be of good moral character as determined by the department. [Section 1 (e)]” As the largest training body in the world, the Board and upper reaches of DONA may wind up having a particularly privileged position to determine what is acceptable behavior within our profession in the eyes of the governmental bodies of one of the most populous states in the country. We need to continue to push against initiatives that block access to our already difficult to access yet important work through means disguised as advancement. As DONA and the other larger organizations with larger boards given more access than many other certification bodies in policy decisions take up the mantle of professional recognition, they need to take heed of their modes of visual representation and know that their views don’t reflect those of a large portion of the birth workers in this country. If they want the seat of power given to what they proudly tote as the supposed “world’s best”, they must accept greater responsibility, pull in more diverse voices, and pay attention to their negligence. **

I personally, have long felt that DONA does not represent me as a doula. I actively avoided being trained by this organization from the outset. In the months leading up to choosing my doula training, I was working at a non-profit in Holland doing legal research for under-represented persons around the globe. I didn’t feel compelled to spend the little money I had to train under an organization that didn’t seem that focused on combatting the systemic issues within the American healthcare system that made doula work as critical and political a profession as it is. I talked to too many DONA trained doulas who felt unprepared for the realities of how political and challenging their work would be fresh out of their trainings and I wanted better. I wanted more. I wanted to be challenged. I wanted the tools to challenge the system. We all should have those skills so that fewer of us get burnt out after just 2-3 years in this field. Initially in my practice, because I chose to train outside of DONA, I was barred from volunteering at many programs (YES, VOLUNTEERING) and those who were blocking my access were very vocal about why they thought I was unworthy of supporting their efforts. I was admonished openly in doula gatherings (and this was in Seattle and Tacoma — the birthplace of DONA) and told to just make cookies for nurses and not cause too much fuss.

That was a decade ago (just had my 10 year anniversary as a doula earlier this month!) and I feel that the gap in the reality of this work and what DONA as an organization promotes as doula work is ever widening. I am proud to have been trained by toLabor and proud to work with more radical training programs like Cornerstone. I am proudly developing my own training program that has a particular bent toward more activism and policy goals and means to bust this broken system from within and without starting this fall. Doulas need more diverse and BETTER representation than they’re getting through DONA.

So what can we do here as allies? There are three main things, as I see it :

  1. Stop giving DONA money, if you can. If you disagree with their policies and practices, don’t continue to train with them or pay for your continued certification through them. At this point, certification is not required to practice as a doula (there are some issues with that, too, but for another day). When you have the opportunity or need to take more classes, choose ones not taught by DONA (there are LOTS). And if clients are concerned about your certification status, you can give a brief explanation of why you chose not to continue with this group. You can still do the work to keep up with your advanced training, but don’t continue to fund an organization that doesn’t represent you or take criticism of their bad practices seriously. They don’t have to remain the top organization in the world if they aren’t living up to that standard. Like it or not, we live in a capitalistic society and money talks.

  2. Whether you choose to stay with DONA or not, SPEAK OUT. Don’t leave it up to someone else to voice your concerns about practices that you don’t agree with. If you don’t want to wade into the swamp of social media with this issue (and I honestly do not judge you for that at all), you can write a personal letter to the board at DONA, a blog post, a letter to your DONA trainer, etc. If you are part of an agency, collective, or group that requires your certification through DONA or if you have a newer doula looking for recommendations, you can speak up on why you’d like them to seek alternatives. I know this gets lost in our digital age, but this work is still fundamentally word of mouth and comes down to making ripples in person in our own communities. This area of our work is no exception.

  3. Show up. SHOW. UP. If you feel that DONA is not representing you, start representing you. This cannot be done just online and it can’t be done just with black women having to do all the work themselves. Submit issues of access in townhall meetings. Start a letter writing campaign. Form strong, local doula community networks so you can show up as a team with an efficient plan and collective voice when issues of determination arise at the local and national level. If you don’t want DONA to be the only seat at the table, you are going to have to whittle together a goddamned chair. That’s just reality. And if you show up and get others to show up, that means that we can divide the work. Someone can take on paying attention to when issues of racism and insensitivity come up. Then another motivated person can formulate comments and official statements against them. Someone else entirely can help make action plans to make sure these issues arise less often. Yet another person can be paying attention to when bills are going to be brought to the floor and how to get more diverse representation in the meetings. No one magical person can do it on their own. It was a team of folks who allowed that image to spread through DONA and onward and it takes a team of people to get it down. We need to show up for each other. That is self care. That is community care.

And I’m going to walk the walk here. I’m not going to cave and pay DONA hundreds of dollars a year to have my courses count for their CEU’s. I was on the fence about it since I feel the doulas they train deserve to have a spectrum of courses offered to them for professional development and because they do have many trainers I respect tremendously. However, I feel that this money I have to grind my teeth in my sleep with stress over getting could be redirected toward scholarship programs, creating more access to my activism training, and supporting the efforts of communities of color having to shoulder so much unnecessary and petty work just to survive a normal biological event in this country.

You are, obviously, allowed to disagree with me about DONA’s structure and trainings in general, but I hope that you will join with me in promoting stronger activism efforts and a push for greater representation in the movement for the legitimacy of our profession and the rights of black persons to have access to safe and supportive reproductive care. If you want to talk more about how, please email me at or fill out a form on the Contact page.

**[Amended] The original posting of this article incorrectly mentioned that DONA and ProDoula were part of the legislative endeavors of NY Senate Bill S3344B. The original source of that information was incorrect and appears to have since been taken down. This article has been adjusted to reflect that. Sincerest apologies for the confusion that had caused.

I'm a Doula Not the Muffin Man

I very recently broke down and returned to Facebook, exclusively for work purposes. I joined a half dozen doula groups on there, and for the most part, have been enjoying the connections and conversations that pop up. Our work is severely isolating, and having some low-to-no cost ways to creatively crowdsource ideas and support is enormous, so I’m grateful to online platforms for providing some form of that. 

There’s one aspect of these group threads is really irking me, though. It’s an issue that bothered me as a brand new doula and it’s one that peeps it’s head up to poke at me every now and again. It’s one that on its face seems to be something hardly worth complaining about, let alone worth dedicating a whole post to, but I believe strongly that it speaks to so many of the battles we face as non-clinical care providers in an under-respected, marginalized, underpaid, high-stress job working in the field of women’s health that is so fraught with enormous physical and cultural implications —I’m sick and tired of doulas being told that they need to make baked goods for nurses and give presents to their clients. 

Okay, I know what you’re thinking,

Em, seriously? What’s the harm in this? Nurses work hard and we want to connect with our clients.” 

I agree.

What I’m arguing is not that you’re wrong for doing these kind things. Not at all. My problem with these things is multilayered and nuanced, so I hope you will hear me out and even if you come out the other end of this post thinking, “I’m still going to bake some cookies for some nurses,” that you will have at least taken the time to consider some of these larger political questions about the whole scope of our profession. 

Exploring the Motivations

My concern with this particular issue is not about whether or not you’re making a generous gesture. What grinds my teeth is how the prompt for the conversation about bringing treats to nurses is about a doula’s desire to either be “liked” by the nurses or that she would otherwise feel she is “bothering” them by her presence if not for coming with a bribe of sweets. 

There’s a lot to unpackage here. all of feminism and then some… I want you to consider the framework of the situation where you need someone to “like” you in order to potentially take you seriously and in turn, perhaps “allow” your client to be their own advocate and have a higher chance of their desired outcomes in birth. And I’m not pulling at strings from the far ends of some conspiracy theory in making this point. I have sat in on more than one doula group meeting where some older (not necessarily more experienced) doula has told me that my issues with the rights of my client being trampled on by medical staff could have perhaps been alleviated if I had convinced them to appreciate my presence via brownies. 

Let’s consider that equation starkly :

Cookie bribe + nurse’s personal approval of doula = fewer medical interventions

Excuse me, but WHAT

nurse gifts doula

This is sincerely a huge motivating factor for me in switching over from client-based work into training doulas. I came into birth work through working with refugees in non-profits, using legal research to appeal for grants and media coverage so that the concerns of refugees and migrant persons (largely women and children) don’t get pushed to the wayside. I came into birth work with a radical perspective on the necessity of change. It wasn’t too long into this career that I realized that EVERY DOULA if doing their job correctly, is radical. That all of birth is political. Therefore, the work that we need to be doing is not being the fairy godmother delivering gifts and cookies and paying for our clients to get massages and pedicures or worrying about whether or not a nurse thinks I’m, or whatever. The value of my time and presence is to be a knowledgable advocate who won’t stand silently by — both in the birth setting and in my non-billable hourly work.

If you show up as a professional, you do your job well, you stand firm in your beneficial role in the birth space, you feel solid in the fact that you are there because your client CHOSE YOU and that your responsibility is to that client and not toward making sure medical staff aren’t having an “off” day, you will earn the respect and care of the staff and your client. The hierarchy of concern toward the client is not dictated on muffins. You are an equally important member of the birthing team and having to gift your way into being respected is, in my opinion, even a bit demeaning toward nurses as professionals.

Again, if you’re coming from a place of making an offering out of respect from one hardworking professional to another and you simply enjoy making things or giving gifts…by all means. However, if you’re motivation is to earn some “niceness” cred or that you think that your worth as a doula is predicated on pandering, you are likely going to experience some sense of failure that is overly personal and might crush you out of this calling, because it is unlikely going to alleviate or safeguard against witnessed trauma. I hear stories about this constantly. Your (reasonable, considering) insecurity about your ability to be a “good doula” in this case is likely more about a disgusting misanthropic culture of misogynistic medical abuse, than about your personality or about some effing cookies. So your time might be better spent on ways of righting those wrongs over baking things for the actors in those scenarios.

Bleeding Hearts and Bleeding Wallets

Someone HAS to talk about the economic and access issues here and how it shouldn’t cost more to be a doula than we’re getting paid—which is often the case for newer doulas and doulas in certain communities. 

The first time I was told that I would gain some sort of approval by baking for nurses was when I just started out as a doula about a decade ago. I graduated college two months before the stock market crashed and walked away from my fancy college with only unpaid internship offers and a five-figure debt to sort out. About a year later, I decided to train as a doula and moved across the country with my then boyfriend who was finishing school in Washington State. I was extremely fortunate that his economic status covered my being able to live with him rent-free for a few months. Still, I had an extraordinarily hard time finding any paid work— in or out of the birth world — and despite having some sort of work everyday, made next to nothing and was on food stamps for the first six months I lived there. 

Imagine working your butt off every day to learn this trade, take on the mandatory volunteer and low-fee clients many training organizations and doula groups require, spending work days glued to a computer learning about SEO and creating business cards, finishing academic certification requirements, and dealing with the stress of being underemployed with $500 a month student loan debt and THEN having someone suggest that spending more time and money on sweets is what will make someone “like” you enough to have them not treat your client poorly.

Maybe you CAN imagine that because you’re living it, too. 

If you live in an area where you are making say $600 per birth client, how much of that should you be expected to spend on nurses and gifts for your clients? And why isn’t it a two-way street? If a nurse shares their bag of chips with you, do you think it will improve your performance? And at the end of the day, is it going to benefit your client and potentially create a safer and more enjoyable process or benefit someone’s ego to have an expectation of exchanging presents?

I think this conversation plays into the idea of doulas as tokens of a certain type of birth and as some sort of talisman to ward off selected procedures. Those things are fundamentally ignoring the point of why doulas are effective and necessary in the system of birth care we have in the United States. 

This is a profession that urges, Give Give Give. Give of your spirit, give of your time, give of yourself. I would not advocate that away. The cooption and removal of this in birth work has created “medwives,” predatory sleep consulting, charging hourly for attending births, and other unsavory elements of status quo-protective birth work. However, giving, in the sense that a doula owes her clients gifts at the onset or outset of a contract or that a doula owes nurses gifts for being “allowed” to do their jobs in partnership with medical staff whose accommodation of doulas is within their professional requirements in deference to the clients, is to reinforce the idea that as a doula we must beg and apologize for our presence. It is to reinforce the notion that we are an accessory when the work that we do is important and should stand up on its own. 

Additionally, being a small business owner is expensive, there’s no two ways about it. Though many doulas come into this work after having full careers in another area and are not using this line of work as a primary source of income, that’s not universal. There are more and more politically passionate birth workers entering the field, and where there is always room for the nurturing hobbyist doulas of the world, the bulk of contemporary doulas are seeking meaningful employment through this calling. Professional expenses add up quickly, we’re taxed at 40% like other freelancers, and there is a growing understanding of the reality of the value of our hours spent working when not directly interacting with our clients. These are costs monetarily, emotionally, and for the legitimacy of our profession as a whole. To be then taxed additionally with some arbitrary need to provide snacks to medical staff is a burden of access — economically, culturally, and in how our time is valued. 

An endless cycle of material and spiritual gift exchanging can drain the pockets and the life force, and for what? For a doula starting out who wants to create lasting change in her community, should she be counseled to spend $20 on a bouquet and card for her client or toward additional training? Which scenario will serve her client more? Their community? And before you get huffy like $20 isn’t much, for the newer crop of folks drawn to this work, many younger and unmarried, straddled with student loan debt and high rent, it is a lot.

And we need those doulas! We need fresh and motivated doulas. We need doulas of diverse economic backgrounds willing and able to serve folks with diverse economic backgrounds. We need doulas fresh out of their Gender Studies majors. We need doulas who are not here to cuddle cute babies (even though we all do), but are here to help dismantle a system of “care” which continues to perform procedures against a person’s will and then turn around and blame them for it.

Telling a struggling doula looking for advice on how to strengthen themselves against these staunch and scary cultural norms via pastry is shallow at best and irresponsible when done from a place of ego and judgement. 

Who is This Even Helping?

Nurses, for all their hard work and how put upon they are, work in a framework which provides health insurance, an HR department, union support, sometimes in-house counseling and certainly in-house legal counsel. I’m sorry, but they don’t need your damn cookies, so we need to stop acting like it’s valid currency in buying favor with them. 

But again, more importantly I think it’s about how we talk amongst ourselves about our professional purpose. If I were to write out the Scope of Practice for a doula — which I am tasked to do often, lately — no where would you find anything about being a provider of baked goods or gifts.

So again, this is not to say that you should never feel inclined to provide a treat or gesture, but rather that it has to stop being such a go-to in our mentoring of other doulas. It’s a lazy response to a colleague seeking the advice you’ve likely earned giving. And we seriously need to stop suggesting that someone is not a “good enough” doula for not bringing presents to anyone. That’s absurd. It’s also patently wrong. 

Too often, women who are called to work in traditionally female-dominated and care professions (and this includes also non-binary and marginalized folks working in a variety of undervalued fields) are made to feel like they have to give far beyond the norms or their means in order to earn their place. It may seem like this whole rant is some worthless, petty vendetta against baking (and I actually worked in a bakery for 5 years and made homemade pie crust as therapy yesterday, so I can assure you it’s not) or against nurses, but it’s the way these things are talked about that stokes this ire. And it’s the way that doulas turn in on each other sometimes. It’s the purity testing and expectations of supreme sacrifice or how all doulas have to fit into some soft, eternal gift-givers that just points to the steady trends of burn out and compassion fatigue that holds this profession back from reaching more legitimacy. 

The point is this — being a valuable, thoughtful, questioning, calm, confident member of the birth team who engages with medical staff by asking for more information and support in their role is not “bothering” anyone. It’s showing up as a professional to do your job well. You don’t need to apologize for your presence with pandering presents. You don’t need to dip into your wallet to prove that you are of worth. 

Call me extreme, but if doulas were spending less time and money bribing nurses and more time reading the NY State bill on certification and seeking to understand it, then showing up in their doula groups to have an open discussion about it’s ramifications, we could be moving ourselves toward a greater goal and (indirectly but efficiently) helping nurses do their jobs better, too. 

So make those cookies...for yourself, because at what point do you think a nurse or doctor is going to show up and hand YOU chocolates and flowers simply for helping them do their jobs? 

I'm Hysterical

My brain is a little fried from the news lately. It’s easy to get worked up and feel like there’s nothing we can do but scream. The word “hysterical” comes from the Greek word “hyster” or uterus. It translates into “wandering uterus.” In the days of Antigone, it was thought that women were empty save for a brain (generous) and a uterus. When they were being “hysterical,” it was because their uterus floated up to their brains and was causing mayhem. The cure for this was to tie a very tight rope around a woman’s waist in the hopes it would keep her stray womb at bay. Misogynist (also a Greek word), yes, but also sort of fantastical and cute compared to the resent assaults and misunderstandings about the internal machinations of womb-owning in our current medical and political bodies.

I rewatched the second season of Handmaid’s Tale, finishing up just before the news coming out of Alabama and Missouri a few days ago. When that show first premiered, half of the people I knew wanted me to watch it to get a doula’s take on it. It felt all to familiar, was my response. I watch women (and other pregnant folx) being told that they’re not good enough to take care of their own bodies or their babies constantly. The scene in the second season where June picks up Hannah from the hospital and is grilled about not being a “good mom” sounds like half of the concerns coming from the lips of the parents I work with in postpartum.

fuck these abortion bans

fuck these abortion bans

Pregnant people over the age of 35 are considered “geriatric” like their uteri are going to collapse in on their precious cargo just for having a fucking birthday. AJOG released research in 2011 outlining how 2/3 of OBGYN practice in the US is not based on high level evidence, but on doctor opinion. No shit. And it’s clear that those opinions can be racists, misogynist, and just downright wrong. So if the people supposedly in charge of understanding our changing bodies can be so brazen, can it be so shocking that 25 white men (and some particularly vitriolic women) who are convinced women are vessels and murderers don’t understand ectopic pregnancy? Or that you don’t need to cut into a uterus to remove 12 weeks of dividing cells?

We are an increasingly unscientific nation. I see that in how parents talk about research they come across (usually poorly digested in mommy blogs and the hellscape of Facebook) and feeling shamed into doing something against their intuition.

For those of us who work with folks in the childbearing year, the burden often falls on us to calm the storm, find and present valid information, and to fight diligently. And we do it as grossly unpaid and structurally unsupported persons in the shadows. Compassion fatigue is high. Burn out is fast and furious.

I’m reclaiming the word Hysterical.

And yeah, this is a shameless plug for the things I’m trying to do with Rosewood. My mission in birth work was always structural. It was always to support the people who support reproductive health and I’m finally carving out more than a marginal space in my life to do so. I want to do more to help doulas collectivize. I want to do more to help prepare birth workers with high level research. I want to help them make their businesses succeed so that they can be sages at 6 years, 9 years, 25 years of practice and not have to walk away from their passion after 2 years of begging to get paid for sleepless nights and combating structural injustices. I want to help birth workers get paid decent incomes so they can take on more volunteer and sliding scale work and serve those who need support most. I want other birth workers to feel that they can move into a position of policy and profit because they have done the groundwork and are ready to create larger platforms for others doing this essential care work.

I don’t have every answer to what’s going on politically. I shouldn’t and won’t be the voice that starts a revolution or changes the world. I had that vision of myself at some point when I was younger and working in non-profits and teaching myself international law in college. Then I was confronted with how much ego gets in the way of progress. Now, after a decade of being in birth work in many different communities, I see how being shamed into retreating too far away from ego, my fellow birth workers are setting themselves up to be taken advantage of (even if not maliciously) and why our profession stays in the margins. I believe that there can be individual triumphs, revolutions in our solo practices, and teamwork across our small communities to create incredible change for ourselves, the families in our care, those not wanting to create families who need our support and guidance, and on a much much bigger scale by showing up for ourselves and each other.

My place in this whole thing will be to help doulas set better expectations for themselves and their clients through their contracts and professional presentation. I will take my experiences of building sustainable non-profits to as many doula groups as I can in hopes that they can great organic, productive, and structurally sound collectives to protect and promote themselves and their colleagues. I will mirror these approaches in the workshops I give to parents and caregivers so they can understand and start to dismantle the influences that want to convince them their not good enough and connect with the passionate care providers who know that they are. I will do my best to listen more, allow my own biases to be dismantled, and to not shut up.

My goal for this year is to be in at least 10 different cities with these classes and consultations. I’m also writing a book on contract writing that focuses heavily on sustainable birth work and joining forces in our communities and country to make changes. If you would like to work with me, please reach out. This work can be exhausting and isolating and it’s not possible to do on your own.

Head on over to my Doula Trainings page to see what workshops I can bring to you. If you’d like me to come to your city this year, please fill out the form on my Contact page with details about you and your doula community and let’s get the ball rolling together. I offer a trade deal for anyone offering to host my workshops in their town. It’s a great way to collaborate, keep this momentum organic and unique to your particular area, and to connect with one another. Plus, you get to take my classes FOR FREE! Looking forward to working together.

Cesarean Awareness Month

cesarean awareness month

It’s #CesareanAwarenessMonth so I want to talk a bit about the discussion around cesarean rates and place of birth / chosen care providers.

I take some issue with this statement by Dr. Neel Shah (Director of the Harvard School for Public Health) in that if you’ve been attending births as long as I have, you can really start to understand why some hospitals have higher rates of surgical births than other.

There is a hospital in SF that is notorious for it’s induction and cesarean rates. The culture of the interactions between doctor and nurse, doctor and laboring person has at times been so hostile that many doulas refuse to take clients choosing to birth there. I am one of those doulas. I’ve seen too much there where I felt my clients were disrespected and put into unnecessarily risky situations, as well as overhearing some disturbing things while walking the halls among the doctors and nurses and no longer feel like my practice benefits from supporting pregnant folks seeking care at CPMC. I’ve lost a ton of potential working opportunities by sticking to my guns on this, believe me, but I felt my will to continue to do this work and the liability aspect of my practice suffer by attending births there. I never looked back.

I’m not the only one who has made this hard choice. The topic has come up with peers and it’s clearly a difficult one. Some doulas do very well in that hospital, they feel comfortable there, their clients are able to be treated well. Those doulas tend to have been working for a long time and are confident and outspoken in their normal lives, let alone in the birth space. I, however, don’t feel like it’s my role to have to fight every arbitrary decision being made for my clients around misused testing and labeling in pregnancy and the lightening speed toward interventions. At the end of the day, these folks chose where they are planning to give birth, chose their providers, and deserve bodily autonomy.

HOWEVER, despite not taking clients at this hospital, when folks email or call me for an interview and tell me they are planning to give birth at this hospital, I often spend some time talking about why I don’t take births there, rather than just funneling them along.

I can say the same things about pretty much every hospital and why the cesarean birth rate is too high (the tipping point is thought to be somewhere around 19% of all births), but there are definitely some practitioners and some hospitals where the outcome of a cesarean birth is much more likely. I feel like I owe it to my clients to be forthcoming about this.

Furthermore, I owe it to them to talk about the non-clinical reasons why most unnecessary cesareans occur, which start building LONG before the day of labor and have EVERYTHING to do with practitioners and where they get their care. If my client describes their visits with care providers with lots of, “well, they don’t ALLOW that,” or “I asked about X but they told me I had to do it anyway,” I don’t shy away from brining up that their care providers aren’t actually able to make them do or not do anything. Ultimately, my clients are in charge of their care and that of their fetus, so they should have the final say in refusing interventions, when they come into the hospital in labor, who is allowed in their room, what tests they may refuse, interventions they may refuse, firing nurses or doctors who make them feel uncomfortable and who’s decisions they don’t agree with, leaving the practice at any point in care, leaving the hospital if they don’t agree with the decisions being pushed on them, and what can and can’t happen to their baby after birth. Too often, doulas are the only gatekeepers to this important dialogue and unfortunately, we’re often the lowest rung on the ladder of care since we are non-clinical providers working with families often after they’ve gotten negative messaging from their clinical providers since conception.

Not all cesareans can or should be avoided, but there is a crisis in maternal care in this country and overuse of technology, interventions, and operations is a large part of the worsening picture. As doulas, we are obligated to speak up about the realities of why this happens. Too many doula trainings shy away from teaching newer doulas how to navigate these gray areas of scope. I do think it’s valid for us to stay within our physical scope of practice in terms of what we can do to help direct outcomes, but it is ABSOLUTELY our role to be forthcoming about systematic neglect of evidence and widespread abuse of role if we see it time and time again in certain places of care. More doulas need to be told this and we need to be more supportive of each other in navigating these tricky territories.

We are not magical talismans to ward off cesarean surgery if our clients are going to be told that their “high risk” from conception without good reasoning. It is not our job alone to protect our clients from unnecessary interventions — we guide them to the sources of empowerment, but they must ultimately empower themselves. And we must collectively empower one another to take the professionally risky move to speak up to our clients prenatally about the abuses we see. Remember that medical bullying often comes with a smile and a reminder that it’s the woman’s fault she’s high risk. We need to fight that language in our own practices and not shy away from telling the truth about certain places of birth.