Changing the Birth Scene: How Doulas and Midwives Redefine the American Birth Experience
Beldina Orinda
aug 2020
Lights, glaring and blinding her as she stares up into space. Pressure... pressure. “Ooh!” She cringes, squeezing her husband’s hand, as she feels the layers of skin, muscle, and uterus—her skin, her muscle, her uterus—being pulled back, hands reaching in. Blue robes. Masks, lights. Only Dad stands, the one familiar face in a sea of doctors and nurses. Gurgling ensues, and then screams. It’s baby. She’s here. But not with her Mama. She is whisked away for cleaning, for syringes and warmers and towels, not the warmer that is her mother’s chest. And mother remains, bare, as her pieces are sewn back up. She is still numb from the epidural. Baby comes; Dad takes pictures as an exhausted Mama kisses baby, who is whisked away soon after. And Mama is rolled away to recovery (Block 45-49; “Emotional Live”).
This scene is a scary one, but sadly all too normal. “For roughly 1 in 3 women in the United States, this is childbirth” (Block 49). Scalpels, lights, and warmers override nature; hospitals, doctors, and medicine take over birth. The doctor delivers the baby—not the mother. And this is the scene that takes place in hospitals every day. One that doesn’t reflect the ideal way for women with low-risk pregnancies to deliver; one that puts women at risk. These procedures are known as C-sections, major surgeries that entail making a cut through the abdominal tissues of the expectant mother, and then delivering the baby directly from the uterus as opposed to delivering it through the vagina. This is a major surgical procedure that carries with it the typical dangers and risks of any surgery—risk for infection, long healing periods, and extreme pain following the procedure being among them—and yet C-sections are often common in delivery wards (Block). Just one piece of the bigger puzzle known as "the medicalization of childbirth." One may ask—“Doesn’t more medicine mean more positive outcomes?” Think again. The rate of C-sections has been rising in the US, not to mention the inductions and Pitocin, and the episiotomies (Amnesty International 78). And yet, the maternal mortality rate in the US is the worst among all developed countries, and the rate is rising as compared to other developed countries. In addition, 50,000 women suffer severe morbidities after childbirth that affect their quality of life (“US ‘most dangerous’ place”). Hemorrhages and hypertension are the leading causes of maternal mortality and morbidity in the US (“US ‘most dangerous’ place”). According to Erin Moriarty of CBS News, “…some medical professionals say the real problem is how those babies are delivered. They blame much of the increase in deaths and near-deaths on a dramatic rise in C-sections” (Moriarty). In agreement is Dr. Neel Shah, a practicing obstetrician and gynecologist (OB-GYN) and a professor at Harvard Medical School, who says that each time a C-section is done, a woman is more at risk of bleeding excessively, which puts her life at risk. Many of these C-sections are unnecessary; in fact, Dr. Shah says that “‘Probably more than half of them [are]’” (Moriarty). So why the increase in C-sections? Jennifer Block, in her book Pushed: The Painful Truth About Childbirth and Modern Maternity Care, argues that the rise in C-sections is because doctors are looking for convenient and ‘safe’ births, as the stigma surrounding natural and/or vaginal childbirth makes it seem more dangerous or risky. Mothers are often coerced, pressured, or scared with inaccurate risks into surgical procedures. Often, mothers don’t think that vaginal birth is safe or attainable—the culture around natural birth has become so negative (Block). The modern birth scene is taking away women’s health and agency in the birthing process.
Medicalization is not the only problem. Doctors also don’t listen to the women they are treating, especially if they are black. This is known as ‘physician bias.’ In Dr. Shah’s words, as quoted by CBS News:
‘I think there is a dimension of gender discrimination… If a woman after a birth goes into a hospital with concerned signs of a complication, there are no rules for how quickly an obstetrician has to see her. And in fact, it’s a routine case that it will take hours.’ And statistics indicate that it may not just be gender that plays a part in dangerous delays, but also race. ‘[If] you’re a woman of color in this country, especially if you are black, your odds of dying in childbirth are three to four times higher on average in our country … we believe black women less when they express concerns about the symptoms they’re having, particularly around pain.’ (Moriarty)
According to Dr. Shah and multiple other sources, black women are 3-4 times more likely to die in childbirth than white women, regardless of class, education, or socioeconomic status (Moriarty; Martin and Montague; PBS NewsHour). This disparity is often caused by lack of access to quality healthcare and racial biases that are seen within the healthcare system—the idea that an expression of pain from a black women is not taken seriously by medical professionals until it is much too late to do anything about it—exactly what is seen in cases across the country (Moriarty; Martin and Montague; PBS NewsHour; Amnesty International). This aspect of the modern birth scene is not just taking women’s health away—it is taking women’s lives away, especially those of black women.
As one of the most developed countries in the world with the highest expenditure on healthcare and first-class healthcare systems, what are we doing wrong? With issues of medical convenience, increased medicalization of childbirth, gender and racial biases, and lack of access to care, I argue that it is time to change the birth scene—it is time to redefine what it looks like to give birth. I argue that alternate health care providers like doulas and midwives may be the answer; that medical and surgical childbirth as we know it, though the practice of it should be improved, may not be the safest and most effective way for women with low-risk pregnancies to experience childbirth. In its place, there is an option for a more natural childbirth, one that is focused on the individual woman instead of a floor of laboring patients. One that gives women spaces to advocate for themselves, voice their pain, and access care as is necessary, regardless of their race. One that gives women agency in their birth experience. Alongside improvements in hospital care and practice, there is a need for women to see a different way to give birth. I propose that integrating doulas and midwives into the medical care system may be the solution to this problem—a solution that will transform the experience of birth in this country and give power back to mothers. Through my use of written and video testimonies that tell stories of real births, I attempt to shift the negative narrative surrounding labor and delivery while pulling back the curtain on the mystery that is childbirth to so many Americans.
MIDWIVES, BIRTH INTERVENTIONS, AND ACCESS TO CARE
“‘The way that births are going is horrible. It’s an injustice to our women that we have a C-section rate that’s so high, a death rate that’s so high. I feel obligated to women and their babies,’ [Linda] told me over the phone before my visit.” (Block 184)
Meet Stacy. A mother of six whose first birth was extremely traumatic. She was induced in a labor ward, and came out with hemorrhoids, stitches, and postpartum depression. For her next few births, she opted for a nurse-midwifery practice which she loved, but when she and her family moved, the closest practice ended up being one hour and 20 minutes away. Stacy had to choose between a home birth and a hospital birth where she was told she would be “‘closely monitored’” (Block 196). Then, in walked Linda (Block 197-196).
Linda is a midwife. According to the American Pregnancy Association, a midwife is defined as “…a health care professional who provides an array of health care services for women including gynecological examinations, contraceptive counseling, prescriptions, and labor and delivery care” (“Midwives”). Midwives are not authorized to perform surgical procedures as OB-GYNs are, and they often operate in more home-like settings, like birth centers and homes. Midwives are not new professionals in this field. Rather, midwives served as the primary caregivers for laboring women up until the rise of modern medicine in the 1800s (Chakraborty 2:38-2:50). Dr. Marsden Wagner, an obstetrician and gynecologist by training, elaborates on the injustices against midwives in his book Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First. He discusses the rise of modern medicine and the idea that doctors are the only qualified professionals that can deliver babies, regardless of the fact that midwives existed for hundreds of years before. At that point, all doctors were male, which created a tense power dynamic that eventually overtook midwives and began to persecute them for their work. As Wagner puts it,“The profession has always attracted strong, independent women in the community, woman who are difficult for men to control and whom some men come to fear. If men wish to control their women, they must find a way to control midwives” (101). Under obstetricians and the ‘superior’ knowledge of the medical professional, women often lose the ability to make choices for their childbirth experiences, as opposed to midwives who hold the philosophy that a woman’s body operates as it is supposed to, and women should have the freedom to decide what is best for their health and their baby’s health. As Wagner puts it, midwives “…reassure, calm and encourage birthing women” (105) while obstetricians “…typically try to get the birth under their own control by overriding the natural processes with drugs and medical procedures and giving orders… Doctors ‘deliver’ babies and believe that having a baby is something that happens to a woman. Midwives assist at birth and believe that giving birth is something that a woman does” (105). Midwives are not necessarily opposed to hospital births and OB-GYNS but oppose the current system and sub-par care that women are provided with. Rather, they would like to offer an alternative and work in conjunction with the hospital to bring about positive outcomes (Block 211).
The heart of midwives’ purpose is to give agency back to the mother; to fight against unnecessary interventions and give the mother space to deliver her own child. This is the work that Linda does as an undercover midwife. She travels—though against the law as ‘an unlicensed professional’—to give power back to women like Stacy. Often traveling hundreds of miles a week, she visits these women in their homes, regardless of how far they are from her own. As is seen here, midwives don’t only advocate for less interventions—they also increase women’s access to care. The integration of midwives into healthcare systems correlates with improved outcomes for mothers and babies, regardless of race or birth setting, according to Vedam et al. (“Mapping Integration” 11, 12). They outlined the creation of the Midwifery Integration Scoring system (or MISS) (1). Overall in the US, 10% of births are attended by midwives as opposed to the 50-75% in other “high resource countries” (2). Because midwives in the US also face more legal and financial barriers and are often caught up in interprofessional conflict with other medical professionals, the tension is proven to have an adverse impact on birth outcomes (2, 3). All this despite the fact that midwives—when allowed to “…practice to their full scope across birth settings, including collaborating with or referring to other health professionals” (2)—are extremely helpful in providing care to those who may not be able to access it otherwise (13). The presence of midwives in the States provides for more alternate settings in which to give birth, such as in one’s home. There has been an increase in the number of homebirths, and midwives are currently the only providers that will attend births at home (12). All this goes to show that midwives don’t only empower—they provide much needed care to women that need it and may not get it otherwise.
And what of Stacy? She gave birth to a healthy baby girl at home, right in the birth pool. She recovered quickly and nursed the baby while “...repeatedly thanking Linda” (Block 200). For someone who didn’t think she was the kind to do a homebirth, the birth turned out to be a positive experience for her. And Linda was able to provide the positive care that she needed access to.
DOULA SUPPORT: EMPOWERING MOTHERS AND IMPROVING BIRTH OUTCOMES
Now, meet Khadija and Kevin. An African American couple living in Brooklyn, New York. Their family is considered low income, which affects their ability to seek out quality care. They have had one child—Olivia—whose birth was traumatic for Khadija. She relates:
When I had Olivia … the doctors weren’t explaining anything to me, they were just going with the flow and then just like, ‘okay do this, do that.’ ‘We’re going to tell you that you have to get induced, we’re going to tell you that you have to do the C-section … and you have no choice or say in the matter.’ They didn’t give us enough information so we couldn’t even make an informed decision. I can imagine if I had a doula, then a doula would have been able to tell me ‘okay, you have rights and your rights are this this, that, and a third.’ (Bustle)
Khadija now was doubting her body and her ability to give birth naturally as she had been wanting to do. And the cost for her family could very well have been a barrier to seeking out alternative or additional care. But what could a doula have done to help her?
Doulas have also existed for hundreds of years, except not by a formal name. They have been the mothers, sisters, daughters, and typically female relatives of the expectant mother for ages, and simply serve as supporters—people to be present emotionally and physically as the mother experiences birth and delivers her baby. Block refers to the concept of a doula as a “vestige of the female labor support that existed gratis for much of history” or as “social birth” (154). Doula traditionally means “slave or female servant” from Greek origins (149) but the traditional role involved cleaning, cooking, watching children, or being a midwife’s assistant. Essentially, whatever needed to be done, they would assist with, traditionally as unpaid helpers (154). But doulas are not medical professionals. Today, they are trained to play the role that nurses used to play before the advent of machines in medical facilities—nurses use the computers, and doulas make up for the “hands-on care” that nurses no longer have time to provide (156). The doula’s purpose is defined by DONA International as “‘mothering the mother’—as providing her with emotional and physical support and ‘assistance in acquiring the knowledge to make informed decisions about her care’” (Block 156). However, especially now, in the age of increased medicalization and in light of gender and racial biases that patients and advocates are fighting, doulas “...end up serving a far different, far more demanding role than simply that of handholder or cheerleader; they also serve as advocate and witness” (Block 156) or “the go-between, the negotiator” for women and their families in the hospital (157). It is in this way that the role of doulas has changed with the ever-changing medical system. This is what Khadija wanted and needed so badly. Someone to support her, guide her, teach her, believe in her, and advocate for her wishes. But the problem lies in accessibility.
Access to care is not just an issue in terms of distance and inability to reach a facility. It is also a financial issue, one that can determine the quality of care that is received by an individual, and thus have an impact on their health outcomes. Currently, Medicaid does not cover doulas in most places across the country, and these services are not available to the low-income population—many of whom are women of color. Medicaid does cover the cost of childbirth hospitalizations in the US, and the cost of a birth goes up with increased complications and interventions. An increase in cost means that state governments are spending a lot more to support their Medicaid or low-income pregnant population. State Medicaid programs paid for 45% of all US births in 2009 (Kozhimannil et al. 1). These patients are low income, and many are women of color, who are already at risk for complications in childbirth (Kozhimannil et al. 1). The benefits of doula care in increasing positive birth outcomes are apparent in decreases in C-sections and pre-term delivery in women that have doula support. This study conducted by Kozhimannil et al. determined that the rates of C-sections and pre-term births were lower among those who had doula support, specifically in the number of those who got C-sections—those who were on Medicaid with doula support were 40.9% less likely to get a C-section than those without doula support (4). Secondly, they assessed the savings that could result if doula care was covered by Medicaid, thus reducing the complications and interventions necessary, and reducing the amount of money spent by the government (3, 4). In this way, doula care is not only provided, but overall government spending is reduced. For mothers who are on Medicaid, access to these services is limited. Even if the financial issues were taken care of, doulas tend to be “…middle aged, married, and well-educated White women from upper-middle class households” (1), and this proves to be a cultural barrier that may discourage someone from taking advantage of the services. Therefore, if doulas are to be covered by Medicaid, diversifying the ‘doula pool’ and making this service available to a wider range of people will allow low income women like Khadija to access the care that they need and produce better personal and statistical outcomes.
And what of Khadija? She was able to get a doula for her second birth through a doula collective for low-income women in Brooklyn. Her doula, Efe, was there to support her every step of the way and to advocate for her wishes. Efe very clearly states—“My role is to make sure that I am protecting her … Whatever she needs me to help her advocate for herself. I am there to empower her” (Bustle 5:51-6:10). Khadija says—“Now I feel more prepared, I feel more relaxed, and I feel more confident” (3:15-3:20) and “the blessing was that Efe was there… and she was able to give me the knowledge that I needed even before birth” (6:43-6:55). Doulas like Efe make up the difference in care and create safe spaces for people like Khadija to feel ‘mothered,’ but most importantly, they create spaces for women to be heard.
DOULAS AND MIDWIVES AS ADVOCATES: FIGHTING MISTREATMENT OF WOMEN IN HEALTHCARE SETTINGS
As we have seen in Stacy and Khadija’s stories, the one thing that both midwives and doulas do is advocate for women. Whether it is by offering them non-medical options or creating the space for them to be heard, both midwives and doulas provide less or non-medicalized spaces that encourage women in their birth experiences. According to Vedam et al. (“The Giving Voice”), women need this support because the care they are receiving in hospitals—specifically that of women of color—is not good enough. Their national study looks at the ways in which mothers across the US who had given birth or were pregnant between 2010-2016 experienced ill-treatment and neglect in childbirth. They looked at both white women and women of color (Black/African American, Hispanic, Indigenous, etc.) and how race influences the experience that one may have because of bias or circumstances. Vedam et al. acknowledge that this study was conducted with ‘patient designed indicators of mistreatment’ coupled with typology developed by Bohren et al.to capture the extent of mistreatment among mothers in medical settings, specifically seven dimensions of mistreatment—“physical abuse, sexual abuse, verbal abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport between women and providers, and poor conditions and constraints presented by the health system” (“The Giving Voice” 3). One in six women on this sample experienced one or more types of mistreatment (7) and women of color were more likely to report having experienced mistreatment (8). Higher reports of mistreatment were also seen with women who had a Black partner, regardless of their race (8). So it is obvious that women and people of color are discriminated against in the medical setting. Therefore, there need to be accessible professionals to help close the gap and advocate for those who cannot advocate for themselves. Just as Linda made sure she was present to offer options to women regardless of the dictates of the law, or as Efe stood by Khadija’s side and advocated for her so that she wouldn’t have a repeat of her traumatic experience at the hands of the doctors, doulas and midwives are about the same thing—giving power back to the woman and advocating for her choices in her most vulnerable state—making sure her voice is heard loud and clear. Women deserve these option—options within the healthcare systems that prove that her choices are valid and in reach.
In this way, both midwives and doulas increase and have the potential to increase access to care, prevent unnecessary medical interventions, and educate and advocate for women and their families and the choices they have made surrounding the care of both mother and child. As we have seen through the stories of Stacy and Khadija, the impacts of these alternative care providers can do much to improve maternal health in the United States, to increase satisfaction and happiness, and to improve outcomes for families, specifically for people of color. In the words of one black father who lost his wife to C-section complications and inattentive physicians—“Women … deserve better” (4Kira4Moms 4:05-4:11). Yes, yes they do. They deserve the power that belonged to them in the first place, and integrating doulas and midwives into the healthcare system is one step towards making that a reality.
Works Cited
Amnesty International. Deadly Delivery: The MaternalHealth Care Crisis in the USA. Amnesty International Publications, 2010.
Block, Jennifer. Pushed: The Painful Truth About Childbirth and Modern Maternity Care. De Capo Books, 2007.
Bowen, Alison. “1 in 3 U.S. Women Have C-Sections. How Chicago Doctors Are Working to Change That.” Chicagotribune.com, 15 May 2017. Web.
Bustle. “Natural Birth Seemed Impossible | Romper’s Doula
Diaries.” YouTube, uploaded by Bustle, 10 Dec. 2018. Web.
Chakraborty, Ranjani. “The Culture War between Doctors and Midwives, Explained.” YouTube, uploaded by Vox, 29 May 2018. Web.
“Deadly Deliveries: How Hospitals Are Failing New Moms, in Graphics” | USA Today. July 26, 2018. Web.
“Emotional Live C-Section Birth!” YouTube, uploaded by The Ever Afters, 7 Apr. 2016. Web.
4Kira4Moms. “Charles Johnson Shares the Tragic Story of His Wife Kira’s Death Hours after Giving Birth.” YouTube, uploaded by 4Kira4Moms, 7 June 2018. Web.
Hotelling, Barbara. “Birth Doulas: The Breakdown of Past and Present.” International Journal of Birth & Parent Education, vol. 3, no. 4, 2016, pp. 12–15.
Kozhimannil, Katy Backes, et al. “Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries.” American Journal of Public Health, vol. 103, no. 4, Apr. 2013, pp. 113–21.
Martin, Nina. “Lost Mothers.” ProPublica, 17 July 2017. Web.
Martin, Nina, and Renee Montagne. “Black Mothers Keep Dying After Giving Birth. Shalon Irving’s Story Explains Why.” NPR.org, 7 Dec. 2017. Web.
---. “The Last Person You’d Expect To Die In Childbirth.” NPR.org, 12 May 2017. Web.
---. “U.S. Has The Worst Rate Of Maternal Deaths In The Developed World.” NPR.org, 12 May 2017. Web.
“Midwives.” American Pregnancy Association, 26 Apr. 2012.
Moriarty, Erin. "Maternal Mortality: An American Crisis." CBSNews.com, 5 Aug. 2018. Web.
Simpson, Monica and Linda Villarosa. Interview with Nawaz Anna. “Why Are Black Mothers and Infants Far More Likely to Die in U.S. from Pregnancy-Related Causes?” PBS NewsHour, 18 Apr. 2018. Web.
“U.S. ‘most dangerous’ place to give birth in developed world, USA Today investigation finds.” CBSNews.com, 26 July 2018. Web.
Vedam, Saraswathi, Kathrin Stoll, Marian MacDorman, et al. “Mapping Integration of Midwives across the United States: Impact on Access, Equity, and Outcomes.” PLoS ONE, vol. 13, no. 2, Feb. 2018, pp. 1–20.
Vedam, Saraswathi, Kathrin Stoll, Tanya Khemet Taiwo, et al. “The Giving Voice to Mothers Study: Inequity and Mistreatment during Pregnancy and Childbirth in the United States.” Reproductive Health, vol. 16, no. 1, June 2019.
Wagner, Marsden. Born in the USA : How a Broken Maternity System Must Be Fixed to Put Women and Children First. University of California Press, 2008.