​I am a doula working in the Porterville and Tulare County area of California. I have worked as an in-home care provider for 15 years. In 2015, I attended a DONA-approved birth workshop. I quickly realized that I had not only found my passion, but I also found a tribe of strong, like-minded, loving and selfless women. I had never met these women, yet they accepted me and supported me -- they believed in me! These women instilled confidence in me and what I held within. My two-day workshop quickly came to an end, but these friends have remained close to my heart.
           
February of 2016 was my first experience as a birth doula, and it was EXTRAORDINARY! I knew without a single doubt this was my calling, this is what I was meant to do.
 
The remainder of 2016 was spent focusing on my family. Before I knew it, 2016 had come to an end. I had been feeling disappointed and very unsatisfied. I reflected back to remember the last time I had felt genuinely happy, fulfilled, and ALIVE:  February of 2016, almost a year before, when I had helped welcome little Miss Katalina into this world. It was crystal clear: I needed to get back into my doula journey -- I need these mommies and they need me!
 
February 2017, I was on Facebook and came across a friend who had just announced her pregnancy. I quickly private messaged her to say congratulations, and in the course of our chatting I mentioned I was a doula, and I shared what doulas do. Then I offered my support if she wanted it, to which she quickly replied, “OMG, that sounds good. Yes!!”
 
I was shocked! What just happened ! Did I just get a client!?!?!?! YES!!!!
           
Our journey as mommy-to-be and doula had begun. She didn't seem to have a lot of support for pregnancy-related things, so I called around to get information about services in our area. Classes were being offered at our local hospital. I asked if she was interested in going, and she said yes. Every Monday evening, we got together for a quick snack, a review of her week, and we went over ideas for her labor and birth. Afterwards we attended the birth class together. Mondays, for the first time EVER, were now my favorite day of the week!
 
At home I read my doula books, strategically put together my doula bag, and went over our family plan on what to do when I got called to a birth. I was very thorough and clear to my family that I could be gone for 24 hours or more, and they needed to take care of each other.
 
April went on so slowly, it seemed like the days dragged! What does one do when their client’s due date is April 20 and it’s barely April 10? Role play! My family helped me out. We acted out different scenarios as laboring mother and doula. I have the best family! I must give credit to my daughters and my wife, they are always so willing to play along with my crazy ideas!
 
Every night I checked my phone, synced my Fitbit notifications so that my watch would alert me when my client called, and made sure my doula bag was all set and ready. I woke up numerous times a night to check things, and then I’d go back to sleep (but not a deep sleep because I was so worried I’d miss the call!).
 
Finally, April 20 had come -- this was the day we had all prepared for, this was the day we had reenacted over and over and over. But no baby came. My client felt great! She had no signs or symptoms of prelabor or labor. Every morning and every evening we’d chat: “How are u feeling? Do u feel any changes?” And she’d reply with a smiley face: “I feel good!”
 
The week went on like this, until one morning, I got the call! My client had been up all night with small inconsistent “cramping.” She was at the hospital. She assured me she was okay and she’d get back to me after getting checked out.
 
I went about my normal day. I took the kids to school, went to work, and gave my boss and coworkers a heads-up that I’d probably be clocking out early. Everyone was super supportive; we had all been waiting on this very special day. By noon my boss said, “get out of here, I can see how anxious you are, we will be fine.” So by 1pm I was clocking out and on my way to Sierra View hospital in Porterville.

Aril 26, 2017, I walked through the hospital doors and was asked where I was going? I proudly said, “I’m going to labor and delivery, I’m a doula.” Along the way I was asked again, where I was going? And again, so proud and full of glee I said, “I AM A DOULA here to see my client” I got buzzed in and at this point I think I was floating through the halls -- not even walking!
 
I opened the door to see my client in bed with the biggest smile I have ever seen. I calmly said “Hello, Honey, this is the day you have been waiting for!” She replied back with, “Yes, I can’t wait to meet my son!” I then introduced myself to the father of the baby and his mother. They looked confused, nervous, and unsure. We had never met, and it was now becoming apparent they had no idea who I was or what on earth I was doing there.
 
I gave them a brief description of myself and what it was I had to offer as a doula. Still confused-looking, they said, “ohhh, okay.” I then excused myself to get things ready. Again, they looked at me like I was crazy, and I know they wondered what the heck I had in this bag that I held onto so closely. Little did they know that my doula bag was my MAGIC BAG, my bag of TRICKS, my Other Half.
 
I went behind the curtain and begin using my electric pump to air up my peanut ball. My pump was not working! I felt my face turning RED, how could this be? My peanut ball was my main tool! Then I remembered I had also packed a hand pump just in case something like this happened. After airing up my peanut ball I set up a diffuser, battery-operated candles, a portable speaker, and massaging lotion just like my client and I had discussed.
 
Next I asked my client if she’d like to get up and “walk the baby out?” She smiled and got out of bed. We walked around and around and around -- I was definitely putting in my Fitbit steps! Every time the nurses came into the room they oohed and awed over how relaxing the room felt and how it had smelled so good!
 
Contractions got slightly stronger but still were not consistent. It was now 6 pm and my client's progress was slow. The doctor recommended Pitocin. My client declined -- she knew the pros and cons and opted not to take it at this point. Her doctor supported her decision and said she’d check back in at 9pm. 9pm came and still not much change had happened. Father and grandmother were sitting in the corner of the room and were now starting to look a bit more concerned. They were unsure how to help the laboring woman.

​​There is often confusion over what a doula is. Many times I have talked with couples nervous about a doula possibly taking over their birth. They are afraid that a doula may guilt them into  a certain type of birthing. To add a little silliness I have illustrated examples below with my subpar Window’s Paint skills. These show the differences between someone that will fight against your birth, a duel-a you could call her, and a doula, or birth support for your choices.

​This may be new to you, but doulas are not just for natural birth. They are for anyone wanting more support for their birth. Doulas are helpful in cesarean births, medicated births, natural births, hospital births, home births, single parent moms, and so much more. Whether you have a plan or not, we are here for you, no light sabers involved. Note: In the odd case that you want light sabers at your birth, we can help you with that. We do not discriminate against nerds; we just won’t use them to stop your choices.
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The next concern often had regarding doulas: "But I want my husband involved. I want him to intuitively know what I need.” If he helped start this baby business, then it totally makes sense to want him right there involved in the birth.

​Can I tell you my secret? We LOVE it when dads are hands-on and involved. It is our biggest goal to facilitate the best connection between you and your partner. We know that dad helps get the oxytocin and birthing hormones going. Some men need a little direction along the way. They are new to this. Our job isn’t to replace dad, it’s to help him help you best. If dad isn’t there this works the same for grandmas and friends. We will not erupt in flames if someone else gives you counter-pressure.
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I met with a doctor today. He was a little on-guard, and he felt the need to explain how he goes out of the way to help his patients. Sadly, too many providers have met some kind of duel-a, or have heard stories of them. All he knew was that I was a doula and he assumed that I had a negative view of him as a doctor.  In reality,  I have yet to meet a provider that did not want the best for mom and baby. Sometimes they have differing opinions on care, and different points of view, but they all care. Doulas are not out to defy anything medically related. We need the medical team so that we can focus on emotional support and comfort for mom and the family.

​Doulas work with mom’s birth team to help her best reach her desires.  Doulas will encourage you to choose a provider that you feel you can trust that you can work with together. They encourage mom to ask questions, find evidence-based information, think over benefits and risks, and if needed, help mom stand up for herself. Our job is not to have a show down with the medical staff. Our job is not to speak for you. Our job is to help you get the information you need to make choices, and to support you as you speak for yourself.
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I am not a duel-a. I am not out to fight or prove anything. I am a doula -- a supporter of women, babies and families.

Becky Hartman serves as a birth, postpartum, and bereavement doula, birth and pregnancy photographer, Benkung belly binder, and energy worker. She has been shaped by her own births, and the realization that education factors into creating an empowering experience. Becky strongly believes women can follow their hearts and they will know the decisions that are right for their situations. She encourages families to learn, explore, develop ideas, and then go with the flow of their birth experience. Becky lives with her family in Clearfield, Utah. ​

​“Why are you still working?! Your due date is next week, what if your water breaks while you’re at work?”

“Oh that’s not going to happen to me, they do that in movies for dramatic effect. In real life, the water breaking in a gush only happens to about 8% of women, that won’t happen to me, I will be fine”

This was a conversation between myself and my good friend Jammie one week before my October 13th due date with my first child. I had an easy pregnancy, no morning sickness or vomiting, and I had not taken a single day of work off the entire nine months. I manage an office, it’s not physical work and since I had felt fine, I felt no reason to stop working even with my due date right around the corner. I wanted to maximize my time off after the baby arrived. Little did I know, I was about to be one of those 8%...

On the morning of October 14th, one day overdue, I awoke to my dog barking. She doesn’t usually bark at night unless she needs to be let out to answer the call of nature. I groaned internally. “Ugh, it’s 2:30 a.m., I don’t want to get up and let her out,” I complained internally. Then I thought, well I probably have to pee anyway, it’s only been an hour since last time I peed and everyone knows how often pregnant ladies need to pee. I heaved my big, pregnant belly up and began walking to the bathroom. "Oh, I guess I really had to go," I thought, as I felt fluid trickle. By the time I got to the bathroom, there was a gush and a lot of fluid. Apparently my water had broken, signaling that the arrival of my baby was imminent. I called to my husband and told him to get up and let the dogs out while I cleaned up.

The first call I made was to our doula. I had made the decision to hire a doula fairly early in my pregnancy, and she came highly recommended from a mother of 6 that I have known my whole life. I hired a doula because I was afraid of having a hospital birth, I was afraid of being forced into taking unnecessary medical interventions during labor, and afraid of being bowled over by a medical team that had never met me, knew nothing about me or my baby, and didn’t know what I wanted from my birthing experience. I envisioned an intervention-free birth, preferably at home, with a midwife. My husband, rightly concerned with my health and that of our unborn baby, objected to my home birth plan and preferred a hospital setting. The compromise came in the form of our doula, who I wanted to help me through an intervention-free hospital birth.

“My water just broke, should I go to the hospital?”

“How do you feel? Have your contractions started yet?”

“I feel fine, I am not in pain and having no contractions yet.”

“It’s up to you whether or not you’re ready to go to the hospital. However, it can take some time for the contractions to catch up once the water breaks. Since your water is broken, if you do go to the hospital, it's likely they won’t allow you to leave once you’re there.”

“Ok, well I don’t want to go too early, I think I will wait a while and go later. I should not go to work though, right?”

“NO!!! Do not go to work, and keep me updated.”

After getting off of the phone, I called my mother and told her the news. I told her I wasn’t going to the hospital yet and I didn’t expect the baby to arrive for several hours, probably not until late evening. I expected a long labor, everything I had heard and read said that most first time mommies have a long labor so I was prepared for a marathon. With this in mind, I decided to go to work. This decision was made because I knew I couldn’t get someone to cover me, I work at 4:30 am, and I just planned to go briefly to give a quick morning meeting and inform my staff that I would be out until the end of my maternity leave. My husband got dressed and drove me to work, and I was there for half an hour before we left and drove through McDonald’s for breakfast to be fueled up for all the work ahead of me!

At home around 6:30 am we both laid down, I wanted us both to try to get some rest for the long day ahead. I was having minor contractions at this point, 15-30 seconds long and 5 or so minutes apart. At about 9 am I sent my husband to drop our dogs off at a friend’s house. My contractions had increased in frequency and length but I was still not ready to go to the hospital. I was texting our doula and asked how long I could safely wait to go to the hospital? She said it was up to me how long I felt safe staying home, and she advised me to contact my doctor for an appointment to check my progress. If I had progressed enough, I could go directly to the hospital, but if I wanted to go back home, I could do that too. That sounded ideal to me, my doctor’s office was located in the parking lot of the hospital I would deliver at.

This is why I wanted a doula and why I decided to go with our doula specifically; she listened to me, asked me how I felt, and asked what decision I thought was best for me. Essentially, she helped me to decide for myself instead of just telling me what to do or what she thought was best. From our prenatal courses, she knew my concerns about having a hospital birth and advised me with that in mind. Our doula knew that I was concerned about going to the hospital too early in labor, and that I was concerned about having my movement in labor restricted by monitors and hospital rules.

The most important thing that I learned from our doula was that I had choices for this process. I could be in charge. There were productive ways to communicate with hospital staff to facilitate the birth that I wanted, and decisions that I could make to affect my birth, like the decision to stay home and labor for a while instead of going straight to the hospital when my water broke. I didn’t have to be merely a participant in my labor, I had choices and a voice. In our prenatal courses, we had talked extensively about my birth plan, making 2 or 3 drafts before we were satisfied with it. I also made a gift basket for the nurses and doctors in the hospital, to thank them for their hard work, and partly to schmooze just a little bit! The birth plan would help to communicate what I wanted in the heat of labor, and the gift basket would help them to remember me in a positive light.

​I called my doctor’s office. When I told them my water was broken, they told me to go straight to the hospital. I explained that I wasn’t ready yet and that I wanted my doctor to check me first. Fortunately my doctor was working and agreed to see me at 11:15 am. I took a shower, which was the best shower I have ever taken in my life, so relaxing! And my husband and I departed for the doctor. We pulled into the parking lot shortly after 11 am and I knew in my heart that we weren’t going home. My pain level had increased significantly since 9 am, but I was still unsure whether or not to go straight to the hospital. In my mind, I was clinging to the 4-1-1 rule (contractions every 4 minutes, 1 minute in length, happening for at least 1 hour) and I wasn’t there yet! My contractions were only about 30-45 seconds long, and I didn’t think they were long enough for me to go to the hospital.

Once in the doctor’s office, I had trouble disrobing from the waist down and getting up onto the exam table. When my doctor arrived and checked me, we were both surprised to find that I had already dilated to 5! It was time! I was going to the hospital! I was put in a wheelchair to go across the parking lot. I texted our doula: “I am at 0 station and 5 centimeters dilated, I need you here ASAP!” “I’ll be there as soon as I can!” My husband accompanied me to the room and I sent him back out to the car for the hospital bag. The desk nurse gave me a hospital gown and asked for a urine sample. I got into the gown but the urine sample wasn’t going to happen. I was in too much pain, and I curled up on the hospital bed in the fetal position instead.

When my husband got back from the car, I was crying. “I need an epidural, I can’t do this, I’m going to die!” Cue the theatrics! He went for help. The nurse checked me and immediately ordered a birth kit; baby was coming faster than any of us anticipated. I asked for an epidural. My husband asked if I was sure, and in that moment, I certainly was! The nurses told me it would be at least an hour before I could get one; in retrospect I am sure they knew there simply wasn’t going to be time. The baby was going to be there before the anesthesiologist anyway! Our doula arrived around noon I believe, and everything became a blur. I was very lucky that my doctor was on duty and was there for the birth. Between her, our doula, my husband, and the nurses, everything seemed to happen at lightning pace. Almost immediately, they had me pushing, I had plenty of help and support. My dear husband, who had pledged to stay by my head during labor to avoid the potentially traumatizing show, found himself holding one of my legs up while I pushed, after a nurse said “here, help her." Before I knew it, baby was crowning. My doctor asked if I wanted to touch the head? “No! What are you talking about?! We are wasting time, let’s get her out of there!”

At 1:13 pm, Tegan Janine arrived. 7 pounds, 3 ounces and 18.5 inches of pure, healthy perfection. I remember seeing her for the first time, her arms outstretched. As they laid her on my chest, I was overwhelmed with emotion and disbelief. She had arrived so quickly, I was caught off guard and burst into tears, “I’m just so happy." Delivering the placenta was slightly problematic, it didn’t want to dislodge itself. The doctor massaged away at my abdomen for 20-30 minutes, and I cursed loudly…but it was eventually delivered. I was given a shot of Pitocin in my thigh because I was bleeding a little more than they would have liked, but otherwise everything was fine.
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All of the preparation and planning were worth it. The decision to hire a doula and educate myself on my choices and decisions was crucial. I am extremely fortunate that I had an easy pregnancy and a fast labor, many mothers aren’t as lucky as I was. I recognize that genetics and pure good luck played a huge part in me having a positive labor experience. I hope that by sharing a positive story of birth, other mothers can feel more confident. There are so many terrifying stories of labors gone wrong, I feel that women need to hear that labor can be a positive experience.

I hate to be Debbie Downer, that is not in my heart at all. I hired a doula for what I thought were realistic reasons. Like so many others, I read the statistics:  shorter labors, lower uses of epidurals, happier feelings after the birth; those were the ones that stuck in my mind. I just didn't expect things to go the way they did, and when they went, they went fast. I felt like my doula went along with that, while I was left behind feeling alone.

I know one admirable quality of any doula worth her salt is good working relationships with the nurses and doctors at the place of birth. I was impressed by the stories I heard from my doula, the goings out to lunch with nurses, the sittings next to doctors at conferences. I will admit, it made me feel like she integrated well into the hospital process. What I didn't expect was that she might need to maintain that balance. When push came to shove in my situation, I did not feel she was with me, on my side. I felt like she was on their side, and it was her job to get me to feel good about coming to their decisions and preferences. 

In a way, this was the beginning of the isolation. I had heard hospital doulas who are provided by the hospital or volunteer/work for the hospital sometimes have a hard time being neutral. I did not worry about this, because my doula was independent and nonaffiliated with the hospital. She did have a family member who was high ranking on the infrastructure of the hospital board, but again I saw this as a bonus, not a deficit. In reality, I think it aligned her with the hospital's way of doing things. It made it seem like her job was to help me buckle to that agenda in a less threatening way than if it came from a staff member.

I had a complication when it came time to push. Suddenly I was being rolled over, yelled at urgently, and told to push, even without a contraction. Extra people came rushing into the room. I was hearing all kinds of instructions at once. I closed my eyes and tried to do what they told me. My husband was no where to be seen or felt. My doula was also lost in the haze. I had no clue what was happening. I needed the tiniest bit of an explanation. The one person I would have expected this from was not there. My doula.

After the baby came out there was an audible sigh of relief. She was taken to a flat table to be given air and make sure she was breathing like she should. I felt the smallest touch from my husband's hand, and I wanted to gobble it up and have it take me away. He was scared too. We watched as our baby was being poked and prodded, mask on her face, lights flashing and alarms beeping. I looked for my doula and she was talking to the nurse about how frightening that was, and how she was sorry the nurse had to get up on the stool to help move me because the nurse was pregnant.

I could have used the emotional support my doula was giving my nurse.

It took a while before anyone explained what happened. It took even longer before our baby was brought to us. I felt pretty insignificant. I felt alone and afraid. Soon after the bustle in my room went down and I was considered recovered, my doula announced she needed to go move her car before her meter ran out. She said she would be right back. 

"That's ok. I think we are ok now." She looked at me with a puzzled expression. "But the baby isn't back from the nursery. Do you want me to wait and see if we can get you nursing?" I let her know I was really tired, and I would ask for help from the staff if we needed it. She came over, gave me a hug, and said, "Thanks for having me as your doula." 

Really I just felt sad. I felt let down. I wanted more mothering, and I got what seemed like a bubble gum teenager who was only with me until the cooler kids came (her friends at the hospital). I am not writing off doulas forever. I still can't deny those statistics. But next time, I am going to ask different questions, and remember to be impressed by different answers. 

There was a woman who named herself after the mountains where she had communed with other women and wrote poetry. In the end she went berserk with agitation, climbed out of her hospital bed in an attempt to lie on the earth again. We covered her in blankets as her community of friends took turns sitting vigil. Her strong body and spirit would not give in to disease without a great fight. Back in bed, she lasted for weeks like that, feeding off the fuel she had accumulated over a lifetime until one day, the flame burned all the way to the core and released her free at last.

​There was a woman quiet and withdrawn, who only nodded yes or no. Yet when a dear one entered and approached, she open her arms to bring them in close. Her adult children had lost a father just two years before and her illness had mostly been a secret, a failed attempt at protecting her loved ones from pain. All we can do is be there to support and minimize suffering. The existential journey is their own. At a time when one can no longer deny death, loved ones gather with tears and smiles for all the healing that can finally begin. In the end, friends and family gathered in the chapel to acknowledge and honor her life. Then came a parade of flowers our way, grandiose bouquets perking up the solarium.  

A volunteer angel drops in every now and again, effortlessly singing A cappella, opening the portal within the spirits of the dying, attempting to free them of blocked emotional meridians and move them forward on their individual path, on the labyrinth of existence.  

​An emaciated woman already a skeleton slowly turned to look at me and offer a weak smile, appearing to wonder about my treatment or judgement of a lifelong multi-drug abuser lying on her death bed before she was even old. She is estranged from all family. I offer reassurance that she will be cared for with kindness and respect. She replied "thank you". I suggest that she has experienced a lot of trauma in her life. She replied "scary". Perhaps at birth, or in the mother's womb, she was already addicted. Maybe now, in a time as vulnerable as birth, she can finally just receive love and care without having to do anything to earn it. She seeks to have her pain and anxiety resolved, just like any other human being. And in a couple days, after a week hiatus in the desert, I will return to this work, wondering if she survives still. As a death doula, I will either care for her with kindness and compassion, or if she is gone, I will care for the others who come next to this house.

I'm a doula. I love what I do, and I am really good at it. It is always an honor to help a family through birth by offering physical, informational, and emotional support unique to their situation. And I also recognize, as a certified Lamaze educator teaching families in the Bakersfield and Visalia areas, there are many reasons why a family might choose NOT to employ the services of a doula. These reasons might range from cost, to comfort, to hospital rules. In this situation, I want pregnant people to know how to shape their partner or other birth supporters into a doula. 

What are the advantages of a doula? How is she different than a partner, BFF, mom, etc.? She has no agenda or investment in this birth experience except to help a laboring person feel supported and know their options. 

What are the advantages of the partner, BFF, mom, etc.? You know this person better than anyone in the room. You know the likes and dislikes, the history and beliefs of this person, and you will be around after the baby is born.

I often open this topic by asking each person to tell me something he or she knows about the person they have come with. I like this activity because it shows there will be professionals surrounding this birthing family, and while the professionals will know all the medical "stuff," the partners will know the pregnant person better than anyone in the hospital. Labor support is not rocket science. When you know what a pregnant person likes and dislikes, when you know what care this person would appreciate when sick or stressed, when you know what relaxes and what tenses -- this puts you in a prime position as a supporter, and suddenly you have something just as important as the professionals around you. By sharing things they know about each other ("She loves rocky road ice cream," "He hates his head touched") they see already they are armed and ready to doula their loved one. 

​I make goodie bags for all the families. They are filled with objects that symbolize a trait, activity, or way to support someone in labor. 

• Ladybug Straw: stay hydrated; bugs remind us of germs and the need to wash our hands, put a towel on the birth ball, put shoes on when walking, etc.
• Tissue with Yoda on one side, R2D2 and C-3PO on the other: Yoda's "Do or do not, there is no try," for encouraging words, peace through The Force, learning from the master (who's the master???); the droids represent friendship/partnership, C-3PO interprets what R2D2 says like a partner can interpret what a laboring person needs
• Plastic Frog: all fours position for labor or pushing, staying active and changing positions,  change/metamorphism (if it's not working, change it up)
• Sucker: be sweet as you offer support, it's wrapped up like a baby in a pregnant belly, it can provide pressure to a receptor spot on the roof of the mouth which released endorphins, and a reminder to eat while in labor
• Ring Squirter: use of hydrotherapy -- shower, tub, ice
• Gold Medal: treat laboring person as a champion with lots of verbal reminders, and be a cheerleader
• Gum: it smells good (reminder to use comfort scents), partner is not allowed to have bad breath, it "sticks together" like partner and pregnant person
• Watch: of course we time contractions to help us know where in labor we might be, reminder to "watch" the pregnant person and not the machines or the clock
• Head Band: this can bring comfort for unruly hair, it can also remind us this is an athletic event
• Whistle: blow stress away, there may be loud noises, and as a support person, "don't blow it!" 
• The Princess bags: If there ever was a day a person should be treated like royalty, it's the day you birth your baby!

When you love doulas, believe in their benefits, and are a professional doula yourself, it can be hard for class participants to feel you are unbiased on the subject (even if you are a professional childbirth educator, as well). I feel by offering an activity like this, you can show there are many different ways to create a birth support team -- and with anticipatory expectations of what a laboring person's needs are -- that doesn't have to include a doula.

My journey to becoming a doula makes plenty of sense in retrospect, but it is a winding journey. I entered college as a pre-veterinary science major, ultimately switched to a Psychology major, hated counseling but fell in love with animal behavior research, and graduated with a BA in Psychology, Biology minor, and Biology Honors. I then entered a PhD program at the University of Nebraska-Lincoln in the Biological Sciences with the intention of becoming a research professor. I actually completed my coursework for a PhD, but cut my research short to graduate with a Masters when I decided a career in academia was no longer what I wanted. After graduation, I became a homemaker and mom when our son was born 5 months later. When he was 10 months old I completed my doula training with DONA International, and attended my first doula birth one month later. Now my husband and I have three children, I am a certified birth doula with DONA International, a Hypnobabies Childbirth Hypno-Doula, co-leader of ICAN of Lincoln (International Cesarean Awareness Network), and have attended more than 55 births. I have a passion for teaching others, empowering women and families to love one another better, birth, birds, and chocolate.
 
I wanted to write a guide to other doulas and to parents-to-be on how to find, read, understand, and use primary research literature. When you have found, read, and understood the research, using the information will be a highly individual decision that only the patient themselves is able to make, based on their intuition, desires, trusted counsel, and circumstances. Yesterday, I discussed how to find and read research papers in Part 1. Here in Part 2, I walk you through a short research article and talk about how to understand the paper, and how to use that information.
 
Here is a short example of how I read a research paper. This article is a short write-up of a conference poster session. This is preliminary research, it is probably not peer-reviewed (critiqued by other scientists in the field to make sure it is done well), and though we can still gain valuable information from it, keep in mind our knowledge can change drastically with more studies, more research, and better analysis. Go read it. Really. It's quick, you'll be back in no time! Here is the paper (if you want to and have the means, print it out and grab a pen!):
 
Afshar, Y; Wang, E; Mei, J; Pisarska, M; and Gregory, K. 279: Higher odds of vaginal deliveries in women who have attended childbirth education class or have a birth plan. American Journal of Obstetrics & Gynecology, 2016;214(1):S162.
 
Since this is such a small write-up, there is no introduction or background section, simply a research objective. Do Child Birth Education classes (CBE) and/or birth plans impact the delivery mode of those women?
 
Let's look at the study design. The authors looked in the past (retrospective) at a group of women all from the same period of time with similar demographic characteristics (cohort study), and give the dates and type of birthing facility. Because birth modes can differ so much between singles and multiples, the authors only looked at singleton births. They also divided the groups into all moms, and just moms having their first birth (nulliparous). Then they divided each group into moms who attended CBE, those who had a birth plan, and those who did both.
 
Understanding statistical analysis is a whole other ball of wax, and there is no way I can explain everything here. What you need to know is when p-values are reported (p=0.01, p>0.1, p<0.0001, etc), the smaller the p-value, the greater the effect of the variable being tested. The p-value is basically the probability that any difference between the groups is due to chance, so if the p-value is small, the difference between the groups is probably due to the different variables. There is a lot more to statistics than just understanding p-values, but there's your crash course in statistics for today.
 
In this study, there were over 14,000 births that were included in the analysis (met inclusion criteria). There were differences between groups of women who did and did not attend CBE and/or have a birth plan. After adjusting for these population differences, the authors found that women who had attended CBE, had a birth plan, or both, had higher odds of a vaginal delivery compared to the group who did none of those, but there was no stronger effect of doing both. This effect was true of first-time moms as well, so the impact of CBE and/or birth plans is the same no matter which birth this is for a woman. In their original poster session, the authors likely included more figures, including their logistic regression analyses, which would help us understand the relationship between the variables and their effects, but it's a simple study and we can understand the basics with the information given here.
 
The authors conclude that attending CBE and/or having a birth plan increase the odds of a vaginal delivery, and they state that further research is needed to understand how this works. In my opinion, given my cursory understanding of this study, I think this conclusion is sound.
 
The questions I have after reading this are:

• Does the type of CBE class and/or birth plan matter?
• It seems like the number of women who had both attended CBE and used a birth plan and those who only wrote a birth plan were very close. Did most of those women who wrote a birth plan also attend a CBE, or is this an incorrect assumption?
• Does the type of class a woman took impact whether or not she writes a birth plan?
• I would have liked to know about how many scheduled and unscheduled (emergency) cesareans were in each group of moms. And the reason for the cesarean?
• How about assisted vaginal delivery (forceps or vacuum) and CBE and/or birth plan?
• I would have liked to see figures of the data, not just the study design, hopefully this research will be published in full soon.

Finally, the authors found a statistically significant difference in delivery mode based on CBE and/or birth plan, and with a relatively small group of women! In human research, 14,000 people is really not much. That's approximately the population of downtown St. Louis, MO. To find a statistically significant effect in a small sample size suggests that either it is due to random chance, or this is a very strong effect. I am excited to see what further research shows in this area!
 
In lengthier research articles, there would be a list of references. For more information on the topic and related topics, this list is where you want to start. In lengthier research articles, there would be a list of references. For more information on this and related topics, including additional studies, this list is where you want to look.

Now, how do you use this information, either for your doula or CBE clients, or for yourself? First, you must understand that research does not, and can not predict your outcome. Research is not a crystal ball, it cannot predict with certainty, in real life, who will and will not experience which outcome. In addition, the facts, found in the scientific literature, are an important piece of any decision-making process. But your intuition, your desires, the availability of options, the counsel of trusted medical caregivers, and many more variables will come together to determine the best decision for you in your circumstances. Science tries to isolate variables, to pinpoint and quantify the exact effect of one thing, which is vital for understanding how one thing affects another. But we do not live in a laboratory. Applying those results to real-life, complicated, individual healthcare decisions is something that only the patient themselves can do.
 
I hope that now you are better equipped to find, read, understand, and use primary research articles. Happy reading!

I’ve been a doula-ing most of life, long before I was a professional birth, then postpartum, doula. How is that? Well, the term doula may have started with birth, but the role, the intention, is really about continuous support. We now have postpartum doulas and bereavement doulas. There are even end of life doulas. To doula is to be someone well-informed about an experience another person is having and to offer continuous support. It’s about meeting that other person where they are and offering to be fully present with them as they experience intense feelings, sensations, and processes. It means to be open and supportive of their loved ones as they work to balance their own needs and that of the primary person in this particular journey.
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• When a friend in middle school struggled with nosebleeds that were uncomfortable and embarrassing and I would go with her quietly to a rarely used bathroom, hide in a stall with her and figure out what she needed to get back to feeling normal, that was doula-ing.
• When a friend in high school told me and me alone that she was having a miscarriage from an unplanned pregnancy that she had shared with no one, and I went home with her to sit with that process, that was doula-ing.
• When a friend’s dog was dying and being put to sleep and I sat with them at the veterinarian’s office and held space for that experience, that was doula-ing.

These are intense experiences through which I offered continuous support for people involved -- I met them where they were and included as much information as I could in how the process might be eased for them. I offered guidance in what choices they had to make. In each experience there was struggle and joy and pain, humor and grief. Things that might be petty to others were looming, and things that might overwhelm another were handled with resilience.

​This brings me to where I am now in my life and career. I call myself a tongue tie doula. What does that mean? It makes sense to start with the literal. Tongue Tie is the common term for the medical condition ankyloglossia.  It’s where the lingual frenulum (band of tissue that connects the tongue to the floor of the mouth) is restricted of function through being too far forward, too short, or lacking elasticity -- or some combination of these.

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It is okay, stay with me. I know you are saying, what? Why would we talk about Doctors during doula month?!!? Doctors are the reason women need doulas in the first place! I would agree, wholeheartedly, that women need doulas, in part, to help navigate the maternal health care system. But I would also agree that part of the reason that women need doulas is that doctors desperately, desperately need doulas too.

I became a doula nearly 14 years ago in my twenties, and I’m not going to lie, I didn’t last long. I had some births that resulted in healthy babies and the mom was…not disabled at the end of it. Even with a doula, these moms did not receive mother-centered care. For a long time I thought I was just unlucky to get some bad birth situations, but now I know, they were all pretty routine. A male doctor telling me in the middle of a baby crowning that most women urologists would much prefer to have Cesarean births because it preserves the pelvic floor (is this really the time? While this patient is purple pushing her baby out in a lithotomy position that only benefits you?). That time the doctor was in tears because she had agreed to induce at 37 weeks because winter holidays were coming up, and no, to keep it short, it didn’t go flawlessly. I don’t doubt she was crying because she was tired, and maybe a bit raw, and dismayed that the baby needed resuscitation and extended procedures to make the transition to independent breathing.  And yeah, her medical malpractice insurance was about to get tested. I certainly had views on the doctors in these births!

So in my thirties I went to school for a Masters of Public Health with the goal of changing birth outcomes through public health, and if that meant throwing the doctor out with the bathwater, so be it. It was no more than they deserved for being such out of date, out of touch jerks.

But now I’m in medical school in my forties.  I see classrooms nearly half full of 21 year old women being called “Guys” by every lecturer and attending, being erased by every lecturer and attending. I see course curriculum that includes nothing on breastfeeding, and when asked a question about normal breastfeeding, an obstetrician says she knows that answer because she has breastfed for three months! Not because as an OB she has extensive and comprehensive training on breastfeeding (they don’t get any), but because she has beaten the odds as a breastfeeding physician (66% of physician mothers do not meet their breastfeeding goals, most don’t make it to three months).  She is also the one that told the class vaginal delivery was a procedure done by a surgeon.

Physician mothers have nearly a two-times increased relative risk of birth complications, because they are doctors, and if anecdata is anything to go by, can anticipate having every medical intervention in the book --  evidence based or not -- thrown at them (perhaps accounting for that increased risk?).

After birth? For the 30% of women residents that are pregnant, they have minimal leave; it may be paid -- or not; they may get to finish the program on time -- or not. There is no required minimum maternity policy for residencies. Even if leave is allowed, many won’t take the whole of it because pregnant physicians are considered a burden on the residency program by attendings and male residents. Most are expected to return within six weeks, if not sooner. Maternity leave for practicing doctors isn’t much better.  On paper they may have 6 weeks of paid leave, but in reality? Maybe their partners have made it clear that the business will not tolerate that much time away.  Don’t even think about taking time to pump! Their employees and staff have better maternity leave.

So get to the point already, you say, why am I advocating doulaing the doctor? Because if ever there was a group that was high-risk for all the bad outcomes of birth and postpartum, while simultaneously seeming to have all of the protective factors, it is women doctors. They set out to become doctors when they are 18, start medical school at 21, and spend the next 4 years being erased as women and indoctrinated into the medical system's way of maternity care. They often have minimal exposure to safe alternatives to standard medical maternity care because of their training, and even if they want something else, the systemic pressure on them is nearly crushing. They are shift workers as residents, they have no protection under the law for breastfeeding because they are salaried, and sure, they have lots education but also lots of debt and not much income. If they are part of a private practice, they struggle to balance breastfeeding and bonding time with the need to go back to work immediately in order to become a partner and thus-financially secure.

​And yet they do not utilize doulas, because they KNOW about birth, they’ve been TRAINED, their OB is the BEST, the nursing staff will help. The research is pretty clear on this too -- doulas improve birth outcomes, increase breastfeeding rates and reduce postpartum depression. Also, research tells us that doctors are frankly the worst patients in the world, because they are doctors. They literally refuse to ask for help because they shouldn’t need it, they have the training, THEY know what to do.  So a high-risk group that would clearly benefit from doulas isn’t using them, doesn’t realize they need them, and I’d like to see that change.

Great, so I want to see that change. What is the big deal if they don’t use a doula? Most women don’t.  True, although that is changing as doulas become more available and the research on their benefit expands. But the big deal is this: Women physicians have the highest suicide rate of any profession, 250% higher than the rest of the population (men physicians are 100% higher than the population rate), and 400% higher than women in other professions. We are doing something so profoundly wrong in our profession that women who should be healers and leaders and colleagues and parents are killing themselves.

​Suicide has many causes, but here is one I think we haven’t talked about enough: physician mothers are providing care and getting none. Maybe if we nurture our physician mothers through their intense times of change and challenge, support them during their births, help them bond with their babies, meet their breastfeeding goals, maybe we could change that suicide rate. Birth can be transformative, or traumatizing. Doulas can help shift the balance for women, and women physicians need this as much as any other high risk group. Time to doula some doctors and change the world.