Let’s review: Is it ethical to promote normal birth?


Kudos to bioethicist Anne Drapkin Lyerly for the natural childbirth version of speaking truth to power.

Lyerly is is Associate Professor of Social Medicine and Associate Director of the Center for Bioethics at the University of North Carolina, Chapel Hill. She writes about social and moral issues in women’s health and reproductive medicine. She has also been a member of the Editorial Board of the journal Birth: Issues in Perinatal Care, published by Lamaze International. She has dared to question the ethics of “normal birth” within the pages of the premier journal of the normal birth industry.

The abstract succinctly summarizes her argument.

The concept of “normal birth” has been promoted as ideal by several international organizations, although debate about its meaning is ongoing. In this article, I examine the concept of normalcy to explore its ethical implications and raise a trio of concerns. First, in its emphasis on nonuse of technology as a goal, the concept of normalcy may marginalize women for whom medical intervention is necessary or beneficial. Second, in its emphasis on birth as a socially meaningful event, the mantra of normalcy may unintentionally avert attention to meaning in medically complicated births. Third, the emphasis on birth as a normal and healthy event may be a contributor to the long-standing tolerance for the dearth of evidence guiding the treatment of illness during pregnancy and the failure to responsibly and productively engage pregnant women in health research. Given these concerns, it is worth debating not just what “normal birth” means, but whether the term as an ideal earns its keep.

Lyerly explains the problem:

… [I]n its emphasis on birth as a physiological but not pathological or “medical” process, the concept of normal birth has served to highlight the harms of unreflective and routine medical intervention, and promote access to low intervention or what some have termed “natural” birth for women who desire it. Second, in its emphasis on birth as a social process, the concept of normal birth has helpfully promoted an understanding of birth as meaning imbued… [E]thically speaking, as an organizing principle for the good, the notion of normalcy raises a trio of concerns.


1. Not all women need or want a “normal” birth, and therefore, it is wrong to suggest that this type of birth is “normal.”

… “normal” indicates something that is normative or morally preferable—a state we ought to strive for. The result is a “fundamental tension” between normal as an “ordinary healthy state” and a “state of perfection toward which communities can strive.” In this way, the “normal” birth becomes (in hearts and minds) the good birth, potentially leaving women who use technology to conclude that they have somehow failed or missed out during their entrée to motherhood.

2. Why should avoiding technology be a goal when many women don’t want to avoid technology?

… [M]edical interventions— pharmacological or epidural analgesia, for example—can improve the experience of birth for women who desire them. In both cases, normalcy as a goal for populations does not track well with normalcy as an ideal for particular women. An unintentional and untoward consequence is that women who use and benefit from technology may nevertheless conclude that their births are somehow less than ideal, at a distance from a notion of the “good” that was either out of reach or inconsistent with their values and preferences.

3. The emphasis on “normal” birth as a socially meaningful experience misses the point:

… [A]re not all births, whatever the degree of intervention, socially meaningful? … Among the approaches {Diony Young, Editor of Birth] lists are respectful care, antenatal education, support in labor, informed choice and consent, supportive environment, evidence-based information and practice, mother baby togetherness, and availability of midwives for
one-to-one care… [N]one is specific to normal birth—that most if not all would be beneficial to a childbearing woman regardless of how medically complicated or involved her delivery.

… [N]ormalcy raises particular problems from the standpoint of justice, to the extent that it fails to attend to the needs of those who are disadvantaged, physiologically or otherwise. Some
prominent theories of justice require attention to, in some cases priority for, the interests of the least well-off. My concern is that the linking of social and psychological meaning and the nonuse of technology under the umbrella of normalcy implies that in complicated pregnancies, the social aspects of birth are somehow less relevant. Of course, they are not; indeed, women who face birth and illness together feel perhaps more pressingly the need for supportive, respectful care.

4. Many women experience pregnancies that are not normal. Natural childbirth advocates simply ignore these women, reinforcing the tendency of researchers to ignore these women.

… [I]n a 2010 Research Forum held at the National Institutes of Health entitled “Issues in Clinical Research: Enrolling Pregnant Women,” the tag-line read “Pregnant Women Get Sick, Sick Women Get Pregnant.” Of course they do—but that it was an extremely effective phrase was a telling reminder of our myopia when it comes to illness and pregnancy.

Lyerly’s critique, while measured and understated, is nonetheless devastating. It’s especially powerful because Lyerly takes NCB advocates at their word that they are acting on behalf of women and demonstrates that it’s fatuous to claim to be acting on behalf of women when you ignore, marginalize and denigrate a substantial proportion of them.

I agree with Lyerly that the promotion of “normal” birth is ethically suspect. However, the reason is simpler than Lyerly supposes. It’s money.

Midwives, doulas and childbirth educators can only make money from births that involve minimal or no technology. Therefore, they have idealized the births that represent their profits. The promotion of “normal” birth is a marketing strategy. Like Mitt Romney and the 47%, Those who promote normal birth believe that it is “not their job to worry about those people” who want services other than those that midwives, can provide.

Lyerly is clearly a less cynical person than I am. That makes her critique all the more powerful. She takes NCB advocates at their word and finds their word to be ethically suspect.

This piece first appeared in November 2012. It is worth revisiting in light of the deaths at Morecambe Bay.

132 Responses to “Let’s review: Is it ethical to promote normal birth?”

  1. Dr Kitty
    March 10, 2015 at 7:02 am #


    “Gail Johnson, professional advisor for education and research at the Royal College of Midwives, said the disparities were likely to be due to differences in health service models and the overall health of different populations.

    She said the percentage of women giving birth by Caesarean in the UK was still “a bit too high”.

    “A Caesarean is an emergency procedure, done when a normal birth isn’t going to work.

    “It’s not a lifestyle choice, and although it’s a safe operation, it does carry more risks than a vaginal birth.””

    From an article about the different CS rates within the EU.

    I think what Ms Johnson means to say is that a CS is an emergency procedure done when a normal birth isn’t going to work, OR done pre-emptively when the risks of a normal birth are higher than that of a CS or are considered unacceptable by the woman and her obstetric team.

    CS carries *different* risks to attempting VB, whether or not it carries *more* risks or * a more unacceptable risk* isn’t clear cut, and will vary on a case by case basis.

    Cyprus has the highest elective CS rate in the EU.
    It is also a traditionally religious society…so I wonder if it is a way of limiting family size…

    • fiftyfifty1
      March 10, 2015 at 8:47 am #

      “It’s not a lifestyle choice”

      It was for me. It was all about lifestyle frankly. It was the choice between a lifestyle with just some manageable urine and stool incontinence, or risking much more severe incontinence. Nothing like a good crap in your pants at an inconvenient time to put a damper on your lifestyle.

      The colorectal surgeon laid it out for me pretty clearly: what even the best surgeon can do in the face of pelvic floor damage is very meager.

      • Dr Kitty
        March 10, 2015 at 9:32 am #

        To me the fact that with an elective CS I can eliminate the risk of shoulder dystocia, cord prolapse, foetal distress or hypoxic damage during labour, and perineal damage and instrumental delivery completely outweighs any benefits of a VB.

        TTN, increased bleeding, infection, longer recovery, risks of Placenta praevia/accreta/percreta in future pregnancy- I’ll happily take them in return.

        Oh, and I’m not in love with the idea of labour and pushing a baby through my vagina, so there’s that too.

        I find it interesting that the EU countries with the lowest CS rate also have the tallest, thinnest citizens. Almost as if having a larger pelvis and lower BMI makes it easier to give birth or something…

        It’s like no-on has considered that variations in CS rates might actually be appropriately based on different populations with different ethnicities, priorities and baseline health, demographic and socio-economic circumstances.

        I’m always being nagged by the powers that be because Northern Ireland prescribing rates for antidepressants and painkillers are higher than the rest of the UK.

        The fact that the rest of the UK doesn’t have a significant proportion of the population who were shot, blown up, abducted, imprisoned or interned and who lost friends and loved ones during the Troubles and that we have worse deprivation and poverty than the rest of the UK…nope, irrelevant apparently. We have big issues with PTSD, chronic pain and depression. I’m supposed to prescribe the same drugs as a GP in a leafy London suburb or rural Scotland. Nope.

        • demodocus' spouse
          March 10, 2015 at 11:44 am #

          But the Troubles were *so* long ago, why would they make anyone sad now?? >sarcasm<
          My mother-in-law tells me that my father-in-law (born and raised in County Tyrone) lost a cousin to a bomb back then. He's never mentioned the Troubles in my hearing.

          • Dr Kitty
            March 10, 2015 at 12:12 pm #

            It’s not like being blown up or watching people being blown up stays with you or anything…

            We have a deeply divided society and a general ethos of just getting on with things (as epitomised by the fact that we call 30 years of virtual civil war and constant terrrorist threat “the Troubles”). There is a lot of somatisation and functional disease (i.e. people who manifest their emotional and psychological distress physically- IBS, fibromyalgia, chronic headaches etc) and people don’t like to be labelled as suffering from PTSD or depression.
            Most people here don’t like to talk about their feelings. I always offer CBT, psychology and counselling if appropriate…I’m rarely taken up on it. Culturally- they’d rather have pills and keep it all bottled up.

          • The Computer Ate My Nym
            March 10, 2015 at 1:04 pm #

            I lived in NYC in 2001. In particular, in southern Manhattan. And I worked at Bellevue. I didn’t personally witness the planes running into the towers, but I did see some of the victims and help treat them (though not that much because it was one of those unusual emergencies where there were few injuries compared to the number of deaths and so medical personnel were not that needed.) I’m relatively unaffected. I certainly don’t have PTSD or anything like that. But a couple of nights ago I dreamed about planes being flown in a deliberate and controlled manner into the ground. This dream came completely out of nowhere: I hadn’t been thinking about the attacks or anything. Just…there it was one day. I can’t imagine how people who lived with this sort of crap for decades are supposed to just be over it one day.

          • demodocus' spouse
            March 10, 2015 at 5:08 pm #

            He does tend to the laconic, unless we’re talking sports.

    • Amazed
      March 10, 2015 at 9:42 am #

      Why am I not surprised that at the face of her colleagues; fuck ups, a representative of midwives is still crowing about the evils of c-sections?

    • March 11, 2015 at 12:50 am #

      Why do you say “normal birth”, out of curiosity?

      I’m not pregnant but do plan on having a baby someday, and know that it’ll be a c-section birth because of a past injury which has left me with an increased risk of something going wrong during vaginal birth. If someone told me that my baby’s entrance to the world wasn’t normal, I’d be deeply hurt.

      I mean, it isn’t ABnormal, you know?

      • Young CC Prof
        March 11, 2015 at 1:13 am #

        Dr. Kitty doesn’t call it abnormal, but apparently Gail Johnson does.

  2. AmyH
    March 9, 2015 at 4:06 pm #

    I was at WIC getting my second son enrolled last month, and they asked me if he was born by C-section or “normally.” I couldn’t help responding, “He was born vaginally.” I am a prude and don’t even like the word “vaginal,” and I get that some of her clients probably do a double take or don’t understand when they hear it. But in that moment I couldn’t bring myself to acquiesce in the idea that my C-section friends should feel their babies were born “abnormally.”

    • SporkParade
      March 9, 2015 at 4:16 pm #

      Why does WIC even care? That seems like the sort of question that is only relevant to medical professionals.

      • toni
        March 9, 2015 at 5:26 pm #

        yeah what could possibly be the relevance of that? nosey buggers.

        tbh I usually say when I’m asked for my medical history by nurses that my son was born ‘normally’ or ‘the usual way’ rather than ‘vaginally’ because my mouth fights with me when I try to say the word and it comes out as an inaudible mumble. I don’t mean to denigrate c-sections

      • Anj Fabian
        March 10, 2015 at 11:06 am #

        The same reason that birth information is requested for kindergarten registration – to keep an eye on risk factors for other issues.

        There’s quite a list of risk factors for cognitive issues:
        extreme prematurity
        low birth weight
        very low birth weight
        intra uterine growth restriction
        NICU stay
        traumatic birth
        low apgar scores

        • SporkParade
          March 11, 2015 at 3:02 am #

          Yes, but you can have any or all of those with a vaginal delivery as well. Wouldn’t it make more sense to ask if the baby was term, and if there were any complications with the pregnancy or birth?

          • Who?
            March 11, 2015 at 3:40 am #

            That would be the less judgy way to ask, certainly. Which might give a clue to the thinking behind the question as it was asked.

          • toni
            March 11, 2015 at 3:23 pm #

            yeah ‘vaginal’ or ‘caesarean’ doesn’t tell you anything regarding poor health/good health. So unless there were more specific follow up questions it was a worthless thing to ask

        • An Actual Attorney
          March 11, 2015 at 9:03 pm #

          They ask you those things at kg registration? Are you in the US? At my kids school they want to see a vaccine record, a doctor check up, a dental check up, and to know if we need help with food or shelter.

    • DiomedesV
      March 9, 2015 at 5:07 pm #

      Why does WIC care how they were born?

      • Guesteleh
        March 10, 2015 at 9:47 am #

        Probably so they can compile stats on the overall health off WIC recipients.

  3. Jocelyn
    March 8, 2015 at 12:20 am #

    OT: We need to change something. If you google “Is home birth safe?” the information box that comes up at the top of the result page quotes BabyCenter and says that “a number of studies show that giving birth at home is just as safe as giving birth in a hospital.” You can click “Feedback” on the lower right corner of the box to report this as inaccurate and tell Google why. They do change what shows up in the top information box based on feedback.

    • Jocelyn
      March 8, 2015 at 7:59 am #

      If you type in “Is homebirth safe?” and “Is home birth safe?” it gives different results. Make sure to give feedback on both of them! It looks like they’ve already changed “Is home birth safe?”

      • Hannah
        March 8, 2015 at 9:50 am #

        It showed for me too! Good. I gave feedback on the one still showing BabyCenter

        • Hannah
          March 8, 2015 at 9:53 am #

          Actually I just looked again… it just changed to a different website making the same claims. Drat.

          • Jocelyn
            March 8, 2015 at 1:09 pm #

            *Noise of frustration*

  4. Sue
    March 7, 2015 at 10:40 pm #

    Homebirth MWs don’t promote “normal, physiological birth”, they promote HBMW-assisted birth.

    If they preferred the entirely physiological, why would we need them?

    The faux-interventions they offer are still promoted as interventions, even if they don’t work. So why not just let nature take its course, and sell their knitting on etsy or something…or, even better, give it away to the homeless.

  5. Lizzie Dee
    March 7, 2015 at 5:52 pm #

    I just readd this on the statement from the patient group that pushed for the enquiry:

    note that the Maternity Risk Manager at the Trust was a key figure in
    the band of ‘musketeers’ and that she was also a former RCM official”

    Too depressing!

  6. CrownedMedwife
    March 7, 2015 at 1:59 pm #

    I’ve just got to put this out there. After the Morecambe Bay Investigation report was released this week, it was picked up by the media with links, articles and discussions readily accessible. It had been noted in a previous discussion that the most likely response from Midwifery organizations and NCB advocates would be deafening silence. Deafening silence it is…nothing from Midwifery organizations such as ACNM, MANA, Midwifery Times or NCB advocates including Improving Birth, Human Rights in Childbirth, BM, VBACFacts, EBB, ICAN, Tritten, BWF or TFB. For a group of sites so concerned with touting benefits of NCB and midwifery, public health initiatives and so forth, not a word to address the Morecambe Bay report and the issues of a setting of midwifery dysfunction and unparalleled obsession of NCB at all costs, even when those costs included the lives lost and damage done to mothers and babies. It is no surprise, in a cultish mentality of followers, posts or links to the Morecambe Bay Investigation are lacking as well.

    We didn’t expect any less, but I did expect something. I expected a discussion to explain away the outcomes without placing blame in the hands of the midwives or their ideological misgivings. Yet silence. After all, what could possibly be said to explain the results of the investigation without critical reflection and accusation of the very ideology used by NCB to define themselves? The very beliefs used as their rally cry in the name of supporting women, improving perinatal care and decrying the overmedicalization of birth.

    Enter Birthrights.org in a post renaming the results of the Morecambe Bay Investigation with the title “Kirkup Report” in a sly effort to introduce an element of cynicism to the results by the evil physician leading the investigation. Tactic One: Blame physicians. Move forward to question the blame of ideologic underpinnings of natural childbirth by touting its existence as the underlying premise as a ‘best means of ensuring that woman and baby emerge from labour in good health’. Tactic Two: Proclaim the safety of NCB, but ignore the existence of its ideology as a contributor of harm. In the next step to displace blame, Birthrights.org seems to question the validity of the NHS decision to move forward with a review of safety of Midwife-led units, despite a direct link to Midwives and a rogue culture to the events at Morecambe Bay. Step Three: Repeat after me and proclaim “We’re not all like that.” In conclusion, Birthrights.org shifts the fault in the poor outcomes by acknowledging “systemic failures of communication and management that arose in all of the professions – midwifery, obstetrics, peadiatrics” but then asking “have our healthcare institutions become too big to protect the humans at their heart?”. Step Four: Blame the hospitals. Have you considered a Homebirth?

    There had to be a spin and the Morecambe Bay Investigation had to come along in a NCB discussion eventually. How artfully Birthrights.org manipulated the results at heart with an attempt to neatly distance NCB and Midwifery ideology as far away from the deaths of mothers and babies as possible. Well, played Birthrights.org. It is with great frustration that I look forward to your counterpart attempts to do the same.

    • March 7, 2015 at 2:06 pm #

      I look forward to #notallhomebirths. :/

      • Elaine
        March 9, 2015 at 11:21 pm #

        Every conversation I have with my pro-homebirth friends is already #notallhomebirths. Not all midwives are bad, you can’t judge them all by Faith Beltz, Christy Collins, Darby Partner, etc. etc. etc. It’s hard to imagine this rhetoric making much headway on a larger stage, though. By the time that gets busted out, you’ve already basically lost.

        • Who?
          March 9, 2015 at 11:44 pm #

          They aren’t wrong, of course. Not all of any group are one way or another or anything in particular.

          The challenge with midwives who offer homebirth is there is no objective way to review what they have done, how they work, how they will actually care for someone vs what they say they’ll do, or anything else of interest.

          We’ve seen challengers shunned, dead babies buried twice, and midwives continuing to work. That’s the trouble.

          • :(
            March 13, 2015 at 10:46 pm #

            I agree. As a homebirth midwife, I cannot express the frustration with the difficulty of getting a license pulled and I don’t know what they do in states that don’t regulate at all. Or having a judge give back a license that the governing midwifery board removed.
            There is a review board, but a rogue midwife doesn’t even let clients know it exists. She is supposed to by law. Unethical people don’t obey laws.
            However, talking to some doctors/nurses in the area. I found they have the same frustration with doctors they feel shouldn’t be practicing.

        • Young CC Prof
          March 9, 2015 at 11:57 pm #

          Even assuming there are some really good homebirth midwives out there, here’s an analogy for you:

          If someone served you a salad with fresh lettuce and notebook paper all shredded and mixed up together, would you be happy? No? Then why would you be happy with a movement that makes no effort to distinguish competent practitioners from the incompetent, or the valid information from nonsense? Getting things right sometimes isn’t evidence of reliability.

          Or, as Bofa put it, when everyone says, “Not all of them are bad,” the profession has a real problem.

          • Roadstergal
            March 10, 2015 at 12:40 pm #

            #NotAllMidwives #ButWeWon’tBeDoingAnythingToHelpYouTellTheDifference #OrDisciplineTheBadOnes

          • playing devils advocate
            March 13, 2015 at 10:38 pm #

            “Not all of them are bad,” the profession has a real problem.
            I hear from NCB advocates the same phrase though regarding doctors.
            So does the same reasoning apply? 😉

          • Young CC Prof
            March 15, 2015 at 10:42 am #

            There are mechanisms in place to sue bad doctors, or even remove them from the profession. There are uniform and stringent training requirements to get in to the profession, and there are formal published standards of care. If midwives had all that, I don’t think this blog would exist.

    • Young CC Prof
      March 8, 2015 at 5:24 pm #

      The Birthrights article was absurd. It basically advances the claim that care failures happened because the NHS is a big bureaucracy, so we should just give up on the medical system altogether. Never mind the fact that the deaths were caused by lack of timely intervention, NOT by inappropriate interventions.

      • CrownedMedwife
        March 9, 2015 at 8:57 am #

        There is something to be said for a post to be so artfully written as to manipulate and distract the reader from the overt obsession with an ideology as the etiology of the dysfunction and lethality of its presence. The ability of Birthrights to publish a piece in response to such an atrocity beautifully illustrates the agenda of NCB, but only for the reader with the knowledge to critically evaluate their response. I’m unsure which speaks louder, their hipocrisy or the silence of all the others. Such a hypocritical response of silence by Midwifery groups and NCB sites who all purport to possess a goal to ensure mothers have access to practices and providers to promote optimal care. Yet when the underlying premise of their ideology is at fault in the Morecambe Bay report, their response is silence and no effort is made to identify the distinction between safe practice and ideology.

        I realize I have belabored the issue in both responses, but I cannot distance my mindset from an ethical violation. NCB ideology caused the deaths at Morecambe Bay and the silence from Midwifery and NCB groups allows those deaths to be in vain. The silence leaves their proponents and followers unaware and the deaths of mothers and babies at Morecame Bay buried twice.

        • Amy Tuteur, MD
          March 9, 2015 at 9:22 am #

          They are like creationists in that they start from an immutable conclusion. In the case of creationists, the conclusion is always that God created the universe. For NCB advocates, it is always that unmedicated vaginal brth is best. Since they will not allow the conclusion to be threatened by actual evidence, they either ignore what happens, excuse it, or blame in on rogue members of the group.

          • CrownedMedwife
            March 9, 2015 at 7:31 pm #

            I appreciate your anaology and its ability to rationalize the silence of NCB on the Morecambe Bay Report. The clear lack of ethics and misplaced priorities on behalf of NCB advocates and Midwifery groups is being blatantly demonstrated by their silence. Honestly, it doesn’t surprise me in the least, but it also doesn’t keep me from feeling nauseated by the hypocrisy of groups who claim to be advocating for women.

  7. Annie
    March 6, 2015 at 7:27 pm #

    How can doulas only make money from births with minimal or low technology? Doulas get paid no matter how the birth goes. And not all doulas push in medicated birth anyway.

    • fiftyfifty1
      March 6, 2015 at 7:47 pm #

      You hire a doula to help you “cope” with labor pain. They are in direct competition with epidurals, which are a proven effective way of coping with labor pain. The livelihood of doulas depends on demonizing epidurals. Even those doulas who don’t personally demonize epidurals, still indirectly depend on the idea that “natural is best”.

      • JJ
        March 6, 2015 at 8:09 pm #


      • Annie
        March 6, 2015 at 11:24 pm #

        I think you may have a really limited view of doulas. People hire them for all sorts of reasons. I hired one knowing that I would most likely get an epidural. Some women hire them for planned cesareans. And even if you hire one to cope with pain, some women may think epidural are perfectly fine, but want to experience birth without an epidural. I don’t think wanting that experience competes with epidurals.

        • Bugsy
          March 7, 2015 at 8:42 am #

          It probably depends a lot on the doula. We have a close family friend out-of-area who is one, and she also is the type who would be completely supportive of the patient’s right to choose an epidural. She’s so great that we interviewed a local doula in the hopes we could meet someone similar. Bad experience. She was the “all-natural-is-the-only-way-to-go” type who spread medical inaccuracies to support the pseudo-science she believed. (Antibiotic cream for the eyes? Nah…that’s just a vaseline jelly they put in babies’ eyes for no reason.)

          The biggest difference between the two is that our family friend works directly for the hospital, and the doula we interviewed was a private doula. The first one didn’t depend on demonizing medicine for her livelihood, but the second very much did.

          • fiftyfifty1
            March 7, 2015 at 9:01 am #

            But even your friend the non-demonizer, still depends indirectly on NCB for her job. Why would the hospital she works for have paid to hire a doula? Probably because so many women were bringing in their own nutsy anti-medicine doulas. So the hospital hired its own so they wouldn’t have to fight.

          • Bugsy
            March 7, 2015 at 9:47 am #

            I agree 100%. She worked for a large hospital in the suburbs of NY, for what its worth. Lots of NCB activists in the area.

        • fiftyfifty1
          March 7, 2015 at 8:48 am #

          People hire doulas for all sorts of reasons…that go back to NCB value systems. Doulas are popular where there is strong NCB influence in the community, where even if an individual woman is open to the idea of getting an epidural if really needed, an unmedicated birth is still seen as “best” as something they should “want to experience”, where a CS is seen as traumatic enough that you will want to hire someone to support you through it (or at least to show that your values are in line and you would have done it naturally if only you could have). In contrast, in places where NCB doesn’t have influence, people don’t hire doulas. If they hire anyone at all it is a “baby nurse”, who helps out for the first days postpartum. Doulas, even the good ones like Doula Dani, would be out of a job in a culture that placed no value on NCB.

          It’s like personal trainers. People may say that they hire them for any number of goals. But the reality is that the job does not exist in cultures that don’t overvalue thinness and youth.

          • Cobalt
            March 7, 2015 at 10:40 am #

            I disagree. Yes, a lot of times it is as you describe. BUT, women’s needs are too varied for “it is always this way”. A doula that provides education, helps to manage and reduce fear, and handles some of the emotional aspects of care of laboring women would still be valuable to some women regardless of the details of birth. Sometimes it helps to have someone there for the non-medical support the medical team might not have time for.

            Even if you take away all the false goals and ideology, some women will still want more (or something other) than an epidural.

          • The Bofa on the Sofa
            March 7, 2015 at 10:57 am #

            I didn’t see anything in fiftyfifty1’s comment that says it is “always this way.” It is a strawman.

          • Annie
            March 7, 2015 at 11:15 am #

            Fiftyfifty1 said that all reasons for hiring a doula go back to the ncb value system, ie that it is “always this way.” I think that’s what cobalt was responding to.

          • The Bofa on the Sofa
            March 7, 2015 at 12:43 pm #

            People hire doulas for all sorts of reasons…that go back to NCB value systems.

            Nope, that’s not what she said.

            “all sorts of reasons that go back to the NCB” does not preclude the possibility of reasons that don’t go back to NCB.

          • Annie
            March 7, 2015 at 1:07 pm #

            Fiftyfifty1 clearly thinks that all reasons go back to the ncb value system.

          • The Bofa on the Sofa
            March 7, 2015 at 1:16 pm #

            Does fiftyfifty1 think there are no exceptions to this? Nothing she said suggests nor implies that.

            Actually, this isn’t about what she said so much, it’s about the typical internet response to whenever someone says, “X does this” that someone feels a need to jump in with an “not every X is like that” apologetic. So what? No one, when they say, “X do this” means that every single one of them will do exactly that, so jumping on them because they didn’t adequately qualify their statement to allow for a few exceptions is just being overly pedantic and a waste of time.

          • fiftyfifty1
            March 7, 2015 at 1:34 pm #

            Exactly. Is there perhaps a woman out there who has a deformed spine and is allergic to narcotics and so MUST have a med-free birth and who hears from her OB that there is something called a doula that can help coach her through alternative pain relief strategies, or is there perhaps some woman on a military base with zero friends and no family near, who hears there is something called a doula and decides to hire one? These are examples of women who are hiring doulas for non-NCB reasons. And they may well benefit. But the very EXISTENCE of this thing called a doula to hire is due to NCB philosophy. And these women are very much exceptions to the rule.

          • Bombshellrisa
            March 7, 2015 at 1:57 pm #

            There is a volunteer doula practice here that serves women of color, their goal is to help these women ask the right questions so they understand their care and make sure they get pain relief when they ask for it. Those are not goals identified on the DONA website. I haven’t met a lot of doulas who are women of color and who serve this population. This is another non NCB reason to have a doula, but it’s not the usual doula/client scenario.

          • The Bofa on the Sofa
            March 7, 2015 at 1:59 pm #

            That sounds like a pretty good service, I think. The more we can do to assist in maternity care for the more at risk populations, either through direct care or helping them access care, is a good thing.

          • fiftyfifty1
            March 7, 2015 at 2:07 pm #

            This sounds like a great service. Still, I find it telling that they are there located on L&D. It’s sad that women of color (or any women) need a patient advocate there to make sure they get pain relief relief for their labors when they ask. Doesn’t this point back to the NCB philosophy that belittles labor pain in general and specifically denies that women of color experience it the way women “of the better classes” do?

          • KeeperOfTheBooks
            March 10, 2015 at 9:27 am #

            That sounds like a brilliant service–good on them!

          • Cobalt
            March 7, 2015 at 1:36 pm #

            I think calling being concerned about women who are struggling and need help beyond what the medical team typically provides, and making sure those needs are recognized, “just being overly pedantic and a waste of time” is one of the reasons NCB is so popular.

          • The Bofa on the Sofa
            March 7, 2015 at 1:38 pm #

            But the objections being made are not about “the concern about women who are struggling”, it’s silly semantics games.

          • fiftyfifty1
            March 7, 2015 at 1:42 pm #

            Even the fact that there are needs “beyond what the medical team typically provides” is due to NCB. Either those “needs” are manufactured by NCB (e.g. you must deliver med free, so you NEED pain coaching), or those needs are real but are having resources pulled from them due to the NCB philosophy that birth ain’t an illness (e.g. mandatory rooming in, pressure for constant skin-to-skin, nurses don’t bathe or change your baby, early release from hospital).

          • Cobalt
            March 7, 2015 at 2:25 pm #

            I agree completely with

            “Either those “needs” are manufactured by NCB (e.g. you must deliver med free, so you NEED pain coaching), or those needs are real but are having resources pulled from them due to the NCB philosophy that birth ain’t an illness (e.g. mandatory rooming in, pressure for constant skin-to-skin, nurses don’t bathe or change your baby, early release from hospital).”

            But I’m still yes and no on

            “Even the fact that there are needs “beyond what the medical team typically provides” is due to NCB.”

            Yes, NCB as an ideology is damaging in all sorts of ways, and this is one of them.

            No, not all needs would be met by the medical team in its absence, because not all needs can or should even be striven to be met by the medical team. Some things just aren’t covered under medical, and some things they just don’t have time for (because they’re busy with the medical), and if a need exists there a doula might meet that need.

          • fiftyfifty1
            March 7, 2015 at 4:50 pm #

            I wonder why it is seen as good to strive to meet all the needs of people who are hospitalized for non-L&D reasons, but believed that “not all needs can or should be striven to be met” when it comes to birth. I think it’s still the philosophy of Birth Isn’t an Illness, which is NCB at heart. There is no other cause of hospitalization where it would be seen as remotely acceptable, much less ideal, for a patient to be in so much pain that they may go 30+ hours without sleeping a wink. Where somebody sleep deprived or on narcotics would be not just allowed, but actually expected to care for a newborn 24/7. Where you need to have somebody stay with you post-procedure because you are expected to start working on round-the-clock duties immediately. L&D wards didn’t used to be like this. Women actually got recovery time! Their sleep was protected! They and their babies were cared for! Now the amount of help every woman receives is the amount she would need if she had had the ideal NCB birth–straightforward labor, normal vaginal delivery, no tearing, no pain meds needed. The hospitals are all too happy to go in the direction of NCB values, because it saves them $$$. Nobody would put up with it in any other area of the hospital.

          • Cobalt
            March 9, 2015 at 10:13 am #

            My point was that the medical team in L&D’s appropriate primary focus is on medical needs. They should be courteous and such, but not counted on for primary emotional or other non-medical support as they might be too busy with medical issues.

            The way hospitals treat women under the “Baby Friendly” banner is wrong, medically contraindicated, and should be changed with all possible speed and sensitivity to patient’s actual needs.

          • Bombshellrisa
            March 7, 2015 at 1:31 pm #

            Three of the four reasons to have a doula listed by DONA go back to the NCB value system:
            “reduces negative feelings about one’s childbirth experience
            reduces the need for pitocin (a labor-inducing drug), forceps or vacuum extraction and cesareans
            reduces the mother’s request for pain medication and/or epidurals”
            Why try to avoid Pitocin, cesareans, or epidurals unless you value a natural birth?
            I once had a couple hire me because the husband believed the usual misinformation about doctors, hospitals and epidurals. It was the husband who wanted a doula there so his wife wouldn’t ask for pain meds. When she did ask for an epidural, I refused to try and talk her down in anyway and the husband was furious with me. This was when I was first getting into my NCB journey. I would never have accepted a client like that now.

          • SporkParade
            March 8, 2015 at 10:34 am #

            I don’t know why someone would want to avoid Pitocin, but if I could reduce the chances of forceps or vacuum delivery without compromising the baby’s safety, I would.

          • Roadstergal
            March 10, 2015 at 12:45 pm #

            “I would never have accepted a client like that now.”

            It sounds like you were in the right place at the right time. Hiring someone to keep his wife from getting pain relief? What an asshole.

          • fiftyfifty1
            March 7, 2015 at 11:12 am #

            “A doula that provides education, helps to manage and reduce fear, and handles some of the emotional aspects of care of laboring women would still be valuable to some women regardless of the details of birth.”

            Sure, some women would benefit from this. But the numbers who would seek out and pay someone to do this would be small, to the point that nobody could make a living doing it, and it would be rare enough that it wouldn’t even have a name. Most women would turn to friends or family members or nursing staff for this sort of support. It is NCB that has turned this into a job description. It is NCB that has promoted the idea that labor and birth come with emotional and physical needs that can only be met properly through a “birth worker”. It really is like Personal Trainers. Sure some people may benefit from personal training. But the idea that people NEED personal training, and the fact that it is CAREER is something entirely made up by the fitness center/health club industry, and the existance of the health club industry relies entirely on a culture that overvalues thinness and the appearance of youth.

          • Elaine
            March 7, 2015 at 12:54 pm #

            I disagree. I think that part of the rise of the doula is due to people’s networks shrinking as we have smaller families and move further away from them. Granted I haven’t done labor with an epidural, but no matter how you slice it, it’s the process of getting a human out of your body after spending 9 months growing it, and it’s a big transition. The doula takes a support role that might be filled by a mother, sister, aunt, or close friend, and for someone who doesn’t have anybody nearby and free to fill that role, a doula could be really valuable. I did not hire a doula, but my husband was able to be with me for both of my births and stay in the hospital post-partum (the second time around, my older child stayed with her grandparents while we were in the hospital). If he hadn’t been able to do that, I would have given serious thought to hiring a doula because I would have wanted to have somebody. I’m willing to bet that most people who go into the hospital for several days for surgery or for other causes would also benefit from having someone there with them all the time.

            The rise of the doula may be due to NCB ideals, but I don’t think the desire to have a support person when going through a major medical event is an artifact of NCB ideals.

          • fiftyfifty1
            March 7, 2015 at 1:21 pm #

            “I don’t think the desire to have a support person when going through a major medical event is an artifact of NCB ideals.”

            Then why aren’t we hearing about joint replacement doulas?

            Certainly having a joint replaced should mark a spiritual transition for a person, no? You go from being 100% yourself to partially bionic. It is the beginning of saying goodbye to your body, a process which will culminate with your death. It is a rite of passage between Young and Old. Certainly you will want a calming voice and hand holding during the surgery as many are done under spinal while you are awake. If nothing else, you will need a lot of practical help afterwards. You won’t be able to walk. What are the chances your family will live near, or that they can really properly support you even if they are? Of course you will want and need 24/7 soothing and encouragement from a wise, supportive, professional who has gone through the transition themselves and knows how to help you view it, no?


          • Elaine
            March 7, 2015 at 1:27 pm #

            No, there aren’t joint replacement doulas. But I bet that most people who have the surgery do get family/friends to help out otherwise and I also bet that those who have the surgery who don’t have someone to help out would jump at the chance to get someone in if they could. That’s my point. What’s so anathema about the idea of having a support person during/after a major medical event? And if you don’t have a family or friend to do it and have to hire someone, better to get someone knowledgeable about the process if you can.

            Medical professionals forget sometimes, I think, that while they do this every day, the patient doesn’t. It can be nice, as a patient, to have someone in your corner who is focusing on the fact that you are going through a big thing.

          • The Bofa on the Sofa
            March 7, 2015 at 1:42 pm #

            No, there aren’t joint replacement doulas. But I bet that most people who have the surgery do get family/friends to help out otherwise and I also bet that those who have the surgery who don’t have someone to help out would jump at the chance to get someone in if they could.

            Thanks, Elaine, for illustrating the corollary to the point I made below:

            Actually, this isn’t about what she said so much, it’s about the typical internet response to whenever someone says, “X does this” that someone feels a need to jump in with an “not every X is like that” apologetic.

          • Cobalt
            March 7, 2015 at 1:28 pm #

            People do hire help sometimes after joint replacement surgery. Of course, usually by the time you have a joint replaced you’ve had a few more years of experience with doctors, hospitals, inpatient procedures, and coordinating your care than the typical first time mom, so it might be less intimidating than the first trip through L&D. You’ll likely be more concerned with practical than emotional help, but if someone wanted it, I would want them to have it.

          • FEDUP MD
            March 7, 2015 at 8:57 pm #

            Well, one difference I can see is that with joint replacement surgery you are not usually leaving the hospital with a tiny extra person dependent upon you for every need…..

          • fiftyfifty1
            March 8, 2015 at 9:39 am #

            Yes, and the role of helping in the first days at home was traditionally filled by family or if you could pay, a baby nurse or housekeeper. And some people pay their doula extra to help out afterwards also. But the main role of a doula is labor support/coping with pain coach.

          • Alexicographer
            March 9, 2015 at 11:49 pm #

            I’d really happily have hired a joint replacement doula for when my husband had hip replacement surgery, actually. Keeping our household (though it was at that time just the two of us) and my life running while also (not) finding time to be with him in the hospital as much as he wanted me to be and keeping his family apprised of how he was doing would have been wonderful.

            And a joint replacement doula might have pointed out things that were not pointed out to us by the hospital staff prior to the surgery, even though we went to the “orientation” (or whatever it was called) about what to expect and how to plan — you know, stuff like buying the needed rehab equipment (a seat for in the shower and so on) and making sure that all our staircases had handrails, so that I didn’t have to deal with hiring and meeting a contractor after the surgery, while DH was still in the hospital an hour from our home and wanting me with him 24/7.

          • fiftyfifty1
            March 7, 2015 at 1:25 pm #

            “The doula takes a support role that might be filled by a mother, sister, aunt, or close friend, and for someone who doesn’t have anybody nearby and free to fill that role, a doula could be really valuable.”

            Doulas are not marketed as replacements for family, close friends or a spouse. Quite the opposite. NCB specifically markets them as a “birth worker” who cannot possibly be replaced by family, friends or spouse.

          • Elaine
            March 7, 2015 at 1:32 pm #

            Yes, they’re being marketed that way. But you missed my point, which is that even the NCB marketing aside, there is still a useful role for that person during and after birth. A family member or friend could fill that role (and bonus points if that person has given birth themselves and knows what it’s like), but what if you live 1000 miles away from your family, all your friends have little kids too, and your husband is deployed? Who are you going to call? A doula might not be a bad choice, even if you plan on an epidural or a c-section.

          • fiftyfifty1
            March 7, 2015 at 1:53 pm #

            I’ve never said anything to the contrary! Like I have said, a woman “may very well benefit” from a doula. Just like someone may very well derive some benefit from a personal trainer. That doesn’t change the fact that the very existence of the job description “Doula” relies on NCB philosophy. Every doula business around would have to fold if all of a sudden elective CS and/or epidural were truly accepted without guilt. They simply couldn’t keep running based on the rare women with true contraindications to pain meds or isolated on military bases. Just like every health club/ fitness center would go under it became cool to look 75 and have a BMI of 35.

          • Sue
            March 7, 2015 at 10:52 pm #

            I suspect some of this difference in attitude relates to how open you are to share this experience with a (relative) stranger. Even if you get to know her through the pregnancy, she is generally not an intimate in your life. I can understand not wanting someone like that to be your support person, but I can’t blame someone who does.

          • Somewhereinthemiddle
            March 7, 2015 at 2:51 pm #

            I certainly can’t speak for all women but I can give you an idea of why I hired a doula even though I wasn’t married to the idea of having an unmedicated birth. 1) She was familiar with the staff and facilities where I gave birth and helped me not have to think about logistics too much 2) She could walk me through vulnerable moments during my pregnancy and was able to be objective when my friends and family would not have been 3) My husband, though an amazing man, doesn’t “do” labor well and ends up sitting in a corner watching the action 4) Was able to help me communicate more clearly my needs and wants, i.e. that I wanted the heplock before it was time for pushing because my labor was going fast and the nurse wasn’t in any sort of hurry 5) Got me extra warm blankets, clothing changes, food, cameras, took pictures without me needing to ask for them 6) Provided physical and verbal support during labor that I would have needed with or without pain meds 7) Followed up with me every couple of days after I had my baby for about two weeks because I have a history of postpartum depression 8) Helped me line up back up care for my kids while I was in labor if family members had not been available 9) Referred me to postpartum care professionals/ baby nurses to I could better care for myself and my kids while I was recovering.

            That isn’t to say that all women *need* to have a doula but all women ideally should have objective, kind, unbiased support available to them if needed. I have so many friends, including a physician friend, who have gotten terrible or non existent support from spouses, friends, and family. Yes, some doulas have an agenda and they SUCK, but not all do. The good ones really are fantastic.

          • Annie
            March 7, 2015 at 11:35 pm #

            I hired a doula because my husband frequently passes out in hospitals. I needed to let him off the hook.

          • toni
            March 8, 2015 at 12:30 am #

            i was pretty much alone the whole time because my husband slept through almost everything. The nurse came in frequently but for short periods. I thought she was busy with other women but right towards the end she said I was her only patient and she just hadn’t wanted to disturb me and my husband. She said ‘I can stay with you if you’d like..’ Before she could finish i said ‘please stay!’. I was really bored and kinda lonely. so I got an awesome back rub from her at the end and my kitten was born about forty minutes later. wish she had told me earlier that I could have had her all to myself. I can’t be the only one with a partner that ignores them and I imagine in most cases you wouldn’t have a nurse dedicated to you. So a doula sounds reasonable to me. I would have had my mum or sister but they both live half way across the world. I think birth is different to other things that happen in the hospital because you’re not just worrying for yourself but for your child and it’s generally something you want to remember fondly. I don’t care to remember having pins put in my femur. Not that I even do as I was put to sleep for that.. but anyway it was more of a massive inconvenience than a life altering, scary transition

          • SuperGDZ
            March 9, 2015 at 5:44 am #

            Hah, halfway through my c-section the obstetrician suddenly barked “Watch dad!” and my husband was gently assisted to a seat.

          • KeeperOfTheBooks
            March 10, 2015 at 9:23 am #

            If I could find someone like that, I’d seriously consider hiring her even if DH was in-country for a birth.

          • Somewhereinthemiddle
            March 10, 2015 at 12:13 pm #

            Yeah, she is pretty awesome and worth every penny for me. She’s been in the doula biz for decades so she knows her stuff and has seen it all.

          • Annie
            March 7, 2015 at 11:11 am #

            Well do you think it is possible for a woman to value NCB without claiming there are any medical benefits? I think it is. Again, I think you are ascribing motivations to women that aren’t necessarily there. It’s pretty belittling to say that a woman only wants a doula for a cs because she wants to show where her values are. People have different needs and desires.

            Although I agree with your general point that the crazy ncb culture creates a market for doulas.

          • Bombshellrisa
            March 7, 2015 at 11:28 am #

            What does it say about DONA that only ONE birth out of your three to qualify for certification can be a CS? That is very revealing.

          • fiftyfifty1
            March 7, 2015 at 11:54 am #

            “It’s pretty belittling to say that a woman only wants a doula for a cs because she wants to show where her values are”

            I never said that was the only reason. The main reason I listed is seeing CS as something that you need to be “supported” through. And yes, that goes back to NCB teachings. Think about it, what other surgery do people believe you need to hire a professional support person to educate and “support” you through….oh, there are none.

          • fiftyfifty1
            March 7, 2015 at 12:29 pm #

            “Well do you think it is possible for a woman to value NCB without claiming there are any medical benefits? ”

            Yes. Actually I believe the MAIN motivators behind NCB are not medical concerns but rather social and/or quasi-spiritual beliefs. Examples include:

            concerns regarding bonding
            a proof of “naturalness”
            a trial of courage
            a mountain top experience
            proof of trusting God/trial of faith
            mystical connection to women of the past
            rejection of the patriarchy
            proof of specialness
            fitting into peer group
            “not a sheeple”
            rite of passage
            proof of “fitness”

          • Laura
            March 7, 2015 at 4:03 pm #

            I agree with you on these points and feel that midwives are more motivated by these ideals than by money-although of course they want to make money off their beliefs. But that their main drive is not profit motive as Dr. Amy asserts – but ideology and validation of it.

        • SporkParade
          March 7, 2015 at 8:52 am #

          I agree with you, but I do think most doulas are out there to promote “natural” birth. I took an online course on childbirth from an international perspective, and there were many, many doulas who were there to learn about how “native” women learn not to fear birth, and then were extremely disappointed to find out that the first class was entirely “reasons women in developing countries die in childbirth” and the second class was entirely “reasons women in developed countries die in childbirth.

        • Deborah
          March 7, 2015 at 2:37 pm #

          I’m not sure how it would work to have a doula for a planned cesarean, because most hospitals have the “one support person only” rule for cesareans, which would mean choosing between the usual two people in the OR (baby’s father or patient’s mom) and the doula.

          • Cobalt
            March 7, 2015 at 3:09 pm #

            If neither the patient’s mother or partner can be there (distance, illness, lack of relationship, whatever) the woman might want a doula.

            There is no guarantee in life that any individual will come to any situation with free support structures in place, fully prepared.

          • KeeperOfTheBooks
            March 10, 2015 at 9:22 am #

            Yep. I’ve considered this from time to time as DH and I plan the next kid; if we got pregnant during certain months, he’d be across the world when I gave birth. Which is why we’re avoiding during those months, but nothing except abstinence is 100% effective. 😉 If he weren’t going to be here, I’d vet one pretty thoroughly (“I’m trying for a VBAC, I’ll probably want an epidural, if anything looks wonky for baby or me, C-section it is, and if you have the slightest problem with any of that tell me right now because I will not tolerate that sort of attitude in the delivery room.”) and hire her. We have no family in the area, and most of our friends have small kids or jobs–not really feasible for them to take 24 hours away from either to be a support person.

          • DiomedesV
            March 7, 2015 at 9:51 pm #

            I had the option, and I had a planned cesarean. In fact, the nurse who was in charge of teaching the childbirth education class (which I didn’t take because I knew I was having a C-section) and who had formerly taught the “planned C-section class”, which I wanted to take and was no longer available, offered to be my doula free of charge. In the end, I chose not to. I don’t think I regret it because even though I had a clear indication for planned C-section, I still got shit from one L&D nurse (“you’re not even going to try”?) and I just don’t want to even think about how much more angry I’d been if I’d even gotten a whiff of judgment from my doula.

            I wonder now if I would bother with a doula at a second C-section. I hadn’t thought of it until now. In fact, it was very hard for my husband to take care of me and the baby. But to be honest, I just don’t respect the profession. I’m not sure I want any kind of support from someone whose education level is so far below my own in terms of science, statistics, and experimental design, and who I simply can’t trust to be free of NCB bias.

          • Elizabeth A
            March 8, 2015 at 12:50 am #

            If my last pregnancy had gone to term, I would have tried to find a c-section doula. Her job would have been either to be in the OR instead of DH (who did almost pass out), or to come in as support person if DH needed to go to the NICU with the baby. DD arrived while I was still working on those plans.

          • Amy M
            March 8, 2015 at 10:04 am #

            I called DONA and asked about a doula for a C section, since I thought I would be having one. They (of course) said it would be good to hire a doula anyway, but I figured since I wouldn’t be dealing with labor, why would I need help coping with labor pain? And when the time came, and I didn’t have a Csection, I just got an epidural anyway. My husband was there and the nurse on duty at the time was a great pushing coach. I have NO regrets about not spending 300 or more $ to hire an NCB-minded stranger. I could see how it would have made sense if I had no husband or family to help out, especially after the birth, but in my case, it would have been a waste.

            Also, I have a friend who wanted (and got) a natural unmedicated birth, and was AP-lite. She hired a doula and later told me that the doula was a total waste of money. She didn’t find the doula helpful—she didn’t find the doula harmful either, but not worth the $, she said.

        • Elizabeth A
          March 8, 2015 at 12:47 am #

          My view of doulas isn’t all that limited – but nor is it all that flattering to the profession.

          1. I am generally speaking an anxious person – I have struggled with clinical anxiety and depression on and off for most of my adult life. Pregnancy makes the anxiety worse. So a doula to help me breathe through things and do some reality checking would be awesome.
          2. Also, my husband is terrible with hospitals.
          3. It sure would have been good to have someone experienced to help us figure out when we *needed* to head to the hospital, as opposed to the decision process we did have, which was “I am having contractions every 9 minutes and feeling really anxious so we are leaving the house RIGHT NOW you do not have time to tie your shoes.

          There’s this profession that could be very helpful, given the current state of our society, and the people who talk about engaging in it tend to be birth hobbyists without the practical sense God gave a doorknob. It seems that there are a large number of women who, after having a baby of their own, want to be in on more births, or something? And so they maybe take a weekend class or two and hang out their shingles as doulas. But (1) their main qualifications are “hey, I gave birth, too!”, and (2) providing labor support is physically demanding work with a highly unpredictable schedule, and these women tend to have young children of their own whom they are trying to raise in a hugely labor-intensive way (doula and AP mom tend to be closely linked), and they are in a profession that doesn’t pay well enough to cover flexible childcare arrangements.

          (When I was pregnant the first time, an acquaintance offered to be my doula, since she was going in to the profession and needed the experience for certification. She was planning her own wedding for less than a week from my due date, but still felt she could commit to being labor support for me.)

          There’s also been plenty of incidents over the years where I’ve seen doulas complain about their clients on open web boards. Clients are such whiny babies, and so demanding. This doesn’t make me feel great about having a doula in the room with me when I’m under physical and emotional stress. I guarantee I will be a demanding whiny baby in those circumstances – that would be why I hired someone to deal with me.

          And then there’s the interesting disparity in the number of doulas who offer homebirth, natural birth, any birth services, and those who are willing to show up post-partum. Fascinating differences in rates for that too – you can get someone to be labor support for free, or for under $500 in a lot of places, even though there is no limit to the hours involved in that, and the timing is usually unpredictable. If you want someone to show up after birth though, there will be a schedule and an hourly fee.

          There are undoubtedly some wonderful, professional doulas out there, but the current state of the profession is that they are vastly outnumbered by flakes and hobbyists.

      • March 7, 2015 at 1:53 am #

        Doulas could be eliminated if hospitals had staffing patterns where there was one nurse or CNM per patient. The market for doulas has been created because too often the nursing staff has to cover two or more rooms at the same time and women in labor need consistent support. Nothing is worse than strong contractions and being left all alone for considerable periods of time.

        • fiftyfifty1
          March 7, 2015 at 8:52 am #

          “Doulas could be eliminated if hospitals had staffing patterns where there was one nurse or CNM per patient.”

          I disagree. The system I work in has a hospital with such staffing (1:1 nursing while in active labor). Doulas are popular anyway….with the women who are striving for NCB. Those women who have the plan of “gimme my epidural just as soon as I ask for it” don’t hire doulas.

        • Laura
          March 7, 2015 at 9:48 am #

          I would agree with you – IF all the nurses were willing to put in the hard work of consistent, supportive, and effective labor support.

          • CrownedMedwife
            March 7, 2015 at 9:58 am #

            …and if there weren’t such a priority placed on the time-consuming task of EMRs. Ideally, it should improve documentation and ease of charting, but instead RNs are pulled away from the bedside to do so. The newer RNs only know EMR and can be so focused on looking at the computer screen instead of patient care. I swear, I just attended a birth and the new RN completely missed the entire birth because she was busy charting and processing orders with her back to the patient. I understand this wasn’t the intention of EMR, but it really is cumbersome for RNs. I also see many of the newer RNs less knowledgeable about providing labor support or feel a woman should have a doula if she is desiring labor support, instead of viewing it as a part of her role in providing patient care or having the satisfaction in doing so.

          • Laura
            March 7, 2015 at 11:25 am #

            I totally agree with you. As a student nurse, I only know EMR charting. I do have a clear understanding of how to provide effective labor support, having had 6 babies myself (no c/s). So, my frustration and challenge will be how to quickly and efficiently check all the boxes on that &$^$% computer screen while attending to my patient. At some point, how will that be addressed? I have yet to start working and will have to figure that out as I go along.

          • Sue
            March 7, 2015 at 10:46 pm #

            Two great points, CMedwife. First, EMR is more about collecting data than helping the clinician to do their documentation.

            And second, (dare I say it) younger RNs seem to be less interested in providing comfort and reassurance.

          • CrownedMedwife
            March 10, 2015 at 2:04 pm #

            Yes, even when newer RNs have moved beyond the novice stage of task completion, too often their identity as a L&D RN seems more focused on documentation and interpreting EFM than being at the bedside for support. Then again, if they didn’t begin their experience in an era with less accessibility to labor epidurals, it probably makes more sense to them to readily offer effective epidural pain management in lieu of labor support…which isn’t always a bad thing. However, for the women who desire to attempt to avoid an epidural, having their RN as a constant labor support person may help them cope and reduce the uncertainty along the way.

          • Laura
            March 9, 2015 at 10:26 am #

            Thought this article would interest you…http://www.kevinmd.com/blog/2015/03/pay-doctors-nurses-time-spend-charting.html

          • CrownedMedwife
            March 10, 2015 at 1:56 pm #

            That post is so true. The majority of RNs will spend the last hour of their shift hoping to avoid a change of shift delivery, because it means staying late to finish inefficient EMRs while risking the tsk, tsk of administration coming down on them for overtime. Hence, efforts are focused on completing EMRs, not attending to the direct needs of the patient and fear of the repercussions from administration by going into overtime.

        • Sue
          March 7, 2015 at 10:44 pm #

          As a medical student doing OB rotation, I spent an entire labor with a fourteen-yr-old before delivering her baby. I guess I was doula-iing for her – rubbing her back, reassuring her.

          If I reflect more now, I ask myself: where was her mother? Where was the social worker? The pastoral care person? It was over thirty years ago, but I still cringe to think that my young self was the only support person for this complete stranger.

          • KeeperOfTheBooks
            March 10, 2015 at 9:16 am #

            But I’m sure she was eternally grateful that you were there for her. She’ll never forget your kindness.

  8. the wingless one
    March 6, 2015 at 7:14 pm #

    This is why I love this blog so much. I had a high risk pregnancy that ended abruptly at just shy of 35 weeks with an unscheduled c-section for fetal distress. My son is now a funny and intelligent two year old ball of energy. Without all the monitoring and interventions I received throughout my pregnancy he likely would have been stillborn. It still turns my stomach to think about what would have happened if I hadn’t been followed by medical professionals who truly had only one goal in mind – mom and baby surviving pregnancy and birth.

    When I was first told that I needed a c-section with no TOL, I was upset and cried. Then the nurse gently told me that if she were in my position she would want the c-section, because why risk it? I had already been an avid reader of this blog so I’m not even sure why I was so disappointed that I couldn’t have a TOL. Between the nurse’s comment and thinking about this blog, I quickly stopped beating myself up about “failing” to have a vaginal birth.

    If I haven’t said it before, let me say it now, THANK YOU DR. AMY!

    • Allie
      March 7, 2015 at 12:48 am #

      Aw, it’s natural to mourn the loss of something we may not even have known we wanted until we were told we couldn’t have it. For no sane-person reason I cried when I was told I had gestational diabetes. I was embarrassed (no idea why) and swore my husband to secrecy because I didn’t want anyone to know. I still don’t accept I ever had it, but I followed the diet and had a healthy baby, so that’s all that matters.

      • fiftyfifty1
        March 7, 2015 at 9:29 am #

        GDM carries a stigma. Society, and especially NCB philosophy, claims it is preventable if you do everything “right” and don’t “eat junk” and aren’t a “couch potato”. Of course they have no idea what they are talking about. But the stigma persists.

        • LibrarianSarah
          March 8, 2015 at 2:50 pm #

          I think diabetes in general carries that stigma not just GDM. Sometimes I think the worst thing to happen to diabetics was the association of diabetes with obesity and unhealthy eating. Nothing saps a person’s empathy like having a medical condition be “your fault.”

          This trend to moralize health needs to stop.It is bad for the sick, it is bad for the disabled, and it is bad for the poor. Eating kale and running marathons does not make you a more moral person. It just makes you a person with hobbies and tastes. Health is amoral.

          • fiftyfifty1
            March 8, 2015 at 3:43 pm #

            “This trend to moralize health needs to stop.It is bad for the sick, it is bad for the disabled, and it is bad for the poor. ”

            Agreed. It can also be bad for the healthy and rich if it leads to anorexia/orthorexia or leads them to stick their heads in the sand over potential health problems because they lead a “healthy” lifestyle. It’s bad for everyone. Healthy =/= Good

          • Young CC Prof
            March 8, 2015 at 5:33 pm #

            Indeed. Is the man who has emphysema or cancer because he spent 40 years working in a factory to support his children any less moral than the man who enjoys great health in middle age because he worked in an office and had time to go jogging before work every day?

          • Roadstergal
            March 10, 2015 at 12:49 pm #

            People don’t understand the various types of diabetes, and the various factors that influence them. When I talk to the average layperson, they think that there’s just one ‘diabetes,’ and it’s a simplified form of Type II.

      • Medwife
        March 7, 2015 at 1:09 pm #

        I have had quite a few women burst into tears when I gave them the news that they have GDM. It’s very sad because I say GDM, they hear “you are fat, lazy, and aren’t trying to lead a healthy lifestyle for your baby’s health”. We have talks about the pathophysiology of GDM and the strong genetic link that exists.

  9. fiftyfifty1
    March 6, 2015 at 5:47 pm #

    What’s somebody with her head seemingly screwed on straight doing on the editorial board of Birth?

    • Mattie
      March 7, 2015 at 10:45 am #

      Trying to be a voice of reason maybe?

  10. Cobalt
    March 6, 2015 at 5:40 pm #

    Unmedicated vaginal birth is only safer if it occurs in the absence of indications for intervention. Otherwise it’s clearly the more dangerous choice. How is it ethical to promote dangerous choices as normal?

    • March 6, 2015 at 5:48 pm #

      Complacency. Just like the people who don’t believe in vaccination because they’ve never been confronted with the reality of communicable diseases, they’ve come to see these preventable situations as the lesser of two evils.

      Since so few people gave birth at home, they saw more babies and mothers who were the victims of those freak hospital incidents and came to the conclusion that it was more dangerous. As more people are giving birth at home and we’re, as a result, seeing more fatalities and injuries because of it, some are rethinking their beliefs but unfortunately it seems that even more are digging their heels and latching onto whatever questionable evidence they have “proving” the correctness of their decisions.

      Sorry if that was illegible. So sorry, so stomach flu. ):

    • Roadstergal
      March 6, 2015 at 6:08 pm #

      I just think these people get things totally widdershins. If an unmedicated vaginal birth is a good option for you, then you are a very lucky person with a very uncomplicated pregnancy. They seem to think it works the other way around – that if you force an unmedicated natural birth, you’re making your pregnancy uncomplicated.

      I guess it’s along the same lines of “Sick people are in the hospital, therefore staying away from the hospital means I’m not sick.”

      • Elaine
        March 6, 2015 at 11:34 pm #

        They think that a lot of problems are caused by mucking around with birth. The prototypical narrative of the long difficult first birth with Pit, epidural, tiring out, pushing for hours, maybe ending in c/s, etc. places the initial intervention as the source of the problems, rather than the interventions all being responses to problems that already exist.

        To be fair, I do think a decent percentage of NCBers do meet the “uncomplicated” criteria. If you say no primips, no grandmultips, no breech, no multiples, no VBACs, and no chronic health conditions, there are still a fair number of people under that umbrella. The problem is, they keep trying to extend the umbrella, and they also don’t recognize that bad things can happen even to people in this group.

        • Bugsy
          March 7, 2015 at 8:45 am #

          “they also don’t recognize that bad things can happen even to people in this group”

          Yep. In fact, I’d argue many of them believe these bad things can be avoided by having the “proper” lifestyle and attitude.

          • Cobalt
            March 7, 2015 at 1:14 pm #

            If wishing worked, children would all have superpowers.

          • The Bofa on the Sofa
            March 7, 2015 at 3:23 pm #

            At Thanksgiving, my 6 yo pulled the big half of the wishbone and wished for a stuffed Rabbit from Winnie-the-Pooh.

            The next day, there was a package that came to the front door. He said, “Maybe it’s my Rabbit?”

            Alas, it was not.

          • Cobalt
            March 7, 2015 at 4:04 pm #

            What would you have done if it was? If someone had happened to order one for him for whatever reason, and his wish had appeared to come true?

            I’m just curious how other parents handle “magic” with little kids.

          • The Bofa on the Sofa
            March 8, 2015 at 10:10 am #

            We would have known about it ahead of time if that was the case.

            Considering that this wish was something completely out of the blue, there was no chance it was happening.

      • Cobalt
        March 7, 2015 at 1:13 pm #

        It safer to not have bypass surgery because those people have arterial blockages, and you don’t want blocked arteries!

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