Disparities in the Doula Model of Care

After the Community Health Worker training that ended today, I'm faced with the reality of how many gaps there are in not just health care, but doula care.  Health disparities are everywhere, and there are amazing organizations and agencies out there gathering funding to provide free preventative health care to the under- and uninsured.  When it comes to doula care, however, access is limited to those who can pay out-of-pocket.  Painfully ironic is the fact that those who can afford it are in need of it the least.  

That's not to say that the privileged pregnancies that are on the receiving end of a doula do not deserve it.  But populations, particularly teens and women of color, who see the most health disparity and the worst maternal and infant health outcomes, are the most underserved by doulas.  How do we, as doulas, approach this?  Many of us offer our services for much less than what we should be making even for our full-paying clients.  If we have a particular interest in working to solve health disparities and applying social justice to our work, we work for next to nothing.  I've done many births where, in the end, I was getting paid a shocking hourly wage for expert advise, 24 hour on-call availability for weeks on end, and physically strenuous overnight hours- much less than minimum wage in the end.  This is not rare.  Ask the doula next to you if this is the case and you will likely get an emphatic "YES".  

What is the root of this?  My belief is that it stems from doula care existing in a for-profit model (as much of health care is, but that's another blog post).  That doulas have settled on charging their clients directly undercuts the potential of doula care- applying the benefits of doula care on populations that see the worst outcomes in order to make the most amount of change.  Taking a new approach is critical in improving outcomes.  But it will require doulas rejecting the for-profit model that so much of us have accepted.  We need to explore new options in receiving funding for our work, to generate public and private interest in doula care from stakeholders in maternal and infant health, and to work together, and not in competition like so much of the for-profit model encourages, to make our work sustainable for not only our clients but ourselves.

We know the benefits of our work.  It's time for doulas to get out of our comfort zones, advocate for those benefits, and start creating change.  We are at the forefront of improving outcomes with our unique advantage to spend time educating and empowering patients.  A public health approach to doula care is desperately needed if we actually want to see our work make a difference.

(If you know of a fabulous community doula project, or have seen doulas used by public health agencies, please leave some information in the comments!!)

Manifestation

I'm overwhelmed.  

The blessing that came my way today is my sign, really the culmination of the task I've had at hand- pave way and open space for the gifts of the universe to unwrap themselves for me.  Over the past year I've had two major break ups (three if you count a business partner), I moved out of my first home, quit (and got fired from) a few jobs, stopped taking classes, and opened my heart.  I surrendered my sense of control, of beating my life into submission, and learned to just be.

You know what happened?  Pregnant moms started to call on me.

The Goddess (or who/whatever you will) made it unmistakably clear that serving the rite of birth is what I'm supposed to be doing.

People often wonder how I got into birth in the first place.  Well, my interest in women's health happened on accident- I went to Plan-It X Fest in 2006 where there was a workshop on self cervical exams put on by DC's Down There Health Collective.  I was blown away.  I went home from Bloomington with an arm full of zines, including Alicia non Grata's Take Back Yr Life and Hot Pantz.  That was how I first was introduced to herbs, the idea of inducing your own miscarriage, and not using tampons anymore.  I was 18 and it felt good to be a woman.  

When I moved to Denver, I had no inhibitions about teaching a free school class (if these ladies could do it, so could I!)  So for six months every week I taught a class called Positive Menstruation.  It was wonderful.  It resulted in the safest space I had ever been in, a lovely fluidity of topics from feminist spirituality to anatomy and physiology.   We talked so much about how not to get pregnant using the Fertility Awareness Method that it didn't occur to me (at age 20) that birth was part of this circle I was a part of.  I first learned what a doula was through my tribe of women there but I didn't feel called to that until I was pregnant myself.

All the while, in the back of my head, through births, talking with women about their most intimate details, getting emails asking me questions from what kind of vibrator to get to difficulties with arousal and heavy menstrual flow, receiving phone calls from women in crisis, and seeing a clear need for holistic, understanding, compassionate health care for women and their allies, I've had a dream of what my practice would look like.  How can I best serve people?  I need somewhere that people (women, genderqueers, and men) can come for workshops, to buy supplies, to receive consultations and services such as screenings and pregnancy tests.  I need somewhere to teach natural birth control, childbirth education, and herbal intensives.  And by somewhere I really have thought "something".  I just want this dream to turn into a thing.  To manifest.  I don't know if as my business, as a non-profit, or as a collective.  I just know that this is what I want to pour myself into and that there is a need for it.  

Today I was given a space for it.  

I have access to two beautiful yoga studios, plenty of storage space for educational materials and medical supplies, and the potential (if we grow) to move into an office space of my very own- one that I could see my clients in, do treatments in...  It's in a beautiful house which held a Buddhist temple there for the past several years.  The woman that owns it wants to see this happen (almost) as badly as I do.  I can't believe it.  I have to believe it.

So now the pressure is on.  If I don't make it happen, some karmic apocalypse will have me for dinner.  Lots of decisions to make, lots of energy to give to the design of this project.  

I need help.

Sexual assault, the mind-body connection and birth.

I'm picking this up again because I find myself posting much to Facebook, it not being quite as gratifying as I wish it were, and I have lots more to say these days than that space allows.

Back to back births this week and I have yet to debrief with another doula- I will resist the urge to do it here.  I will say, however, that for the first time I saw the powerful grip that sexual trauma can hold on a woman's body and learned how essential it is to address that deep shit in pregnancy.  I'm finding that my work in the future is in creating deeper safe spaces with women, addressing our relationships with our pelvises, genitalia, getting to know our cervixes, and letting go when we are surrounded by love.  Creating spaces of safety and love for women.  Healing universal and personal trauma.  Opening our hips.  Letting go.  

I need to get a copy of Penny Simkin's "When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women"  I'll review it once I do.  There have been hints lately that this is where my work will take me- I want to bridge gaps between disaster relief, emergency medicine, midwifery, sexuality education and sexual assault awareness.  I've been asked by a few women this week if I have been sexually assaulted and I've admitted that I have not.  (I should count the time I woke up with a man's hands down my pants.. and all the times my step dad hit on me or told me about how much sex he wasn't having with my mom..)  I do however feel highly tuned in to institutional baggage and the rape of the Earth.  I believe in a past life I was persecuted and murdered for being a healer (were my breasts cut off of me?  dragged through the streets and killed in front of my family?)  I feel these things, but I know I am safe now and that nobody can do that to me here.  Perhaps it's my job to let all of these other women know that it's safe here for them, too.  And that nobody can hurt them here, right now, in this space.  That their labor is not the enemy.  That their bodies are not the enemy.  


The pain of birth, of change, is safe.


So what does it look like?  This woman was crawling out of her contractions.  She looked like she was in transition so we checked her and she was dilated to 3 centimeters.  And I think it was at that point when her confidence melted away.  After that, she was completely frustrated with her body, angry actually.  Later she described feeling her body pull up every time she tried moving her energy down, as I suggested she do.  I kept saying, "Don't crawl out of it, sink into it."  She would move the energy down, feel baby move down, but her pelvic floor (and her cervix) tightened up in complete resistance.  Truly, this woman suffered.  At one point, we had her running the hospital halls during her contractions to try and open her cervix.  I pulled her aside to tell her, "I don't know what you've been through, but moving through this will make you a stronger mother."  She just looked back at me and said, "I don't know what I'm doing wrong."  At one point, only I could be near her.  She paced a part of the hall, gripping the hand rail- literally crawling it, battling her contractions.  She said at one point, "I wasn't prepared for this."


And it was partly my fault.  This woman did everything right- worked out 4-5 times a week, did acupuncture and massage, yoga, and ate great.  I took for granted that her lifestyle meant she would have a peaceful, lovely natural birth.  Before labor starts, I tell all of my clients that it's impossible for their contractions to be bigger than them because they are them.  Something bigger than her got in her way, took her strength and sent her on a ride.  


It's amazing what comes up during birth.  You find out what you think you've let go in your mind but your body has held onto.  Isn't it incredible the power our bodies have despite our minds, and our minds over our bodies?

Of unquantifiable value- radical doula services in a capitalist society.

I'm beginning the process of putting together a sort of childbirth education discussion group with my back up doula and a yoga teacher I'm friends with.  I really appreciate it when things just come together organically, as far as organizing things goes.  There have been so many times I've tried to put things together after sitting on it for a long time, only to find that the idea was so much better than actualizing it will ever be.  But this morning was refreshing.  No second guessing, no hang ups.  It's a really sweet thing to find an effective, efficient group of folks who are passionate about getting something done.    

It's making me consider my feelings about charging for my services, though.  As an anarchist, I am definitely cost-prohibited (in reality as much as in theory), not to mention that I think doula services are something that every mama has a right to.  I know that this is something that other radical doulas have struggled with.  What are the implications of applying the capitalist system to childbirth?  Beyond just the thought that health care is a right, but is it appropriate for me to adhere to a hierarchical cash exchange over something with unquantifiable value?  Does that make sense?  I just feel a little hypocritical sometimes with the thought of engaging my sisters in a system that is often oppressive to us (especially mothers).  My practical, mothering mind says, though, that this is what I've got to work with, and that my time and skills are valuable- I am an intelligent, gifted woman who wants to help others- and until we are set up in a different framework, I have to find someway to make my life sustainable now.  I just always feel like I have one foot in and one foot out with a lot of this stuff.

Oh, and to update, I got lazy with the emmenagogues.  I guess I just get to a point where I ultimately trust my body to do what it needs to do, instead of trying to control it or coerce it to doing something that's comforting or convenient.  That's what it's all about, anyway.