Believe it or not, this seemingly core concept of the doula role has long been one of the most hotly debated topics among professional doulas. The question comes up again and again in professional forums: What exactly is the doula’s role when it comes to advocacy? How much advocacy is too little? How much is too much?
Because the definition of “advocacy” is a little amorphous to begin with, it’s understandable that there would be some confusion and difference of opinions when it comes to the types and nature of advocacy in a professional setting. Compound this semantic difficulty with the systemically oppressive nature of the American healthcare system, and you have a recipe for a rather touchy subject.
Through the first several years of my doula career, and based on concepts learned in my early doula training, I understood the action of “advocating” to be similar to “empowering.” Specifically, while “to advocate” or “to empower” are often understood to be transitive verbs – that is, they indicate exerting an action on an object or subject – the very transitive nature of the verb contradicts the implied meaning. In other words, if I am doing the advocating or empowering to/for you, you cannot hold the power or the strength for yourself.
Power is something that cannot be given, only taken. I cannot empower you; if I am to try, I am limiting your power by doing the action for or onto you. True empowerment comes from actions we take for and on behalf of ourselves. Advocacy, to a certain extent, falls along the same lines. If I am advocating for you, or on your behalf, I am necessarily limiting your voice, and risk speaking over or even silencing you.
In terms of a doula’s advocacy, then, a popular doula mantra is that our role is to help you advocate for yourself. We can provide tools and resources, and information and constructive language, to help you articulate your own needs with your care provider… or in any context requiring advocacy or even plain old speaking up.
This is a great starting point, and for many of our clients this is sufficient. A majority of our clients have had a supportive care team, an accommodating birth setting, a strong voice, and/or other privileges that yield self-empowerment and self-advocacy.
But privilege is an important point in this conversation. Not everyone is privileged to have access to a supportive healthcare setting and care team. Not everyone is privileged to have access to easy communication. (Also note: as most of the clients we work with identify as women, sexism is a prevailing point in many interactions, through life and in the birthing and postpartum experience. Additional forms of systemic oppression only compound the disadvantages.)
We serve clients of color, LGBTQIA clients, clients with diverse abilities, neuro-diverse clients, and others who are disadvantaged by systemic racism, sexism, ableism, and other forms of oppression. We serve many clients for whom English is a second, third, or even fifth language. We serve clients who are deaf and hard of hearing and require an interpreter to communicate. We serve clients who have a history of trauma, who are shy, or who are not interested in having their energy drawn to self-advocacy when it should be resting on the birth process and the baby they are working to bring into the world.
We have a responsibility to ALL of these clients to provide access to equity in their birth experiences. In the current healthcare landscape, equity is not guaranteed. To the contrary: inequity can almost certainly be guaranteed. [For more on this, please take a look at the CAP Report: Eliminating Racial Disparities in Maternal and Infant Mortality.]
They say that the longer you're a doula, the more you will witness the system oppression of our impersonal, broken American healthcare system. This has certainly been true for me. I, like many doulas, entered this profession wanting to help my clients have a more pleasant birth experience, not fully understanding what “pleasant” meant in the larger context of a patriarchal medical system that often provides the illusion of choice without providing choice itself.
[Side note: I am not bashing doctors, midwives, nurses, or any other medical professionals. The system as a whole is broken. In the interest of supporting the bottom line and limiting liability, insurance companies and hospital bureaucracies enforce policies and practices that are often contrary to the health of the patients themselves. All players in the system are victims of this hierarchy – but no one more so than patients themselves.]
And this is where the role of doula as advocate must be examined in a new light. Yes, an important part of my work with you is to support you towards self-advocacy and help you find self-empowerment. But when self-advocacy fails, there has to be a backup plan. Sometimes that’s your partner, your sister, your mother, or another trusted support person. Sometimes – and hopefully this is the exception rather than the norm – sometimes that is the doula.
A doula’s advocacy can be broken down into three tiers. The first tier is education. We provide resources, access to evidence-based medical information, support in changing providers if necessary, and other means of gathering the information, tools, and resources needed to make informed decisions before, during, and after the birth of your child(ren). While a doula is not inherently serving as a childbirth educator, it is nevertheless the doula’s role to help clients access meaningful information that can guide their unique journey. And we do this without judgment, as our role is to help you have your best possible birth experience, whatever it is that that looks like. We help you find access to the information in tools so that you can make informed decisions for your best possible birth experience, on a deeply personal level.
Education sets many families on the path towards a positive birth experience. But from time to time, education alone is not enough, and sometimes the impersonal and policy-driven medical setting gets the best of us. In such cases, the doula’s role is to uplift the client’s voice. We can speak to you directly to remind you of the preferences you stated in prenatal visits or in a birth plan, we can narrate what we witness in the room around you to help keep you informed in the moment, and we can facilitate communication between you and your care providers when it seems that there may be a communication breakdown. Sometimes the doula serves as interpreter, translating medical language into layman's terms, or communicating our client’s stated fears or concerns to medical staff in a holistic health-related way. This approach keeps the power in the hands of the birthing person, and allows for smoother communication and a greater inclusion of your preferences in the process. Doulas support and protect patient-directed care, and help to center your voice in the conversation regarding your care.
But for all the uplifting we may do, there are times when that is simply not enough. Birth trauma is real, and is often the direct result of a birthing person’s feelings of disempowerment and dismissal when articulating their preferences, needs, and rights. When hostility or aggression are present in a birth room, the doula’s role shifts again. In such moments, the doula can leverage her own privilege to help to restore the power to the client. We remain mindful not speak for a client without the client’s express instruction. But the doula does, when called upon, use her own voice when a client is unable to use theirs. Sometimes, hostility and aggression have required that I leverage my white privilege, my educational privilege, and even just the very fact that I am tall, to shift the power imbalance in a birth setting and restore the power to the hands of my client, where it rightfully belongs and should stay.
And the doula’s advocacy extends beyond the birth setting as well. It's not enough for us to simply help to manage a single moment. We take an active role in our greater community, helping to bring additional resources to birthing families, communicating with care providers about alternative methodologies, spreading knowledge and information, and fighting legislation that seeks to oppress birthing people and limit choices.
This three-tiered approach represents a shift in the way we as a team approach our role as your doulas. While we have historically taken a more passive approach to advocacy, in an effort to center your voice, time and experience have shown us that this approach is insufficient. With our nation’s rising maternal mortality rates and an increasing number of women reporting being mistreated in labor, we must take more assertive action to affect change – before, during, and after your birth. We see the problems, and we will not stand idly by. We take our cue from activist Rachel Cargle: “I don’t want your love and light if it doesn’t come with solidarity and action.”
We have updated our company philosophy, as a commitment to you to serve as your advocates in whatever capacity is required. We will soon begin teaching Evidence Based Birth® classes for professionals and families, to improve access to evidence-based information for truly informed decision-making. And our team members are engaging in ongoing training through Birth Monopoly and other organizations so we can learn how to better support you.
We are so excited to show up for your birth while you rock it out! We are very much looking forward to celebrating your baby’s birth-day party! But our role as your doula, and your advocate, doesn't end with the birth of your baby. Our work is ongoing, trying to make birth safer, better, more empowering, and less traumatic for all birthing persons.