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Insights and Reflection of a Doula of Twenty Years

Monday, March 18th, 2019

This year, World Doula Week has an additional substance for me as I celebrate my 20th year practicing as a birth professional.
Yes, of course, I still support birthing mothers individually, and I wonder if I’ll ever stop. During these 20 years, L&Ds and other birthplaces have been my synagogue; where I strengthened my faith in the universe, in nature, in people, and in my body. Witnessing my clients in their moments of triumph strengthened me from within and taught me that I am a powerful force. Supporting them through low moments of pain, despair or doubt reminded me I’m a vulnerable human being.  Stepping aside allowing couples to have their moments of touch, love, care, and the deepest connection we experience during birth, made me realize how precious my marital relationship is to me. I am lucky to have found a supportive partner who is an amazing father to our three daughters.

 

Thank you, Yifat, for sending this picture of our moments together 19 years ago!

As I reflect on my career as a doula, I feel abundance – spiritual, mental and emotional abundance. Becoming a doula made me appreciate the wisdom in the Bible.
The word ‘doula’ means servant. Who are we serving? My doula mentor, Shoshana Goldbaum from Jerusalem, taught us that we are serving the Presence (God). According to Judaism, the Presence comes down every time a woman gives birth, and doulas are her servants. I also learned that according to the Biblical story of the birth of Moses, the doula profession is recognized as the first female profession and the women who practice as doulas are the strongest protectors mothers and babies can have, just  like Shifra and Puah, the Egyptian doulas, who disobeyed the Pharaoh’s command to kill every Israeli boy. I also learned that the birth stool is called MASH-BER in Hebrew, meaning ‘crisis’, and therefore implies that moments of crisis are the biggest opportunity for growth. And imagine my thrill when we celebrated Phyllis Klauses’ birthday a couple of weeks ago, and she was addressing the Jewish value of Tikun Olam, meaning repairing the world, in her speech. For twenty years, I’ve been saying that doulas repair the world one birth at a time.  We fill a role that women have filled for each other for millennia: providing non-judgmental support. This support from an experienced woman can make a profound difference during any major life transitions and the research backs this up. Do you recognize the spiritual abundance that I have found in being a doula?  

 

As I reflect on my career as a doula, I feel victorious.
When I began twenty years ago, nobody in the secular community of Israel knew what a doula was. Once we found our first clients, the hospitals closed their doors in our faces and threw us out. The midwives reacted with rage to the thought that doulas would share their territory and charge clients out of pocket money for their services. I worked hard to establish the first doula support program in a central hospital in Israel, and throughout the years the program has had its ups and downs, doulas’ privileges were taken away and were given back. Nevertheless, the program still exists and this week the hospital hosted a successful doulas’ convention, in which hundreds of doulas participated in lectures and workshops. I also celebrate so many successes as a birth activist – wireless or intermittent monitors were offered in response to our call for women’s freedom to change positions and use the shower, putting an end to routine episiotomy for every first-time mother was another demand, and the new recommendations in favor of Trial of  Labor After Cesarean are a great success. And did you know that word ‘doula’ is now an entry in the dictionary?

 

As I look back at my career, it strikes me how much I have learned and grew professionally.
The year-long doula training I took was only the cornerstone for years of attending lectures, workshops, and more training programs. Because of my deepest commitment to support women and their families, I am always looking to add more strategies and modalities of care and leadership. The field of childbirth support is so rich and infinite; one birth experience is nothing like the other in the same way women and families are so different. And yet, there is something universal, a collective concept of pregnancy and birth, and the physiological and anatomical aspects of the process. This field offers an abundance of perceptions, dilemmas, challenges, and emotional and mental responses. Navigating through these, and leading others to safely and confidently navigate, made me a better mother and a wiser woman.

 

The emotional abundance is hard to grasp since it shows itself in so many forms and shapes in our field. Touching families’ lives is not a cliche, it has been my reality for the past 20 years.
Some of them became long-life friends, and others carry me in their hearts. Only last week, I woke to find a Facebook message which said; “Wow, I am so glad I found you! You were my doula 18 years ago when I had my first baby. You were amazing! You taught me how to give birth, and because of you, I have two more kids”. Then she asked me if I remembered her.  What do you think? Off course I do! She had a posterior baby, and I spent so many hours with her and her partner in their home, coming and going, until we finally got a good and steady pattern of contractions and some pressure that means it was time to leave to the hospital. Becoming a doula, I also found a sisterhood which is rare. The sisterhood among women who take care of other women is like no other friendship. My back-up doulas became my family, and we can always call each other, any time of the day or at night, for advice or for powering words. Doulas and midwives, L&D nurses, they are my source of wisdom, strength and tribal belonging. I’m so grateful to you, sisters! 

There is also an abundance of professional dilemmas and challenges in our field.
For me, the tension between the medical caregivers and birth support figures, and the fact that expectant couples are caught in the middle of it, is my biggest concern, or challenge.
It has become my goal to resolve it. I am so determined to rescue the couples and extract them out of it. I want to give them the power to make their choices based on their belief system and capacity rather than being told by either side – medical caregivers or birth support figures, what’s right. Because there is no right way, and there is no ideal birth experience. I believe that prenatal coaching is the pathway to resolving this dilemma and facilitating the change we are here to create.

Coaching towards a Successful VBAC

Tuesday, February 19th, 2019

While the coaching strategies are valuable in supporting and leading every expectant woman who would like to give birth healthily and experience high levels of satisfaction, they are even more crucial when supporting and leading a mother who wishes for a VBAC, because of the additional elements, or challenges, she faces :

  • Environmental challenges: The external constraints this expectant woman needs to react to and overcome are much bigger than a woman who did not undergo a cesarean. Medical providers aren’t supportive of her VBAC decision, and even when she finds a caregiver that will agree to a TOLAC (Trial of Labor After Cesarean), Agreeing to a VBAC doesn’t mean Supporting it. The difference is being manifested by the medical imposition and restrictions that aren’t supportive of her vision for her birth.
  • Behavioral factors: These are the specific action steps taken in order to reach success. The client who desires a VBAC not only has to find a caregiver that will agree to take her on, but she must learn what the biggest hurdles are to achieving her desired goal, such as the need for induction or any other medical intervention, including an epidural. Once this TOLAC is medically managed, the chances of achieving a VBAC meaningfully decrease. Therefore, your client needs to be well informed about this, and take the right steps to be successful.
  • Capabilities: These have to do with the mental maps or strategies that lead to success. It obviously takes a mental strategy to go through nine months of pregnancy and to complete all the action-steps in order to achieve a VBAC while all along being told by family, relatives and your caregivers that it is dangerous. Advocating for yourself is another mental capability, and coping with pain is another.
  • Beliefs and values: These relate to why a particular path is taken and the deeper motivations which drive people to act. My experience has been that this is one of the most important steps towards achieving a successful VBAC. Clarifying the woman’s motivation in a coherent manner that is also aligned with all her other beliefs is crucial for the actualization of her desired VBAC. Additionally, as her doula, you will be able to tap in her motivation during moments of crisis during her journey and empower her.

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A series of prenatal coaching sessions is therefore essential in order to successfully achieve a VBAC. Here are some of the most important steps I have successfully used in coaching my VBAC clients:

  1. Clarifying the mother’s motivation for having a VBAC: Please ask questions such as: ” Why is it so important for you to have a successful VBAC?”, or: “What do you think will be different in your life when you will achieve your goals?”. Listen to the direction of the motivation – is she choosing a VBAC in order to avoid something (away from) or to have something (moving towards)? Taking actions toward something desired is a stronger motivation than running away from.
  2. Protect the positive mindset of your client: She already chose to have a VBAC knowing all the risks and objections. Help her adopt strategies to block the environmental ‘noise’ and continue with confidence toward her goal.
  3. Work with Affirmations: Affirmations are word pictures that can engage the mind and attract what we desire. After having an unplanned and unwanted cesarean, your client holds a negative memory of her first birth. Writing and regularly reciting her affirmation is one of the best coaching strategies to get her mind focused on what she wants rather than what she fears. You can learn more about the rules and process of writing a strong affirmation HERE.
  4. Emphasize cultivating new coping skills: Since one of the most important actions towards achieving a VBAC is to avoid taking pain medication, you’ll want your clients to practice labor support tools until these become her habitual responses to labor strains.
  5. Help the mother avoid an induction: Your clients can’t appreciate the importance of avoiding an induction for their successful VBAC. Help them be proactive in inviting the birth to take place spontaneously. Discuss with your clients all the proactive actions they can take in order to avoid an induction such as acupuncture, homeopathic tinctures, chiropractor’s adjustment, prenatal massage, herbs, sex, and more.
    Provide spiritual support: Have faith in your client – trust her body and her process, and trust her caregiver (until proven otherwise). Coaching from a positive mindset while expressing your full trust in her ability to achieve her goal is one of the keys to her success.
  6. Provide spiritual support: Have faith in your client – trust her body and her process, and trust her caregiver (until proven otherwise). Coaching from a positive mindset while expressing your full trust in her ability to achieve her goal is one of the keys to her success.

Five Best Coaching Strategies for Childbirth’s Moments of Crisis

Sunday, January 20th, 2019

The process of childbirth presents birthing women with some recognized moments of emotional crisis, as well as some unexpected ones, related to the unfolding of the birth. My experience has been that the known and expected emotional crises occur during transitions or changes occurring throughout the process. It is common knowledge that the transition from one phase of the birth to another triggers an emotional reaction. For example, the transition from the early phase of labor to active labor is symptomized by the emotional change in which excitement and self-confidence give way to fear, despair, or self-doubt. Birthing mothers express these new emotions in a variety of ways: If they are talkative, they might express them by sharing their thoughts, such as: “Do you think it’s time to head the hospital”? Or “Do you think all these contractions are doing anything”?, “Do you think I’m progressing?” and “How much more painful will this be”?  If they are more withdrawn and introverted, they might cry or breathe heavily. If you are a practicing doula, I’m sure you are very familiar with the repeated situation of a client bursting in tears upon your arrival at her home, despite her successful coping with the process. This is due to the fact that doulas usually join the couple when the mother transitions from the early phase of birth to active labor.

There are other transitions in labor that can stimulate an emotional reaction, such as the physical change of leaving the couple’s home toward the hospital, or even a change in caregivers during shifts replacement. These moments are destined to stimulate emotional reactions, which for some can be experienced as an emotional crisis. Coming to think of it, it worth examining these transitions, or changes, as sources of stress and discomfort that lead to moments of emotional crisis, rather than focus solely on labor pain as the main cause for childbirth strains. Likewise, this suggests that the support women need in these moments is not so much physical support as much as it is emotional and verbal support or coaching.

It appears that leading a birthing woman to overcome these moments of emotional crisis, skillfully and with confidence, is important artistry a childbirth support practitioner should master. Therefore, I gathered some coaching strategies that have served me and my birthing clients as we strive through these moments:

1Echoing: Echo is the repetition of a word or phrase. Repeating the client’s words back to her exactly as she said them reassure the client that she is being heard.
Our automatic reaction when we support our loved ones, or our clients, is to search for a solution. As birth workers, we might suggest a change of position or a new massage technique, when all the mother needs to recover her doubt or other challenge is to know that we are present for her and to be reassured that she’s been heard. For example, if your client says: “How much more painful will this be”? You can echo her by saying: “I understand that you’re in pain now and you want to know how much more painful it will be”.

2. Tapping on her motivation: Conducting a series of prenatal coaching sessions allows you to become familiar with your clients’ personal motivations. Some examples of those can be spiritual in nature: “It is important for me to experience childbirth the same way the long chain of women I come from experienced it’. Others can be physical: “I want to stay connected with my body, I don’t want to give-up and num all the sensations”. Your clients’ motivations should appear on your intake form and you can remind yourself of these while preparing to join her in labor. Have them available for you when she needs to give rise to strength relying on her own words and wishes.

3. Remind her that she is giving birth by choice: Pain and bodily discomforts are associated with the emotional reaction of stress, sometimes referred to as fight-or-flight response. Studies in the field of pain define pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. Labor pain is not pathogenic in nature, but women react to it in the same way. Reminding birthing mothers that they are in the process of becoming mothers and giving birth to their child, and are therefore in it by choice, has proved itself to be extremely valuable in my practice. You may just say: “Do you remember how much you wanted this healthy labor that you’re having? You are giving birth to your baby just the way you wished to!”

4. Reassure that it is healthy: Similar to reminding the mother that she is going through this process by choice is the needed reminder that the process is healthy. Saying: “You are giving birth in the most healthy way possible, and everything you feel now is healthy” is a much-needed reminder for the primal brain that reacts to bodily discomforts as threats to our survival.

5. Break the process into short intervals: When a woman is emersed in the process of giving birth, it might seem to her like an awfully long process with no prediction to its end point. Therefore, breaking it into short intervals can help her navigate through the process and conduct herself better. You can definitely coach the mother by saying: “I get this is how you feel right now, and I think it’s the result of  ______________(Here you would name the transition or change that you know just occurred), therefore I suggest that we try for another 15-20 minutes before you take any major decision.” Then look at the clock and state the exact time in which you will revisit a new pathway for her birth. It is my experience that when the time arrives you’ll be able to say “You can be really proud of yourself, look how you have triumphed these past 20 minutes and how strong you are now!”

Over the years and throughout my book I have shared more coaching strategies around the topic of coping with labor pain and strains. Many of you will be happy to know that I am finally about to release a course dedicated solely to coaching throughout pregnancy and childbirth. The course will consist of online classes and Zoom meetings to allow the community of birth pros. to grow together as coaches.  You may click HERE to receive notifications about the upcoming course. 

To Healthy Birth on Earth!

The #MeToo Movement, Birth Activism, and the Future of Childbirth Support

Monday, December 24th, 2018

As we are coming to the end of 2018, I feel called to share my thoughts about the relationships between the #MeToo women’s movement of the year and birth activism. The #MeToo campaign has coincided with the 20th anniversary of my career as a childbirth support practitioner; exactly twenty years ago, I graduated a yearlong hospital-based program, taught in Jerusalem, and began practicing as a childbirth educator a birth doula. Throughout these years, I also established and directed birth resource centers, and have been training the next generation of doulas. About four years ago I developed the Birth Coach Method approach and published the printed guide The Art of Coaching for Childbirth shortly after. Today, I am proud to explain how the coaching for childbirth approach and strategies, manifest the spirit of the #MeToo movement in this field.

Those who follow my blog and webinars know that I often question and challenge the current approaches accepted by many birth support figures. For example, I have been continuously stating in blog posts and webinars that contrary to the accepted notion,evidence-based studies do not empower women to own their childbirth experience, because women base their decisions on a set of predetermined beliefs rather than the evidence. (If this idea sounds familiar to you, it’s only because you recognize it from the introduction to Henci Goer’s book “The Thinking-Woman Guide for a Better Birth”, in which she applies this decision-making process to OBGYNs). I also repeatedly urge birth support professionals to avoid the term ‘Natural Birth’, along with the idealization of the un-medicated childbirth over the choice to receive medical assistance for coping with labor. Perhaps this can explain my fascination with the debate among feminists around the #MeToo movement, and the tension around its possible outcomes.  

The tension I recognize between childbirth support and birth activism is what makes the #MeToo movement relevant to our field. As the campaign was spreading frantically, we witnessed women standing by one another, associating themselves as a force that will no longer be quiet about sexism and misogyny. There is more than the scream for no more sexual harassment in the #MeToo arousal- women have had enough! They are done being quiet and they want to speak up their voice. The movement is definitely also about self-worthiness. While there were many empowering voices, there were some active feminist voices that disagree with the movement and its message. Since I always considered birth activism to be a niche of feminism, I followed the debate which led me to some new understanding about the field of childbirth support.

The split among women in regards to the #MeToo movement is between two polarized approaches in feminism – Socialist feminism and Individualist feminism. The socialist approach recognizes that women are oppressed, and attributes the oppression to capitalism. Thus they insist that the only way to end the oppression of women is to overthrow the system. On the other hand, the individualist approach states that in order to lead the feminist project of releasing women from the appression, we need to empower women as individuals. In other words, the two paradigms are the social one, that strives for a collective liberation vs. the individualist one, that strives for individual empowerment. According to the individual empowerment approach, the social one weakens women by sending the message that they need protection from the system and can’t stand up for themselves.

Coming back to the field of childbirth support, we can see how some birth activists are geared toward a collective liberation and focus on changing the system – such as the Improving Birth Coalition or CMQCC, or the informed decision approach represented by Henci Goer’s book mentioned above, whereas other approaches like Birthing from Within, Active Birth, and Coaching for Childbirth focus on empowering the individual to find her voice and her inner strength to actualize the birth she desires. Throughout decades of birth activism, we have witnessed the two approaches – we had birth activists who focus on providing knowledge and tool to birthing mothers, and those who were fighting the medical system for abusing the traditional pathways to childbirth and birthing mothers.

Is there a place for both collective liberation and individual empowerment in the field of childbirth support?

Absolutely yes! And yet, we need to be clear on the role we play in order not to evoke a new type of #MeToo campaign, in which birthing mothers who might have felt that they were pushed to breastfeed or judged for their birth choices, will stand up for themselves and the value of their choices. We should be careful not to impose an agenda on women or become judgemental about their birth choices. As a birth-keeper and activist, one can idealize the un-medicated birth as well as fight the authoritative, and sometimes aggressive, maternal care provided by hospitals. However, in our birth support practice, we shouldn’t promote this agenda because this is how birth activism can easily be the reason for fear of childbirth instead of being a resource of empowerment for women. When I support a client towards her desired birth, I lead the mother through a self-discovery process with the goal of allowing her access to her beliefs, wishes and strengths around her nearing birth. If my client chooses a hospital-based birth, I avoid expressing my criticism of hospital-based maternal care when I coach her, because this can easily instill fear and insecurity.

Practicing birth support from a social liberation position, you might act in the following ways:

  1. Decide to support only expectant mothers who desire to have a natural childbirth or even a homebirth, or in general – serve only clients who are aligned with your birth activist philosophy.
  2. Express your disagreement with your clients’ care-provider, and what you think should be done in the situation.
  3. Provide couples with studies that contradict the information they were provided by their caregiver.
  4. Offer to join couples for the next visit to the clinic, and facilitate the dispute or confrontation with the back-up of the new evidence.
  5. Encourage couples to switch to a new OB practice, which you know to be more supportive of your philosophy of care.
  6. Express your lack of trust in the medical system as a whole in light of this new and better evidence which you just provided, telling them that their desired experience won’t be respected by the system.
  7. Speak-up and advocate for your clients in L&D and protect them from the system.

Practicing birth support from an individual empowerment stand, you will see this as an opportunity for your clients to find their voice and advocate for themselves. Respecting your clients’ choice of a hospital-based birth, you will conduct an inquiry and a facilitate self- discovery as follows:

  1. What do you feel about your caregiver advice?
  2. Did you fully understand the goals and the procedure, or do you need more information?
  3. Would you like to follow this advice or search for other options?
  4. Would you like me to provide you with more resources?
  5. How can I best support you right now?

 After the client read more resources or when you are already in L&D, you may ask:

  1. How do you feel about it now? (be open and supportive to all the options)
  2. How would you like to proceed?
  3. Would it help you if we practice your discussion with the OB? We can practice role-playing.
  4. How can I best support you right now?
  5. Do you feel confident about making this decision, or do you need additional support?
  6. Are you ready to call the nurse/OB back to the room and express your needs and decision?

As we approach the new year of 2019, I urge you to respect the wave of women who have had enough with others defining them or harassing them. I want you to join forces with women and help them find their voice! Please be curious about the women you support, and if you need to idolize something, let it be their visions. Be mindful of their individual circumstances, beliefs, values, desire and so forth, and do not let those dissolve in birth activism.

The Coaching for Childbirth approach provides birth support professionals with all the questions, strategies and tools they need in order to conduct the inquiry and lead expectant mothers in a self-discovery process. It helps women find their inner truth and beliefs, and carve their birth experiences in accordance. While some studies can provide evidence in support of epidural, induction, or any other medical procedure, and other studies can provide the evidence against those interventions, a respectful and sensitive coaching process can reveal the inner truth of your client, which counts the most.

Additional Resources about birth activism and women’s right of choice:

“Your Referrals and Support Would Be the Most Beautiful Holiday Gifts”, Said Every Business Owner in History.

Tuesday, November 20th, 2018

Back in August, when Birth Coach Method sent out our subscribers’ survey, asking how we can best support you in your career, so many of you wished to network with other doulas and to have more clients. Everyone wanted to connect with other business owners and thrive. I knew right then that this will be a wonderful topic for the Holiday Season, in which we tend to meet and greet more often than other times of the year. Whether it is a block gathering at a neighbor’s house, a community gathering at your kids’ schools, or a community gathering at your local church or synagogue, these are all wonderful opportunities to tell the world that you are a birth doula and to ask for your communities’ support in telling expectant parents about you.

I am not an expert in marketing. To be honest, as an introvert, I am very challenged in this field. However, as a pioneer doula in my homeland, I had no choice but to spread the concept of a doula and endlessly share the doula benefit statistics. But that was in the old days (LOL). Nowadays, ‘doula’ is a dictionary term, and all you need to do is put yourself out there as a doula. I sat down and gathered a few ideas that served me well over the years.

  1. Storytelling: Since there is no need for you to promote the profession of a doula, I feel that you’d better avoid the “doula benefits statistics” talk. Instead, try to connect with your listeners on a personal level and build rapport. People are more likely to remember you and to refer to you when they feel comfortable with you. Have you ever met a new person and after 10 minutes felt like you just found your long lost pal? That’s rapport! Share your story of what inspired you to become a doula and how you were moved and changed for the rest of your life by this new career path. While sharing statistics sounds very knowledgeable, it doesn’t move your listeners or inspire them as much as your story. So this holiday season, take the time to reflect on your path and write your story in a manner that moves you. If you find yourself laughing or tearing up, you can be sure it will move your community.

2. Marketing materials: While you keep writing and editing your story, start designing and making simple business cards or a one-sheet bio with your photo. I advise my students to launch their business using simple homemade marketing materials. It’s better to invest in the more expensive and professional ones only once your professional identity, meaning what makes you unique as a birth worker, becomes clear to you. When both your story and your homemade business cards are ready, you can begin the holiday networking adventure. Recite your story before every holiday gathering in order to feel ready and confident to share.

3. Reconnect with your past clients: If you have already been practicing for a while, and you want to attract more clients, the holidays are a wonderful opportunity to reconnect with past clients and express your gratitude for the privilege of supporting them in the most profound and intimate experience in their lives. Here, again, you can use your story and share how being a birth worker inspired and influenced you. End the holiday card, or email, writing something like this: “I cherish you, and our joined experience and I look forward to serving and supporting your friends, relatives and community members. Your referrals and support would be the most beautiful Holiday gifts ever!”. (The advantage of investing in a greeting card is that you can insert some of your business cards in the envelope). You may also consider asking clients to write you a supportive review to share on your site if you already have one. 

I am going to walk the talk myself and ask you to gift me this Holiday Season with your referrals. Please post the link below on social media groups, or email it to your colleagues, describe my contribution to your practice and encourage birth workers to join our Birth Coaches’ tribe.

http://www.birthcoachdoulatraining.com/New-coaching-materials/

4. Throw a holiday gathering for birth pros: The holidays are awesome for networking events. My friend Patricia, a seasoned doula, already sent out an invite to our community, for which I’m so grateful. Create a one-page invitation to hang at birth resource centers, yoga centers, holistic centers of all types. In addition, post the electronic version of the brochure on social media. Search for professionals who provide services for expectant couples on a wide spectrum like acupuncture, massage, behavioral therapy, midwives, and more. Another idea is to search for birth workers in your area in the members’ lists of the certifying organizations. Gather the community of birth workers in your area for a holiday potluck and become a community leader. You may prepare some ice-breaking games or some childbirth jokes and humor. Prepare white posters and markers, and brainstorm with the participants on how the local community can continue to grow together. Explore the following ideas:

  •  A monthly peer review.
  • A monthly Meet the Doula Night, where couples get to learn about doulas and meet them.
  • Throwing a yearly event for the community of local expectant parents.
  • Establishing a non-profit organization and thinking about possible fundraising events.

There are so many more creative ways to expand your community and attract clients. My friend Darlene MacAuley of Inspired Birth Pros. is a real expert in establishing and expanding your practice, and she offers a Holiday promo, so hurry up and visit her site. 

I hope that my ideas inspire you and you will explore additional ways to enjoy the holidays while gearing up your business. 

Celebrate the Holidays and Grow Your Business!

The Birth Plan from a Coaching Perspective

Monday, October 22nd, 2018

It’s a strategy, not the end goal!  

When birth workers, such as doulas and childbirth educators, first envisioned the birth plan in the eighties, the main idea was to help expectant parents prepare for the physical and emotional aspects of the birth process, explore how they want various situations handled during their actual birth, and provide a tool for parents to communicate with each other, their care provider, and the hospital staff prior to the birth (Simkin, 2007; Simkin & Reinke, 1980). As sometimes happens, the mean comes to be associated with the goal, and as such, expectant couples and some birth workers, associate writing the birth plan with achieving it. This association may evoke some unexpected outcomes:

    1. Couples tend to get attached to the choices they checked on their plan and react with rigidity to unpredictable situations, such as imposed medical conditions or restrictions.
    1. Couples tend to assume that when they write a birth plan and hand it to their care providers, the later become accountable for their birth experience. This is true even when it comes to their birth doula; I have heard many doulas who share that they feel their clients are not committing to the steps which will bring them closer to achieving their birth plan, and yet expecting the doula or the medical staff to deliver these magical results. 
    1. Couples’ vision and desired experience remain fragmented rather than becoming a compelling and motivating vision of the birth process.  This fragmentation is misleading because it obscures the fact that birth is not an event or a list of small events, but rather flowing and unpredictable process.
  1. The medical staff uses this digital format of check-boxes to standardize the care and therefore handing them a birth plan in this format doesn’t lead to the desired individualized care.   

Reflecting on the process of writing the birth plan from the perspective of Coaching for Childbirth, can help us reduce, or even eliminate, the undesirable aspects that currently present themselves in the writing process. When coaches begin leading a new client, they invest a good amount of time clarifying their clients’ goals or desired outcomes. We ask our clients: “What will you see, hear and feel when you go through your desired birth experience? We help our clients make their goals as achievable and compelling as possible, by eliciting the states or experiences associated with the goals. Nevertheless, we make sure that our clients’ goals are very specific – we search for the details of the client’s desired experience, and for the steps needed to achieve them.  In comparison, most birth plan templates that I have seen are in the format of a checklist. In my opinion, this digital format is in contrast to the idea of a compelling birth experience. It bears the potential to remain an itemized list instead of a vision.  In other words, fragments of the desired experience might not come together to create a compelling vision, nor do they elicit the emotional engagement or motivation needed to fulfill the vision, whereas a vision can be broken into its parts and steps in order to become achievable.

Another disadvantage of this digital format of check-boxes is that it is the same format used by medical figures in order to provide standardize medical care. Therefore, this format shouldn’t be used in order to individualize the care.

So how can you make the process of writing a birth plan more valuable, and eliminate the undesired outcomes?

I suggest that you begin the prenatal process by asking your birth client: “What are the achievable outcomes of the prenatal coaching process? This question and the ones below will help you clarify the desired experience:

      1. What will you see, hear and feel when you go through your desired birth experience?
      1. What specifically do you want?
      1. What is the next action you need to take in order to achieve your desired birth experience? Can we think about the future steps following this one?
      1. Do you know why you chose this outcome;  what is your motivation?
      1. Are you the only person in charge of your results, or are there others involved who need to be aligned with your vision?
      1. Is it achievable? Do you know of anyone who has achieved it before? How did they do it and what resources did they rely on?
    1. What resources do you have that will assist you in achieving your desired birth experience? (knowledge, skills, and strengths, support group)

This process allows the integration of the birth plan template as a strategy to specify the desired outcomes. For example, you may suggest looking at the template while discussing question (#2): If your birth client doesn’t know the specific details of her desired experience, you might say: “Would you like us to look at this list of options to help you specify the details of  your desired experience”? Or you can mention the birth plan in question (#3) as one of the future steps which will help clarify her options.  The conversation about question (#5) is also a suitable one to bring up the birth plan as a strategy to communicate the client’s birth vision with others who take part as decision makers during her birth – the care providers. In all these potential moments you can make sure that the list is only a strategy, and is neither the goal nor the desired outcome.

This new perspective- seeing the birth plan as a strategy to either: A. specify the vision or to B. communicate the clients’ wishes with others, rather than seeing it as the vision itself, may reduce the couples’ potential attachment to the itemized list, which tends to create rigidity. You may also find that it can eliminate your clients’ temptation to hold the medical staff, or you, accountable to the fulfillment of the desired outcomes. You are shifting the focus from an itemized list to the vision, by means of eliciting their emotional and mental engagement and making sure your clients understand that the step of writing the birth plan is a strategy in their process towards their desired birth and not the goal. This understanding will lead to a higher level of accountability for their process, regardless of the unpredictable outcomes of childbirth.  

Your Client Chose A Hospital-Based Birth: Now What?

Thursday, September 13th, 2018

http://www.attachfromscratch.com/birthing-at-home.html

Whether you are a childbirth educator or a birth doula, you know that most expectant couples you’ll teach and support plan a hospital-based birth. The statistic is that out-of-hospital births are less than 5% of all births. I trust you to be deeply invested in your clients’ well being as they prepare for their nearing birth, and that’s why I am going to teach you how to lead them with respect to their choice of birthplace. I intend to show you how to do these two things:  

    1. Recognize your client’s context around the place in which she chose to give birth.
  1. Lead her in a way that doesn’t evoke internal conflict and resistance between her choices.  

When your client plan a hospital-based birth, there are some presuppositions that you want to listen to and respect. The nature of presuppositions is that they are not stated explicitly, but rather are being implied. For example, when I say:  “Breathing techniques are probably the best labor support tools that help you cope with labor strains”, I presuppose the existence of labor strains and the need to cope with them. I feel pretty comfortable when I share this presupposition, even when I become aware of the implication of it – this presupposition implies that I do not believe in a childbirth experience in which labor strains do not exist, and in a birth experience in which there is no need for coping tools.

My actions, just like my choice of words, manifest some presuppositions that I hold around childbirth. Choosing a career in the field of childbirth support, I revealed to hold the following presuppositions:

    1. Laboring women need doula support (presupposition of necessity). 
    1. Doula support throughout labor leads to less medical interventions and lower cesarean rates (presupposition of cause and effect).
  1. Practicing as a birth doula will allow me to spread the importance of physiological, active and healthy birth and will make me feel fulfilled. (presupposition of possibility and awareness to my feelings).

Just as my choice of words and actions demonstrate my presuppositions, so do the ones my clients chose. So what are the presuppositions that your clients demonstrate when they choose a hospital-based birth? Here are some options:

    1. I can give birth at a hospital. (Presupposing the existence of the hospital and the possibility of giving birth there)
    1. I must choose a hospital-based birth according to my insurance. (Presupposing lack of other options)
    1. When I choose a hospital-based birth, I am _______________or I get ________________(Presupposition of cause and effect)  
  1. When I choose a hospital-based birth, I feel _______________ (Presupposition one’s needs, values, feelings)

I leave the blank lines so that you’ll play with optional words that can complete these sentences. I trust that throughout your career you have heard many presuppositions like these from clients, and maybe neglected to pay the close attention they deserve. These presuppositions represent your birth clients beliefs, decisions, challenges, and areas of strengths. Neglecting them might prevent you from understanding their model of the world, and you risk disrespecting this model. You are not required to accept their model, but to respect it and lead them in accordance.

For the purpose of teaching, I am going to risk a broad generalization and say: When your student or client chooses a hospital birth, it presupposes that: 

  1. She believes that it is a safe place for her to give birth in. AND
  2. She believes that the hospital has something to offer her that she needs for her birth. And/Or
  3. She believes she has no other options available for her.

Therefore, any choice of words or actions on your behalf, that implies that your client is not as safe as she might think, or/and that her choice is in conflict with other needs and wishes she has for her birth, can potentially harm her well being. In other words: Expressing any lack of trust in her medical team or the medical system in general, will increase her fear or even elicit her conclusion that childbirth in general, isn’t safe.

Since I trust it is not your intention, I suggest investing a few moments prenatally,  inquiring about your client’s choice of a hospital-based birth. Simple questions like the ones below can lead her to beautifully conduct herself and communicate with the hospital staff :

    1. When you choose a hospital-based-birth, what do you expect the hospital to provide you with?  

      http://www.birthcoachdoulatraining.com/wp-content/uploads/2018/09/Coaching-around-Hospital-Based-Birth.pdf

    1. How does a hospital-based birth serve your needs?
    1. What are your hopes and expectations of the medical staff?
    1. How will you know when the staff actually meets your expectations and needs, how will that feel?
    2. Do you feel that the choice of hospital-based birth is aligned with other wishes and goals you have? Are there any potential conflicts?
  1. Would you like us to explore ways to resolve this conflict in order to get it out of the way?

I hope that you see how these coaching questions allow you to respect and learn your clients’ context; her beliefs, values and emotions, around hospital-based birth and lead her toward autonomy and ownership of her choices. You can begin coaching your client, or even suggest it as a group exercise in the childbirth education classes you lead, right away! Just download the coaching handout and begin to lead clients with respect to their model of the world.

Distinguishing Truth from Myth and Fears from Reality about Labor Pain

Tuesday, July 3rd, 2018

As I was looking for more studies about the drastic increase in birthing mothers who get an epidural for childbirth, I found the following research, published by Stanford medicine, titled:

Study shows women prefer less-intense pain at the cost of a prolonged labor.

Here is what the researchers did: ”For the study, Carvalho and his colleagues gave a seven-item questionnaire to expectant mothers who had arrived at the hospital to have labor induced but were not yet having painful contractions. The questionnaire pitted hypothetical pain level, on a scale of zero to 10, against hours of labor. The women took the survey a second time within 24 hours of giving birth. A sample question asked, “Would you rather have pain intensity at two out of 10 for nine hours or six out of 10 for three hours?” Both pre- and post-labor, women on average preferred less intense pain over a longer duration, according to results published in the British Journal of Anesthesia.”

I find this study to be somewhat disturbing but revealing at the same time. It is even useful from a coaching perspective. The questions the researchers asked were misleading. Women were asked to weigh their options and choose between coping with labor pain or having a prolonged birth as a potential implication of getting an epidural. But – –  are these the real options they weigh? Is prolonged labor the risk associated with taking an epidural in childbirth, or is it a side effect that might lead to many other potential risks?  I searched “ACOG (American College of Obstetrics Gynecology) on the risks associated with prolonged labor”. Guess what came up first in my search results?

Safe Prevention of the Primary Cesarean Delivery

Yep, the risk of Cesarean! Do women really choose between being with labor pain vs. longer painless birth, or between experiencing labor pain vs. higher potential to have a medically managed birth or a cesarean delivery?

This is exactly the role of prenatal coaching: Distinguishing truth from myth and fears from reality in a world that offers a wealth of online misleading information. A false belief about labor pain and the means to alleviate it was suggested by the researchers. However, the publication of this study and the spread of the false belief it has manifested reveals more than just a careless work of the researchers. It is a reflection of the fear of labor pain and the role of this fear in masking the truths about labor pain and epidural as the most popular mean to avoid it.

How will I coach the client who believes that she chooses between coping with labor pain and a longer but painless birth?

Here are some great coaching questions:

    1. How did you come to the conclusion that you are choosing between these two options: coping with intense labor pain or with long hours of painless birth?
    2. What do you know about labor pain? (you may use the acronym of PAIN to facilitate an understanding of the true nature of labor pain: Purposeful, Anticipated, Intermittent, Normal),
    3. While we both agree that taking an epidural might lead to a prolonged childbirth, and I can see why you wouldn’t mind about these painless long hours, I wonder if you know of any risks associated with prolonged labor?
    4. Would you like us to research these?
    5. Now what seems to be the options you are choosing from?
    6. Is it possible that with professional support, a doula who uses coping skills and provides comfort measures for childbirth, you will not experience intense pain?

With these coaching questions, you will lead your birth client to a self-discovery. She can find answers within herself that are different than those she found online. Those answers are more authentic, and they tend to be more aligned with her true self, with her beliefs and vision for her birth. If you want to learn more on how to conduct coaching conversations around the decision of taking an epidural in childbirth, you might consider listening to our webinar Coaching Your Client through the Dilemma of taking an Epidural” in  which we shared some of our best coaching strategies around the topic, like the math of labor pain, the wording of it, and the role of curiosity and exploration in coping with it.  

Mothers; May the Force Be With You!

Wednesday, May 9th, 2018

A Birth Worker’s Reflection on Mother’s Day

On May 4th, while volunteering at my daughter’s school, I noticed many teachers wearing Star Wars T-shirts. Being foreign to both the American culture and to the Star Wars fan club, I failed to detect the meaning behind this collective fashion decision of the teachers. But later that day, when my daughter came home from school and shared the meaning with me, I was inspired to give this idiom its meaning from the perspective of my club – the birth workers club, and of another holiday, closer to my heart, that we celebrate in May – Mother’s Day.

Birth workers all over the world are a force. We are the force that is being with new mothers and making sure each of their transformations along the path of motherhood goes as smoothly and healthily as possible. We protect, support, and empower birthing mothers and new families. We are the force that fights their cultural battles; calling our politicians, physicians, human right activists, and reporters to put mothers and maternal care on their social agenda, and it better be the first item on the agenda if they want a healthy nation!  

This Mother’s Day, I want to recognize some of the major battles this force fought with great success: 

    • The right to the supportive presence of family, friends, and doulas.
    • The right for breastfeeding support.
    • The right for more comfortable environments for labor and birth, such as the use of shower, physio balls and peanut balls in L&D rooms.
    • The elimination of routine episiotomies in some parts of the country.
    • The growing number of hospitals hiring hospitalists and allowing TOLACs (Trial of Labor after C-section) and VBACs.
    • The movement towards individualized maternal care that has been accomplished with hospitals handing parents birth plan templates to fill out.  
  • The battle for intermittent monitor policy that allows mothers more freedom.

All these changes and more have been achieved by the force of birth workers around the world.

I know the situation is far from being perfect, and there is a lot more work ahead of us: routine electronic fetal monitoring remains widespread, even though it doesn’t improve outcomes and raises rates of unnecessary cesareans. There is an epidemic of inductions of labor, which increases labor complications. Epidurals are still being pushed by the medical system as if they were vitamins, and not identified as dangerous drugs that can slow labor, generate fevers and necessitate further interventions for both mother and baby. Cesarean rates are still skyrocketing at 32 percent. Birth doulas are not being covered by insurances. Maternity leave is ridiculously short and is considered a vacation rather than work which should be compensated by the states. However, on this Mother’s Day, I choose to acknowledge and recognize the positive change created by the force.

Mothers and birth workers;  may the force be with you! 

Why Are Birth Doulas So Darn Picky?

Tuesday, February 6th, 2018

It is my understanding that by being choosy about clients and committing to those who demonstrate the highest level of commitment to physiological and unmedicated childbirth, who are also most likely to choose a like-minded caregiver, doulas try to protect themselves- their souls and their hearts.

During the holiday season, I attended a local birth community gathering in San Jose.  Our lovely host, a DONA trained and seasoned birth doula, invited us to introduce ourselves saying: “Tell us how you practice; what is unique about your practice, so we know which birth clients to refer to you.” The first doula to go shared that she is mainly practicing in one particular hospital, because everyone knows and respects her there,  and she only supports birth clients who are strongly committed to a natural and unmedicated childbirth, and state that they are open to medical solutions if these are needed. Her introduction set the tone for our community freely share their preferences, and the trend became very clear: Doulas are picky about the clients they take on- and it has nothing to do with specializing.  

I began practicing 19 years ago as a pioneer doula in my country. At that time, I was struggling to convince expectant parents of the value of hiring a birth doula. Needless to say, I did not have the privilege of being picky about my clients. Did I enjoy supporting certain types of birth clients more than others? Of course! But it never occurred to me to choose clients in accordance with the OB practice or the hospital, nor with their level of commitment to avoid pain medications or other medical interventions. I was passionate, and still am, about supporting every potential client in hopes of leading them toward a healthy and satisfying birth experience. While I can’t say when the trend of filtering through clients began,  I have some ideas about the reasons that brought it to the surface.

The practice of a birth doula is a hard one due to a vast array of aspects, including practical or logistical, physical, emotional, social and financial aspects. Being a change agent, or an activist promoting natural childbirth, you already stand out in every social gathering outside of the birth workers community.  Your close friends are mostly birth workers who speak your language and share your passion and are the only ones who, like you, live their lives constantly on-call, practicing flexibility and willing to change plans in a blink of an eye, with no hard feelings. Your family and friends are always secondary to your devotion to attend your clients’ unpredictable births. As for your own mental state, commitment to as little as one birth a month means that you are not making big plans like birthday parties, or a romantic getaway, without stressing out about this one client.

Now let’s look at the emotional and physical hardship of being a doula. While modern society is committed to alleviating pain –  physical or emotional pain, doulas are the only caregivers on Earth to accept pain, embrace it, and work through it.  Supporting our clients throughout labor contractions by containing their pains, doubts, fears and moments of crisis and despair takes its emotional toll. In addition, providing massages and physically supporting our clients’  bodies as they change positions, for an average of eight hours, is physically exhausting. On top of it all, we often deal with these challenges during night time, or at the end of an active day. And when medical complications arise, we coach our clients towards making an informed and mindful decision, empowering them to demand patient-centered care and not give up on their birth vision too fast.  

It is my understanding that by being choosy about clients and committing to those who demonstrate the highest level of commitment to physiological and unmedicated childbirth, who are also most likely to choose a like-minded caregiver, doulas try to protect themselves- their souls and their hearts. Doulas want to guarantee their clients are committed to unmedicated physiological childbirth as much as they are committed to supporting and leading them throughout this kind of experience. They, therefore, refuse to support clients who say “I am attempting natural childbirth, but I’m open to the option of taking epidural”. Doulas try to avoid the draining scenario of medicalized childbirth and being a witness to the frustrating cascade effect of medical interventions. By supporting only clients of caregivers we trust and with whom we are compatible, doulas avoid witnessing abuse in Labor and Delivery. Overall, this trend of carefully choosing one’s clients serves doulas’ need to decrease the hardship of their practice and get a sense of control over the birth experience they take part in.

As a seasoned birth doula and a doula trainer, I get it, I really do! And at the same time,  I still find myself being drawn to those clients who “try for a natural birth but are open to…epidural”. Perhaps it’s because I’m a dinosaur in the doula community, but for me, there is a special reward, a triumph, in leading that birthing client, who wants the natural childbirth because she sees the value in it, but is being honest about her doubt in her strength and abilities to be with pain. Leading this mother all the way to an unmedicated and healthy birth, looking into her wide open eyes and her joyous expression when she says: ”I DID IT!”  is so rewarding for me. It empowers me as a woman, a doula, and a doula trainer.  

In order to increase my chances to avoid the draining scenarios of medicalized births and to make sure my clients demonstrate a high level of commitment to their healthy and vaginal birth experience – I practice prenatal coaching. Prenatal coaching is my leading technique, and it is how I make sure my clients and I are aligned in our belief system about birth, clear about their goals and what it takes to lead them towards achieving their desired birth experience, and we’re equally accountable to what it takes to get there. While I understand doulas motivation to decrease the hardship of our practice, I see prenatal coaching as the pathway to achieving this goal, rather than filtering clients.  Serving only those who are mentally and emotionally prepared for a physiological birth means that we gave up on one of the most important ambitions for doulas’ emergence – facilitating a cultural change in maternal care.  

To healthy births on Earth!