I wish I would never have had to write this blog post, but I am afraid it is the only way for me to heal my own trauma – the trauma of a birth doula who witnessed a birthing mother and her partner being abused. I felt helpless, because I felt I had to remain silent. This experience made me think of all my doula sisters who are witnessing the abuse all over the world and remain silent. I want to be the gate keeper in L&D, just like the news reporters who report crimes against humanity and call the world to take actions towards resolution. I am afraid that otherwise abuse in L&D will remain, and abuse towards women will continue to find ways to be legally accepted in our society.
Vicarious traumatization (VT), sometimes refereed to as Secondary Traumatic Stress (STS) as well as Compassion Fatigue , is a professional term describing the trauma of the caregiver. It is a transformation in the self of a trauma worker or helper that results from empathetic engagement with traumatized clients and their reports of traumatic experiences. Even this term cannot describe the trauma of the doula who witnessed her birth client being abused. I did not hear the traumatic birth story, I was present during the abuse.
I request that you read the birth story below twice- the first time read only the black text; the second time read the parts that are in green italic letters, as well. The point of this exercise is to point out the positive birth experience this could have been without the abuse. The birth story is at the bottom of this post.
I am not the first one to report Labor and Delivery abuse. As part of my healing process I searched articles about expressions of abuse in L&D, and found them in the two languages I speak and read; English and Hebrew. Apparently, just a few months ago, an article came out in one of the most prestige Israeli newspaper describing the horror and abuse Israeli moms go through in L&D.
I found Abuse in Hospital-Based Birth Settings? By Susan Hodges, MS, to be very helpful in achieving my goal – defining the trauma of the doula who witness abuse. Hodges describes the expressions of labor and delivery abuse as well as the dilemma of the abused patient: “Verbal abuse includes behaviors such as threatening, scolding, ridiculing, shaming, coercing, yelling, belittling, lying, manipulating, mocking, dismissing, and refusing to acknowledge—behaviors that undermine the recipient’s self-esteem while enhancing the abuser’s sense of power, typical of bullying. Most of us would recognize these as abusive behaviors in just about any other setting. However, because we are socialized to both expect trustworthy and professional behavior in the hospital setting and to be “compliant” with medical directives, these behaviors are seldom recognized and interpreted as abuse. Furthermore, staff and doctors are the authorities in the hospital, while the pregnant and laboring woman is merely a “patient.” Such a huge power imbalance allows, even encourages, bullying and abuse. We tend to feel helpless, so we rationalize and accept these behaviors while denying our experience of them. “
By using the word ‘we’ in the last sentence Hodges implies that patients and doulas, or other witnesses, are in the same position – feeling helpless and rationalizing this behavior as ‘poor bedside manners’ – which we tend to be more forgiving towards, as a society. How many times did you hear the sentence, “He has poor bedside manners, but he is a great doctor, so if you want to know you’re in good hands it worth it?”
My goal is to point out that the doula patient positions are different in regard to an abusive environment in two aspects:
- Doulas are more knowledgeable, aware, and experienced than their clients: While the doula and the expectant couple can both equally recognize rude behaviors such as “ridiculing, shaming, coercing, yelling, belittling, mocking, dismissing…,” the doula is more knowledgeable and experienced in the field of childbirth, and is far more equipped to recognize threatening, manipulation, and lying. Identifying these in Labor and Delivery will require basic knowledge of the field terminology, ‘evidence based care’, and basic understanding of causality in childbirth. This means that the doula can detect and identify abusive behavior that her clients may perceive as care. As we all know, many times the wish to become a doula or a childbirth educator originates when we overcome being “socialized to both expect trustworthy and professional behavior in the hospital setting and to be “compliant” with medical directives” (Hodges,2009), or it can show up during the training, as women share horror birth stories and healing their own birth traumas. Hodges points out the need to educate women in order to reach an informed consent: “Women who are well-informed and ready to ask questions about procedures, treatments, and interventions during labor can address some deficiencies of “informed consent” and not be hoodwinked into unnecessary interventions.“ However, this kind of education triggers a general lack of trust in the medical system and its representatives for he mother. This situation is described by Christine Morton as the doulas advocacy dilemma in her book ‘Birth Ambassadors’, and there is a general agreement among organization who train doulas that doulas should refrain from conducting a war of tug with the medical system in L&D. Another challenge that I encountered as a seasoned doula and childbirth educator is that while this type of education seems successful during the prenatal meetings or classes that I hold with my clients, it seems to be flying out the window in light of abusive behavior such as spreading overwhelming fear using big words like ‘deterioration’, ‘brain damage’, ‘respiratory distress’, etc.
- Doulas lack the ability to file a complaint or take any affirmative action: Several organizations, such as CIMS, LAMAZ, and Citizens for Midwifery, encourage mothers, who suffered abuse in L&D, to file a complaint following the birth. According to Hodges, this action is not only with the purpose of reducing the expressions of abuse in L&D, but instead is perceived as an act of empowerment: “Filing complaints alone will not solve the problem. However, women I’ve spoken with who did so felt empowered, and it helped them acknowledge to themselves that they had been mistreated and were not at fault.“ Well, here lies a big difference between the patient and the doula – Doulas remain silent. There is no complaint form that we can fill, and being extra-territorials as we already are in L&D, we have no voice. A doula who shares her disappointment of a care giver or of the hospital staff is taking the risk of becoming persona- non- grata at that practice of this facility in the future. We are lucky to have our doula support circles, and we can always cry on our peers shoulders and get their support, but this is equivalent to the mother sharing her trauma with a friend, and this might not be enough for a true healing.
I find some comfort in the fact that this post will lead doulas to brainstorm and search for a type of affirmative action we can take, and most importantly – be aware of our vulnerable position when witnessing labor and delivery abuse. We need to heal our professionals’ traumas, and be mindful about preventing them, even if this means not accepting a client who is under the care of an abusive OB.
Now that I’ve shared some general insight about abuse in L&D, here is the birth story that I promised to share with you. For your own benefit, please read twice as previously requested.
My client, Beverly, woke up at 4 am in a puddle; her first labor began with a rupture, and her contractions began shortly after. By 7 am her contractions were around 50 sec. long and about 5 min. apart. At 10 am her contractions intensified and occurred every 3 minutes for about 1 min at a time. At point Bev noticed she was bleeding and decided to meet me at the hospital. Upon arrival to the hospital, she was vaginally checked and measured to be 4-5 cm dilated and 90% effaced, and after a 30 min EFM we went to the shower. Bev was breathing beautifully and handling her birth with grace and confidence. Her OB was out of town, and the on-call OB from his group showed up and went into the shower to listen to her lungs. After the OB visit, Bev’s partner came out of the shower, and shared that the doctor was commenting on the couples request to delay the cord clamping, by saying that he can wait only 90 sec, as too long of a wait can lead to a disasters. He shared an article he has just read about baby’s leg amputation due to a cord clamping delay. I went back to support Bev in the shower, and she shared her disappointment that her OB was not the one to see her through her birth. After a long hour in the shower, Bev felt some pressure towards her anus and was asked to come out and be checked. She was 6-7 cm, 100% effaced, baby in station (-2). It felt for her like the right time to get the epidural she has planned on taking, and by 4 pm the nurse began the drip of fluids. Coping with the contractions in the room Bev was convinced that taking an epidural is the right thing for her. She asked for a low dose epidural, but the anesthesiologist has said that preference is to begin with a good dose and then slowly lowering it. Following the administration of epidural, Beverly’s contractions have totally stopped, her blood pressure went deeply low, and the fetal monitor showed a 4 minute deceleration, which was controlled and recovered with change of position and oxygen. She had no sensation nor ability to control her legs. While the nurse and the anesthesiologist were mainly occupied with recovering the low blood pressure and the baby’s FHR, I was concerned with the lack of contractions. I thought it will be wise to prepare my clients for the possibility of administrating Pitocin, reminding them that it is one of the possible side effects of epidural. After 3 hours wait, with no sign of contractions, The OB came into the room, and began explaining to the couple that as for now, a process of deterioration of the baby’s brain has already begun, and if they do not manage the birth and bring it to an end than this deterioration can become a brain damage. (I am sharing the nuggets of it, as he rambled on and on for a good 10 minutes ,sharing ‘studies’ and medical schools ‘All in favor of the couple making an informed decision’. ) When the couple asked for a few minutes to think about all that they have heard, the OB looked me in the eyes and said: ”Just for you to know, under the law of California, any medical advice is considered practicing medicine and you will be in a big trouble”. The couple decided to follow the OB’s suggestion, who has inserted the IUPC and began Pitocin. Following the administration of pit. Bev’s contractions has recovered; by 8pm she was fully dilated, with baby still in (-2). A dose of antibiotics was given to the mother due to maternal fever and the long rapture. By 10pm, with the baby in (-1) she began to push. When the baby came down to (+1) Bev was able to feel the pressure being build, and she pushed strongly, making progress with each contraction. The nurses changed shifts and we had a new, refreshed and very supportive nurse in the room. As the baby descended there were a few more declarations that recovered after the contractions was over. The nurse kept encouraging and complimenting Bev for her effective pushing, and then the OB came again to the room and began talking to the partner. In his words, he said “I know you do not like it when I bring things ahead of time, but I think it is important for you to make an informed decision, therefore I want to talk to you about choosing between forceps and vacuum”. Then he stopped because Bev felt the urge being build and we all attended to her as she pushed, husband is next to her head and counting, nurse at her perineum and I stood by her side supporting her leg. The contractions is over and the OB continues talking: ” I personally prefer the forceps, but it is matter of medical schools, as most doctors these days will use the vacuum…..” and he stops again as Bev is asking for our attentions and is pushing like a lioness, I swear. As he went out of the room, leaving the partner to make his decision, the partner asked me what was going on. He felt like one of us is lying to him, not telling the truth; how can it be that the nurse and the doula are being all excited about the progress, and the OB is asking him to choose between the vacuum and the forceps? Both I and the nurse tried to reassure him that there will be no need for him to choose, but he was so terrorized and said:” I know the vacuum to be safer for the baby, but I’m afraid to choose against his preference, he might get really angry and decide to end it now with a cesarean”. In order to lead him back to his logical thinking, I began asking questions: ”What do you know about vacuum and forceps”? And then asking the nurse: “Percentage wise, what would you say is used more here in the hospital?” The nurse was reassuring the dad that he needs to choose based on what he feels more comfortable with. This coaching conversation took place in between moms pushes. I went ahead asking the nurse: “Is there a medical reason that you are familiar with to end this birth with a cesarean now?”, and we both reassured the dad again and again, while all along the mother kept pushing, and — here comes the head! The OB was called to the room, and began dressing. While it was clear that in the next contraction the head was going to show up, he said “Well, because you were waiting so long since the water broke, and as I explained the deterioration has begun hours ago, and there is already maternal fever, your baby will go to the NICU and will stay there for two days for special care”. The NICU team arrived and a few minutes later we heard the baby crying his lungs out. The neonate doctor said: ”Why was I called? This baby boy is so strong, here mama” and she puts the baby on the mother’s chest. Bev’s healthy and strong baby boy was born at 12:30 am, and he nursed right away. The couple had two beautiful hours of bonding with the baby.