Doula Courses | Education | Doula
By Emma Ashworth
Today, March 8th, is International Women’s Day, a day to celebrate the strength, power and, of course, history, of women. I want to share some history which affects every woman or birthing person who has a child: The history of hospital birth and home birth. How did we come to birth most of our babies in hospital, and is it the safest option?
[Read more…] about The history of hospital birth and home birthBook review by Marius Griffin
The AIMS Guide to Your Rights in Pregnancy and Birth, by Emma Ashworth, is available from the AIMS shop as a printed book or on Kindle, for £8: https://www.aims.org.uk/shop
[Read more…] about Nurturing Birth Book Review: The AIMS Guide to Your Rights in Pregnancy and BirthBy Emma Ashworth, Nurturing Birth doula
Why are you a doula (or want to be a doula)? At the heart and soul of it, we passionately want women and people to have incredible, empowering, beautiful births, right? And because we see when that’s not happening and we want it to stop! For many of us this leads us down the path of activism – which is what this blog is all about. Can you be a birth activist and a doula?
You might wonder why not… indeed, many amazing doulas are also extraordinary birth activists. Birth activism changes the birth world for the better – as do doulas – so in a way, every act of doulaing is an act of birth activism. However, there are some parts of being a birth activist which need to be kept quite separate from being a doula.
Being a doula means that we support the pregnant woman or person who is our client, and, if they want us to, their family (eg partner, children). We are there to help that woman or person to find their way through the maze of maternity care. We are not there to guide them through it. We are there to show them what doors are available, support them in their decision about which door is right for them, and then walk with them through those doors. We don’t tell them which door to take.
Sometimes we may see injustice and as doulas who care so deeply for our doula clients we want to fix it. Right now, we are seeing deep injustice, and in some cases real trauma, from Covid-related hospital rules which are limiting access to hospital for partners and other supporters (including doulas). As has been pointed out in a recent social media campaign, if we can go to the pub, why can’t we have the person we want with us at an antenatal scan? As birth campaigner Ruth Weston points out in her excellent blog, some pregnant women and people find out at a routine that their baby died. Not only is hearing this alone a horrific experience for the pregnant woman or person, the other parent has to hear it over the phone, or second hand in the car park.
Here’s the thing. Here’s where it is absolutely imperative that we are completely clear about separating out being a doula and being a birth activist.
Our client may be really upset at the idea that they may have to attend an appointment alone, or be alone through much of their labour if they birth outside the home, or be alone on the postnatal ward. They may be able to have one birth partner there, but not two, and this might mean that they have to choose between their doula (you) and their partner. This feels wrong. This is wrong. So what do you do?
It may feel obvious that the right answer is to get on the phone, or send emails to a senior midwife, telling them how anxious this situation is making your doula client. Perhaps you might go through the details of your doula client’s specific case. Maybe she had a miscarriage last year that she only found out about at her 12 week scan. Maybe they are wanting to talk to a doctor about having a caesarean and they are worried about it being denied. Isn’t it our job to fix it?
No!
This is tricky stuff, and of course your doula mentor would be an amazing person to talk to about the complexities of the boundaries of a doula, however here is a starting point to this hugely important area.
One of the most important roles of the doula is to work with our doula clients to help them to achieve the pregnancy, birth and parenthood experiences that they want. Here’s the key words:
“to help them to achieve”
There are two big risks of “fixing” things for doula clients
When we see things which are wrong in the maternity system, it is absolutely fine to work towards fixing them. If we see guidelines, protocols or limitations of care which are unfair, unreasonable or unkind then fight against them with all of your power, if you wish to. Just do it as you, as a birth activist, rather than trying to do it on behalf of your client. It’s fine to say, “I know local women who this policy is affecting very seriously”. This is powerful and desperately needed work. You can absolutely be a birth activist and a doula.
What we have to be extremely careful to avoid, though, is trying to fix things ourselves, for our individual doula clients, when we see injustice happening. Instead, we are better focusing on what we can do to support our clients to make the changes that they want to see for themselves, so that they remain in control of their decisions and we don’t accidentally push for something that they’re not totally ready for. This means that our doula clients are the ones who are deciding which doors to walk through, and this is how they work with and build on their own power and strength.
There is huge benefit in large numbers of people campaigning on a specific issue, so many pregnant women and people feeding back to the trust and pressing for change is the most likely way that things will improve. But the only people who can do this are those who are wanting to do so. As with all options around pregnancy and birth, we, as doulas, can ensure that our doula clients know that this ‘door’ is there, but, like everything else, it we must show them this option with no pressure, no judgement and with no attempt to encourage them through it, but if they decide to open it themselves then we can step through it together with them, if they want us to.
Birth activism becomes a heart-need for many, and activism in the birth world is essential for change. We can campaign for change as we see the need, and yet ensure that we keep our doula work separate, carefully ensuring that we support our clients to achieve what they want, not what we want to see done better.
Emma is a Nurturing Birth doula, and manages the Nurturing Birth blog. She is also a breastfeeding counsellor, birth researcher and writer and a birth activist with AIMS.
By Emma Ashworth
What is the Montgomery ruling?
‘Montgomery’ refers to a legal case, formally known as ‘Montgomery V Lanarkshire’, where Montgomery is Mrs Nadine Montgomery, and Lanarkshire is the Lanarkshire Health Board in Scotland. The case was brought after Mrs Montgomery’s son was severely injured during his birth. During pregnancy, Mrs Montgomery was very concerned about her forthcoming birth because she felt that her baby was too big for her to birth vaginally. She had diabetes, was very small herself, and the baby appeared to be large. However, her obstetrician did not offer her a caesarean birth as an option to consider.
During the birth, Mrs Montgomery’s son experienced a very severe shoulder dystocia. After a variety of interventions he was born by caesarean, and now lives with cerebral palsy and a damaged shoulder.
The injuries that occurred during his birth are rare, and, statistically speaking, were unlikely to occur even with the risk factors that Mrs Montgomery had. However, the legal case came about not because of the complications themselves, nor how they were handled, but because the obstetrician made the decision to not share the information about the possible outcomes of a vaginal birth and a caesarean with Mrs Montgomery, thus stopping her from being able to make an informed decision herself over what was right for her. Ultimately, the case came down to whether or not information was shared to support informed decision making – and, the case found, it was not.
What did it change about consent and birth?
Before the Montgomery case, what doctors shared with pregnant women depended, basically, on what other health care providers were sharing. They could decide to limit what information they shared with women as long as other doctors were doing the same. This was known as the ‘Bolam Test’, and it states, “If a doctor reaches the standard of a responsible body of medical opinion, he is not negligent”. This applied to all areas of medicine, and led to many outdated principles still occurring (eg immediate cord clamping) because, from the practitioner’s point of view, if they did what most other doctors did, they had more protection against being sued.
With Montgomery, all this changed. Rather than just relying on what most other people did, practitioners are now obliged to share information on ‘all material risks’, meaning any risk (of an intervention or NOT intervening) that might be important to that pregnant woman or person, irrespective of what was normally done by their colleagues. If followed, this gives the pregnant person information they need to be able to make an informed decision about their own care.
Why do doulas need to know about it?
Sadly, no single legal ruling can resolve all of the problems that we have within the maternity system. Montgomery has given us a hugely valuable legal framework to support informed decision making. It means that the pregnant woman or person must be offered information to ensure that they are able to make an informed decision about their care. If your client isn’t experiencing this, you can suggest that they raise this as an issue with their health care provider, and remind them that they alone can make decisions about their body.
Unfortunately, there are downsides to this ruling in practice, if not within the aims of the law. The ruling states that providers should ensure that they take “reasonable care” to ensure that “patients” are aware of “material risks”.
The text reads, ‘The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.’
What this should mean is that individualised care is offered, with doctors and midwives ensuring that women are given information that is relevant to them, personally, depending on their personal needs and wishes. What is happening in reality is that doctors and midwives misunderstand this to mean that they have to tell women of every possible horrific outcome that might happen if they decide to decline an intervention, or birth outside the hospital. They seem to be forgetting that their obligation is to offer a balanced picture of all of the material consequences of interventions and non-intervention (when was the last time that you heard all the potential risks of an induction, for example?), and they also seem to be forgetting that women are not obliged to listen to any of this!
Pregnant women are still autonomous beings, and they alone can decide what they want to hear. Our clients do not have to attend meetings with doctors or midwives who they don’t feel are supportive of their rights or decisions if they don’t want to. They don’t have to listen to a stream of possible horrific outcomes if they don’t want to. If they want the information, they can choose to ask for another midwife or doctor, and they can point out that being told only one part of the picture is coercion, not informed consent, and is going against the Montgomery ruling just as much as not being offered information is.
Further reading
The online content of Nurturing Birth’s Expansive Doula Course has a video on consent which includes information on Montgomery. This presentation is also available to Nurturing Birth graduates who purchase the online modules after completing their Intensive Doula Course.
AIMS has published a helpful article on the Montgomery ruling by a solicitor who looks at the ways it can be used in medical negligence cases within maternity: https://www.aims.org.uk/journal/item/montgomery
The MDU (Medical Defence Union) has a web page on Montgomery which clearly explains the legal situation: https://www.themdu.com/guidance-and-advice/guides/montgomery-and-informed-consent
Birthrights is continuing its work on consent, following the Montgomery ruling, by offering workshops to midwives and doctors on this topic, and they are part of a team launching an app for women to use in labour: https://www.birthrights.org.uk/campaigns-research/montgomery-and-consent/
Emma Ashworth is a Nurturing Birth doula, a trustee of AIMS and she is currently the AIMS Journal Editor. She has a special interest in consent and has written extensively on women’s rights in birth. Her book, “The AIMS Guide to Your Rights in Pregnancy and Birth” is available from AIMS. You can find Emma at her Nurturing Birth Directory listing here…
Sophie Brigstocke,
Nurturing Birth
Telephone: 07305 044482
Email: info@nurturingbirth.co.uk