Radical Psychology
Volume Nine, Issue 1

Young Mothers’ Experiences in Maternal Healthcare: Exploring the Role of Doula Support

Heather L. Holland *


Introduction   

    Doula care in Canada is predominantly available on a private fee-for-service basis. A doula is a woman experienced in childbirth who provides information and emotional support to women during pregnancy, labour and birth. Community-based doula care programs aim to increase the availability and accessibility of doula care by providing services to women who are considered at risk. In these programs volunteer doulas are matched one-to-one with pregnant women and are on-call to these women at all times. Doulas often attend prenatal classes and medical appointments, respond to questions and provide information, network women with community resources, and provide support and information on breastfeeding and infant care. The community-based doula care model is a relatively new approach that can be understood as an intensive, strengths-based intervention (Abramson, Breedlove, & Issacs, 2006), yet it is under-recognized relative to its degree of success.

    Research indicates that women who are supported by a doula are more likely to be satisfied with their childbirth experiences (Hodnett et al., 2003) and are 45% less likely to experience operative birth (Klaus, Kennell, & Klaus, 2002). Doula supported women are also more likely to initiate and continue breastfeeding (Rosen, 2004) and to experience positive maternal attachment (Martin et al., 1998). Much of the research that has been conducted on doula care to date has focused on the positive obstetrical outcomes associated with doula care (e.g., Kennell, Klaus, McGrath, Robertson, & Hinkley, 1991; Meyer et al., 2001; Scott, Klaus, & Klaus, 1999). Many of these previous studies have been in the form of randomized controlled trials and have provided valuable epidemiological statistics on the benefits of doula care; yet there are few existing qualitative research studies on doula care (cf. Breedlove, 2005; Campero et al., 1998; Koumouitzes-Douvia & Carr, 2006; Low, Moffat, & Brennan, 2006). A multifaceted understanding of an issue or intervention often requires both “numbers and… stories” (Patton, 2002, p.14). According to Campero et al. (1998), qualitative research is an “indispensable complement” to quantitative epidemiological research in the area of public health because “it allows the exploration of the subjective dimension of the processes under study” (p.401). At present, there seems to be a growing understanding that doula care is effective yet countless questions remain about how and why it works. The current study aims to provide some insight into the workings of community-based doula care with young mothers.
 
    Young mothers’ experiences of the maternal healthcare system can differ markedly from those of adult women. Wilson and Huntington (2005) examined the literature surrounding teenage motherhood and explored the ways in which societal constructions of “normal” motherhood have shifted over the past few decades to position teenage mothers as stigmatized and marginalized. According to one teenage mother: “teens in the obstetrical care system are always told, never asked…they are often treated badly, as if they are being punished for being pregnant… they are afraid of the system and the system is afraid of them” (Ford & Van Wagner, 2004, p.244).

    Ruddick (1993) explains that the adolescent mother has become a symbol of “sexual and social disorder” and she argues that young motherhood, even more than teenage pregnancy, has become a representation of “the causes as well as symptoms of intergenerational cycles of poverty and despair” (p.126). Ruddick’s (1993) claim is reflected in the work of Fraser and Gordon (1994) who trace historical shifts in the usage of the term “welfare dependency” in the U.S. They argue that this term serves to “enshrine certain interpretations of social life as authoritative and to de-legitimate or obscure others, generally to the advantage of dominant groups in society and to the disadvantage of subordinate ones” (p.311). These authors argue that the ultimate contemporary expression of welfare dependency is the “young black single mother” and explain that she “simultaneously organizes diffuse cultural anxieties and dissimulates their social bases” (Fraser & Gordon, 1994, p.327). Through interlocking dominant discourses such as these, the adolescent mother as a symbol of social disorder (Ruddick, 1993) and the young black single mother as welfare dependent (Fraser and Gordon, 1994), normative notions of motherhood are raced, classed, and gendered (O’Reilly, 2006).

    The notion of young mothers as “bad” mothers is challenged by the many young mothers who fare better in the long-term than dominant discourse would predict (Smithbattle, 2003). Studies have shown that many young mothers have quite positive outcomes; researchers have described adolescent pregnancy as a motivator for positive behaviour change and future planning (Flanagan, 1998; Logsdon, Gagne, Hughes, Patterson, & Rakestraw, 2004) and as life changing and joy giving (Dominelli, Strega, Callahan, & Rutman, 2005). Moreover, most teenage mothers do not share the societal view that having a child at a young age ruins a teenage mother’s life or limits the future life of her child (Nelson & Sethi, 2005).

    One of the ways in which societal stigma affects young mothers in the maternal healthcare setting is that the social, economic, and demographic issues presented by young mothers can become medicalized; “a woman’s social and economic status, age, and the number of babies that she has had [are seen as] an automatic indicator of risk” (Ford & Van Wagner, 2004, p.254). Similarly, Oakley (1993) explains that unmarried patients are often routinely referred to a medical social worker whereas married patients, who may well be experiencing social problems, are not likely to be viewed as a “high risk” group. Although Ford and Van Wagner (2004) and Oakley (1993) are referring to two somewhat different categories of “risk” (medical risk and social risk, respectively) they share a critique of the ways in which risk has been constructed, where signifiers, such as being young and/or single, can come to negatively and predominantly shape a young mother’s experience of the maternal healthcare system. In this way, societal stereotyping and stigma surrounding young motherhood might arguably be contributing to young mothers experiencing the very risks that have been correlated with their social group. Pregnancy complications that are more prevalent for teenage mothers include premature labor, intrauterine growth restriction, low birth weight and perinatal mortality; these complications are often linked in part to low body mass index, smoking, and young gynecological age (Gilbert, Jandial, Field, Bigelow, & Danielsen, 2004).

    While doulas are certainly not immune to societal stigma surrounding young motherhood, I would suggest that the continuous and individualized support that is provided by a doula can help to affirm the subjectivity of a young mother’s birthing experience. I will analyze participant comments which indicate that societal stigma and stereotypes surrounding young motherhood can create anxiety for some young mothers as they navigate the maternal healthcare system. I will then draw on literature on the medicalization of childbirth to look at how participants narrate the “choices” that are made during birth and how a young mother’s sense of control over her birth experience can become diminished. Throughout the discussion that follows I will draw from participant comments to posit that doulas can enrich maternal healthcare for young mothers by providing support and helping to facilitate their voices being heard in a maternal healthcare context where some young mothers may feel they are judged and lacking support.

Methodology

    I have drawn from the insights of both a postmodern feminist perspective and an anti-oppressive approach in this work and adopted a feminist approach to the design and methods of the research project itself. Eight single semi-structured interviews with doulas and young mothers who were clients of a community-based doula program were conducted. Participants were recruited through Mothercraft Ottawa’s Birth Companion Program volunteer list-serve, routine follow-up calls to clients by Birth Companion Program staff, and advertising by staff at a partner agency in Ottawa that services many of the same clients.

    Given the small participant sample size, the findings of this study can only be said to reflect the experiences of the study’s participants and cannot be generalized to all doulas and/or clients of community-based doula programs. The young mothers that were interviewed ranged in age from 16 to 23 when their babies were born. All had given birth in an Ottawa area hospital; three had an obstetrician as a primary caregiver and one had a midwife. One identified as Native and Canadian, and the rest as European-Canadian or Canadian. The doulas that were interviewed had all been doula volunteers for a minimum of one year, and three also took on private doula clients in addition to their volunteer work. They all identified as European-Canadian or Canadian and they represented a range of ages and income levels.

    I undertook analysis of the interview transcripts with the intention of using grounded theory. Through the analysis and writing phases (and through critical reflection) I came to realize that I adopted a slightly different, more deductive approach, but maintained an analysis strategy consistent with a grounded theory approach (Strauss & Corbin, 1998). In line with a postmodern feminist approach to research, I explored the effects of my interpretive role on the research and analyzed the participants’ interviews with attention to their own interpretive roles. For example, I paid attention to how analysis and narrative are constructed within contexts (Trinder, 2000). Lastly, I solicited participant input at two stages in the study in order to more accurately represent participant views and to foster a sense of participant investment in the research.

Results and Discussion

 Stigma, stereotypes and discrimination:

 Jennifer , one of the young mothers that I interviewed, felt that she was treated differently in the maternal healthcare system because she did not fit the profile of a “good” mother. She felt that assumptions were made about her at the hospital because of being unmarried and pregnant at a relatively young age. At one point in her pregnancy she went to the hospital because she suspected something was medically wrong. She received the impression that she worried too much and was referred to a hospital social worker. Similarly, on a visit to emergency, a hospital staff person said to Jennifer that she looked “depressed”. The referral to the hospital social worker and the comment about looking depressed may have been intended as supportive but Jennifer experienced them as judgmental. Jennifer did not feel heard or respected by hospital staff and stated that she felt that this was because of her age and marital situation: “in the hospital they just may not understand you…some of them seem to be… against younger people having kids that aren’t married”.

    Young mothers’ experiences of pregnancy, childbirth, and motherhood are arguably impacted by pervasive social discourses and related notions about good and bad mothers. Kulkarni (2007) conducted ethnographic interviews with 30 young mothers and two key themes that emerged were “pressure to be with their children’s fathers” and “stigmas associated with teenage motherhood”. This later theme was quite prevalent, with more than 60% of the participants sharing experiences with discrimination due to stigma. I would suggest that Jennifer’s narrative may reflect the impact of societal stigma surrounding young motherhood and how such stigma can produce anxiety and experiences of felt discrimination in the maternal healthcare system.

    Participant comments also indicated that young mothers may experience stereotyping. For instance, the notion that young women are less able to handle physical and emotional challenges than older women may influence the way that care providers treat young women in labour. Anne, a doula, told a birth story about advocating for her match and being open to seeing through stereotypes:

I got the call at around 11 o’clock at night and I asked her how far apart she was and she said she was three minutes. Normally I wouldn’t worry too much about it but then I asked her if she was feeling pressure and she said yes, she was feeling pressure in her bottom and I immediately thought—ah oh, a light went off….  So I went to get her to bring her into the hospital and I got her in the car and in the car she was having contractions and was talking [through them]… it wasn’t the picture of someone in labor.  [I thought] she’s either really early in labor, like barely started, or she’s really far along. So we got to the hospital and the staff kind of took their time and then the pain became very intense.  I wasn’t sure if it was a fourteen year old being a fourteen year old and not dealing well with the contractions. But there was something… my instincts kept telling me… I thought she was farther along, 8-9 cm kind of thing. I really had to convince the doctors to check her. They thought she was just very early in labor and not coping very well.  So I finally convinced them to check her and she was 8-9 cm. So that was a situation where I really had to advocate on her behalf. (Anne)

Anne acknowledges, and seems to criticize, the doctors’ assumption that her match was not handling the labour pain well, yet indicates that the pervasiveness of this stereotype affected her own assessment of her match’s stage of labour as well. Anne herself states “I wasn’t sure if it was a fourteen year old being a fourteen year old and not dealing well with the contractions”. Anne’s narration of her match’s birth story also suggests that her match displayed some contradictory or confusing behaviour. For example, she states that “it wasn’t the picture of someone in labour”. Fortunately, Anne acknowledged that she “wasn’t sure” and focused on “advocat[ing] on her behalf”. Anne does not include any clear indicators of what her match was requesting at this point, such as whether or not she wanted to be checked. It is unknown precisely what factors motivated or enabled Anne to advocate for her match. She reports that her “instincts kept telling [her]” that the woman was farther along in labour than it first appeared. It seems that Anne was able to minimize the influence of a stereotype and advocate for the woman in labour to be assessed.

    Research indicates that when care providers and support people themselves draw on the stereotype about young mothers not being able to handle pain in labour, it can negatively affect a young woman’s experience of pain. According to Lowe (2002), the element that best predicts a woman’s experience of labor pain is her own level of confidence in her ability to cope with labour. And her confidence in her ability is affected by those attending to her in labour. Lundgren and Dahlber (1998) found that a woman’s experience of pain is related to the context (i.e.., setting) and “especially to the people with the woman… women need to trust the people around them and they need to be affirmed in their efforts… security, support and encouragement [are] described as important” (p.107). In other words, conveying confidence in a young mother’s ability to manage labour pain and affirming her in her efforts can have a positive impact on her experience of labour pain. Conversely, displaying a lack of confidence in a young mother can negatively affect her experience of labour pain. In this way, an alternate discourse of young mothers as capable of managing labour pain may improve the effectiveness of labour support for these women.   

    An analogy can be drawn to caregiver attitudes towards young mothers and breastfeeding, as alternate discourses on young mothers and breastfeeding may be able to open up a young mother’s sense of her options for infant feeding. All of the doula participants described providing information and support on breastfeeding as an important part of their role in working with young mothers. A participant and young mother, Natasha, made reference to a conversation with her doula on breastfeeding:

The funniest thing is that when I was pregnant I didn’t know about breastfeeding… I didn’t really know about it until I started seeing breasts popped out everywhere.  But it was [my doula] who asked me if I was going to nurse or if I was going to bottle-feed and I said, “bottle feed” and she said, “Well are you going to try it?” and I thought well I might as well try.  So she’s actually the one that introduced me to nursing.  So when [my baby] was born I just did it and he was hooked. (Natasha)

Natasha does not indicate whether or not she had been subject to any stereotypes about young mothers as non-breastfeeders. She does indicate a lack of familiarity with breastfeeding and credits her doula with “introducing” her to nursing. While the question posed to Natasha (i.e., “Well are you going to try it?”) does not indicate that her doula provided information or support specifically, it is possible that her doula helped to open up an alternate discourse by not assuming that Natasha would be bottle-feeding.

    In training for the Birth Companion Program, doulas are encouraged to discuss societal stereotyping of young mothers as non-breastfeeders with their matches, to convey their own confidence in their match’s ability to breastfeed, and to challenge their matches to defy the stereotype (Sippert, 2005). I would suggest that this alternate discourse (young mothers as capable of defying the stereotype) is arguably more supportive, and can help to encourage a behaviour that is considered healthy. At the same time, it is important to recognize that it is still somewhat coercive in its delivery in that it works by substituting one narration of young mothers and breastfeeding with another. I think it is possible for this approach to be taken up in ways that can increase a young mother’s sense of her own capability and options while also supporting the particularity of her views on, experiences with, and choices regarding breastfeeding. The program’s approach to breastfeeding appears to be effective, with 90% of Birth Companion clients initiating and 53% establishing prolonged exclusive breastfeeding; this rate greatly exceeds the national breastfeeding average for young mothers (Horsley & Sippert, 2006).  
 
    Conversely, researchers Dykes, Moran, Burt, and Edwards (2003) have found a connection between stereotyping by health professionals who often assume that young mothers will not be breastfeeding and teenagers’ views on and experiences with breastfeeding. According to one participant in a study by Dykes et al. (2003), “I wasn’t asked how I was feeding. I was asked how many ounces is he having… then when I said I was breastfeeding they like looked and said “oh you’re breastfeeding” and I was like “yes” and they said “oh…that’s good” (p.394). Adolescents reported that they felt watched and judged by older people. Dykes et al. (2003) draw a connection between this feeling of being watched and young women’s lack of confidence in their ability to carry out breastfeeding effectively. In the study by Dykes et al (2003), the feeling of being stereotyped as a likely bottle-feeder is explored in relation to age; similar results have been reported by Dracup and Sanderson (1994) in relation to socioecononmic status (as cited in Dykes et al., 2003) which, I would add, may intersect with and intensify the impact of stereotyping for the many young mothers who have low incomes or are living in poverty (Health Canada, 1998).

    Participant comments and related research indicate that there are multiple ways in which young mothers’ experiences of being stereotyped and judged can be affected by dynamics surrounding other aspects of their identity and background. Anne, a doula, tells this story:

She had a history of drug abuse and it became very clear that the nurse was not treating her very nicely because of it and she kept asking her about it and she’d say, you know I got off the drugs very early on in the pregnancy I got clean and all that, and she was just not being supportive of her, and kept asking about the father in a very impolite way.  So she was not treated very well through the whole thing and unfortunately when the baby did come out, she [the birthing woman] was white and the baby was a darker colour, the nurse did make an unfortunate comment about the baby and the colour of the father.
Interviewer: You mean a racist comment?
Anne: Yes. (Anne)

This excerpt offers an opportunity to explore multiple readings of the issue of drug use during pregnancy from the varied perspectives of the women involved (i.e. those of Anne, the nurse, and the birthing woman). Anne, by expressing criticism of the nurse’s treatment (e.g., “[the nurse] was just not being supportive of her [the birthing woman]”), may be illustrating that she holds a view that women in labour deserve unconditional support. From the nurse’s perspective, it is possible that she saw drug use during pregnancy as a sign of irresponsible parenting given that many street drugs can cause harm to the foetus; her concern for the baby’s health may have affected her view of the mother. For the birthing mother, it appears the pregnancy may have served as a catalyst for getting off of drugs. Anne reports that “[she] got clean and all that” and that she “got off drugs very early on in the pregnancy”. I would suggest that rather than there being one “true” story about a birth, it is possible to see in this excerpt how each of these women’s perspectives may have shaped and influenced their interactions with one another.  
 
    The excerpt from Anne’s interview can also highlight the multiple ways in which women can be classified and marginalized as “good” and “bad” mothers. While there may not be one “true” story about a given birth, I think it is possible to critique and mobilize around the ways that some mothers have more social power to exercise in creating their own birth experiences. In this mother’s situation, I would suggest that the racist comment that Anne says was made by the nurse about the baby and the skin colour of the baby’s father can be seen as an illustration of the intersecting oppressions that are experienced by many young mothers. Coll et al. (1998) explain that the more a mother deviates from the dominant prototype of white, married, middle class etc. the more likely that she and her mothering practices will be marginalized. Research with young women of colour found that one in five reported that they had encountered racism in the Canadian health care system; these experiences included cultural insensitivity from their doctors (8.6%), name-calling or racial slurs (2.5%), and receiving an inferior quality of care (6.2%) (Ali, Massaquoi, & Brown, 2003). In this way, marginalization due to racism, classism, and/or other forms of discrimination can intensify a young mother’s experience of felt discrimination within the maternal healthcare system.

Doulas as a part of the childbirth team:

 As was noted, stigma surrounding young motherhood is pervasive (Ruddick, 1993) and affects both doulas and hospital staff. Many hospital staff and doulas alike are open to seeing through such stereotypes about young mothers and providing care that is respectful and supportive. Several participants in this study spoke positively about the care they received from hospital staff. For example, Catherine, a young mother, said:

They [the nurses] were really nice… I had one nurse who, I wasn’t sleeping that well at night and she had to give [the baby] her test. She actually took [the baby] for the full three hours so I could get some sleep and brought her back when it was time to feed again…. I had a second night [and] the nurse I had when I came into the hospital, she was like, “you’re still here?” and she sat in the room with me ‘cause the floor wasn’t busy… she sat in the room with me and did her paperwork. (Catherine).

I would suggest that doulas can enrich young mothers’ experiences in the maternal healthcare setting by working collaboratively with other health professionals on the childbirth team to achieve a shared aim of providing respectful and supportive care.

    At the same time, doulas can make a unique contribution to the childbirth team by providing continuous care and encouraging women’s positive birth experiences. Anne states:

I think that regardless of their income level, their life experience or whatever, whether it’s their first baby or their eighth baby this is a time when women need support and in the reality of our medical system…it really is a crap shoot of the quality of nursing and medical care that they will get at the hospital, most of the time it’s really good but I think that…it’s important to know that one person is going to be there regardless of what else happens… you’ve got one person who is known to you, is familiar with your birth plan and what you want and knows what the issues are, what your concerns are and can help address them as early as possible, as they become issues and just to be there and aware of what you want and what’s important to you and who you are and see you as an entire person as opposed to the medical system. They have a different job in this and a different role and it doesn’t always connect with what women need. It’s good to have the [doula] that’s focused on the whole person rather than just getting the baby out. (Anne).

Anne’s narrative may reflect a broader discourse of the alternative birthing movement as she positions a doula’s woman-centered approach to care as separate from, and fundamentally different than, medical approaches to care. In practice, I would suggest that the lines between woman-centered approaches and medical approaches to care are less defined than they have been put forth here. For example, it is not universally the case that medical personnel are focused on “just getting the baby out” and many medical personnel would likely report that they are also concerned with factors such as what is important to the birthing woman and with providing support regardless or irrespective of a woman’s “income level [etc.]”. Conversely, some doulas may also be focused on “getting the baby out” and doula care can also be considered a “crap shoot”. At the same time, Anne’s narration captures some of the realities of the various roles on the childbirth team; obstetricians, midwives and nurses do hold clinical and medical responsibilities that are their first priority, while doulas are able to focus on providing continuous support to the mother and attending to her emotional needs. Nurses carry a busy patient load and regularly assess women in labour, whereas a doula’s role is defined by her continuous support. A doula’s attention to a woman in labour often begins in early labour and continues to delivery, with the doula leaving only for toileting. Anne’s comments highlight the mother’s birth experience as a central priority in the doula’s approach to care. 

Diminished control and the compromising of informed choice:

   Of the four young mothers who were interviewed, all had given birth at an Ottawa area hospital. Three were attended by an obstetrician and one by a midwife. Some striking contrasts were evident in the way that the midwifery birth and obstetrical births were narrated by these women. Natasha, who was attended by a midwife, used language like “offered me” and “I declined” when referring to a decision to not receive stitching for tears incurred during delivery. Her language seems to demonstrate a positive sense of her own agency. This is an excerpt from Natasha’s birth story:

Then we went back to the hospital and they showed me… my room and my staff and stuff and I needed to pee so I went into the bathroom and I peed like fully clothed, we’d just gotten to the hospital and I went pee and then I opened my door and I was completely naked, like buck naked, and I opened the doors wide open and my [doula], and my midwife just stopped and looked at me and one of them asked, “Do you want to get back in the Jacuzzi?” and I was like, “Yeah, I do”.  We were walking, she was completely dressed, boots and everything, and me buck naked going, “Which way to the Jacuzzi?” It was hilarious. (Natasha)

Natasha expresses a sense of ownership over the space and her birth experience when referring to “my room and my staff”.  

    In contrast, the rest of the mothers spoke about feeling as though decisions were pushed on them or described their birth experiences without discussing choice at all. In the following excerpts Catherine describes medical staff as “pushy” regarding pain medication:

Catherine: …they were pretty much like, yeah, “you want the epidural, you want the epidural… you need your rest, you need the epidural”. They pushed the epidural like a lot…
Interviewer: What did you say when they were pushing?
Catherine: Well I didn’t really want it but then my mom… they figured [not having the epidural] would be a bad choice for me. They gave me Demerol just to like, it takes the edge off, but it’s not going to help that much. Like you’ll need to rest and you’ll need to save energy to push and if you don’t have the epidural then you’ll be really tired and your labour is not going to go as well.
---
Interviewer: What were the hard parts [of childbirth] and what were the easy parts?
Catherine: The long wait. That and I didn’t like needles. I didn’t want the epidural. I didn’t want to get an IV in me. (Catherine)

Here, Catherine conveys that there was a sense of choice around whether or not to get the epidural but she indicates that the choice was up to her mother and the medical personnel at her birth (e.g., “they figured [not having the epidural] would be a bad choice for me”). Catherine does not explicitly indicate whether or not she includes her doula amongst the “they” who were pushing the epidural. Catherine’s description of the extent to which the attendants at her birth (both medical and personal) pushed the epidural indicates that she resisted the “pushing” and did not comply right away. Yet, the way that she narrates the choice to have an epidural indicates that she saw the medical personnel and her mother as having the bulk of the control.

    The importance of women’s choices and their sense of control during labour runs as an undercurrent through much of the feminist literature on the medicalization of childbirth (i.e. as is seen in Fox & Worts, 1999; Martin, 1990; Rothman, 1994). I think that women can use medical technology for their own purposes and benefits; yet also believe that women’s agency is often exercised in a medical context that constrains their access to informed choice and decision making. Many critics argue that the medicalization of childbirth has (re)constructed labour and delivery as hazardous and has resulted in unnecessary interventions during childbirth (Fox & Worts, 1999). Fox and Worts (1999) argue that the medical management of birth can disempower, and decrease the control of, the birthing woman, fail to improve the physical and emotional outcome of the birth, “and even alienate the woman from a potentially empowering experience” (p.328). Simonds (2002) argues that there have been a wide range of improvements in the medical management of birth due to feminist and consumer activism but contends that the approach remains patriarchal, technocentric, and interventionist and that none of the changes that have been made have altered the “fact of masculinist medical authority” (Simonds, 2002, p.561).

     It is possible to be critical of such elements of medicalized childbirth without positioning the medical system as diametrically opposed to women’s needs and interests. For example, obstetricians do not always subscribe to masculinist ideology and midwives do not always represent a rejection of this ideology (Simonds, 2002). While I personally define childbirth as “natural ”, I agree with post-structuralist critics of the natural childbirth movement who suggest that childbirth is not inherently either natural or dependent on medical technology; but can rather be understood as natural for those who define it as such and medical for those who define it as such (Treichler, 1990). In trying to reclaim choice and control for women in labour, the alternative birth movement has in some ways replaced the story of childbirth as medical with a story of childbirth as natural (O’Reilly, 2004). However well-intended, this newer story can also serve to constrict and constrain birthing women. Glorifying the natural can construct those births that do not conform to this ideal as unnatural which can deny women who experience such births both “agency and humanity” (Michie & Cahn, 1996, p.48).

    Therefore, regardless of whether a woman’s birth plan involves a high degree of intervention or a low degree of intervention it is important to elicit her views and support her choices. Another participant, Amy, said that she knew that her doula was against the epidural because she had given a “long speech on the side effects of the epidural”. I asked Amy about this: 

Interviewer:  It’s interesting for me to hear you say that you knew that she [the     doula]     wanted you to do things a certain way…. Did you feel a pressure to?
Amy: No because I told her [the doula] that I wanted the least drugs as possible.
Interviewer:  So that was something you said was important to you.
Amy:  She was like, okay…she wanted to respect my wishes, so she was like there are signals we can work on and if you give me that signal I’m going to ask you to repeat it twice so that you are really sure of what you are doing…. well I was like what if I’m in labour and I don’t remember what the signal was? And she was like ask me once then wait five minutes and then if you ask me again I’ll go get the doctors…. Yeah…she made me feel so relaxed that I actually had the chance to experience natural childbirth before the epidural so I had a long time to know what it was like. (Amy)

While Amy says that she perceived her doula to be against epidurals, Amy also conveys that she felt her doula established the communication plan because “she [the doula] wanted to respect my [Amy’s] wishes”. In Amy’s case, I suspect that Amy’s doula likely defines birth as natural and that her own views may have aligned well with Amy’s desire to have “the least drugs as possible”. Conversely, it may have been more challenging for her doula to provide respectful support to Amy had her birth plan involved a high degree of intervention.

    Another young mother, Jennifer, wanted more interventions and she narrates this aspect of her birth story in this way:

They told me to push and I was demanding a c-section…they told me to push and I wanted more pain medication…they told me I had to push it out that I wouldn’t be able to push it out unless {inaudible} and so finally going through some painful contractions they gave me more pain medication and then they told me that the vacuum would help to get her out and I kept saying cesarean and they kept trying to talk me out of it and tell me why. And then the head doctor came in and told me the vacuum would probably help with this…. I got help and with three pushes she was out. (Jennifer)

Jennifer’s narrative may speak to her sense of who held the control in the delivery room. Jennifer is assertive in demanding a c-section. She positions herself in opposition to her care providers (likely including her doula); “they” are not narrated in a supportive way but are described instead as telling her what is going to happen: “they told me that the vacuum would help to get her out and I kept saying cesarean”. Her reference to the “head doctor” coming in also speaks to her awareness of the medical hierarchy in the room, implying that the “head doctor’s” position is superior to hers because s/he gets the last word. Some of Jennifer’s additional comments suggest that she sees her doula as a supportive member of the childbirth team. Earlier in our interview Jennifer said: “I was really nervous and scared but my [doula] made me realize that I can” and “she was with me at times like at the hospital with the nurse…actually when she was and they knew I had her help they weren’t on my back as much, they kind-of saw, like you know, she has this help and she seems good and stuff”. When speaking about her doula at these times she seems to emphasize her own capability using terms such as  “I can”, and  “she seems good”. She also seems to suggest that her doula’s presence sometimes acted as a buffer between herself and her nurses; this echoes her earlier positioning of herself in opposition to her care providers. At the same time, she seems to acknowledge that the nurses may have been “on [her] back” out of concern and a desire to help because they were less so when they saw that she had her doula’s help. This differentiation on her part suggests that she may have been more receptive to the labour support provided by her doula. 
   
    I think that all women who birth at a hospital are affected by hierarchical and interventionist hospital policies and practices to some degree; yet women’s expectations and views on childbirth vary widely and this setting reflects some women’s interests better than others. In addition, some mothers may be shielded from hierarchical and interventionist hospital practices by constructed signs of a “good” mother such as age, whiteness, middle-class status, and marital status. Women’s expectations regarding, and experiences of, control are influenced by their varied social locations (Fox & Worts, 1999) and can represent “complex negotiations via the body that are produced by different class and work experiences” (Martin, 1990, p.311). For example, Davis-Floyd (2006) points out that the middle class are used to exercising choices which may predispose them to feeling entitled to a sense of choice and control during childbirth. Furthermore, according to Sherwin (1998), systemic discrimination and stereotypes about women who are considered at risk can undermine their credibility and authority in healthcare contexts. For example, young mothers’ rights to informed choice may become influenced or compromised by stereotypes surrounding young motherhood (i.e.., being seen as too young to make rational or competent decisions about their own health and the health of their baby). I would conclude that from their social location as young mothers, participants’ birth stories may reveal the ways in which control of their birth experiences can be diminished, and their experience of informed choice compromised.   

Individualized doula support:

Many participants spoke about how doula care can support young mothers in the hospital setting. Anne, a doula, explains how she sees her role:

I think for someone to come in that’s really neutral and doesn’t have their own opinion on whether they should give the baby up for adoption or whether they should have aborted the baby and is just concerned with the woman and her interests and getting her connected with the right programs and just being there to talk to her and have all her concerns voiced and being able to listen to them and also give her the option, present her with various options for the birth itself so that she doesn’t have to feel disrespected and make sure that her voice is heard in the delivery room.  (Anne).

And when asked “What do you think are the basic principles and values of doula care?” Marisa, a doula, said:

Support. I think some of the moms in the program are alone and they don’t have healthy relationships with other individuals that can give them that unbiased support. That unconditional helping hand so to speak that regardless of their situation that there is someone there that really wants the best for them and for that child—no agenda.  And for a lot of women at risk, they don’t have that in their life. (Marisa).

Marisa suggests that a doula can be “that unconditional helping hand” for women who may feel alone. And Anne positions the doula as an important support person and advocate, whose role is to help ensure that the woman in labour “doesn’t have to feel disrespected” and “make[s] sure that her voice is heard in the delivery room.” Both Marisa and Anne speak about the importance of remaining “unbiased” and “neutral” when providing such support. Although doulas will inevitably have their own views on a woman’s childbirth choices, these excerpts from Marisa and Anne suggest that doulas try to put boundaries around their views in order to facilitate informed choice and provide support in a less biased way. It is not clear, however, whether or not these attempts are effective. Amy’s perception that her doula was “against” epidurals, discussed earlier, indicates that it is not universally the case that doulas are able to effectively minimize their biases. Moreover, I would suggest that the provision of informed choice is inevitably subjective despite the best efforts of any doula or health care professional to put boundaries around their biases. Even many subtleties in verbal and non-verbal communication can convey approval or disapproval of the options that are being presented. I would suggest that doulas’ capacity to put boundaries around their biases may warrant further development as a component of the practice in order to enhance their potential to facilitate young mothers’ voices being heard.   

Conclusion

    Critiques of the medicalization of childbirth have moved from exploring the medicalization of a “universal, objectified [woman’s] body” to deconstructing “the social and cultural constructedness of all bodies” (Macdonald, 2006, p.239). An important part of this shift involves recognizing and challenging the ways that women’s sense of choice and control in the maternal healthcare system can be intensified or buffered by experiences of oppression and privilege.

    Drawing from literature and the experiences of participants in this study, I have argued that young mothers’ experiences can be shaped and influenced by societal beliefs about young motherhood and notions of immaturity, incapability and irresponsibility and that, as a result, the impact of stigma and stereotypes that surround young motherhood can carry into experiences of felt discrimination in the maternal healthcare system. Many young mothers deviate from social constructions of “good” motherhood (Coll et al., 1998; Ladd-Taylor & Umansky, 1998) which can compromise their authority and credibility in healthcare contexts (Sherwin, 1998). For these women, the effects of “masculinist medical authority” (Simonds, 2002) can be particularly hard-hitting when not buffered by factors such as age, whiteness, middle-class status, and marital status. Furthermore, I have posited that doula care can enrich maternal healthcare services for young mothers by providing individualized and continuous support and helping to facilitate young mothers’ voices being heard. Doulas can make a unique contribution to the childbirth team and can work with other healthcare providers to elicit young mothers’ childbirth views and choices and to demonstrate respect for their birth experiences. However, more qualitative research with young mothers who are clients of community-based doula care could help to better determine the role of broader social support during pregnancy and the postpartum period in clientele’s experiences of support during childbirth.
 
References

Abramson, R., Breedlove, G., & Issacs, B. (2006). The community-based doula: Supporting families before, during, and after childbirth. Washington, DC: Zero to Three.

Ali, A., Massaquoi, N., & Brown, M. (2003). Racial discrimination as a health risk for female youth: Implications for policy and healthcare delivery in Canada. In Women’s Health in Women’s Hands Community Health Centre. Toronto: The Canadian Race Relations Foundation.

Breedlove, G. (2005). Perceptions of social support from pregnant and parenting teens using community-based doulas. Journal of Perinatal Education, 14(3), 15-22.

Campero, L., Garcia, C., Diaz, C., Ortiz, O., Reynoso, S., & Langer, A. (1998). “Alone I wouldn’t have known what to do”: A qualitative study on social support during labor and delivery in Mexico. Social Science & Medicine, 47, 3, 395-403.

Coll, C.G., Surrey, J.L., & Weingarten, K., (1998). Mothering against the odds: Diverse voices of contemporary mothers. New York: The Guilford Press.

Davis-Floyd, R. (2006). Qualified commodification: The creation of the certified professional midwife. In R. Davis-Floyd & C.B. Johnson (Eds.), Mainstreaming midwives: The politics of change (pp. 163-204). New York: Routledge.

Dominelli, L, Strega, S., Callahan, M., & Rutman, D. (2005). Endangered children: Experiencing and surviving the state as failed parent and grandparent. British Journal of Social Work, 35, 1123-1144.

Dykes, F., Moran, V., Burt, S., & Edwards, J. (2003). Adolescent mothers and breastfeeding: Experiences and support needs—an exploratory study. Journal of Human Lactation, 19, 4, 391-400.

Flanagan, P. (1998). Teen mothers: Countering the myths of dysfunction and developmental disruption. In C.G. Coll, J.L. Surrey & E. Weingarten (Eds.), Mothering against the odds: Diverse voices of contemporary mothers (pp. 238-    254). New York: The Guilford Press.

Ford, A. & Van Wagner, V. (2004). Access to midwifery: Reflections on the Ontario equity committee experience. In I. L. Bourgeault, C. Benoit, and R. Davis-Floyd (Eds.), Reconceiving midwifery (pp. 244-262). Montreal & Kingston: McGill-Queens University Press.

Fox, B. & Worts, D. (1999). Revisiting the critique of medicalized childbirth: A contribution to the sociology of birth. Gender and Society, 13, 326-346.

Fraser, N. & Gordon, L. (1994). A genealogy of dependency: Tracing a keyword of the U.S. welfare state. Signs, 19, 2, 309-336.

Gilbert, W.M., Jandial, D., Field, N., Bigelow, P., & Danielsen, B. (2004). Birth outcomes in teenage pregnancies.  The Journal of Maternal-Fetal and Neonatal Medicine, 16, 265-270.

Health Canada. (1998). Nutrition for a healthy pregnancy: National guidelines for the childbearing years. Ottawa: Minister of Public Works and Government Services Canada.

Hodnett, E.D, Gates, S, Hofmeyer, J.G. & Sakala, C. (2003). Continuous support for women during childbirth. CochraneDatabase of Systematic Reviews.  Online: Update Software. 3, CK003766.

Horsley, R. & Sippert, G. (2006).  Birth and parent companion program: Building a healthier community one family at a time. Ottawa: Canadian     Mothercraft of Ottawa-Carleton.

Kennell J., Klaus, M., McGrath S., Robertson, S., & Hinkley, C. (1991). Continuous emotional support during labor in a US hospital. Journal of the American Medical Association, 265, 2197-201.

Klaus, M.H., Kennell, J.H., & Klaus, P.H. (2002). The doula book: How a trained labor companion can help you have a shorter, easier, and healthier birth. Cambridge: Da Capo Press.

Koumouitzes-Douvia, J. & Carr, C. (2006). Women’s perceptions of their doula support. Journal of Perinatal Education, 15, 4, 34–40.

Kulkarni, S. (2007). Romance narrative, feminine ideals, and developmental detours for young mothers. Affilia: Journal of Women and Social Work, 22, 1, 9-22.

Ladd-Taylor, M. & Umansky, L. (1998). “Bad” mothers: The politics of blame in twentieth-century America. New York: New York University Press.

Logsdon, M.C., Gagne, P., Hughes, T., Patterson, J. & Rakestraw, V. (2004). Social support during adolescent pregnancy: Piecing together a quilt. JOGNN, 34, 5, 606-614.

Low, L.K., Moffat, A. & Brennan, P. (2006). Doulas as community health workers: Lessons learned from a volunteer program. Journal of Perinatal Education, 15, 3, 25-33.

Lowe, N.K. (2002). The nature of labor pain. American Journal of Obstetrics and Gynecology, 186, 5, 16-24.

Lundgren, I. & Dahlber, K. (1998). Women’s experience of pain during childbirth. Midwifery, 14, 105-110.

Macdonald, M. (2006). Gender expectations: Natural bodies and natural births in the new midwifery in Canada. Medical Anthropology Quarterly, 20, 2, 235-256.

Martin, E. (1990). The ideology of reproduction: The reproduction of ideology. In F. Ginsburg & A. Lowenhaupt Tsing. Uncertain terms: Negotiating gender in American culture. Boston: Beacon Press.

Martin, S., Landry, S., Stellman, L., Kennell, J. & McGrath, S. (1998). The effect of doula support during labor on mother-infant interaction at 2 months. Infant Behaviour and Development, 21, 556.

Meyer, B., Arnold, J., Pascali-Bonaro, D. (2001). Social support by doulas during labor and the early postpartum period. Hospital Physician, (Sept.), 57-65.

Michie, H. & Cahn, N.R. (1996). Unnatural births: Cesarean sections in the discourse of the “natural childbirth” movement. In Sargent, C.F. & Brettell, C.B. (Eds.)., Gender and Health: An International Perspective (44-55). Englewood Cliffs, NJ: Prentice Hall.

Nelson, A., & Sethi, S. (2005). The breastfeeding experiences of Canadian teenage mothers. JOGNN, 34, 5, 615-623.

Oakley, A. (1993). Essays on women, medicine & health. Edinburgh University Press.

O’Reilly, A. (2004). Labour signs: The semiotics of birthing. In A. O’Reilly (Ed.), Mother matters: Motherhood as discourse and practice (pp. 29-36). Toronto: ARM Press.

O’Reilly, A. (2006). Rocking the cradle: Thoughts on motherhood, feminism and the possibility of empowered mothering. Toronto: Demeter Press.

Patton, M.Q. (2002). Qualitative research and evaluation methods, 3rd Ed. Thousand Oaks: Sage Publications.

Reiger, K. (2000). Reconceiving citizenship: The challenge of mothers as political activists. Feminist Theory, 1, 3, 309-327.

Rosen, P. (2004). Supporting women in labor: Analysis of different types of caregivers. Journal of Midwifery and Women’s Health, 49, 1, 24-31.

Rothman, B.K. (1994). Beyond mothers and fathers: Ideology in a patriarchal society. In Glenn, E.N., Chang, G., & Forcey, L.R. (Eds.), Mothering: Ideology, experience, and agency (139-157). New York: Routledge.

Ruddick, S. (1993). Procreative choice for adolescent women. In A. Lawson & D. Rhode (Eds.), The politics of pregnancy: Adolescent sexuality and public policy (pp. 126-143). Ann Arbour: Yale University Press.

Scott, K.D., Klaus, P., & Klaus, M. (1999).  The obstetrical and postpartum benefits of continuous support during childbirth. Journal of Women’s Health and Gender-Based Medicine, 8, 10, 1257-1264.

Sherwin, S. (Ed.) (1998). The politics of women’s health: Exploring agency and autonomy. Philadelphia: Temple University Press.

Simonds, W. (2002). Watching the clock: Keeping time during pregnancy, birth, and postpartum experiences. Social Science & Medicine, 55, 559-570.

Sippert, G. (2005). Birth Companion Program Coordinator, personal communication, January 2005.

Smithbattle, L. (2003) Displacing the ‘rule book’ in caring for teen mothers. Public Health Nursing, 20, 5, 369-376.

Strauss, A. & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory, 2nd Ed.. Thousand Oaks: Sage Publications.

Treichler, P.A. (1990). Feminism, medicine, and the meaning of childbirth. In M. Jacobus, E.F. Keller, & S. Shuttleworth Body/politics: Women and the discourses of science (pp.113-138). New York: Routledge.

Trinder, L. (2000). Reading the texts: Postmodern feminism and the ‘doing’ of research. In B. Fawcett, B. Featherstone, J. Fook & A. Rossiter (Eds.), Practice and research in social work: Postmodern feminist perspectives (pp. 39-61). New York: Routledge

Wilson and Huntington. (2005). Deviant (m)others: The construction of teenage motherhood in contemporary discourse. Journal of Social Policy, 35, 1, 59-76.

Biographical Note:

Heather Holland recently completed her Masters of Social Work at Carleton University, Ottawa, Canada.  She has worked with the Birth Companion Program at Mothercraft, a community-based doula program in Ottawa, Ontario. She is currently the Executive Director of Planned Parenthood Ottawa.  Her interests are in the areas of women’s sexual and reproductive health and issues of access, equity, and identity.