Through Birth, A Companion

It was close to midnight when doula Hana Lehmann ’13 joined her clients at the hospital. The first-time mother’s water had broken early in labor, increasing the likelihood of bacterial infection—and throwing the parents-to-be’s birth plan out the window.

“She wanted to give birth naturally, with no anesthesia or surgery,” says Lehmann, who has supported nearly 100 births. To speed things up, doctors administered Pitocin, a powerful drug that induces labor. The mother grew anxious, given her family history of complicated deliveries.

“I had to be creative about what comfort measures we used,” Lehmann says. “I held the fetal monitor the entire 12 hours of labor, and we just kept rocking and rocking. I coached her through every breath until, finally, with one last push, she gave birth to a baby girl. That was beautiful: to come alongside her, to push against these traumatic histories.”

Disorientating, transformational: Every birth is unique, but no birth is easy.

“The truth is, I can’t take away pain,” Lehmann says, “but I’m not going to let you suffer.”

Stripped of culture-of-birthing baggage, this is the essence of a doula: empowering, validating, nurturing—there, so a mother is never alone.

THOUGH emotional support has always been a part of childbirth, doulas as a formal profession are somewhat new. As the birthing process became increasingly medicalized over the past 50 years, doulas emerged to supplement, not replace, medical staff—by caring for pregnant women “from the waist up.”

However, they’re not universally admired: Even at the best of times, birth is dangerous, says Emre Kayaalp ’95, a professor of obstetrics and gynecology at the Weill Cornell Medical College, and critics worry that doulas drive their own agendas, pressuring parents to eschew hospitals and modern medicine in favor of “natural” births that may unduly endanger mother and baby. But medical schools are also increasingly teaching that doulas can provide additional, valuable service.

“Whoever the patient wants with them to have a more comfortable, positive experience,” Kayaalp says, “that person is fine with me.”

Doulas are neither anti-doctor nor anti-medicine, says Penny Payson Simkin ’59, heralded as the mother of the modern doula movement. Rather, she says, they help women understand they have options and can make their own decisions.

A trained physical therapist, Simkin began her career in 1968 teaching birth classes, with several students inviting her into the delivery room. At first Simkin simply observed, but her role evolved, in part because of the serendipity of science.

In the 1970s, two pediatricians, Marshall Klaus and John Kennell, studied maternal–infant attachment in Guatemala. They observed that with someone else continuously present, the mothers had better birth experiences and outcomes—even though the observers weren’t trained to support the women.

Such accompaniment stood in sharp contrast to the shifting birth culture in America. As women increasingly moved from home births to hospitals—where doctors and nurses attend to many mothers at once—women lost the one-on-one nurturing they once had from midwives and female relatives. In this tension between medicalization and support, Simkin saw potential to augment what hospitals and family provided.

Twenty-five years ago, she co-founded the nonprofit Doulas of North America (DONA) in hopes of improving the birth experience for all mothers. Now known as DONA International, it’s the largest doula certification program in the world.

“We can’t control how long labor and delivery will take or whether it’s complicated or not,” Simkin says. “What we can control is how we care for women. She is never going to forget this experience—how she’s cared for is more important to her long-term feelings about the birth than anything else.”

Whether pursuing birth or postpartum certification, Simkin’s doula training recommends completion of a DONA-approved workshop, familiarity with a reading list developed by the world’s top doulas, acquired expertise in breastfeeding methodology, and auditing a childbirth class. Would-be doulas must also practice hands-on support for several clients, receive a professional evaluation, and develop a community resource list.

Simkin and DONA’s ultimate goal is a doula for every woman who wants one. But with services ranging from $400 to $4,000—and insurance rarely covering the cost—they’re still often seen as a luxury. Many doulas are trying to change that, by volunteering or using a sliding scale for their fee. Furthermore, charitable organizations across North America also provide doula services to underserved communities.

LEHMANN says she still encounters pushback from skeptics who see her work as little more than alternative-medicine quackery. That’s why part of Simkin’s advocacy is highlighting the science behind doula work.

“I’m pretty hard-nosed about sticking to a scope of practice demonstrated to improve outcomes,” says Simkin. “We can prove that we lower cesarean rates when we stick to a particular model of care.”

In 2013, for example, the prestigious Cochrane Library published a systematic review of 22 randomized controlled studies and found that women receiving continuous birth support as opposed to usual care had shorter labors, fewer cesareans, and reduced use of analgesics, oxytocin, and forceps.

Even the best hospital staff cannot provide continuous attention, because doctors and nurses must focus on clinical aspects of care, and often juggle multiple patients. The ability to focus attentively on a single person, to support her through every moment of the experience, is one reason some choose to become a doula instead of a doctor or midwife. But continuous care is demanding. Labor can last for 18, 24, even 36 hours, and a doula attends to the mother through all of it, massaging her through the pain.

Now a great-grandmother, Simkin no longer attends births professionally, focusing instead on education and advocacy. But a new generation is carrying on her mission in the birthing room—many supporting parents years older than themselves.

“You don’t need to have given birth yourself to be present, openhearted, and grounding for the person giving birth,” says Emma Thomas ’13, who trained through the student group Swat Doulas. “My job is to support people to trust themselves. When the person giving birth feels out of control, it’s you who needs to hold it down and provide and project that confidence.”

FOUNDED in 2012 by Sonja Spoo ’13, Swat Doulas, which offers DONA certification while hosting discussions about America’s culture of birth, was born from Spoo’s desire to put academic knowledge into practice. As a political science major, Spoo studied how national and state policy affected individuals; she wanted to use what she learned by helping local communities.

“That fits within a Swarthmore education as far as being one that gears you to serve the broader public and the common good,” says Spoo, who still volunteers as a doula but is focused mostly on reproductive justice and policy in Washington, D.C. “When you’re in the birthing room, you see the human impact of all these policies. There are massive disparities in access to quality maternal health care in the United States, especially for black and brown women, which is one of the reasons why maternal mortality rates are higher in the U.S. compared to peer industrialized nations.”

Communication can be an issue, too. The summer before her senior year, Miriam Zoila Pérez ’06 volunteered as a doula in a North Carolina hospital. A woman walked in: alone, unable to speak English, and in labor. A cesarean section was the last thing she wanted, but she couldn’t tell the staff—until Zoila Pérez translated.

“With birth, there are a lot of levels of medicalization, race, class, and language,” says Zoila Pérez, a bilingual child of Cuban immigrants. “There’s a lot to unpack. As the one person in the room who speaks both languages, how are you not going to communicate to this person what’s happening?”

FOR Killian McGinnis ’19, a current member of Swat Doulas, it’s an unspoken communication that’s often most meaningful.

“I’m inspired by the quieter, subtle moments of connection between those in the delivery room,” she says. “Sitting by a mother’s bedside in the wee hours of the morning after a long and stressful labor, reassuring her of her strength before she delivers. Holding someone’s hand as they breathe through strong contractions. Seeing a couple’s relief and joy when they finally have their baby in their arms.”

Those moments, too, are why Lehmann continues as a doula. Even now as a master of divinity student at Princeton, she makes time to mentor the members of Swat Doulas and to remind them that the physical and emotional demands, the skepticism of critics, the long, draining hours of labor and delivery—they’re worth it to act as an advocate for mothers and a witness to the wonder of childbirth.

“It’s exhausting, but I love being a doula,” Lehmann says. “I’ll keep doing this forever.”