Centre for Biomedicine, Self and Society

Consent, payment, and care: how doulas challenge social structures 

A discussion of how doulas shape the experiences of people giving birth - and challenge social norms in the process, by Andrea Ford

Andrea Ford

Would you pay someone to be supportive of you during a time of transition? This is what a doula does during childbearing, which includes pregnancy, birth, and infant care. Some doulas support pregnancy termination or pregnancy loss, HIV, or death.

They originated in the US in the late 1990s and are becoming more common in the UK. Much of my anthropological research prior to joining CBSS was about birth and doulas (I trained and practiced as a birth doula in California for a few years, and have just started practicing in Scotland). Analysing and developing conclusions about my research data is an ongoing process. 

"Paid family members"

Some of the most interesting questions that buzz around my mind are about the role of payment. A friend and fellow doula once described doulas as "paid family members" and this stuck with me (I gave a talk about it earlier this spring). Which relationships are considered worthy of pay says so much about society and its structure. Family members are often precisely the people you don't pay for their services!

Of course, there are long traditions of paid domestic work in Anglo-American cultures -- nannies, wetnurses, governesses, maids -- with national and regional variations that have a lot to do with different histories of race and class. There is also an interesting history of how domestic care work, especially mothering, became romanticized as too "pure" to be part of the labor market, part of the private sanctuary of "home" away from the stress of an industrial wage-laboring public.

For wealthy white women, the domestic feminine role was extolled as "priceless." But there is a slim difference between priceless and worthless, and this difference is constantly in play as doulas negotiate how to value the important work they do. 

Doulas as activists

Lots of doulas consider themselves activists because they want to change the system of maternity care and help childbearing people have better experiences. This is especially important for people who are typically marginalized in healthcare settings, whether that be due to race, ethnicity, LGBTQ+ issues, disability, and even weight. The racial disparities in maternal and infant mortality and morbidity are appalling in both the US and UK.

There is ample evidence that doulas significantly improve outcomes such as infant birth weight, rates of intervention, and experiences of trauma. But the people who most benefit from this type of support are often those who cannot afford to pay for it. 

Some doulas work on a sliding scale, and some volunteer with agencies like Doulas without Borders or Glasgow's Amma, but this doesn't account for the fact that those who are the best doulas for the socially marginalized have personal experience of marginalization themselves and are therefore the least able to work for free.

Moreover, in a society that measures value with money, doing doula work for free perpetuates the idea that care work and women's experiences are unimportant. Some advocate that doulas become professionalized and get paid by hospitals or insurance, but one of the main reasons they are effective is that they are directly accountable to their client, not the healthcare systems that they are working to reform. 

"Consent workers"

This is especially true when you consider the doulas as a "consent worker," a term I use in a recently published article. Doulas work to facilitate consent in the birthing room, and this is not just the "informed consent" that is supposed to be the foundation of the doctor-patient relationship, but a deeper type of consent that I call "attuned consent." Informed consent is based around a contract model that presumes both parties are equally empowered to agree to the terms of the contract.

There are many power differences in hospital settings, and using terms like "risk" and "emergency" can be coercive, especially in the moment. Birth is exhausting, and hospital providers don't have a lot of time, both of which mean giving and obtaining adequate consent can be challenging. By contrast, attuned consent takes power differences into account. It makes sure the person has adequate information and isn't pressured into a particular decision, and pays attention to things that are unsaid or were stated at a different time. It has to allow for complexity and ambiguity, because it's not always simple or easy for someone to know what they want. Embodied and emotionally-aware communication are key. 

Emotional labour 

Facilitating attuned consent is hard work! It's demanding, complex, and has high stakes. It requires tact and taking into account all the perspectives in the room, because angering a provider is not going to make the client's experience any easier.

People's birth satisfaction hinges largely on whether they felt they actively consented to what happened, and their birth experience has rippling implications for their postpartum mental health, breastfeeding and bonding ability, and the baby's ability to thrive.

What would it look like to really value this work? It would require some restructuring of how we as a society think about labor, care, and money.

This blog is based on a journal article Andrea has coming out later this year. “Attuned Consent: Birth Doulas, Care, and the Politics of Consent” is currently in press with Frontiers: A Journal of Women Studies