Are we saving each other or preventing our escape?
for doulas, birthworkers, & all keepers of thresholds
(This essay has been a long time in the making, developed over many conversations with fellow birthworkers. A special thank you to Cassandra Sirl and Colleen Kennedy-Schroeder for your friendship, your brilliance, and your passionate commitment to birthing families!)
The Reality
Every friday after leaving the breastfeeding medicine office, after hearing again & again about how much mothers are suffering under our current healthcare system—about the traumatic births & the expert misinformation & the insurance issues & the exhausting run-around of navigating the healthcare system—i wonder what the hell we’re doing.
How is any of this practicing accountability to eachother?
Holding Time emerged from deep confusion about how to meet everyday from within empire & climate collapse. How to attempt accountability to forces & futures we can’t see, let alone understand. How to move toward futures-to-come for the sake of our children & children’s children & onward. tbh, I’m not any less confused today than I was 3 years ago.
Yet as much as I’ve learned that there’s so much we don’t know, I’m also frequently reminded that there’s a lot we do know about accountability to futures-to-come.
We know that the billionaire lifestyle is not accountable to Earth’s future.
We know that war is a major contributor to climate collapse.
We know that supremacist beliefs harm all of us.
We know that racism is a public health emergency.
We know that racism & misogyny (and the interaction of the two, named misogynoir) has been clearly identified as a main cause of death & serious complications in pregnancy, childbirth, & postpartum.
We know that racism & sexism come from the people in power within the systems & from the structures of the systems themselves, which have always been scaffolded by capitalist colonialist patriarchal logics.
And we know, without a doubt, that the institutions of care that are supposed to be committed to our health & wellbeing are killing us. In fact, compared to 2013, the year I had my first child:
The maternal mortality rate in Ohio has tripled.
The racial disparity has grown worse: Black women in Ohio are over 3 times more likely to die from pregnancy-related causes than white women.
The number of preventable maternal deaths has risen sharply since the early 2010s; the most current data we have from Ohio reports that, in 2021, 88% of pregnancy-related deaths were fully preventable with adequate care.
We must do more. But what exactly is the “more” we should be doing? Could it be that we really need to be doing less?
The Intervention
One strategy that healthcare systems are employing in response to the real-life harms of institutionalized maternity care is to create programs that integrate doulas into the hospital system.
Doulas are companions to birthing & dying people, to humans in transition.1 Doulas provide physical, emotional, and educational support to people who are pregnant & birthing, to families during the vulnerable postpartum period. Some doulas care for people before, during, and after an abortion.
Nowadays, there’s so much more awareness about the benefits of doula support. When my husband and I moved to Cleveland from Oregon 13 years ago, right at the cusp of my third trimester with our first child, I was so eager to start working as a doula even though most everyone I knew had no clue what a doula was.
As part of the requirement for my master’s thesis, I had collaborated with a birth center and the doula training organization DONA International (which, coincidentally got its start in Cleveland) to offer a bilingual doula training for Spanish-speaking mothers. I attended the birth & postpartum doula training over a weekend that coincided with finding out I was pregnant.
While some people in Oregon and Washington were familiar with doulas, I didn’t hold much hope for Cleveland. But very quickly I found out there are thriving birthworker collectives and doula communities here. And these days, most people I interact with have at least heard of doulas. Increased attention to maternal & infant mortality rates, driven by Black birthworkers & Reproductive Justice activists, has led to massive growth in the doula industry.
I often encourage the families I see to hire a doula for their birth & postpartum, especially when they have no family support close by. Doula care can decrease the risk of both preterm birth & cesarean birth. During the postpartum period, doulas tend to ease maternal anxiety, support breastfeeding initiation, and often help new parents keep pace with the medical system’s expectations for postpartum follow-up (it’s so hard to leave the house with a newborn, let alone after major abdominal surgery!).
In Ohio and other states where doulas are gaining traction as an “intervention strategy” to “improve patient care”, there are new pilot programs designed to show the benefits of hospital-based doula support and campaigns for insurance coverage & doula licensure.2 Many doulas I know are thrilled to finally be covered by some insurance companies because this provides a predictable payment source, even though insurance payment does not guarantee doulas actually get reimbursed fairly for their work.
This integration into the health insurance system continues to expand the doula industry: Licensure demands training standards & scopes of practice, which require training organizations. Doula training organizations compete to be the “approved” training credential recognized by hospitals. All of these extra steps increase the cost to even become a doula in the first place.
Add to this the problem of burnout, which should come as no surprise to anyone familiar with carework. With all the hustle needed to survive as a birthworker within capitalism, doula agencies & collectives are continuing to pop up everywhere, promising doulas a more sustainable workload.
Doulas can hold space in many ways, but doulas working within harmful systems will always be subjected to the harms of the systems. When these institutions claim long enough to be “the way things are”, they become the way things are.
We are seeing the consequences in the form of increasingly horrific maternal mortality rates that have not improved, even with more access to doulas.
We are seeing the consequences of high rates of burnout in birthwork, like in healthcare, social work, and other types of carework, like all “interventions” that keep harmful systems intact at the expense of the carers themselves.
All of this together leads me to the question: Do we really need more interventions, or could the interventions themselves be part of the problem?
The Consequences
When the intervention only addresses some aspects of harm & not the underlying structures that create the systems of harm in the first place, what is the purpose of the intervention?
Let’s look at what the intervention does.
When doulas are brought in by hospitals as interventions to the harm the hospitals themselves are enacting, some people are able to access doula support when they need it the most. Some lives may be saved, such as when a doula notices a lot of vaginal bleeding postpartum and is able to call a nurse in quickly for help. This is great! Every life saved, every birth witnessed is a cause for celebration.
I also see at least 3 other things that happen as this intervention rolls out:
The healthcare systems signal their commitment to improved outcomes without actually making hospital birth safer. This stated commitment means that the hospital will get funding & stakeholders can be appeased, regardless of whether or not there are actually fewer people killed or traumatized through interaction with the hospital system.
Hiring doulas to provide “emotional support & comfort techniques” during hospital births will not actually address racism in healthcare, no matter how much the pilot programs promise that they “improve patient experience and birth equity”. Commitments to make hospital birth more comfortable rather than actually safer is really an investment in silencing our voices, in gaslighting us to believe that the institutions are not actually abandoning us & extracting from us every chance they can get.
The healthcare industrial complex is right there to support this signaling. For example, an organization called Health Leads claims, “Implementing standards for doula-friendly hospitals allows patients and doulas to know they’re in good hands.” Essentially, they are selling their “customized doula-friendliness intervention” via their “Doula-Friendly Hospital Model and Guidebook” and “statewide doula-friendly designation” as a way for hospitals to signal to families that they are a safe place to birth, even when they are not safe places to birth.3
Companies that claim to be expanding patient access to doula care “by reducing institutional barriers and formalizing referral partnerships”—something that Health Leads claims to be doing with their “doula-friendly hospitals pilot initiative”—obscure the fact that formalized referral partnerships ARE part of the institutional barriers. Cleveland Clinic, for example, doesn’t “allow” their clinicians to refer outside of their system, even if their own clinicians cannot provide the needed help. In this example, the “referral partnership” itself is the barrier to improved care.
Hospitals delegate responsibility for “patient satisfaction” to doulas, while simultaneously making it harder for doulas to respond when they witness & experience harm. When doulas become intervention strategies employed by hospitals & insurance companies, doulas are forced to become more responsible to hospital-defined scopes of practice, to clinicians & hospital staff, and even to training organizations & boards of health than to the families they are in relationship with. This limits their ability to advocate for the birthing family unless it is done in a system-approved way, within the same systems that continue to kill us.
Directing doulas to be a “calming” influence within hospital systems that are actively harming women is telling us to stop naming what we see, to be more complicit in the ways we are traumatized by healthcare systems and all the ways this affects how we connect with eachother. (I’m always including myself in this! There is no innocence.)
The call for “clearer roles” and “consistent policies” for doulas is a demand to make human support & care more legible to those in power because then we will be easier to control and blame. When the expectation is set that doulas are supposed to work with clinicians, to “collaborate” in an “integrated”, “respectful”, and “effective” way within the systems that are even more harmful to us now than they were 10 years ago, we are then set up to continue to perpetuate the same harms and/or experience harm ourselves when we attempt to disrupt dangerous scenarios. When these are the standards we adopt for ourselves, we are choosing to hold ourselves accountable to the institutions rather than to mothers and babies.
When hospitals “integrate” doula care into their systems with the aim of “Clinician-Doula Collaboration”, they defer accountability for negative outcomes while taking credit for any positive outcomes.
Through “integration” of doulas, stakeholders can claim to be working toward “birth equity” as a buzzword while not actually changing anything within the inequitable systems. “Integration” assures that if there are improved maternal health outcomes, the hospital will take full credit even though all they’ve actually done is removed their own barriers to “allow” the doulas to be present.
Pilots and programs that aim to “refine what works” to create “scalable approaches to equitable maternity care” are trying to sell someone something. Equitable maternity care begins and ends with listening to mothers, to each & every person, each & every time they seek care. Equitable maternity care means caring directly for mothers in the ways they need to be cared for, instead of investing in organizations who pledge to “test collaboration processes within real births.”
Taken together, when systems express verbal commitments without real change, while shifting responsibility for improved outcomes from hospital systems & clinicians to doulas, people in power can defer accountability indefinitely.
Our lives are & will always be at unnecessary risk when hospital systems (like Cleveland Clinic) are more accountable to stakeholders, financial advisors, insurance companies, & political power than to the human beings they care for, the employees they hire, & the communities within which they sprawl out their concrete bodies.
You might be asking at this point, “ok… but what can be done? Isn’t something better than nothing?” After all, doulas are important support for birthing people.
And this is where abolitionists like Ruth Wilson Gilmore and Mariame Kaba have taught me that we don’t need to keep trying to fix what’s broken. We don’t need to save the hospital systems from themselves. We don’t even need to save mothers from the dangers of birth.
The reason so many women in the US, especially Black women, are dying during pregnancy & postpartum is because the intervention of hospital birth as the standard model of care causes harm, because the standard models of care in the US have never been determined by Black women, or by anyone other than capitalist white men.
Of course, hospitals also help. Hospitals save lives & hospitals end lives & hospitals save plenty of lives that were only at risk because they were in the hospital (remember the statistic that 88% of pregnancy-related deaths in Ohio were fully preventable? A significant number of these are categorized as provider error such as failure to recognize warning signs leading to a delay in treatment, or an unwillingness to listen and believe what the person in front of you is saying).
Yes, hospitals help people and hospitals hurt people. Both things can be true, and both things are true. This is a contradiction that we are forced to face and learn how to negotiate in our own lives & collectively.
There is no designation or scalable solution that will solve the problems inherent in these systems built on racial capitalist patriarchy. When we insist on being legible to systems that extract from us, we’re consenting to our own dehumanization & the dehumanization of those we care for. The ways we are trying to save eachother may be preventing us from escaping the systems altogether.
we don’t need more treatment plans. We need to find our escape routes out of this stuck place of needing interventions for the symptoms of the interventions for the conditions caused by the interventions. There’s no intervention that will show us how to escape from the pain of being in bodies that have been shaped to hold self away from other, other from self. There are no interventions offered by an empire that is crumbling before our very faces that will save us from its crumbling.
These days, I read everywhere “we will save us” and yes yes yes this is true, but this will only happen if we find each other first. Each of us stuck in the paradigm of separation, we need to find our escape routes first.
From Dystopia to Thrutopia
The majority of modern stories around maternity care–pregnancy & birth & breastfeeding & all of it–exist in one of 2 realms: Dystopia or Utopia. Breastfeeding, for example, is either one of the hardest & most painful things you could subject your body to, or it’s a glorious experience of bonding & mutual care. We don’t hear much about the in-between, even though most of us have experienced a little bit of all of it.
The in-between can be a really uncomfortable place to be. It’s not easy to recognize the contradictions we’re living within without trying to resolve them as quickly as we can. Living contradictions means we can’t guarantee eachother safety or ease or clarity. We can’t even promise eachother comfort, because discomfort is inevitable when we move through transitional moments.
What is needed now isn’t more stories of dystopia (they’re not hard to find) or of a utopia that seems too far-fetched to be real. What these contradictions call in now are thrutopian stories. “Thrutopian visions craft grounded, plausible and inspiring route maps from a recognisable present towards a future we’d be proud to leave behind.”
Doulas & all birthworkers have so much power to seriously disrupt the harms of our current healthcare system because we know how to hold eachother within these threshold timespaces. If we didn’t, then we wouldn’t have hospitals & insurance companies & boards of health trying to “integrate” us as interventions, to extract our care in order to fill in the gaps that threaten to swallow us all.
Now I ask us, birthworkers & deathworkers & doulas, How might we integrate with eachother instead of with the institutions? How might we strategize differently in these transitional thrutopian times?
Those of us positioned at thresholds, attempting to hold timespace for eachother in this wildly uncertain time, we don’t need to prove our success. We don’t need to prove our offerings as scalable or marketable because we don’t need to follow any template–our own or others’. We can, instead, move “forward” in time not by walking a straight line but by prioritizing the next generation, and then the next, and then the next.
Mothers, birthers & carers of futures-to-come, we aren’t holders of the threshold because we agree to be walked over. We’re the threshold because we’re the pivot point, the door that can learn how to open itself to new possibilities.
Birthworkers, our value doesn’t emerge once we’re properly integrated into the systems or once we’ve built a sustainable business. Training programs & certifications don’t grant authority or wisdom. We are guardians of threshold spaces.
We are all bridges that grow ourselves with our own longing for the other side of the turbulence, bridges toward thrutopian tomorrows. Empire wants us to forget this so we must keep reminding eachother: only when we center life can we grow into our full humanity—not as raced & gendered citizens, not as eternal caregivers, not as birthing vessels, not as human bottles, but as holders of time, as forces of nature, as sovereign & responsible selves.
Doulas are birthworkers, but not all birthworkers are doulas. Even within the world of birthworking, there are controversies about what doulas should do & how, about the economics of doula businesses, and even about the word doula itself. Currently, I work as a birthworker specializing in lactation, and no longer work as a doula.
There are many models being practiced, and exploring them all is beyond the scope of this essay. My point here is not to call out any specific program or organization, but rather to name the patterns of response to maternal & infant mortality that I’ve observed & participated in for the past 15 years, while working as a public health educator, a postpartum doula, and a board-certified lactation consultant at an outpatient clinic. I found this article to be a helpful overview of current campaigns to address maternal mortality rates in Ohio, spearheaded by Black birthworkers and activists.
For the record, I’m not singling out Health Leads or any single doula initiative. I’m writing about it because it was featured in a recent newsletter sent by the US Breastfeeding Coalition, under the heading “Action Opportunities”. I’m sure there are plenty of other examples to choose from… after a very brief search I found the Doula Friendly® Initiative, a whole different designation based out of Florida. This is capitalism grinding along: lots of branded ideas based on other successfully branded ideas (think: Baby-Friendly USA), and, ultimately, very little change.