When your client lives with abuse....

Within minutes after stepping through her front door, I felt it.  Stifling static tension, he sits in his leather LazyBoy watching soccer, not taking his attention from the game as I enter. She noiselessly, gracefully moves around the room as to not disturb him.  Ushering me into her bedroom for our prenatal doula meeting, no mention of her husband stoically sitting in the other room. 

She didn’t reveal and I didn’t ask at that first meeting. I knew something was amiss between them.  I didn’t get it all put together until my postpartum visit in that same bedroom 5 weeks later.  Mari’s husband, hits her, belittles her, shames her and ridicules her.  His abuse is as long lasting as it is painful.  Mari has three daughters with him and this birth brings their fourth child, first son into the family.  She is in the midst of a long and secretive process of getting protective immigration status so she can free herself from her husband’s control.  In the mean time she endures his abuse.

Once Mari is settled into the labor and delivery room he begins to complain about how cold his feet are. Five minutes pass, and he is excusing himself stating his feet are just too cold- he’s headed home to change out of his sandals and will return soon.  He lives 3 miles/10 minute drive from the hospital.  His son entered the world 15 minutes after the cold footed father left the hospital.  Aamazing considering she was 4 cm with “lazy” contractions every 7 minutes when he left.  It was the fastest labor I had witnessed.  The OB nurses were quite surprised.

It was as if her body hurried to birth the baby while he was gone.  Maybe he left on purpose as to give her this space? I’m not sure he is that sensitive or perceptive.  Was her body tuned into some kind of instinct that protected her birthing from his intimidating, dominating, demanding presence? I’ll never know.

Yessica is a client I met through the neighborhood clinic I worked for as a contract doula.  Prenatally the clinic informed me that she having a baby with an abusive boyfriend.  Yessica and I spent lots of time prenatally discussing her relationship with her boyfriend and her wishes for his participation (or lack of) during the birth.  She was clear, he was not to be present.  The physician agreed with Yessica that it would not be safe for him to be present for the birth.  The plan was to alert security once she was laboring at the hospital as to keep him from entering the labor room, all parties agreed this was the safest and preferable plan.

After three hours of active labor at the hospital, Yessica begins to give up on herself.  I am pouring myself into supporting and encouraging her.  With each passing contraction she grows more and more pathetic.  The physician enters the room to observe her status.  Noting her distress, he stays to provide support.  It becomes clear Yessica has decided that she cannot and will not do this.  She wants help, is crying for help, begging really.  But not accepting anything we offer.  It reminds me of my toddler throwing a fit.  She is rude, loud, demanding and dramatic.  All her energy goes into her protesting and fighting her labor, making it all the more painful.  At one point she is combatant, swinging and clawing at me when I try to hold her hand and encourage her further.

As things escalate, a nurse informs us that her boyfriend is waiting outside the room and wants to enter.  He has charmed his way past the front desk and is pleading for a chance to enter the room.  The physician quickly exits to talk with him outside the door.    As I anticipated there is drama that distracts us all from the process of this labor and birth.  As a doula I am concerned for my safety.  

Stepping back from the scene, I realized she is playing the role she always does.  She made herself the helpless, victim to be pitied and rescued.  Miraculously her body continued to labor effectively opening and pushing even despite her best effort to fight it.  Within minutes of the baby’s birth the boyfriend entered the room, as agreed upon.  Yessica became a different woman.  She nuzzled into him, glowing with accomplishment and hungry for his affection.  It turned my stomach.  I felt so much sadness for this little family. 

What is a doula to do in cases where abuse is suspected/confirmed? Ignore or inquire?  Pity or probe?  The social worker in me wants to get the details.  I want justice. I want her to be protected, for her to heal and to know her worth and stand up and leave.  And it is not just her I worry about, but her children as well.  Leaving an abusive relationship is a move that takes time, support, resources and planning.    

There is a cross cultural element to be considered.  Culture and religion can make it even more difficult for a woman to break out of an abusive relationship.  For so long they accept his control, his power over them.  They feel shame, blame for their situation.  Religion tells them to trust, pray, forgive and forget.  Not addressing the need for protection, healing and separation.  Culture tells them he has the right to be controlling, to treat her how he wants.  She must be an attractive, attentive and passive mate; or he will mistreat her or stray.   

To answer my own question I think it is responsible of the doula to report any abuse she witnesses if there is physical evidence of abuse (bruises, scars etc).  Often it is not that clear or reportable.  Start with asking her questions, build on the rapport gained through the labor and birth. Don't ask if you aren't willing to do something with her answers. Follow up with her health care provider.  Give her information on resources, community counseling, woman’s shelter etc.  If nothing else, use the moments of empowerment and victory from the birth to reinforce her strength and power.

Both Mari and Yessica were already connected to services in the community.  They knew there was a problem, looked for support, and connected to professionals that can help them.  Unfortunately, even with education, support and counseling they still are in ongoing relationships with men that treat them horribly.  Abuse is a bondage that is challenging to break free of.

As I write this I realize that with Amish women there is a huge barrier to accessing these same services.  The Amish church’s patriarchal system handles transgressions internally.  There is a process of confession, repentance, and forgiveness- then silence.  There is no divorce; there is no leaving unless conditions are proven to be severe or highly dangerous.  I am frustrated at the lack of protection for the abused women and children in the Amish church.  Is there opportunity for counseling, sorting out the abuse and healing?  A chance for a fresh start, and new self-worth?   Where does the cycle of abuse end when children grow up with it?  How does it carry on to the next generation?

When it comes to abuse, I wonder is my little bit of love and encouragement enough?  Does an empowering birth where a woman is respected and protected make a difference?  I’d like to think it can. So doulas, midwives, doctors, nurses, model respect for her and birthing power. Give her a safe place to bring forth life.  Pay attention to her needs, work to earn and keep her trust.  Empower her in every little detail and pray that it will ripple into her life beyond the birth.

Two Brothers and Their Mother

My pay per minute cell phone rings at 2 am.  It is Cindi calling, her voice is soft and tired. She is calling me, her doula, for moral support.  She’s been uncomfortable for a day or so with contractions every 10 to 15 minutes.  Unable to sleep she is desperate for the contractions to either stop or really start in earnest.  My Spanish is fairly choppy at this hour of the morn, but I am able to reassure her that this long start is fairly normal. 

Carlos, Cindi and I walk up to the nurses’ station as the sun comes up.   The fresh faced nurse welcomes and shows us to the room we will be spending the day labor and birthing in.  Cindi immediately gets settled in bed, her contractions irritate her every five to seven minutes.  The fatigue and lack of strong/close contractions has me worried we are in for a long one.  Carlos is fluffing pillows, stroking back her loose curls, sitting on the edge of the bed.  He can’t get close enough.  Her discomfort is obviously unsettling for him.

As I watch Carlos care for his wife throughout the day, I see his love for her manifested in tangible ways.  So genuine is his focus and attention on her.  Sitting in the closet size bathroom as she showers, his muffled words of love and encouragement slide out under the door.  As she walks he guides her from table to bed to window and table again, circling the room.  Cindi’s cervix is held up at 7 cm for hours on end.  Carlos’s attention is not smothering or controlling, but sweet and soft.  I perch myself in the upholstered chair in the corner of the room, an observer.  My hands are not needed in this labor.

Nose buried in a cross word puzzle, I give Cindi and Carlos their space.  Attentive with a sharp ear, I add a word of encouragement when needed.  I am in awe of the instinctual way Carlos cares for his wife.  Up to this point my experience with Hispanic partners has been very different.  A culture that values macho men who guard their emotions in public often makes it hard for Hispanic men to feel comfortable in a birth room.  He has not once put his own interest or needs before hers, something here is different. 

As I work my puzzle I realize this scene is oddly familiar.  Two months prior, in the same labor room, another couple birthed their second child.  It is a few days past Christmas and Guadelupe’s labor is going faster than she can keep up.  Her handsome husband Marcos is sitting in bed with her upon my arrival.  Her eyes are closed, head cocked to her left resting on his shoulder while he holds her.  Their calm appearance is a façade, fear dwells just under the surface.  This is the second labor and birth for Marcos and Guadelupe.  Their first child, a son, was stillborn: lost to an accident with the cord at 34 weeks.   They now face their biggest fear, hoping that within hours their baby will cross over into their arms alive.  I notice we are not alone in the room.  Sitting by the small table with her hands folded in her lap and a soft smile on her face, a grandmotherly Abuela (Spanish word for grandma) waits.

Guadelupe moves into advanced labor and starts to stir in bed.  Abuela steps in behind her son, Marcos,  whispers something in his ear and he moves aside.  Abuela pours comfort and compassion on her daughter-in-law.  Speaking in a Spanish motheresse she expertly rubs over her back, down her legs.  Marcos looks to me and smiles shyly watching his mother in action.  All the sudden I find myself within a moment so full of love I am overwhelmed and have to step out of the room. 

I return to find Guadelupe soothed to sleep in bed.  Abuela returned to her chair by the table, her son Marcos sits in her lap enfolded in her embrace.  How a grown man still fits into his mother’s lap is beyond me.  I felt as though I was intruding on a private moment.  His head resting on her shoulder softly talking, Marcos, did not seem to mind my presence. 

Within the hour Guadelupe and Marcos welcome a small but healthy baby girl into the room.   A joyful exuberance of tears fills the room.  Abuela wails with relief at the sight of the first girl born to her family in two generations.  Marcos and Guadelupe hold each other and weep as their baby Natasha screams pinking with new life.

I turn to up from my puzzle as Carlos comes out of the steamy bathroom.  “No me aguantes (I can’t do this anymore),” comes wearily from behind him.  Cindi, hair dripping from the shower, is moaning and swaying against the bathroom sink.  Carlos’s weary look communicates his hope that after 7 hours of lazy contractions and no progress finally something has changed.  Just at that moment, the door to the hospital room opens, in walks Abuela!  As all heads turn, she greets us with a gentle loving confidence.  Her smile seems to say, “Its ok now, I am here.” I sense the relief from Cindi and Carlos. 

Abuela, as it turns out, is the mother of both Marcos and Carlos.  I felt sheepish I hadn’t put it together earlier.  How had I missed the similarities:  handsome brothers, both so caring and selfless with their wives, obviously influenced by this strong loving matriarch.  Just as she did before, Abuela enveloped her children with love- providing a much needed boost in morale.  Once settled, she noticed me sitting in the corner, and greeted me with a hug as well.

The matriarchal family structure is a cultural feature I studied in college.  However, I had never really seen it lived out in quite this way.  I will never forget the last scene in the birthing room.  Within the hour following the birth of Cindi and Carlos’s baby boy, the whole extended family assembled in the room.  Abuelo (grandpa) and Marco’s family with baby Natasha had all been waiting in the lounge down the hall.  I faded into the background as Abuela introduced the new baby boy to his grandfather, aunt, uncle and cousin.  More tears and celebration, blessings and prayers of thanksgiving, and of course hugging.  Abuela is the queen of hugging.  My favorite photo from that birth is Abuela seated in the rocking chair with her grown sons on either side, their arms around her shoulders.  In her arms she tenderly holds her new grandson.  

That annoying client that you just can't seem to like...

A doula is a trained professional labor coach.  Characteristics like patient, kind, compassionate run the top of list when looking for a good candidate.  I meet that criteria, my personality is well suited for tense situations, able to live through the unknown moments with others.  But I’m human and I have moments where my client is getting on my last nerve, the doctor is obnoxiously demonstrating he holds the power, when I just want to punch the father of the baby in the face.

The first time I really struggled to like the client was in my early years of hospital doula work.  This mama was a young woman, 19 years old.   I stepped in to cover for the primary doula who had already been in attendance for 18 hours.  The day prior, the mama arrived at the hospital barely in labor.  Her bag of waters broke at home and she checked in at the hospital within the hour.  No contractions. No labor.  Her doula, a newbie, was eager to attend a birth and so arrived early as well.  They spent hours in the room visiting, watching TV, waiting for the contractions to start.  As evening set in her contractions started on their own.  The contractions grew in strength and crept closer together through the night hours, keeping her from a restful sleep.

Upon arrival I discovered my young new mama client to be in a foul mood.  In the beginning I felt genuine compassion. I introduced myself with a bright smile and reached out to touch her shoulder.  She tensed under my hand and felt cold to my touch.  I noticed her eyes were freshly lined with black eyeliner, her long smooth hair in place, dressed in cute tight yoga pants and even tighter tank top.  Her basketball belly looked as though it would pull her 100 lb self forward and onto the floor. No ugly hospital gown for her. The primary doula clued me in that this young mother was alone, father of the baby an older married man would not be showing up to support her during her birth.  Again I was full of compassion, what a lonely place to be during an intensely vulnerable experience.

Soon the doctor ordered Pitocin be administered to bring on stronger contractions and active labor.  It took three nurses about an hour to start her IV.  With every anticipated needle stick there was drama, wailing, delicate rivers of eyeliner streaking her cheek.  And so I doulaed her through it.  I used all my tricks to calm her: holding her, encouraging words, distraction, relaxation, visualization- she quickly drained all the compassion from my heart.  “Good Lord,” I thought “if she can’t stand to get an IV how is she going to deal with the coming labor?”  Finally the queen bee nurse came in and took charge.  A motherly figure, all business and expert at both starting IV’s in tricky veins and handling a whimpering patient, finally successful with the IV start.  As the nurse left the room, she turned to look over her shoulder at me.  She gave me a knowing glance and with a sigh, “Good luck in here, you’re gonna need it.”  Fortunately the client spoke only Spanish and didn’t understand the nurse’s words.

The contractions swelled from loosely spaced mounds on the computer display to sharp peaked mountains every several minutes.  She was drowning, struggling to keep her head above water that was the pain.  Her lack of effort irritatied me. But I continued to give her my all.  Forced compassion, in soothing tones discussed how to get her through this experience.  She decided to get an epidural and as soon as she consented, she quit trying to cope.  Mama flailed for the next 20 minutes it took to get the anesthesiologist, signed consents and prep ready. 

With painful patience I held her as she had her final freak out.  Epidural meant more evil needles, she hadn't thought that far ahead.  After the IV experience I realized her fear of needles was real, no matter how illogical I thought it to be.  So with more wailing, an anesthesiologist’s harsh words and fresh kind nurse’s able hands we helped this mother receive the pain relief she needed to move through her labor. 

Once the nurse tucked her into bed, no longer feeling the crashing waves of contractions, mama closed her eyes and fell asleep.  Relieved, I left the room for a meal and some fresh air.  The surge of irritation and struggle to maintain compassion for this mama worried me.  Of course I had moments in other labors where it took efforts to step aside my own feelings to provide good care.  Somehow this was different.  I just didnot like her.  I hated to admit it to myself. I surely didn't want her to know or sense how I felt.  I spent extra effort compensating for my dislike.

For days following this birth I was haunted by how difficult it was to like her.  I felt shame.  This new mama so lonely, isolated, and young.  I understood why she acted so much like a child.  An unintended pregnancy leading to a life of increased obligation does not a joyful birth make.  Her life is so much more complex and difficult than mine. Did she sense my irritation, my effort to be kind and caring?  I'll never truly know.

This is a dilemma all care providers face from time to time.  As birth professionals it is our responsibility to process a our reactions. Self-reflection, honesty about our own prejudices and prickles lead to better self awareness and stronger ability to care for others. I know I am not a perfect human, or a perfect doula; but I don't want my imperfection to get in the way of giving competent care.

I 

Ten years since that first birth...you are invited to my party.

Evening is settling into the neighborhood.  Families are finishing their outside chores and gathering around the kitchen table to share a meal.  I sit at the stop sign exiting my cul-de-sac.  My daughter is sitting beside me.  She’s layered in a light pink hooded sweatshirt with her orange softball team t-shirt on top, her mit rests in her lap. We wait for the oncoming buggy to pass before I pull out.  A large gloved hand lets loose of the reigns and gives me an energetic wave.  His wife quickly peeks out of the side window, a 4x6 inch opening.  I can see her young eyes behind petite glasses and pointy nose.  She recognizes me and leans past the 7 month little boy sitting on her lap with a big grin and wave. 

“Another couple from your class?” my daughter sighs with slow exasperation.  “Yup” I say while returning the buggy greetings.  I glance over at my daughter, whose game I will miss tonight.  “They really like you mom, you must do a good job.” She comments.  In that moment I am reminded all at once, the price I pay each time I leave to do birth work and the gain in each new couple I connect with.  The cost and the reward.

Tomorrow is my ten year anniversary from that first life altering birth I attended as a doula,  May 7, 2004. Every year I pause to remember.  Writing it now it seems unreal.  Ten years.  I kept count for a while of all the births I attended.  By year three I’d lost track exactly.  If I had to guess now I’d say its anywhere from 150-200 births I’ve attended as a doula or midwife’s assistant.  I have only been teaching for three years, but I am closing in on 200 couples in my classes. 

This trophy is a treasured gift from a family that
 I was able to doula through both of their daughter's births.  

Last night as I waited for the caffeine and teaching induced adrenalin to drain from my body. I imagined- what would it be like if I could gather all these families together for one big party?  What would that look like?  Where are they all today? Do they remember me?  I decided there would be three distinct groups of people in attendance. 

*Disclaimer these are generalizations and not every family fits just perfectly into my categories*

The First Year Families: 

These are families I met through my work with Maple City Health Care Center, a low income health clinic in Goshen.  The clinic gave me as much doula work and I could stand those first few years of my career.  The families were Spanish speaking Mexican immigrants, living in a new place and far from their family support system.  It was such an honor to usher them through their births, buffering them from the healthcare system, comforting them when their mama or sister could not.  All these babies are now grade school students, ranging from third grade to Kindergarten.  I bump into these families at community soccer games, the county fair, chess meets and shopping at the mall.

Usually the mother and I exchange some shy glances trying to figure out “Is that who I think it is?”.  I am the first to make the move, to introduce myself again, sometimes I remember their names or the name of their child, but not always.  Recognition flashes in their eyes and a warm smile spreads across their face.  We are quickly reminiscing; she calls over her child and introduces them.  The timid and irritated child not fully understanding what the big deal is all about, flashes me a smile and “hey” and is back to the activity at hand.

The Mainstreamers:

This group of families is sprinkled through the years of my work. As much as I love working with people in other cultures, it is enjoyable to be with families “like me” as well.  Living in and around Goshen, alumni of the same school, enjoying comfortable midwest lives I feel an ease with them.  They drive family vehicles shuttling their kids to sports, the park, and school; balancing work and home life.  These families have means, strong partnerships and resources.  They are self-empowered, informed consumers of birth.  Working with these families allows me to utilize a different skill set.  During the labor and birth I work to honor their specific birth plan.  Partners are more informed about the process and participate intentionally in it. This informed and intentional aspect draws deeper meaning to the victory of the birth and welcoming of a new life.  Doula babies born to these families pop up in my Facebook feed- growing up before my eyes.    

The Amish:

If the Amish families I work with came to my imaginary party, they fill the parking lot with their family size “minivan” model buggies.  There would be several van loads dropping off the couples from the same neighborhood or same family.  A small herd of three and four year olds run about while their mothers bounce their still-in-arms siblings.  In reality, I encounter my Amish families throughout my daily life, neighborhood walks, local grocery store, weddings, and funerals.  Last winter I was on call for a very important homebirth 5 miles from my house.  On the verge of a huge blizzard, the forecast had me sleepless at night.  I soothed myself to sleep by counting in my head all the families between my house and hers that I knew from birthwork.  Families that would open the door if I knocked, families that would buggy me the rest of the way to the birth if I got stuck in the snow.  Would you believe it was 12 places between my home and hers? Twelve families who knew me, “Betsy Black, the lady that helps at births”.  What a blessing to know and be known by those around you.

Writing this impresses upon me that this is quite an accomplishment, this web of relationships.  This way of belonging to my community, to my neighbors; it is valuable.  Lately, I struggle to know where my professional life is taking me. The insecure question, “Am I doing enough with my life/with my gifts and abilities?”  creeps into my mind in quiet moments.  I struggle to defeat that insecurity.  Today as I celebrate at my imaginary party I am overwhelmed with the richness that birthwork brings my life and the value of my work. I am important just as I am.  My work matters. I am enough.