repercussions of doula's redefining the word "advocate" - Mothering Forums
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#1 of 69 Old 06-02-2008, 04:06 PM - Thread Starter
 
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The word advocate means;

From Dictionary.com

advocate
–verb (used with object)
1.to speak or write in favor of; support or urge by argument; recommend publicly: He advocated higher salaries for teachers.
–noun
2.a person who speaks or writes in support or defense of a person, cause, etc. (usually fol. by of): an advocate of peace.
3.a person who pleads for or in behalf of another; intercessor.
4.a person who pleads the cause of another in a court of law.

intercessor
–noun
a person who intercedes.

Advocate does NOT mean, "to empower, to support (just support), to encourage, to remind, or to hold the space for".

Now, I am not making judgements about doulas here or doula certifying organizations, because I realize they are in a pickle, and if they did actually advocate, they would risk being barred from the delivery room altogether. I just want to discuss what the ramifications of calling yourself an advocate, yet clearly not advocating, are. And why exactly do doulas, and some doula certifying agencies, use a term that they do not really fulfill? Why confuse what your role is by using a term, and then redefining the term? Why not simply leave the term out of it?

If you say, "I'm an advocate for you" and then stand by and watch a birth go sour, powerless to do anything lest you lose your certification, what affect does this have on the mother? And if she comes back and says, "you didn't advocate for me", you will just say "no, I DID, it's just that, well, when we say advocate we don't mean advocate." Huh? Honestly, does this really fly in the doula world? How do you doulas reconcile this obvious conflict?

I think that representing oneself as an advocate, and then being unwilling to actually advocate, sets women up to arrive at their births unprepared to protect themselves. It also leads to feelings of anger and betrayal at the doula, as in, "why didn't she say something? why did she just stand there and watch this happen?" It also leads to the doula feeling traumatized, and being forced into a role where she has to witness clients being manipulated, coerced, or abused, yet she is powerless to do anything about it.

There is also the issue of a doula, who is not allowed to actually advocate, yet who has to try to convince clients that this alternate made-up definition of the term advocate is really what advocate means despite what your dictionary may say, has to then sugar coat the birth to make for good birth memories for the clients. Doesn't this feel like jumping through many convoluted hoops for the doula? So, if a birth goes sour, and a doula is forced to simply stand by and watch, she then must convince her clients that advocate doesn't really mean advocate, and that the birth was actually a great experience, despite the trauma the woman herself may actually be feeling. And some certifying agencies actually discourage contact between clients and doulas after the 1 or 2 postpartum visits, so when the woman's true feelings of the birth do come to the surface, the doula, who "held the space", who "protected the memory" is generally long gone out of that woman's life, which makes true processing impossible.

How does this benefit women in the long run? The hospitals can just keep getting worse and worse, and doula's can just keep buffering and reframing it to the clients. But then will change ever occur?

Of course, my above comments are only applicable in cases were an "advocate" is needed. In wonderful smooth hospital or home births, a doula can simply do what a doula does best and support and comfort the mother. I wish that is how all births went and then this wouldn't even be an issue. But the truth is, the hospital system is not a great place to give birth in, and doulas must encounter this issue quite often I would imagine.

I had a doula and I found her to be a big comfort, and to some extent an advocate, but she could only go so far and her main job was trying to reduce the stress on me that was being caused by the hospital staff. So, I am not anti-doula, I am simply wondering how they and others feel about these issues.
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#2 of 69 Old 06-02-2008, 08:32 PM
 
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I don't know, but that's exactly why my interest in becoming a doula lasted all of a week.

I thought the whole point was to speak for those who could not speak for themselves due to the hormones of labor so that women could be in their own space and in control of their own births without having to worry about pressure from the outside world. So that women didn't have to say "yes" again to what they had already asked for or "no" again to what they had already refused.

But it isn't. And if you try to make it that, you get in trouble and get a bunch of other people in trouble too.
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#3 of 69 Old 06-02-2008, 08:37 PM
 
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I dont think I have ever used that term in reference to myself to a client. I am a birth advocate in the general sense of the word, in my work with the community, our birth network, etc. But as a doula, I define my role as one who supports and educates the families and helps them learn how to advocate for themselves. Handing over that job to a doula is no better than handing over your birth to an OB. I think a grander goal is to give the power back to the birthing families.

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#4 of 69 Old 06-02-2008, 10:12 PM
 
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I dont think I have ever used that term in reference to myself to a client. I am a birth advocate in the general sense of the word, in my work with the community, our birth network, etc. But as a doula, I define my role as one who supports and educates the families and helps them learn how to advocate for themselves. Handing over that job to a doula is no better than handing over your birth to an OB. I think a grander goal is to give the power back to the birthing families.


It isn't my job to get them the birth they want. I can remind a woman/ her partner of her desires in the heat of the moment, but it is her birth, she must advocate for herself.

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#5 of 69 Old 06-02-2008, 10:19 PM
 
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I am very specific that I am NOT their advocate. I am their support and their memory, more than anything else. I tell them, dad has to advocate for mom if she becomes unable to advocate for herself. I'm not certified and have no interest in certifying, so it's not that for me. I think about the greater good, and women being deprived of doulas because of something I do that causes some hospital to outlaw them. I am also not a particularly confrontational person and the idea of fighting with medical staff gives me cold sweats.

So, I'll say, "Do you want a few minutes to think about that?" when nurses suggest things, so that when the nurse leaves I can tell them what I know and they can make a decision. I say, "What did your birth plan say about X?" to remind the mom to remind the doctor about what she wants.

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#6 of 69 Old 06-02-2008, 10:38 PM
 
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Getting the *family* to advocate I can see, but getting women to advocate for themselves during labor? Too much neocortex.
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#7 of 69 Old 06-02-2008, 10:51 PM
 
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And that is why, in a perfect world, woman and their care providers would be on the same page... so you aren't hashing things out during labor. One of the huge disadvantages of birth in a hospital.

Midwifery Student and Mama to 2 daughters and 3 sons.     
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#8 of 69 Old 06-03-2008, 06:04 PM - Thread Starter
 
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Originally Posted by sapphire_chan View Post
Getting the *family* to advocate I can see, but getting women to advocate for themselves during labor? Too much neocortex.
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#9 of 69 Old 06-03-2008, 06:11 PM
 
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I agree with others, I am very specific that I can not speak for them in labor. Most of the work I do happens before labor, when we discuss the birth plan and I make sure the parents are well educated about the possibilities. Of course we can't talk about everything, but I make sure they have a pretty strong grasp of the common procedures so that I don't have to start from scratch when the doc comes in and wants XYZ... I can tell clients I can remind them what is in their birth plan and help them get the information they need to make an informed decision, but I will not speak for them.
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#10 of 69 Old 06-03-2008, 07:20 PM
 
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I remember my doula very specifically telling us what her role did and did not entail. She was very specific in saying that she would help facillitate communication, but that the decisions would all be up to me and dh. So, I never felt like her role was to "advocate" for me.

I think it's a really hard line for a doula to walk. Because the family really does need to be the ones with the power and the responsibility, and should be advocating for themselves (although, ideally, they would have supportive caregivers and "advocating" wouldn't be necessary). But, often moms really aren't in a good position to advocate for themselves while in labor, and they do NEED an advocate. And sometimes it really is in mom's best interests for the doula to assert herself a bit more. I know my doula suggested that I get a cervical check, based on my emotional and physical signposts. My nurse, who had not been around during my laboring, poked her head in and said cervical checks were not a good idea since my water had broken, and how about a bath instead? That sounded good to me, but I didn't realize I would have to wait another hour while she went and "got permission" from my doc to use the bath. Meanwhile, my vocalizations really changed, and my doula made a stronger suggestion that I might be ready to push, and perhaps I would like an exam? When I said okay, she went to find the nurse. I found out later she had to practically drag her back into the room so we could tell her I wanted an exam. Sure enough, I was complete and baby was not much longer in coming! So, thanks to my doula choosing an appropriate moment to be a bit more assertive, ds1 was NOT born on the toilet!

There was another point in the birth, when my doula's encouragement/suggestion turned out not to be the best course of action. I was finally told it was okay to push (although my body'd been doing so for awhile at that point all on its own anyways), and my doc asked if I wanted to change positions for labor, as per my birth plan. Worn out and not wanting to make a decision, I heard my doula say that I was progressing really well the way I was, so I just stayed there. Well, in hindsight I'm pretty sure the lithotomy position was the cause of my 3rd degree tear. So, I kind of wish someone... doula or doc... had given me a bit more of a push to change positions. Staying put is what I wanted to hear at the time, but not what I NEEDED to be told, kwim? But, really, it WAS my decision, and neither one of them are fortune tellers. So, I never blamed them or spent too much time kicking myself for that decision. I just chalked it up as a learning experience and decided that next time I would change positions! (Well, next time I stayed home and never had to get back in a stupid bed to begin with, but that's another story!)

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#11 of 69 Old 06-04-2008, 03:49 PM
 
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I'd really like to see this thread moved or re-posted in the Birth Professionals area, is that a possibility?

I know there has to be more than 9 people willing to give it some deep thought and a good discussion!

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#12 of 69 Old 06-04-2008, 05:15 PM
 
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Getting the *family* to advocate I can see, but getting women to advocate for themselves during labor? Too much neocortex.
Yup, I think it is unreasonable to expect a laboring woman to have to fight her way thru her birth, even after being upfront about what she wants and doesn't want.

If you write in your birth plan, I don't want my water broken for any reason. You shouldn't have to fight off nurses, and docs your entire birth to not get your water broken. This is the part that makes me so angry about the system. Why can't the doula just say, "it is in her birth plan that she doesn't want her water broken." The doula isn't 'making' the discision for the mother. She is reminding everyone in the room that the mother has allready made her decision.

Okay, so I know what the answer is and 'why' they can't do that. It just makes me mad is all.

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#13 of 69 Old 06-04-2008, 05:52 PM
 
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Getting the *family* to advocate I can see, but getting women to advocate for themselves during labor? Too much neocortex.
No, I simply remind her and her partner of their desires that they had communicated to me ahead time. Birth is not the time to be going over this.

For instance,
Mom expresses to me that she doesn't want an episiotomy. Doctor picks up the scissors. I say "Mom, Dr. So and so is going to do an episiotomy, is that okay with you?" Chances are she's going to say no. If I hadn't said anything then she would have had no voice whatsoever. Pushing is not the time to be making any decisions that require heavy thinking.

I really hate that birth advocacy is neccesary. I think all women's choices should be valued.

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#14 of 69 Old 06-04-2008, 09:59 PM
 
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No, I simply remind her and her partner of their desires that they had communicated to me ahead time. Birth is not the time to be going over this.

For instance,
Mom expresses to me that she doesn't want an episiotomy. Doctor picks up the scissors. I say "Mom, Dr. So and so is going to do an episiotomy, is that okay with you?" Chances are she's going to say no. If I hadn't said anything then she would have had no voice whatsoever. Pushing is not the time to be making any decisions that require heavy thinking.

I really hate that birth advocacy is neccesary. I think all women's choices should be valued.
This is what I have told my clients I will do. I have it written into the contract that I will not be making decisions or having 'discussions' with their providers, but make it clear that I will get as much information as I can beforehand, so that if the doctor asks me a question, I can say "Well Sarah here said she didn't want the pitocin, but we'll let you know if she changes her mind". Or... if I see him starting something she doesn't want, I have told clients I will do exactly as the PP said- I will loudly confirm with the clients that this is NOT what they had wanted.

It's not up to me that yell at the doctor to put down the scissors immediately- but it is up to me to make sure that the woman is able to make her choices heard. So if she's in the middle of a contraction and I see the doctor reach for the IV, or the scissors, or whatever it may be, then I'm going to let him know that he needs to wait until the woman is able to talk to him.

I think one of the big worries of being an "advocate" is that the woman will start to lean on your ot make their decisions for them- and then as PP'er mentioned- you're no better than an OBGYN..

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#15 of 69 Old 06-04-2008, 10:59 PM
 
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This is what I have told my clients I will do. I have it written into the contract that I will not be making decisions or having 'discussions' with their providers, but make it clear that I will get as much information as I can beforehand, so that if the doctor asks me a question, I can say "Well Sarah here said she didn't want the pitocin, but we'll let you know if she changes her mind". Or... if I see him starting something she doesn't want, I have told clients I will do exactly as the PP said- I will loudly confirm with the clients that this is NOT what they had wanted.

It's not up to me that yell at the doctor to put down the scissors immediately- but it is up to me to make sure that the woman is able to make her choices heard. So if she's in the middle of a contraction and I see the doctor reach for the IV, or the scissors, or whatever it may be, then I'm going to let him know that he needs to wait until the woman is able to talk to him.
To me, this would count as advocating.

I could've sworn I'd read a doula someplace write about not being able to talk to the hospital staff at all, only the laboring mother. It was this huge thing about how it didn't matter if the mother had already made her wishes totally clear she had to be the one to fight for them in labor. The doula could only stand by her and offer support, can't say anything bad like "the doctor wants to do X, you requested no X in your birth plan." Can't "lead" the client into refusing things even if you're 99% sure she's only saying "yes" because of the way labor makes some women complacent, even if she'd said before labor that she absolutely did not want something.

If you are allowed to say, "her birth plan said no X, you need to give her a chance to consent or refuse" that's a huge improvement. If you're allowed to tell nurses "she would prefer no vaginal exams, you'll need to have the doctor come in here and get her consent if s/he feels an exam is necessary." If you can say "Sally has asked not to be coached during pushing, please respect her wishes" and do things like turn the lights back down, the music back up, and keep people from telling your client to be more quiet in labor--that's advocating.
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#16 of 69 Old 06-05-2008, 02:55 AM
 
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To me, this would count as advocating.

I could've sworn I'd read a doula someplace write about not being able to talk to the hospital staff at all, only the laboring mother. It was this huge thing about how it didn't matter if the mother had already made her wishes totally clear she had to be the one to fight for them in labor. The doula could only stand by her and offer support, can't say anything bad like "the doctor wants to do X, you requested no X in your birth plan." Can't "lead" the client into refusing things even if you're 99% sure she's only saying "yes" because of the way labor makes some women complacent, even if she'd said before labor that she absolutely did not want something.

If you are allowed to say, "her birth plan said no X, you need to give her a chance to consent or refuse" that's a huge improvement. If you're allowed to tell nurses "she would prefer no vaginal exams, you'll need to have the doctor come in here and get her consent if s/he feels an exam is necessary." If you can say "Sally has asked not to be coached during pushing, please respect her wishes" and do things like turn the lights back down, the music back up, and keep people from telling your client to be more quiet in labor--that's advocating.
Your first paragraph is correct. I remind her of her previous decisions. I don't get into direct conversations with doctors. I have communicated Mom's wishes to nurses. But I develop a lot more report with nurses while I'm there. Doctors only show up for catching. Almost every nurse I've worked with liked having me there because I made her job easier.

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#17 of 69 Old 06-05-2008, 05:31 AM
 
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Jennica, thank you for posting this discussion! You know I have been frustrated by these pondering and I'm glad you were able to put the words together that I struggled to come up with and then thought to post it here. Thank you!!!

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#18 of 69 Old 06-05-2008, 05:59 AM
 
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#19 of 69 Old 06-05-2008, 10:51 AM
 
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I wonder if it's different with different doula training programs. It was presented to me that the scenarios of telling the mom "dr is about to do an epis, is that what you want?" and telling the dr "mom did not want an epis. can you talk to her about why you want to do one now?" etc are both appropriate to do, depending on which you feel is more appropriate in the situation. We were, of course, taught that it doesn't pay to get snippy or bitchy or argumentative with the staff, and that even being respectful and gentle in the things we say to them is no guarantee that someone will not get their panties in a wad. But we were not taught never to talk to the staff or anything like that.
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#20 of 69 Old 06-05-2008, 01:17 PM - Thread Starter
 
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I should be clear here, that I don't think the doulas themselves are presenting themselves as advocates (they perpetuate it by brochures and things they give out, but they didn't come up with the term and present it to people on their own accord). I do think that the doula certifying agencies are though. If anything, I think that the doulas themselves are trying to counteract this term with prenatal counseling, and since the term is used, and used incorrectly, the doula is standing there with the job of redefining it to her clients. Maybe some doulas do a great job of this, and maybe some don't. A lot of women think that doulas are supposed to advocate, because the agencies tell us that is what they do, printed material lists "advocacy" on it, and websites and books call doulas advocates. Yet they are prohibited from truly advocating. Women are then left to fend for themselves in a hospital during labor. I know what it is like to have people asking you "did you want this, did you want that" during labor, and no, it didn't remind me of what I wanted, it made me feel like I was being yelled at to make one decision after another. If this is advocating, then it is a very poor method of doing so.
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#21 of 69 Old 06-05-2008, 01:37 PM
 
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Yet they are prohibited from truly advocating. Women are then left to fend for themselves in a hospital during labor. I know what it is like to have people asking you "did you want this, did you want that" during labor, and no, it didn't remind me of what I wanted, it made me feel like I was being yelled at to make one decision after another. If this is advocating, then it is a very poor method of doing so.
I agree. It is really frustrating from a doula's perspective. Most of us have gotten into this line of work because we believe in the rights of birthing women. But we cannot make decisions for the parents and we cannot get into confrontations with doctors. I have gone home from a birth really depressed because once the doctor asserted her authority and put her foot down, I was pretty powerless to stop her. I tried the best I could but I swear this doctor when out of her way to punish this woman simply because she was a teen mom. Its maddening.

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#22 of 69 Old 06-05-2008, 01:46 PM
 
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Your first paragraph is correct. I remind her of her previous decisions.
Oops, sorry that wasn't clear. From what I remember, the person said that saying something like "you said you didn't want an epidural" would be considered "leading" the mother.
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#23 of 69 Old 06-05-2008, 02:02 PM
 
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Very good topic of discussion. Thanks for bringing it up, and thanks also for posting the definition.
Very interesting. How proactive I am in a birth depends on the client, however I am always non-combattive and communication works well without too much thought. I do talk to the hospital staff and they talk to me. They often ask me questions about the client. Depending on the question I may answer or I may relay the question to the client.
I just wrote a lengthy post on the role of the doula, and a doulas responsibility(or lack thereof) and a womans responsibility for her birth experience which I think pertains to this discussion, if you are interested in reading it.
http://www.mothering.com/discussions...d.php?t=907778

One of the reasons why I do not certify is because I often do not like the language or certain philosophys of the certifying agency.
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#24 of 69 Old 06-05-2008, 02:12 PM
 
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Do you have specific agencies in mind, jennica? I trained with ALACE and never was under the impression that i would be advocating, nor do i recall them using the term in their literature. I quick peruse of their website doesn't lead me to the term "advocate" either

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#25 of 69 Old 06-05-2008, 02:22 PM
 
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Oops, sorry that wasn't clear. From what I remember, the person said that saying something like "you said you didn't want an epidural" would be considered "leading" the mother.
ooh, that is a whole different thing. We were talking about advocacy. This is more along the lines of support. We are tight rope walking advocates. Support is what we do.

Way before a mom is even asking for an epidural a doula should be able to tell if mom is having trouble coping. Suggesting trying something different for 5 contractions is usually what I would do. I always talk to moms before labor to let them know that I will try this. Once mom is asking for an epidural. I'm not going to try to talk her out of it on the basis that she said she didn't want one earlier. What Mom wants, Mom gets. This is very different from trying to prevent an unwanted intervention.

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#26 of 69 Old 06-05-2008, 02:40 PM
 
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ooh, that is a whole different thing. We were talking about advocacy. This is more along the lines of support. We are tight rope walking advocates. Support is what we do.

Way before a mom is even asking for an epidural a doula should be able to tell if mom is having trouble coping. Suggesting trying something different for 5 contractions is usually what I would do. I always talk to moms before labor to let them know that I will try this. Once mom is asking for an epidural. I'm not going to try to talk her out of it on the basis that she said she didn't want one earlier. What Mom wants, Mom gets. This is very different from trying to prevent an unwanted intervention.
Oh, Mom wasn't asking for an epidural in the example, she was being offered one despite having said that she didn't even want to be offered one.

I suspect the doula in question was either exaggerating or was working in a super-hostile environment.
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#27 of 69 Old 06-05-2008, 02:53 PM - Thread Starter
 
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Do you have specific agencies in mind, jennica? I trained with ALACE and never was under the impression that i would be advocating, nor do i recall them using the term in their literature. I quick peruse of their website doesn't lead me to the term "advocate" either
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They are advocates and a listening ear for birthing mothers, as well as facilitators to her partner.
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#28 of 69 Old 06-05-2008, 06:53 PM
 
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Oh, Mom wasn't asking for an epidural in the example, she was being offered one despite having said that she didn't even want to be offered one.

I suspect the doula in question was either exaggerating or was working in a super-hostile environment.
Ah, I missed that.

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#29 of 69 Old 06-05-2008, 10:56 PM
 
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If you are allowed to say, "her birth plan said no X, you need to give her a chance to consent or refuse" that's a huge improvement. If you're allowed to tell nurses "she would prefer no vaginal exams, you'll need to have the doctor come in here and get her consent if s/he feels an exam is necessary." If you can say "Sally has asked not to be coached during pushing, please respect her wishes" and do things like turn the lights back down, the music back up, and keep people from telling your client to be more quiet in labor--that's advocating.
Thing is, why can't the woman use her own voice?

As a doula I don't speak for my clients, I can't, neither can her partner unless he has medical power of attorney. At the end of the day it is the woman and the woman alone who can consent to or deny treatment. They're not going to listen to me, they're not going to listen to her partner, they need to hear it out of her mouth.

If a woman doesn't want a vaginal exam, she needs to say no. Not depend on a doula to jump between her and her care providers and the doula tell them what she does or doesn't want.

When I have someone call me and inquire about services and the word advocate comes up I'm very clear that I don't practice as an advocate for clients in the traditional sense. I will not, and can not speak on their behalf. Ethically and legally. I am a huge outspoken advocate for natural birth and informed consent in birth, but I can't not be a woman's voice.

If I see that things are deviating from her birthing goals, then I remind her of what we spoke about prenatally and ask if her plans have changed.

There are times when I will ask leading questions of the DR-Nurse-Midwife in order to start a conversation that will lead to informed consent. Or I'll simply turn to the client and say "we discussed prenatally your desire to avoid this particular intervention, would you like to ask any questions or do you want some time to think about it?"

And there are times where I'll turn to a nurse and ask if a particular alternative intervention may be appropriate. If cytotec is being mentioned and induction is necessary I may ask if they use cervidil at this hospital and open up the discussion between the nurse and the client about the benefits and risks of both.

But I don't come in and say "She doesn't want this." "She'd prefer to do that." It's no my job.

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#30 of 69 Old 06-06-2008, 12:27 AM
 
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Thing is, why can't the woman use her own voice?
Lots of women can't speak during contractions. Lots of women can't speak during transition. The very act of engaging the rational brain sufficiently to clearly say "don't do a vaginal exam" or even just "no!" will take many women out of the head space they need to be in to labor and will cause the labor to be more painful and could even stall their progress.

Physiologically, the neocortex should be stimulated as little as possible to best allow the body to give birth. Things like asking the mother questions or even just having conversations in the same room can severely hinder the fetal ejection reflex. "The most important thing is do not disturb the birthing woman" as Dr. Odent is known to say.

If the woman has used her own voice before even coming to the hospital in discussing things with both her care provider and her doula, if she has written her own wishes down, why should she have to think about it again? Why should someone who isn't even her care provider, like a nurse, be given the right to force her to respond to something she's already declined?
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