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Sarah McCabe  mccabe.s.k@gmail.com
Melissa Harris  melissaharrisbirth@gmail.com
Liz Upton   elizabethuptondoula@gmail.com

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"In a world where the majority of breasts and nipples are some shade of brown, we cannot afford to treat white skin as the default in our practice."

- Nekisha Killings, MPH, IBCLC

Founder of The Melanated Mammary Atlas®

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The Melanated Mammary Atlas® improves care for the underserved by broadening the health professional knowledge base in real-time, one image at a time.

Re-envisioning diagnostics. Transforming support. Normalizing brown breasts.

We aim to normalize how breast conditions manifest on patients of color. The more you see, the better you can support.

The Atlas

The Melanated Mammary Atlas® is your portal to a world of images displaying mammary related conditions on Asian, Indigenous, Black and Brown folks. We feature the first and only cache of images of this type available for viewing and constantly updated by health professionals and the public.

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"Indeed, if we are to truly develop an inclusive curriculum, appropriate representation must be given to all racial groups. The shortfall in representation in medical curricula is an important contributor to racial inequality in health-care experience, treatment, and patient outcomes."

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Join the movement to normalize brown breasts® today.

Breast conditions are not shown on dark skin in most textbooks, and as a result, many health professionals are unaware of how differently some conditions present on more deeply melanated skin.

The Melanated Mammary Atlas® was born out of a need. The sad truth is a dearth of images exists in representation of breast conditions on melanated skin in health education. By and large, the images that aspiring medical professionals see during their training are of fair skinned breasts with pink nipples. Not only is this inconsistent with the pigmentation of most of the people on this planet, it creates a gap in acumen that shows up in the care and assessment of patients of color.

Necessity is the mother of invention.

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The Melanated Mammary Atlas | Health Movement

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Health movement to normalize diversity in breast healthcare and education. The Melanated Mammary Atlas™ improves care for the underserved by broadening the health professional knowledge base in real-time, one image at a time.

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Resource List on Systemic Racism in Perinatal Health in Canada

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Resource List on Systemic Racism in Perinatal Health in Canada

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Many of the items on this list have their own links on this padlet - but if you want to read further, this is where to look.

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A review of the studies done on what impact doulas make on birth experiences.

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Get our free, one-page handout on Doulas today to use in your informed decision making!

According to Dr. Christine Morton, author of the book Birth Ambassadors, a birth doula is a companion who supports a birthing person during labor and birth. Birth doulas are trained to provide continuous, one-on-one care, as well as information, physical support, and emotional support to birthing persons and their partners.

In a 2012 survey that took place in the U.S., 6% of birthing people said they used a doula during childbirth (Declerq et al., 2013), up from 3% in a 2006 national survey (Declerq et al., 2007). Of those people who did not have a doula but understood what they were, 27% would have liked to have a doula.

Doulas nurture and support the birthing person throughout labor and birth. Their essential role is to provide continuous labor
support to the mother, no matter what decisions the mother makes or how she gives birth. Labor support is defined as the therapeutic presence of another person, in which human-to-human interaction with caring behaviors is practiced (Jordan,2013).

Importantly, the doula's role and agenda are tied solely to the birthing person's agenda. This is also known as primacy of interest. In other words, a doula's primary responsibility is to the birthing person-not to a hospital administrator, nurse, midwife, or doctor.

A doula can provide labor support via the four pillars of labor support. In the textbook Best Practices in Midwifery, the author describes three pillars of labor support as emotional support, physical support, and advocacy. In the book Optimal Care in Childbirth, informational support is also listed as a pillar of support.

Physical support is important because it helps the birthing person maintain a sense of control, comfort, and confidence. Aspects of physical support provided by a doula may include:

Soothing with touch through the use of massage or counter pressure

Helping to create a calm environment, like dimming lights and arranging curtains

Assisting with water therapy (shower, tub)

Applying warmth or cold

Assisting the birthing person in walking to and from the bathroom

Giving ice chips, food, and drinks

Emotional support helps the birthing person feel cared for and feel a sense of pride and empowerment after birth. One of the doula's primary goals is to care for the mother's emotional health and enhance her ability to have positive birth memories (Gilland, 2010b). Doulas may provide the following types of emotional support to the birthing person and their partner:

Continuous presence

Reassurance

Encouragement

Praise

Helping the birthing person see themselves or their situation more positively

Keeping company

Showing a caring attitude

Mirroring-calmly describing what the birthing person is experiencing and echoing back the same feelings and intensity

Accepting what the birthing person wants

Helping the birthing person and partner work through fears and self-doubt

Debriefing after the birth-listening to the mother with empathy

Informational support helps keep the birthing person and their partner informed about what's going on with the course of labor, as well as provides them with access to evidence-based information about birth options. Aspects of informational support include:

Guiding the birthing person and their partner through labor

Suggesting techniques in labor, such as breathing, relaxation techniques, movement, and positioning (positioning is important both with and without epidurals)

Helping them find evidence-based information about different options in pregnancy and childbirth

Helping explain medical procedures before or as they occur

Helping the partner understand what's going on with their loved one's labor (for example, interpreting the different sounds the birthing person makes)

Advocacy is a pillar of support that is considered controversial by some for two reasons: first, the word advocacy has several meanings and definitions, and second, doulas differ on their beliefs about whether or not advocacy is part of their role.

In an important paper about the concept of advocacy in the nurse's role, Kalaitzidis and Jewell (2015) compiled all of the existing definitions of patient advocacy. They found that in the past, the most common definitions of advocacy were "pleading the cause of someone" or "speaking on behalf of someone." Advocacy can also be defined as "supporting an individual or group to gain what they need from the system" or supporting a person in their right to self-determination.

Advocacy has long been considered an essential component of the nurse's role. However, while some doulas believe that advocacy is a part of their role, others have been specifically trained that advocacy is not part of their role at all. For many years, DONA International, the first doula training and certification organization, has stated in their standards of practice that advocacy is part of the doula's role, as long as the doula does not speak on behalf of the client (DONA Code of Ethics, 2015).

Advocacy can take many forms-most of which do not include speaking on behalf of the client. Some examples of advocacy that doulas have described include:

Encouraging the birthing person or their partner to ask questions and verbalize their preferences

Asking the birthing person what they want

Supporting the birthing person's decision

Amplifying the mother's voice if she is being dismissed, ignored, or not heard, "Excuse me, she's trying to tell you something. I wasn't sure if you heard her or not."

Creating space and time for the birthing family so that they can ask questions, gather evidence-based information, and make decisions without feeling pressured

Facilitating communication between the parents and care providers

Teaching the birthing person and partner positive communication techniques

If a birthing person is not aware that a provider is about to perform an intervention, the doula could point out what it appears the nurse or physician is about to do, and ask the birthing person if they have any questions about what is about to happen. For example, if it looks like the provider is about to perform an episiotomy without the person's consent: "Dr. Smith has scissors in his hand. Do you have any questions about what he is wanting to do with the scissors?"

Taking into account the past definitions of advocacy for nurses, and the desire of many doulas to support the birthing person but not speak in place of them, I'd like to propose a new definition of advocacy in the context of doula care:

Advocacy is defined as supporting the birthing person in their right to make decisions about their own body and baby.

Doulas are not medical professionals, and the following tasks are not performed by doulas:

They do not perform clinical tasks such as vaginal exams or fetal heart monitoring

They do not give medical advice or diagnose conditions

They do not make decisions for the client (medical or otherwise)

They do not pressure the birthing person into certain choices just because that's what they prefer

They do not take over the role of the partner

They do not catch the baby

They do not change shifts (although some doulas may call in their back-up after 12-24 hours)

In 2017, Bohren et al. published an updated Cochrane review on the use of continuous support for women during childbirth. They combined the results of 26 trials that included more than 15,000 people. The birthing people in these studies were randomized to either receive continuous, one-on-one support during labor or "usual care." The Cochrane reviewers stated that the overall quality of the evidence is low-quality, according to the GRADE systems for assessing evidence. In the GRADE system, the quality of evidence for each outcome is graded as one of four levels: high, moderate, low, or very low. A rating of high would be considered great evidence, where the authors are very confident that the true effect of doulas is very close to the effect seen in the study results. On the other hand, a rating of very low means that they have very little confidence in the findings, and that the true effect of doulas is likely to be very different than what was seen in the study results. The middle ratings aren't great, but they aren't weak either. Since it is not possible to blind participants or care providers to continuous labor support, the quality of the evidence for doulas received a lower grade.

Continuous support was provided either by a member of the hospital staff, such as a midwife or nurse (nine studies), women who were not part of the birthing person's social network and not part of hospital staff (doula, eight studies; childbirth educators, one study, retired nurses, one study), or a companion from the birthing person's social network such as a female relative or the woman's partner (seven studies). In 15 studies, the husband/partner was not allowed to be present at birth, and so continuous support was compared to no support at all. In all the other 11 studies, the husband or partner was allowed to be present in addition to the person providing continuous labor support.

Overall, people who received continuous support were more likely to have spontaneous vaginal births and less likely to have any pain medication, epidurals, negative feelings about childbirth, vacuum or forceps-assisted births, and Cesareans. In addition, their labors were shorter by about 40 minutes and their babies were less likely to have low Apgar scores at birth. There is a smaller amount of evidence that doula support in labor can lower postpartum depression in mothers. There is no evidence for negative consequences to continuous labor support.

The results of this study mean that if a birthing person has continuous labor support (that is, someone who never leaves their side), both mothers and babies are statistically more likely to have better outcomes!

The researchers also looked to see if the type of support made a difference. They wanted to know-does it matter who birthing persons choose for continuous support? Does it matter if they choose a midwife, doula, or partner for continuous support? The researchers were able to look at this question for six outcomes: use of any pain medication, use of Pitocin during labor, spontaneous vaginal birth, Cesarean, admission to special care nursery after birth, and negative birth experiences.

For two of these outcomes (designated with asterisks*), the best results occurred when a birthing person had continuous labor support from a doula- someone who was NOT a staff member at the hospital and who was NOT part of their social network. The researchers found that overall, people who have continuous support during childbirth experience a:

25% decrease in the risk of Cesarean; the largest effect was seen with a doula (39% decrease)*

8% increase in the likelihood of a spontaneous vaginal birth; the largest effect was seen with a doula (15% increase)*

10% decrease in the use of any medications for pain relief; the type of person providing continuous support did not make a difference

Shorter labors by 41 minutes on average; there is no data on if the type of person providing continuous support makes a difference

38% decrease in the baby's risk of a low five minute Apgar score; there is no data on if the type of person providing continuous support makes a difference

31% decrease in the risk of being dissatisfied with the birth experience; mothers' risk of being dissatisfied with the birth experience was reduced with continuous support provided by a doula or someone in their social network (family or friend), but not hospital staff

The rate of special care nursery admissions was no different between people who received continuous support and those who received usual care. The rate of Pitocin was also no different but there was a trend towards more Pitocin with continuous support from hospital staff and less Pitocin with continuous support from a doula.

It's important to note that these decreases in risk are relative risk reductions-which requires you to carry out a math formula to understand the true reduction in risk. Relative risk is the risk of something happening to you in comparison to someone else. Absolute risk is the actual, or true risk of something happening to you.

There are several reasons why we think doulas are so effective. The first reason is the "harsh environment" theory. In most developed countries, ever since birth moved out of the home and into the hospital, laboring people are frequently submitted to institutional routines, high intervention rates, staff who are strangers, lack of privacy, bright lighting, and needles.

Most of us would have a hard time dealing with these conditions when we're feeling our best. But people in labor have to deal with these harsh conditions when they are in a very vulnerable state. These harsh conditions may slow down a person's labor and their self-confidence. It is thought that a doula "buffers" this harsh environment by providing continuous support and companionship which promotes the mother's self-esteem ( Hofmeyr, Nikodem et al. 1991).

A second reason that doulas are effective is because doulas are a form of pain relief in themselves ( Hofmeyr, 1991). With continuous support, laboring people are less likely to request epidurals or pain medication. It is thought that there is fewer use of medications because birthing people feel less pain when a doula is present. An additional benefit to the avoidance of epidural anesthesia is that women may avoid many medical interventions that often go along with an epidural, including Pitocin augmentation and continuous electronic fetal monitoring ( Caton, Corry et al. 2002).

This finding-that people with doulas are less likely to have an epidural-is not due to the fact that clients with doulas in these studies were more likely to want these things up front and were more motivated to achieve them. In fact, randomized trials account for these differences-this is why they are called randomized, controlled trials. The people assigned to have a doula, and those assigned to not have a doula, are randomly assigned, meaning that the same percentage in each group would have a desire for an unmedicated birth.

A third reason why doulas are effective has to do with the attachment between the birthing person and doula which can lead to an increase in oxytocin, the hormone that promotes labor contractions. This theory was proposed by Dr. Amy Gilliland in her 2010a study about effective labor support. In personal correspondence with Dr. Gilliland, she wrote, "I believe the Doula Effect is related to attachment. When the mother feels vulnerable in labor, she directs attachment behaviors to suitable figures around her, who may or may not be her attachment figures (parent, mate). When the mother directs attachment seeking behaviors to the doula, the experienced doula (25 births or more) responds in a unique manner. She is able to respond as a secure base, thereby soothing the mother's attachment system. The accompanying diminishment in stress hormones allows for a surge in oxytocin in both the mother and the doula... theoretically, oxytocin is the hormone of attachment, and it is released during soothing touch and extended eye contact, which are habitual behaviors of birth doulas." (Personal communication, Dr. Amy Gilliland, July 2015).

Swedish oxytocin researcher Kristin Uvnas Moberg writes that the doula enhances oxytocin release which decreases stress reactions, fear, and anxiety, and increases contraction strength and effectiveness. In addition, the calming effect of the doula's presence increases the mother's own natural pain coping hormones (beta-endorphins), making labor feel less painful (Uvnas Moberg, 2014).

A recent study in Iran compared first-time mothers' anxiety and pain levels with doula support to those without doula support (Ravangard et al. 2017). They randomly assigned 150 first-time mothers to doula support or no doula support and used standard questionnaires to measure anxiety and pain levels. They found that on average, the mothers who received doula support had less anxiety and lower average pain scores during labor. The authors concluded that the doula's presence has a clinically meaningful impact on anxiety and pain levels in first-time mothers giving birth. They recommend that all hospitals and maternity care centers in Iran provide access to doulas since having a safe and calm delivery is considered a human right.

Based on the evidence, I have come up with a conceptual model of how doula support influences outcomes.

A c onceptual model is what researchers use to try and understand how a phenomenon works. Here is my conceptual model on the phenomenon of doula support.

Nurses provide support when they can, but research has shown that labor and delivery nurses can only spend a limited amount of time in each client's room. In one research study that took place in the U.S., nurses spent about 31% of a person's labor in the room with them. The majority of the time that nurses were in the laboring person's room, they were doing direct clinical care (such as administering medications or performing interventions), maintaining equipment, applying and assessing the electronic fetal monitor, or documenting at the computer. For 12% of each person's labor, the nurse provided labor support including emotional, physical, or informational support, or advocacy. More experienced nurses were more likely to spend time providing emotional support (Barnett et al. 2008).

Three other studies in Canada have found similar findings-that nurses spend about 50-75% of their time outside the birthing person's room. In addition to caring for their assigned client, nurses have many other responsibilities, like communicating with care providers, taking care of other clients, covering for other nurses' breaks, documenting care, and assisting on the labor unit as necessary (Gannon & Waghorn, 1996; McNiven et al., 1992; Gale et al. 2001).

Nurses may also touch the birthing person in a variety of ways, some of which may be unpleasant, like having an IV put in or a cervical check done. Although all of these procedures are optional, they may not be presented as such. When and how a doula touches is up to the person giving birth, so the laboring brain probably anticipates and responds to the doula more positively over time (Personal communication, A. Gilliland, 2017). Nurses may also go off shift, at which point their support ends. Most doulas, on the other hand, remain with the birthing person through birth. Also, nurses are employed by the hospital and while they see themselves as patient advocates, they also have an interest in satisfying their employer, while an the primary responsibility of an independent doula (one not employed by the hospital) is to their client-the person giving birth.

Some people think that they do not need a doula because their partner will be with them continuously throughout labor. It is true that the birth partner is an essential support person for a birthing person to have by their side. However, the birth partner will need to eat and use the bathroom at times, and they are having their own emotional journey that requires support. Also, many partners have limited knowledge about birth, medical procedures, or what goes on in a hospital, while doulas have knowledge and experience about all of these things that they can use to inform and support both the partner and birthing person. Ideally, doulas and partners can work together to make up a labor support team.

In one landmark study that evaluated the effects of doulas and fathers working together, researchers found that combining a supportive partner and a doula significantly lowered the mother's risk of Cesarean compared to just having a supportive partner alone. In 2008, McGrath and Kennell randomly assigned 420 first-time mothers to have routine care (including a supportive partner) or care that also included a professional doula whom they met for the first time during labor. All of the women in the study were classified as having middle- to upper-class financial income levels, having supportive partners, and in the care of obstetricians. During labor, doulas provided continuous support, including encouragement, reassurance, and physical support. They helped the partner support the laboring person, and were careful not to take over the partner's role.

The results showed a substantial improvement in outcomes for women who had both a birth partner and a doula, compared to having a birth partner alone. The Cesarean rate for these first-time mothers was 25% in the group with a partner only, and 13.4% in the group with a partner and doula. The women who had their labor medically induced experienced an even more striking decrease in the Cesarean rate with a doula-the Cesarean rate with labor inductions was 58.8% in the group without a doula, and 12.5% in the group with a doula. Also, fewer women in the doula group required an epidural (64.7%) compared to those without a doula (76%).

Research has shown that the most positive birth experiences for fathers were ones where they had continuous support by a doula or a midwife. In the McGrath and Kennell study, the women and their partners who had a doula overwhelmingly rated the support of their doula as positive-with 93% rating their experience with the doula as very positive, and 7% as positive. In other studies, fathers have said that when they had labor support from a midwife or doula, things were explained to them, their questions were answered, their labor support efforts were guided and effective, and they could take breaks from the emotional intensity of the labor without abandoning their laboring partner (Johansson, 2015).

Access to continuous labor support from a doula is especially vital for birthing people of color. Black women experience higher rates of poor birth outcomes, including higher rates of Cesarean, preterm birth, low birth weight, and infant death (Thomas et al., 2017). Studies show that significant racial disparities (differences) in birth outcomes continue to exist even after accounting for factors like the pregnant person's income, education, marital status, tobacco/ alcohol use, and insurance coverage. In other words, health and social factors alone can't explain the higher rates of poor birth outcomes among Black people. Then what does explain the health inequity? Researchers have proposed that African Americans are subjected to individual, institutional, and other forms of racism throughout their lives; these experiences build on each other and are uniquely stressful; and the increased stress can negatively impact pregnancy outcomes (Giscombé and Lobel, 2005).

In public health, racism influences social determinants of health, which include housing, education, and employment. Researchers have conducted interviews with racially/ethnically diverse, low-income pregnant women to try and understand how doula support may help disrupt negative social determinants of health (Kozhimannil et al. 2016).

The researchers analyzed the women's responses around five main themes:

First, they found that doulas play an important role in Agency. Agency is defined as the capacity of individuals to act or to make their own choices. Doulas helped their clients to understand their options and they facilitated communications with care providers, so that clients felt a sense of empowerment or ownership over their care.

Doulas also contributed to feelings of personal security. When women felt scared by their care providers, they were comforted and reassured by their doulas.

There was a consensus in the interviews that a doula's presence facilitated greater respect and autonomy in decision-making.

Doulas also played a critical role in transferring knowledge about the pregnancy and birth process. They connected clients with resources and "translated" information received from care providers during clinic visits.

Finally, doulas helped women with connectedness so that they would not feel socially isolated. Many of the participants described stressful life situations and desired a doula with similar life experiences, someone who shared their culture and background.

Doula care offers many benefits including better birth outcomes, but people of color often face barriers in accessing doula support. To address this critical need, we need more programs like the By My Side program through Healthy Start Brooklyn in New York that offers free doula services to low-income people in Black and Latino neighborhoods (Thomas et al. 2017). The idea for the By My Side program came about when Gabriela Ammann, a local doula and Lamaze instructor, noticed that many of the women attending her free childbirth-education series did not have reliable support for their labor and birth. Some women's partners were not able to take time off work for the birth; other women needed their partner or mother to take care of older children instead of providing continuous labor support. To address this need, she matched birthing people with volunteer doula care.

In 2010, the process of pairing these women with free doula support was formalized when Healthy Start Brooklyn hired certified doulas to provide support during pregnancy, childbirth, and the postpartum period. The program focused on non-Latina Black women, since this was the group with the highest infant-mortality rate in the program area. The doula and educator with the idea for this initiative is now the director of the By My Side program. Between 2010 and 2015, nearly 500 infants were born to women enrolled in the program. Compared to similar births in the area, program participants had significantly lower rates of preterm birth and low birth weight. In addition, participant feedback showed that doula support was highly valued:
"She showed me she believed in me" "I would've had no one there; it was just me and her. If it wasn't for her, maybe I wouldn't even get through it, because she really helped a lot"
Those who could most benefit from doula care frequently have the least access to it. To address the existing unjust health disparities, it is imperative that continuous labor support be accessible to everyone and provided by a culturally diverse doula workforce.

If you're at all on the fence about hiring a doula, you may want to interview several doulas with your partner. Childbirth Connection has a great list of interview questions for a doula. The website DoulaMatch.net has a great search function for finding birth doulas.

Of all the ways birth outcomes could be improved, continuous labor support seems like one of the most important and basic needs for birthing people. Providing labor support to birthing people is both risk-free and highly effective. Evidence shows that continuous support can decrease the risk of Cesarean, the use of medications for pain relief, and the risk of a low five minute Apgar score. Labor support also increases satisfaction and the chance of a spontaneous vaginal birth. Continuous support may also shorten labor and decrease the use of Pitocin. Although continuous support can also be offered by birth partners, midwives, nurses, or even some physicians, research has shown that with some outcomes, doulas have a stronger effect than other types of support persons. As such, doulas should be viewed by both parents and providers as a valuable, evidence-based member of the birth care team.

References:

Barnett, G. V. (2008). "A new way to measure nursing: Computer timing of nursing time and support of laboring patients." Computers, Informatics, Nursing 26(4): 199-206.

Bohren, M.A., Hofmeyr, G., Sakala, C., et al. (2017). "Continuous support for women during childbirth." Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD003766.

Caton, D., M. P. Corry, et al. (2002). "The nature and management of labor pain: executive summary." Am J Obstet Gynecol 186(5 Suppl Nature): S1-15.

Declercq, E. R., Sakala, C., Corry, M. P., et al. (2007). "Listening to mothers II: Report of the second national U.S. survey of women's childbearing experiences." The Journal of Perinatal Education 16:9-14.

Declercq, E. R., Sakala, C., Corry, M. P., et al. (2013). "Listening to mothers III pregnancy and birth: Report of the third national U.S. survey of women's childbearing experiences." New York: Childbirth Connection.

DONA International. (2015). Code of Ethics: Birth Doula. Published at https://www.dona.org/wp-content/uploads/2016/09/COE-SOP-Birth.pdf. Accessed on July 24, 2017.

Gagnon, A. J., Waghorn, K. (1996). "Supportive care by maternity nurses: a work sampling study in an intrapartum unit." Birth 23 (1): 1-6.

Gale, J., Fothergill-Bourbonnais, F., Chamberlain, M. (2001). "Measuring nursing support during childbirth." Am J Matern Child Nurs 26(5): 264-71.

Gilliland, A. L. (2010a). " A grounded theory study of effective labor support by birth doulas. In Human Development and Family Studies, Vol. Doctorate University of Wisconsin, Madison, Wisconsin, pp. 452. Available at the bottom of this page.

Gilliland, A. L. (2010b). "After praise and encouragement: Emotional support strategies used by birth doulas in the USA and Canada." Midwifery, 27(4): 525-31.

Gilliland, A.L. (2016) "What motivates people to attend birth doula trainings?" J Perinatal Educ, 25(3), 174-183.

Giscombé, C. L. and Lobel, M. (2005). Explaining Disproportionately High Rates of Adverse Birth Outcomes Among African Americans: The Impact of Stress, Racism, and Related Factors in Pregnancy. Psychological Bulletin, 131(5), 662-683.

Goer, H. and A. M. Romano (2012). Optimal care in childbirth: the case for a physiologic approach. Seattle, Washington, Classic Day Publishing. Click here.

Hodnett, E. D. (2002). "Pain and women's satisfaction with the experience of childbirth: a systematic review." Am J Obstet Gynecol 186(5 Suppl Nature): S160-172.

Hofmeyr, G. J., Nikodem, V. C., Wolman, W. L., et al. (1991). "Companionship to modify the clinical birth environment: effects on progress and perceptions of labour, and breastfeeding." BJOG 98(8): 756-764.

Johansson, M., Fenwick, J., & Premberg, A. (2015). "A meta-synthesis of fathers' experiences of their partner's labour and the birth of their baby." Midwifery 31(1): 9-18.

Jordan, C. (2013). "Therapeutic presence and continuous labor support." In Best Practices in Midwifery, Ed. by Anderson, B. A. & Stone, Sjourna. E.

Kozhimannil, K. B., Vogelsang, C. A., Hardeman, R. R., et al. (2016). Disrupting the Pathways of Social Determinants of Health: Doula Support during Pregnancy and Childbirth. Journal of the American Board of Family Medicine : JABFM, 29(3), 308-317.

McGrath, S. K. and Kennell, J. H. (2008). A randomized controlled trial of continuous labor support for middle-class couples: effect on Cesarean delivery rates. Birth 2008; 25:3.

McNiven, P., Hodnett, E., O'Brien-Pallas, L. L. (1992). "Supporting women in labor: a work sampling study of the activities of labor and delivery nurses." Birth 19(1): 3-8.

Morton, C. H. and Clift, E. G. (2014). Birth Ambassadors. Texas: Praeclarus Press.

Ravangard, R., Basiri, A., Sajjadnia, Z., et al. (2017). Comparison of the Effects of Using Physiological Methods and Accompanying a Doula in Deliveries on Nulliparous Women's Anxiety and Pain: A Case Study in Iran. The Health Care Manager, Vol. 00, No. 0, pp. 1-8.

Strauss, N., Sakala, C., and Corry, M. P. (2016). Overdue: Medicaid and Private Insurance Coverage of Doula Care to Strengthen Maternal and Infant Health. The Journal of perinatal education, 25(3), 145-149.

Thomas, M. P., Ammann, G., Brazier, E., et al. (2017). Doula Services Within a Healthy Start Program: Increasing Access for an Underserved Population. Maternal and child health journal, 21(Suppl 1), 59-64.

Uvnas-Moberg, K. (2014). Oxytocin: The Biological Guide to Motherhood. Texas: Praeclarus Press.

We would like to extend our gratitude to our expert reviewer for valuable feedback and critique of this article before publication: Amy Gilliland, PhD, BDT(DONA). We would also like to thank Cristen Pascucci for her medical editing assistance. We are incredibly grateful for the photos supplied in this article from: Birth Becomes Her, @see_baby, @bellaariella, @omorosebless.

Join others who also want to help bring evidence-based care to their local community.

Also, gain complimentary access to a printable library of our Signature Articles, 20+ hours of CE courses, a private community, and more.

Buy EBB Inspirational T-shirts, Due Date Buttons & Birth Affirmation Cards

Stay empowered, read more :

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A birth doula is a companion who supports a birthing person during labor and birth. What is the evidence for using a doula?

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‘We were savages to them’: Legacy of segregated hospitals haunts Indigenous survivors

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Annie Michael is one of many Indigenous Canadians who experienced intimidation and abuse in the health-care system.

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A great resource for doulas and their clients

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A great resource for doulas and their clients

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Healthy pregnancies and full-term births can improve the health of women and babies.

Giving babies the best possible start in life

For many women, pregnancy is a time of excitement and joy, but also a time that can be stressful and feel overwhelming.

UnitedHealthcare and the National Partnership for Women & Families are working together to provide tips that help women have healthy pregnancies and births. The goal is to raise awareness about the importance of prenatal, childbirth and postpartum care. This helps families and helps give newborns the best possible start in life. Full-term births also improve the health of women and babies.

That's why these two organizations are working with media outlets nationwide to share public service announcements (PSAs) about this important topic.
Learn more about having a healthy pregnancy
New public service announcement produced by UnitedHealthcare and the National Partnership for Women & Families

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Giving babies the best possible start in life For many women, pregnancy is a time of excitement and joy, but also a time that can be stressful and feel overwhelming. UnitedHealthcare and the National Partnership for Women & Families are working together to provide tips that help women have healthy pregnancies and births.

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Decolonizing Indigenous birth work and reproductive health | CGSHE Spotlight Series

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Decolonizing Indigenous birth work and reproductive health | CGSHE Spotlight Series

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Decolonizing Indigenous birth work and reproductive health | CGSHE Spotlight Series

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La Leche League International’s page on Transgender and Non-Binary Parents 

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La Leche League International’s page on Transgender and Non-Binary Parents 

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Support for Transgender & Non-binary Parents

La Leche League is an international, nonprofit, nonsectarian organisation. ¹
LLL supports everyone who wants to breastfeed or chestfeed in reaching their goals.
We at La Leche League have all nursed our babies. If you want to do the same, whoever you are, whatever your story is, we're here to help. LLLI is committed to serving everyone inclusive of race, ethnicity, religion, sex, national origin, ancestry, age, marital status, physical or mental ability, socio-economic status, political views, gender identity, sexual orientation, family structure, or other protected status.
Trans men, trans women, and non-binary individuals may choose to breastfeed or chestfeed their babies. You do not need to have given birth to breastfeed or chestfeed, as we can also see in the experiences of those nursing adopted babies.

Canadian LLL Leader and transgender dad Trevor MacDonald writes that, "It is equally important to note that some trans people experience severe gender dysphoria when breast or chestfeeding, and that they may decide not to nurse their babies for mental health reasons. Trans parents choosing to breast or chestfeed and those choosing to suppress lactation and bottlefeed may require the support of breastfeeding counsellors or lactation professionals." 2 It is also the case that some parents with gender dysphoria choose to pump and bottlefeed their milk to their baby. Whether you are pregnant, nursing your baby, pumping your milk, using donor milk, mixed feeding or considering your options La Leche League is here for you.

Please note that some of the links in this post will take you to articles or websites where you may notice gendered language.

Amazing milk

One of the concepts La Leche League is founded on is that: human milk is the natural food for babies, uniquely meeting their changing needs.

Human milk is amazing. It has everything a growing baby needs in exactly the right amounts and babies can easily digest it all. Research shows that a baby who is not fed on human milk is more likely to suffer from illnesses and diseases, both as a child and later in life.
By meeting your baby's needs for warmth, food and security at your chest you give them a secure attachment so they can develop into a conﬁdent child.

Skin-to-skin

Skin-to-skin contact is beneficial for babies and parents; it simply means holding your naked baby on your bare chest. You can drape a blanket over you both for warmth. Within minutes, you will see the benefits of skin-to-skin as you and your baby relax. Your baby's body temperature, breathing, and heart rate will stabilise. Babies often latch on and nurse more efficiently during and after skin-to-skin contact.

It is a lovely way to nurture your baby even if you are not nursing.

Your milk supply

Some transgender and non-binary parents have a full milk supply.

If you have had chest (top) surgery you may be able to produce some milk. Many factors will affect the amount of milk you can make.

Two reasons that a trans man or non-binary individual might have a reduced milk supply are:

1. Milk-making tissue has been surgically removed, and/or ducts have been damaged in surgery.

2. Testosterone interferes with the hormone necessary for lactation (prolactin) and can cause a significant decrease in milk supply. However, taking testosterone would not prevent someone from using an at-chest supplementer and having a nursing relationship.

Trans women can use a protocol similar to adoptive and other non-gestational mothers and stimulate their milk supply: it is called the Newman-Goldfarb protocol. You can read more here and here. A number of different protocols are described here. Our article about Breastfeeding Without Giving Birth may also be useful. Transfeminine nursing parents may also need to take the hormone spironolactone to suppress their testosterone. Read a case report of induced lactation in a transgender woman here.

You can also give human milk or formula supplements using an at-breast supplementer. Your healthcare provider can help you look at your options, and your local LLL Leader can offer support with your breast or chestfeeding goals and journey.

You may find the following websites have useful information, you may notice gendered language in them:

Many parents worry about whether their baby is 'getting enough'. LLL meetings are a good place to get support from others.

These LLL posts are great for checking signs your baby is feeding effectively, you may notice gendered language in them:

Using a nursing supplementer

If your baby needs a supplement of expressed milk or formula you might want to consider using a nursing supplementer. Doing this can give your baby that extra milk while they are nursing.
Supplementers can help parents have an at-breast or at-chest relationship with their baby whether or not they are able to produce milk.

This post has lots of useful information about nursing supplementers.

Read about a transgender dad's experience of using a supplementer here.

Read a mother's story about the long term use of a supplementer here.

Milk sharing

Some transgender and non-binary parents use milk banks to acquire human milk for their babies. La Leche League fully supports the use of human milk for babies; we cannot facilitate or set up milk sharing networks, though your local LLL Leader can help you with contact information for non-profit human milk banks, other regulated collection centres, and formal/medically supervised or informal milk sharing networks. ³
Human milk banks provide pasteurised, screened donor milk. In some countries (for example the US) it may be pooled - this means milk from different donors is mixed. In some countries, and individual milk banks, milk pooling is not carried out.

There are documented benefits and risks to informal milk sharing. Benefits of human milk include, but are not limited to:

Optimal nutrition

Easy digestibility

Immunological protection

Risks of sharing milk can include, but are not limited to:

Transmission of certain infectious agents, like bacteria or viruses, some of which may be found in milk expressed by asymptomatic people

Medicines and other drugs

Environmental contaminants as a result of unhygienic storage and handling of unprocessed donated milk

Human Milk for Human Babies (HM4HB) is an "informed milk sharing network", and is an international organisation that many parents use to source human milk. Another organisation is Eats On Feets, it offers more information about safe milksharing practices, you can find resources here http://www.eatsonfeetsresources.org/ and a world map with milksharing chapters around the world here http://www.eatsonfeets.org/

LLL Support

All nursing parents need support and La Leche League is a great place to find it.

There are LLL groups in over 80 countries across the world, many offer meetings open to all - contact your local group to find out how they can support you.

Many groups also have private Facebook groups where you can ask questions and connect with other nursing parents.

LLL meetings are held in a wide range of venues - LLL is not affiliated to, and does not endorse or support, any business, organisation or religion whose premises we use.

Other support

Queer and genderqueer inclusive LLL Facebook group for support 'Inducing Lactation & Relactation'International Facebook group for 'Birthing and Breast or Chestfeeding Trans People and Allies'
International Facebook group for 'Trans Feminine Breastfeeding and Lactation Support'
Please ask to join the 'Trans Feminine Breastfeeding and Lactation Support' group from within the 'Birthing and Breast or Chestfeeding Parents and Allies' group.

LLL Resources

Breastfeeding Without Giving Birth
My journey: non-binary nursing, a story from LLLUSA
Sostengo per genitori transgender e non binari, LLL Italia
Información general: Transgénero/transexual/ Género fluido, La Liga de la Leche de Euskadi
Lactancia materna. Apoyando a mujeres transexuales, La Liga de la Leche de Euskadi
Lactancia. Apoyando a hombres transexuales, La Liga de la Leche de Euskadi Apoyo Para Parentalidades Transgénero Y No-Binarias, LLLI

OTHER RESOURCES

Adapted from an article first published by LLLGB - https://www.laleche.org.uk/support-transgender-non-binary-parents/
References
1 La Leche League International Bylaws, Section 1: General Purpose
2 http://kellymom.com/bf/got-milk/transgender-parents-chestbreastfeeding/?fref=gc
3 https://llli.org/breastfeeding-info/milk-donation/#Milk

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Transgender & Non-binary Parents - La Leche League International

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Support for Transgender & Non-binary Parents La Leche League is an international, nonprofit, nonsectarian organisation. 1 LLL supports everyone who wants to breastfeed or chestfeed in reaching their goals. We at La Leche League have all nursed our babies. If you want to do the same, whoever you are, whatever your story is, we're here to help.

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The most useful thing I ever read about supporting folks in crises.
https://www.latimes.com/opinion/op-ed/la-xpm-2013-apr-07-la-oe-0407-silk-ring-theory-20130407-story.html

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Continuous support for women during childbirth

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Continuous support for women during childbirth

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The Cochrane is free for all to access, and contains reviews of trials in many disciplines, including obstetrics.

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This week, we're returning to our archives to grapple with the troubling history of medical experimentation on African Americans and how that history connects to the unequal medical care African Americans still receive today.

Black patients continue to receive less pain medication for broken bones and cancer. Black children receive less pain medication that white children for appendicitis. One reason for this is that many people inaccurately believe that blacks literally have thicker skin than whites and experience less pain.

The failure to recognize the pain of black patients can be tracked far back in the history of American medicine. Dr. James Marion Sims, a 19th-century physician, has been dubbed the father of modern gynecology. He's honored by three statues across the United States, one of which describes him as treating both empresses and slave women.

This week, we consider what - and whom - this inscription leaves out. Invisible in his shadow are the enslaved women on whom he experimented. Today, they are unknown and unnamed except for three: Anarcha, Lucy, and Betsey.

Sims invents the speculum. I invent the wincing, the if-you-must of it, the looking away, the here of discovery.

We speak with Dr. Vanessa Gamble, a physician and historian, to investigate Dr. Sims' complicated legacy. He perfected a surgery that continues to help women today, but he practiced this technique through experimental surgeries on unanesthetized enslaved women.

We also speak with poet Bettina Judd. She helps us connect the experiences of Anarcha, Lucy, and Betsey to the ways black patients are treated today.
Hidden Brain is hosted by Shankar Vedantam and produced by Maggie Penman, Jennifer Schmidt, Rhaina Cohen, and Renee Klahr. Our intern is Chloe Connelly, and our supervising producer is Tara Boyle. You can follow us on Twitter @hiddenbrain, and listen for Hidden Brain stories each week on your local public radio station.

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Remembering Anarcha, Lucy, and Betsey: The Mothers of Modern Gynecology

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J. Marion Sims is remembered as the father of modern gynecology. Forgotten are the mothers of that medical specialty - the enslaved women whose bodies were used for the advancement of his research.

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How ‘Weathering’ Contributes to Racial Health Disparities

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How ‘Weathering’ Contributes to Racial Health Disparities

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How ‘Weathering’ Contributes to Racial Health Disparities - The New York Times

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Disrupting the Pathways of Social Determinants of Health: Doula Support during Pregnancy and Childbirth

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Disrupting the Pathways of Social Determinants of Health: Doula Support during Pregnancy and Childbirth

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disrupting social determinants of health.pdf

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The questionnaire below is called the Edinburgh Postnatal Depression Scale (EDPS) The EDPS was developed to identify women who may have postpartum depression EdinburghPostnatalDepressionScale(EPDS)[1]

. Each answer is given a score of 0 to 3 . The maximum score is 30.

Please select the answer that comes closest to how you have felt in the past 7 days:

A score of more than 10 suggests minor or major depression may be present. Further evaluation is recommended [1,8].

Postpartum Depression (Postnatal Depression)

Postpartum depression is major depression that occurs after giving birth. Symptoms are present for most of the day and last for at least 2 weeks.

As many as 1 in every 7 women (14%) suffers postpartum depression [5] . In a study of 209 women referred for major depression during or after pregnancy 11.5% reported start of depression during pregnancy , 66.5 % reported start of depression within 6 weeks after childbirth (early postpartum), and 22% reported onset 6 weeks after childbirth (late postpartum) . One woman reported onset of depression at more than 27 weeks after childbirth [2].

Racing thoughts, psychotic symptoms (such as hallucinations or delusions), or a family history of bipolar disorder (BPD) may indicate bipolar disorder is present [3,5]. The Mood Disorder Questionnaire (MDQ) is a screening tool used to screen for bipolar disorder [4]. The MDQ is available at http://www.integration.samhsa.gov/images/res/MDQ.pdf

Treatment of depression during pregnancy and after childbirth is based on expert opinion. "Within the limits of expert opinion and with the expectation that future research data will take precedence, these guidelines provide some direction". The following are some treatment options that have been suggested .

Mild depression

Psychotherapy such as cognitive-behavioral therapy (CBT) OR interpersonal therapy

Mild Depression postpartum while breast-feeding

Psychotherapy with or without antidepressant (sertraline or paroxetine)

Psychotherapy AND fluoxetine [8].
Alternative medications: sertraline or tricyclic antidepressant

Severe Depression postpartum while breast-feeding

Supportive services AND sertraline [9]
Alternative medication: Paroxetine [10]

Support Groups

More Resources

REFERENCES

1. Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987 Jun;150:782-6. PMID:3651732
2.Cox JL, et al., A controlled study of the onset, duration and prevalence of postnatal depression. Br J Psychiatry. 1993 Jul;163:27-31. PMID:8353695
3.Sharma V, et al., Missed bipolarity and psychiatric comorbidity in women with postpartum depression. Bipolar Disord. 2008 Sep;10(6):742-7. PMID:18837870
4. Hirschfeld RM, et. al., Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire.
Am J Psychiatry. 2000 Nov;157(11):1873-5. PMID:11058490
http://ajp.psychiatryonline.org/article.aspx?articleid=174439
5. Wisner KL, Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings.
JAMA Psychiatry. 2013 May;70(5):490-8. PMID:23487258
6. Altshuler LL, et al., Treatment of depression in women: a summary of the expert consensus guidelines. J Psychiatr Pract. 2001 May;7(3):185-208. PMID:15990522
7. Berle JO, Spigset O.Antidepressant Use During Breastfeeding. Curr Womens Health Rev. 2011 Feb;7(1):28-34. PMID:22299006
8. Yonkers KA, et. al., Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women.
Obstet Gynecol. 2011 Apr;117(4):961-77. PMID:21422871
8. PROZAC (fluoxetine hydrochloride) capsule
http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=c88f33ed-6dfb-4c5e-bc01-d8e36dd97299
9. ZOLOFT (sertraline hydrochloride)
http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=fe9e8b7d-61ea-409d-84aa-3ebd79a046b5
10. PAXIL (paroxetine hydrochloride)
http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=584ace29-6e40-432f-950f-ab7e98653d32
11.HALDOL (haloperidol) injection http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=27cfe684-7d11-4f37-9c8b-b2bdd6b5348e

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The questionnaire below is called the Edinburgh Postnatal Depression Scale (EDPS) The EDPS was developed to identify women who may have postpartum depression EdinburghPostnatalDepressionScale(EPDS)[1] . Each answer is given a score of 0 to 3 . The maximum score is 30.

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The Institute for the Study of Birth, Breath and Death

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The Institute for the Study of Birth, Breath, and Death is an inspiring and nurturing organization/community dedicated to furthering the development and professional skill set of those called to hold space for birthing, living, and dying.

Founded in 2015 by Amy Wright Glenn, the Institute was created to bring together individuals caring for birth and death with those dedicated to mindful, embodied, and compassionate living. Institute membership draws from many vocations: birth/death midwives, birth/death/full spectrum doulas, artists, musicians, authors, hospital chaplains, hospice volunteers, spiritual directors, yoga instructors, teachers, clergy, rabbis, imams, psychologists, healers, and mental health professionals. Bereaved parents and those who are moving through significant life transitions are also active in the organization. All drawn to our study are warmly welcome.

Committed to gender, economic, and racial equity/inclusion, the Institute is a pioneering force providing in-person and online trainings/workshops for the heartfelt engagement and study of life's transformative thresholds.

______

Institute Members & Friends gathered in October 2022
for the Fall Institute Retreat.
Join us next year!
Institute founder, Amy Wright Glenn ~ and her son Taber ~ invite you to join them in meditation.
May we all be safe and healthy as we safely navigate work, parenting, life in the age of Covid-19.
May we always continue to nourish our spiritual/mindfulness practices.

Today, wise and creative cultural pioneers lead a burgeoning movement in applying key elements of the birth doula model to train people to companion each other in death. Given that our experience of death has become so institutionalized and medicalized, applying the doula model of care to death and dying represents a sane and needed grounding in the wisdom of compassion, companioning and proven comfort measures.

Institute founder Amy Wright Glenn teaching
at the International Death Doula Training in Maui, Hawaii ~ Spring 2019

Holding Space does just that for each of us. In a clear, intimate voice, Amy Wright Glenn shares her own experience and wisdom and by doing so makes a space for her reader to develop the same. For anyone going through loss, this book will feel like a treasure. ~ Sharon Salzberg, author of Lovingkindness and Real Love

I lost my son 10 years ago when he was 4 months old and Amy's words felt like coming home. They affirmed everything that I have felt about life and death since in a world that doesn't often make space for such grief and loss. It all resonated so deeply and helped me to see that I am ready to share this work with others and hold space for grief and loss. Thank you so much for the work that you are doing and for sharing your knowledge and experience. ~ Kirsty Pearson, birth doula, UK

This is a beautifully written book about the challenging practice of remaining present - holding non-reactive space - around emotions of grief, sorrow and loss. This practice is brought alive through many touching vignettes from the author's life and work as a hospital chaplain and as a doula for the poignant transitions of birth and death. I recommend Holding Space highly, for hospice workers, religious and medical professionals, and for anyone facing personal loss. ~Jan Chozen Bays, author of Jizo Bodhisattva: Guardian of Children, Travelers & Other Voyagers

The Institute for the Study of Birth, Breath, and Death is a registered LLC in North Carolina.

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A Home for All who Hold Space for the Sacred Thresholds of Birth, Breath, and Death

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The Institute for the Study of Birth, Breath, and Death is an inspiring and nurturing organization/community dedicated to furthering the development and professional skill set of those called to hold space for birthing, living, and dying. Founded in 2015 by Amy Wright Glenn, the Institute was created to bring together individuals caring for birth and death [...]

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Forced Sterilization of Indigenous Women

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Forced Sterilization of Indigenous Women

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Leilani Muir speaks at an Alberta Eugenics Awareness Week event (22 October 2011).

(GrammarLab/Wikimedia CC)

Key Terms

Sterilization

A permanent medical procedure, such as tubal ligation, that prevents pregnancy.

Forced or coerced sterilization

Sterilization of people without their free, prior and informed consent. This can include the use of threats, misinformation, lack of information, or other forms of pressure to influence people to seek or permit sterilization.

Eugenics

A set of beliefs and practices aimed at improving the human population through controlled breeding.

Eugenics and Sterilization

Exhibit photograph scanned from Harry H. Laughlin, The Second International Exhibition of Eugenics held September 22 to October 22, 1921, in connection with the Second International Congress of Eugenics in the American Museum of Natural History, New York (Baltimore: William & Wilkins Co., 1923).

(Wikimedia CC)

Female sterilization is a permanent medical procedure that prevents pregnancy. In the first half of the 20th century, eugenic ideology informed sterilization practices in Canada. Eugenic sterilization was influenced by the work of Francis Galton, who coined the term "eugenics." Eugenics is based on the belief that you can improve the qualities of the human species by encouraging the reproduction of those considered "fit" and discouraging the reproduction of those considered "unfit."

The false premise behind eugenic sterilization was the belief that poverty, illness and other social problems were caused by some sort of innate biological trait, rather than by the way society was organized or how resources were distributed ( see also Eugenics: Pseudo-Science Based on Crude Misconceptions of Heredity). Those targeted by restrictive eugenic policies were often referred to as "feebleminded," "mentally defective," or "sexually promiscuous." A purportedly low IQ and failure to conform to socially accepted gender roles were considered indications of "unfitness."

Sterilization was imposed on many "problem groups" in Canada, including differently abled people labelled as having intellectual or physical " disabilities," those institutionalized in state-run facilities and immigrants, especially from Eastern European countries. Sterilization was also imposed on Indigenous people. With respect to Indigenous people, eugenics served to explain away the negative effects of colonialism. According to eugenic theory, the high rates of ill health and poverty in Indigenous communities were evidence of a lower racial evolution - not the result of colonialism and government policies - and reinforced a view that Indigenous people were "unfit." The criminalization of Indigenous women and the policing of their sexuality contributed to their being labelled "bad mothers," unfit to care for their children. They were also subjected to coerced or forced sterilization.

Legislated Sterilization in Canada

Sexual sterilization legislation was passed in two Canadian provinces: Alberta and British Columbia. Alberta's Sexual Sterilization Act was in effect from 1928 to 1972. During this time, the Eugenics Board, which made decisions on whether or not a person should be sterilized, was presented with and passed 4,739 cases. Of these, 2,834 sterilizations were performed. Researchers have examined records dealing with Alberta's sterilization act and found that Indigenous women represented about 6 to 8 per cent of those sterilized overall during this period. However, the percentage was much higher in the final years of the Act's operation, averaging just over 25 per cent from 1969 to 1972. Jana Grekul and her colleagues concluded that "Aboriginals were the most prominent victims of the Board's attention. They were overrepresented among presented cases and among those diagnosed as 'mentally defective.' Thus they seldom had a chance to say 'no' to being sterilized."

British Columbia also passed a Sexual Sterilization Act, which was in effect from 1933 to 1973. This legislation permitted the provincial Eugenics Board to sterilize any inmate of a provincial institution who, if upon discharge from an institution, was likely to "beget or bear children who by reason of inheritance" would have tendency to "serious mental disease or deficiency." Records concerning sterilizations under this Act, which are said to have been performed on between 200 and 400 people, are thought to be lost or destroyed. However, some of those sterilized were Indigenous. For example, the Supervisor of Social Services at Essondale, a provincial institution housing people with various mental conditions, recommended the sterilization of one Indigenous girl in the following way:

Patient is a mentally defective Indian girl who has always been incorrigible, wild, undisciplined and promiscuous... Sterilization is, therefore, strongly recommended to prevent patient from having illegitimate children which the community would have to care for and for whom it would be very difficult to find foster homes.

Non-Legislated Sterilization in Canada

Sterilizations were also performed in areas where no legislation was enacted. Kathleen McConnachie has shown that sterilizations were carried out by eugenically minded doctors in Ontario. Largely due to the efforts of A.R. Kaufman, an entrepreneur and eugenicist from Kitchener, about 400 women and 1,000 men were sterilized, by physicians who believed sterilization was a means of preventing or alleviating poverty. The full extent to which Indigenous people were affected is unclear, however it is known that by 1928, Indigenous people were being classified as "mentally unfit" and this was often a first step to sterilization.

The sterilization of Indigenous women also took place in Northern Canada. In 1970, Member of Parliament David Lewis alleged that representatives from the Department of Health were persuading Indigenous women to be sterilized. He claimed that interpreters were not always used and that therefore, women did not always understand the procedures they received. It was not until 1976 that the federal government conducted an internal inquiry. Documentation from this internal inquiry shows that from 1966 to 1976, hundreds of sterilizations were performed on Indigenous women from 52 Northern settlements.

These documents also show that between 1971 and 1974, at least 551 sterilizations were performed on Indigenous women in federally operated " Indian hospitals" across Canada, which served primarily Indigenous populations. These documents do not reveal the experiences of each Indigenous woman. However, they show that health workers sometimes failed to follow guidelines on when sterilizations could be performed, that consent forms were difficult to understand and that interpreters were not always used. According to Bryan Pearson, then councillor for the Northwest Territories at Frobisher Bay ( Iqaluit), there was also a climate of racism and paternalism, which led to the view that sterilization was for "their own good."

Contemporary Sterilization in Canada

There is increasing awareness that the coerced sterilization of Indigenous women has continued beyond the eugenic era, casting further light on the enduring impact of past policies. An external review of services delivered within the Saskatoon Health Region documented that 16 Indigenous women experienced pressure to consent to sterilization immediately after giving birth between 2005 and 2010. By early 2019, coerced sterilization had been alleged by approximately 100 Indigenous women, covering a period from the 1970s until as recently as 2018.

According to Senator Yvonne Boyer, modern forms of coerced sterilization have been experienced by Indigenous women in many provinces across Canada. A class action lawsuit alleging coerced sterilization has been proposed in Saskatchewan, and another in Alberta. Women report not being given the time or information necessary to make informed decisions, being pressured to consent when under duress, and/or being told they would not be able to see their newborn child unless they agreed to sterilization.

"Nikawiy Nitanis"by Mackenzie Anderson is the 2017 winner of the Indigenous Arts & Stories contest. This piece, meaning "Mother and Daughter" in Cree, depicts a mother and daughter connected through the sun and the moon. It is about Missing and Murdered Indigenous Women and Girls.

© Mackenzie Anderson/Indigenous Arts & Stories/Historica Canada

Coerced Sterilization and Indigenous Women

The coerced sterilization of Indigenous women is connected to the broader context of colonialism. It is one of many forms of violence committed against Indigenous women in Canada ( see also Missing and Murdered Indigenous Women and Girls in Canada; Highway of Tears; Indigenous Women's Issues in Canada). Coerced sterilization undermines the ability of women to make decisions about their own lives. This practice can be linked to other explicit policies stemming from the Indian Act that have undermined Indigenous women and denied them the ability to participate fully in their communities. One example of such a policy is the Act's definition of who is "Indian," which continues to discriminate on the basis of gender through "status" regulations. The practice of coerced sterilization is also consistent with the way that medical services have sometimes been offered to Indigenous peoples, for instance, through Canada's evacuation policy for pregnant women who live in remote or rural areas, or historical regulations that forced Indigenous peoples to submit to Western medicine. These policies have attempted to control Indigenous bodies and effectively criminalized Indigenous health and reproductive practices.

The coerced sterilization of Indigenous women works to destroy the connections between women and their peoples while reducing the number of those to whom the federal government has obligations. Sterilization breaks the link between Indigenous women and future generations. Other policies did this as well, like residential schooling or the " Sixties Scoop," which forcefully transferred Indigenous children out of their communities and into institutions or non-Indigenous families. In 2004, there were more Indigenous children in the child welfare system than there were in residential schools in the 1940s, at the height of residential school policy. More recently, despite Indigenous children only accounting for approximately 8 per cent of the population under 14 years of age, they make up 52 per cent or more of those in foster care. Interventions like this further perpetuate assimilation as Indigenous children become disconnected from their communities and ways of life. However, there is a finality to the practice of sterilization. The break that comes from robbing Indigenous women of the ability to reproduce cannot be undone, and effectively terminates the legal line of descendants able to claim treaty or Indigenous rights and title to land.

In this way, the coerced sterilization of Indigenous women allows the state to deny responsibility for and avoid doing something about the often deplorable social, economic and health conditions in most Indigenous communities, conditions that the Royal Commission on Aboriginal Peoples recognized as being a direct result of dispossession and colonialism. It is more cost-effective to limit the ability of Indigenous women to reproduce than it is to do what is required to improve the conditions into which children are born. When understood within this context, the coerced sterilization of Indigenous women can be viewed as an act of genocide, or an attempt to undermine the ability of a group to exist.

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Sterilization of Indigenous Women in Canada

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The practice of sterilization arose out of the eugenics movement and has a long, often hidden history in Canada. Sterilization legislation in Alberta (1928-72...

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A cognitive behaviour therapy-based self-management guide for women

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A cognitive behaviour therapy-based self-management guide for women

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Providing the gift of remembrance portraits to parents experiencing the death of a baby. Families We journey together and are here to aid you in your healing, bring hope to your future, and honor your

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Someone (or an institution) who is trauma-informed “realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; responds by fully integrating knowledge about trauma into policies, procedures and practices; and seeks to actively resist re-traumatization” (as cited in Seng & Taylor, 2015)(4).

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Parents-to-be and offspring harmed by disrespectful and abusive perinatal care

Maternal experiences of safety during pregnancy and childbirth support healthy psychophysiological processes in mothers-to-be and their developing babies and positive pregnancy outcomes (1). Trauma-informed care during the preconception, prenatal, and early parenting periods supports maternal-offspring experiences of safety.

Unfortunately, many pregnant women and girls from around the world, including the United States, receive disrespectful and abusive care during the perinatal period, as reported in a statement released by the World Health Organization in 2015 (2). This maltreatment, now referred to as "obstetric violence," includes bullying and coercion by health-care personnel (3). These behaviors often evoke a felt sense of danger and/or life threat in mothers-to-be, which may activate defense system fight, flight, and freeze reactions and trigger traumatic stress symptoms.

Training health-care personnel who provide preconception and perinatal care in the trauma-informed care model would support awareness, prevention, and antidotes to disrespectful and abusive care during pregnancy, childbirth, and the postnatal period. The National Center for Trauma-Informed Care (NCTIC), part of the Substance Abuse and Mental Health Services Administration (SAMHSA), explains that a program, organization, or system that is trauma-informed "realizes the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; responds by fully integrating knowledge about trauma into policies, procedures and practices; and seeks to actively resist re-traumatization" (as cited in Seng & Taylor, 2015)(4).

The six principles of trauma informed care as described by SAMHSA are:

Safety

Trustworthiness and Transparency

Peer Support

Collaboration and Mutuality

Empowerment, Voice, and Choice

Cultural and Historic Issues and Gender Awareness (4)

In stark contrast, the World Health Organization's description of disrespectful and abusive treatment during facility-based childbirth reported by mothers-to-be includes: "Outright physical abuse, profound humiliation and verbal abuse, coercive or unconsented medical procedures (including sterilization), lack of confidentiality, failure to get fully informed consent, refusal to give pain medication, gross violations of privacy, refusal of admission to health facilities, neglecting women during childbirth to suffer life-threatening, avoidable complications, and detention of women and their newborns in facilities after childbirth due to an inability to pay"(2).

The World Health Organization notes that the women and girls most likely to experience obstetric violence are "Among others, adolescents, unmarried women, women of low socio-economic status, women from ethnic minorities, migrant women and women living with HIV" (2). These women and girls may report experiences of racism in their interactions with health-care personnel.

Research demonstrates that women who report experiences of racism may have as much as a threefold increase in the incidence of adverse birth outcomes, including: low birth weight and very low birth weight babies and preterm birth (5). Experiences of racism may also contribute to disparities in maternal mortality rates in the U.S. As reported by the Pregnancy Mortality Surveillance System, black women in the U.S. are three to four times more likely to die from a pregnancy-related complication than non-Hispanic white women (16).

Landrine & Klonoff (1996) explain, "All definitions of racism include the notion of unequal treatment based on skin color or other physical characteristics. Because these characteristics are immutable and often central to one's identity, racism constitutes a profoundly personal and severe threat to well-being" (as cited in (6)). Racism in the context of perinatal care is a form of obstetric violence with very serious potential consequences for mothers and babies.

Perinatal care that is not based upon the trauma-informed care model may inadvertently trigger the physiology of traumatic stress in mothers-to-be, which affects her health and that of her developing baby over its lifespan, may impact the outcome of her pregnancy and negatively affect the developing attachment relationship between her and her infant. It is important to remember that both the pregnant woman or girl and her developing baby are experiencing the violence during these interactions with health-care personnel in the facilities within which they are receiving care.

Given the statistics on the prevalence of violence against women before and during the childbearing years, a significant number of women and girls carry experiences of past and recent abuse and assault into their experiences of pregnancy and childbirth. One in three women report a history of physical or sexual childhood abuse (7). Thirty-five percent of females worldwide over the age of 15 have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence (8). It is important to note that this research did not evaluate the prevalence of emotional abuse, which is another form of violence experienced by women and girls. Seventy-eight percent of women who have been raped were first raped before 25 years of age, and 40 percent were raped before age 18 (9). For these trauma survivors, the experience of receiving disrespectful and abusive care from health-care practitioners may be re-traumatizing (10).

An additional aspect of obstetric violence is the fact that women and girls often feel betrayed by health-care personnel and the facilities in which they receive care during and after disrespectful and abusive treatment. Betrayal has been defined by Kelly et al. (2012) as "feeling as though someone (or something) who should have supported you or protected you wound up being responsible in some way for the event. This could have happened because of something they actually did or something they failed to do" (p. 410). (11)

Betrayal trauma occurs when people or institutions on which a person depends for survival significantly violate that person's trust or well-being (18). Pregnant and birthing women and girls who experience the violation of trust and maltreatment at this vulnerable time by health-care personnel - professionals on whom they feel dependent for their own and their babies' safety, and potentially for their survival - may experience feelings that are associated with traumatic experiences. These include: feeling their life is threatened; feeling intense fear, helplessness, and horror; feeling dehumanized, degraded, and humiliated; and feeling threatened with forced separation (in this case from their baby and the individuals who support them) (17). As explained by Foa, Rothbaum & Zinbarg (1992), "Psychologically and biologically, the severity of traumatic events is related to their being intense, inescapable, uncontrollable, and unexpected (p. 218). (12). These qualities often apply to the disrespectful and abusive experiences suffered by mothers-to-be, which then trigger traumatic stress reactions. The experience of betrayal trauma has been associated with the development of PTSD and an increase in symptom severity (11).

An abundance of research now demonstrates how maternal prenatal stress and traumatic stress impact the health, development, and behavior of offspring over their lifespan (13), (14). Yehuda and Lehrner explain that "there is now converging evidence supporting the idea that offspring are affected by parental trauma exposures before birth, and possibly even prior to their conception" (15).

This evidence illuminates the crucial need for the evaluation of the impact of the quality of care provided to parents-to-be and their developing babies in the perinatal period. It is vital that health-care practitioners understand that the quality of care they provide in the preconception, prenatal, and postnatal periods impacts the psychophysiology of parents-to-be and their developing babies. Care that increases maternal stress and traumatic stress in this crucial period of offspring development significantly shapes the trajectory of the parent-child relationship.

The key question providers and facilities must answer is, "Are we seeking to actively resist the traumatization and re-traumatization of parents-to-be and their offspring?" Providing education and training in trauma-informed care in the perinatal period is one step towards preventing the harm inflicted by obstetric violence. One wonders how the commitment to "first do no harm" in the provision of health care has been overlooked in situations where health-care personnel and facilities have engaged in the disrespectful and abusive treatment of women and girls in the perinatal period.

References

(1) Montgomery, E., (2013). Feeling safe: A metasynthesis of the maternity care needs of women who were sexually abused in childhood. Birth, 40(2), 88-95.

(2) World Health Organization, (2015). The prevention and elimination of disrespect and abuse during facility-based childbirth. https://apps.who.int/iris/bitstream/handle/10665/134588/WHO_RHR_14.23_e...

(3) Diaz-Tello, F. (2016). Invisible wounds: obstetric violence in the United States. Reproductive Health Matters, 24(47), 56-64.

(4) Seng, J., & Taylor, J. (2015). Trauma informed care in the perinatal period. Edinburgh: Dunedin Academic Press.

(5) Dominguez, T. P., Dunkel-Schetter, C., Glynn, L. M., & Sandman, C. A. (2008). Racial differences in birth outcomes: The role of general, pregnancy and racism stress. Health Psychology, 27(2), 194-203.

(6) Nuru-Jeter, A., Dominguez, T. P., Hammond, W. P., Leu, J., Skaff, M., Egerter, S., ...Braveman, P. (2009). "It's the skin you're in": African-American women talk about their experiences of racism. An exploratory study to develop measures of racism for birth outcome studies. Maternal and Child Health Journal, 13(1), 29-39. doi:10.1007/s10995-008-0357-x

(7) Cougle, J. R., Timpano, K. R., Sachs-Erisson, N., Keough, M. E., & Riccardi, C. J. (2010). Examining the unique relationships between anxiety disorders and childhood physical and sexual abuse in the National Comorbidity Survey-Replication. Psychiatry Research, 177(1-2), 150-155.

(8) World Health Organization (2013). Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence.

(9) Breiding,, M. J., Smith, S. G., Basile, K. C., Walters,, M. L., Chen, J., Merrick, T. T. (2014). Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization-National intimate partner and sexual violence survey, United States, 2011. Morbidity and Mortality Weekly. Center for Disease Control.

(10) Muzik, M., McGinnis, E. W., Bocknek, E., Morelen, D., Rosenblum, K. L., Liberzon, I. S., Seng, J., Abelson, J. L. (2016). PTSD symptoms across pregnancy and early postpartum among women with lifetime PTSD diagnosis. Depression and Anxiety, 33(7), 584-591.

(11) Kelley, L. P., Weathers, F. W., Mason, E. A., Pruneau, G. M. (2012). Association of life threat and betrayal with posttraumatic stress disorder symptom severity. Journal of Traumatic Stress, 25(4). 408-415.

(12) Foa, E. B., Zinbarg, R., Rothbaum, B. O. (1992). Uncontrollability and unpredictability in post-traumatic stress disorder: an animal model. psycnet.apa.org

(13) Buss, C., Entringer, S., Moog, N. K., P., Toepfer, Fair, D. A. et al. (2017). Intergenerational transmission of maternal childhood maltreatment exposure: Implications for fetal development. Journal Am Acad Child Adolesc Psychiatry, 56(5), 373-382.

(14) Van den Bergh, B. R. H., van den Heuvel, M. I., Lahti, M., Braeken, M., et al. (2017). Prenatal developmental orgins of behavior and mental health: The influence of maternal stress in pregnancy. Neuroscience and Biobehavioral Reviews, http://dx.doi.org/10.1016/j.neubiorev.2017.07.003

(15) Yehuda, R., Lehrner, A. (2018). Intergenerational transmission of trauma effects: putative role of epigenetic mechanisms. World Psychiatry, 17(3), 243-257.

(16) Pregnancy Mortality Surveillance System. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

(17) Yehuda, R. (Ed.) (2002). Treating trauma survivors with PTSD. Washington, DC: American Psychiatric Publishing.

(18) Freyd, J. (1996). Betrayal trauma: The logic of forgetting childhood abuse. Cambridge, MA: Harvard University Press.

More references

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Trauma-Informed Care Needed to Address Obstetric Violence

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Parents-to-be and offspring harmed by disrespectful and abusive perinatal care Maternal experiences of safety during pregnancy and childbirth support healthy psychophysiological processes in mothers-to-be and their developing babies and positive pregnancy outcomes (1). Trauma-informed care during the preconception, prenatal, and early parenting periods supports maternal-offspring experiences of safety.

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Video about DONA International

https://www.youtube.com/watch?v=u792CxDT7cE&ab_channel=DONAIntl

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Four (and a half) major issues concerning the etymology, connotations, & appropriation of the word "Doula", as well as the gatekeeping of the "Doula" profession through capitalist-colonizer credentialism.

Disclaimer:

For the sake of anti-ableism and Language Justice, I want to be clear that I am open to making this essay more accessible, and available for clarification on things which I have failed to express in a clear and accessible manner. I've tried my best to link certain things to sources and definitions, but this essay was not initially intended for public sharing, so it's not complete.

This essay is not a definitive source of linguistic history or evolution, nor is it an exhaustive list of all of the issues I have seen others bring up with the word "doula" and it's invention and usage. There are over three dozen separate articles and essays like this one that I have seen so far, so if you're interested in other individual yet echoing points of view on the matter, please do seek them out (though, most of them only focus on the same 2-3 points).

I want to merely offer up some my own thoughts on the matter. This essay is just my way of getting an issue off my chest, and trying to explain the major issues and concerns I have with the word "doula" because it's the most commonly-accepted term (in the western countries at least) used to refer to people who offer the same types of professional support services as I do.

Some context about me and where I am coming from in this essay:
I am a mixed-Indigenous, disabled, queer, nonbinary person. I currently offer various types of care and support services on occupied Ohlone and Coast Miwok lands. Among other things, I offer postpartum and fourth trimester support, respect and consent based parenting consultation, and parentbirthing and reparenting guidance. I provide these offerings through an anti-capitalist, decolonized, radically holistic, and radically intentional lens. I weave both modern-scientific and Indigenous approaches together, with science-backed information and community-sourced wisdom. I aim to create a practice that - I hope - provides my clients with care that embodies professional and personal integrity surrounding the values which I hold most dear. Values which include - among many others - language justice and decolonization.

If you don't agree with the following essay, that's ok. All I ask is that you take a moment to read this with an open mind and reconsider your stances on the matter - especially if you use this word in your own professional work, and especially if you actively benefit from privileges afforded to you systemically by dominant culture. The goal of this essay is bring this issue to light and help heal some of the associated ignorance and harms done.

Thank you.

So, all this fuss about a word. Just a simple, innocent word. A term that is beloved by nearly all who encounter it; beautiful, inspiring, hopeful, and all around just swell. That is, if you're a member of the dominant culture in western society - especially within America. If you identify as a member of any non-dominant, traditionally-marginalized community - especially those who are Black, Indigenous, and/or Greek, then you're probably only reading this to see if I've included something you don't already know. Either way, let's go ahead and explore what all the fuss is about, shall we!

This is the current, modern, English definition of the word "doula". This is version that we have all been led to believe is entirely true and correct.

dou·la /ˈdo͞olə/ f. noun.
A woman, typically without formal obstetric training, who is employed to provide guidance and support to a pregnant woman during labor.

Now, before I jump in to the major issues, I want to point out that first and foremost, I take issue with the fact that this definition doesn't even come close to touching the full scope of the services offered by people who generally use the term "doula". There are labor & birth doulas, postpartum doulas, bereavement doulas, death doulas, abortion doulas, gender transition doulas, adoption/surrogacy doulas, and many more types of support work that don't involve childbirth at all.

So in fact, this expansive professional realm as it stands lacks an adequate, all-encompassing term; and the word "doula" is hardly the most appropriate. I actually don't offer childbirth support services at all - so given that specific definition, could I even call myself a "doula"? Do I want to?

Surely there must be a better way to correctly distinguish these support persons and caregivers than with such a narrowly-focused - and as we'll explore soon enough, highly problematic- term.

But I digress...

On to the real issues. Because honestly, this one is the least of the problems, by far. This issue becomes null when we start discussing the reasons why the word "doula" itself, as a name for this profession, needs to die entirely.

1. Sexism, Gender-Essentialism, and Trans-Antagonism.

Let's look at this definition here from above...
" A , typically without formal obstetric training, who is employed to provide guidance and support to a pregnant during labor."

I strive to challenge toxic systemic issues such as gender-binarchy, anti-femme sexism, gender-essentialism, trans-antagonism, body-illiteracy, bodily shame, sexualization of young girls, and other related injustices. Given that these issues are always on my mind, the official modern English definition of the word "doula" strikes a big red-flag chord with me here. There are three parts to this that I want to expound upon.

I'll start with the lesser of the evils.

1. It not-so-subtly implies that doulas are untrained in general, from the tone of the phrasing and the specific terminology and phrasing chosen. Choosing your words carefully - especially in such an intersectional and sensitive field as caregiving, birthkeeping, death support - is so very very crucial. Think about if you were a nervous first-time pregnant person, trying to decide if you wanted to hire something called a "Doula" - whatever that is. Then you see that the definition contains the phrase "without formal...training". Would that make you feel very confident? Hmm, probably not.
But it's not even true. Thanks to the "doula" credentialism standards born from DONA (Doulas of North America; we'll get to them later), "doulas" actually are "trained" and "certified"!

2. This definition is highly gendered and gender-essentialist. By insisting/assuming that all persons involved identify as "women", and that the birthing person must also be a cis-gendered woman, this definition is inherently discriminatory against all other gender identities - especially transgender and intersex birthing people. Being a nonbinary person myself, I have always felt a subtle, yet growing aversion toward the word. The same reasons why I intentionally default to using "they" for all unknown people, so as not to assume. The same reasons why I use "partner" as the default instead of "wife/husband/etc), so as not be exclusionary toward queer relationships as well as to challenge cis-het terminology as the default in general.

3. The term is inherently alienating toward people who identify as male, men, and/or masculine who may want to enter into the profession.

The vast undercurrent of various forms of gatekeeping among the modern doula word is entirely worthy of criticism.
I loathe the existence of gendered terms like actress, heiress, hostess, seamstress, especially words like millionairess, murderess, and adventuress which were not gendered words to begin with! ( How utterly silly and demeaning are those words!) But, ho, it was deemed necessary to put women in their own little sub-categorical labels. It was deemed necessary to keep "the sexes" separate .... " but equal ", right?

By technicality, in this context, the modern definition of the word "doula" is no exception to the rule of gender-separating professional terms - which is an outdated, misogynistic, and ridiculous rule that needs to be put to sleep. Seriously. Just, let's be done with that already. I mean, did the first ten waves of feminism teach us nothing?

But even knowing that there is a "male" version of the word, "doulos", does not help at all. In fact, "doulos" has nothing whatsoever to do with supportive care, birthkeeping, and other similar occupations.
Learning about "doulos" leads to learning about the real origins of "doula" - origins which far precede the western co-opting and coinage of the 1970s, and which shed light on still more problematic aspects...

2. Problematic Etymology and Poisoned Roots; Some words are simply not eligible for reclamation.

Here are the original - and common, current, STILL USED- definitions of the words "doula" and "doulos". Not merely figments of the distant past, but words that are still in use today by the very language and people that actually invented the words a millennia ago in Greece.
(Spoiler Alert : it was not Dana Raphael, and it's not the bible.)

δούλη (doúlē) /ˈðula/ f. noun.
δοῦλος (doûlos) /ˈðu.los/ m. noun.
1. born slave or bondman 1. slave (female) ; 2. (obsolete) maidservant

The Greek definition of both "doula/doulos" means "born slave". Both terms share the same roots as the Greek word "douleiá" (δουλειά), a word that is still used in the modern iteration of the Greek language today. It can mean either "slavery" when the accent is on the 'i' in "douleía" (δουλεία), or "work" when the accent is on the 'a' in 'douleiá' (δουλειά).

I don't know much about their culture and language, but I do know that I've heard and read enough about modern-day Greek people being profoundly uncomfortable with this new western version of the word "doula", and absolutely refuse to use it as the name of this profession in their culture. I know that many Greek support service providers have approached and petitioned various[doula] communities, multiple times over the decades, begging them to change it and replace it with a less toxic alternative. As we can plainly see, all of those efforts have gone unanswered - but that's later in the essay. Unfortunately, I still have yet to learn about their alternative terms, but I assume they suffer from the same linguistic conundrum I face here - going against the grain of dominant culture, and struggling to find that perfect name.

Although one doesn't need to know very much about human history to understand the levels of horror, anguish, and rage caused by human trafficking and enslavement, both past and present.; it seems this superficial understanding of history is not enough to stop us in our tracks and come up with a new term. Terminology that is directly - or even indirectly - associated with slavery is incredibly harmful, no matter how you try to spin it. Harm is harm, regardless of time, and regardless of association. As a person of mixed-Indigenous heritage, a Black ally, and an accomplice to Black civil rights and Land Back efforts, this becomes a second major aversion to the word "doula".

~

White people reading this; I'd like to ask you to imagine for a moment that you are Black or Indigenous...

Imagine having your beloved ancestral family lands taken from you, and forced to live without clean water or adequate access to even basic health care or education. Imagine having your culture demonized and even criminalized; all of your people's music, poetry, artistry, birthing and coming of age rights, medicinal ceremonies erased through violence and genocide; and then watch it all be blatantly appropriated, repackaged, monetized, and commercialized by your own abusers. Imagine your own children, nieces, nephews - many as young as two years old - kidnapped and stolen into boarding schools that were created by the government to "civilize the savage" out of them (as recently as 1996); your mothers, sisters, aunts, and daughters constantly go missing or are found murdered, while law enforcement and government looks the other way; with little to no intervention, let alone acknowledgement from the rest of dominant culture.

Imagine growing up in a country to which your ancestors were brought in shackles and chains - that is, if they happened to survive the starving, disgusting, suffocating, harrowing sea voyage. Imagine being the descendent of whole human beings who were regarded as less than chattel, less than human; violently captured and ripped from their homes and families, who were then enslaved, tortured, dehumanized, and otherwise utterly brutalized to their very souls. Imagine growing up in a country whose laws have changed, but in practice still commits genocide on your people every day through allowing police to murder them in broad daylight, still enslaves them every day through the prison systems, still justifies all of this because of the way you and your community react to being redlined, severely-underprivileged, excluded from privilege and wealth, cornered like the animals this government still sees you as -but swears they don't.

Imagine living in a country that both subtly and overtly belittles, mocks, caricaturizes, fetishizes, mythologizes, objectifies, commodifies, tokenizes, murders, and brutalizes you, your loved ones, your culture, your religion, your history... both historically and to this very day... and the country you are forced to live in/under either does nothing to acknowledge or stop this behavior, or actively endorses and participates in it.

Now imagine being a person of one or both of those roots who is deeply drawn to the profession of caring for birthing families, guiding new parents and caregivers, supporting transitioning people, caring for the dying, and so on... Imagine being told that the only word for your heart-chosen profession that is professionally recognized by all of the training and "certification" organizations (training which in itself is inherently anti-Black and anti-Indigenous - but we'll get to that later), and even the medical health care system itself, was a term that is synonymous with the word "".
Imagine knowing that fact and seeing it ignorantly praised and amplified by the dominant white culture. Imagine not having the privilege of being able to shake off that connotation and just suck it up, because your ancestors are writhing with horror and anguish inside of your very bones about it. Imagine not having any of your formal requests and largescale petitions for an alternative term taken seriously by the people who appropriated and monetized the term. Imagine your pain and suffering being belittled and undermined, simply because these others don't see it as "that big of a problem" - or even a real issue.

~

I don't want anything to do with slavery. I don't want to directly nor indirectly perpetuate anything associated with slavery, including actively harmful and ignorant forgotten terminology derived from its existence. I do not ever want to undermine, ignore, belittle, dismiss, invalidate, or otherwise avoid and disrespect the realities of slavery, nor the realities of languages other than my own. As an ally to those whose ancestors were forced to endure the brutalities and horrors of having been enslaved, I'm adamantly anti-slavery in this regard. As someone who now knows that the word "doula" both historically and currently means slave, then I have no choice but to reject and renounce the word "doula" entirely.

This term was never mine - or yours - to use, anyway. It was never any of ours to use in this way. This alternate, secondary definition - which is barely fifty years old now- isn't one that was given to this novel iteration of the profession from the very culture that invented it or the people who were enslaved and forced to be doulas and doulos. It wasn't a term given by those who's Indigenous and ancestral medicines and traditions were stolen and appropriated to create the very foundations of the profession itself. It wasn't one given to the profession with integrity, moral ethics, love and respect, or even the most basic forms of holistic and authentic consideration.

So why do we use the word "doula" as we do? Where did it come from? It might not surprise you to learn that a white woman from America, named Dana Raphael, took it upon herself to coin it in the 1970's in a book she wrote about postnatal support...

3. Linguistic Responsibilities and Ignorant Appropriation.

Keeping in mind that languages are living, breathing organisms that are ever-evolving through mass media, generational context, notable events, popular figures, and immigration; we must also keep in mind our obligation toward understanding and acknowledging established linguistic base rules - such as, oh how ironically, words that have Greek roots. These linguistic rules not only provide a common understanding of vocabulary - useful for efficient, accessible, and ethical translation; they also, and possibly more importantly, provide bridges to linguistic pasts that directly affect current and future word associations, connotations, and inherent definitions - especially those which have potential to cause harm.

In reality, "doula" is a word, like many others, that happens to have a Greek root, therefore confusing and poisoning its secondary definition. In fact, the western English iteration of "doula" is a totally brand new term, with a borrowed existing external form. To my knowledge, the unwarranted "reclamation" of "doula" that happened in the 1970s, modern day English was done entirely ignorantly. One might even argue "innocently", but ignorant and harmful nonetheless. ( Intentions do not outweigh harm, ever.) Regardless, "doula" was already - and still is - an existing word in the modern world - one with a rather severe and harmful definition that cannot be ignored. And that definition, unfortunately, is not the definition that was told to the creator of this new term.

The western world, in which it is most popularly used - most notably, American - is not likely to change it any time soon, because it is so successfully integrated into the dominant birth support work and parenting culture, as well as the fact that organization like DONA have undergone extensive efforts to get the American health care system to formally recognize is as a valid profession within hospital walls. Dominant culture wants this word, and it's putting everything it has into making sure the rest of the world respects their version of it.

Dominant Culture; cisgender, heterosexual, white, thin, tall, able-bodied, middle or higher class, people, whose first and often only language is English. Those who have never been told by their government that any part of their identity was immoral or criminal. Those who have never had their government create and pass laws which threaten to take away rights that others are given freely and proudly. People who are often so swaddled by their privilege, they are completely unaware of the systematic and incessant marginalization and oppressions that others face.

Dominant culture - and especially those who have never been directly or generationally harmed by slavery- has no dogs in that particular race. It just does not affect them in the ways that it does all Greek-speaking people, descendants of enslaved people, and all others who bear generational witness to such inhumane atrocities. Members of dominant culture do not nurse the deep intergenerational wounds associated with human trafficking and enslavement; they do not feel the same burdens and cultural obligations as those who stand against the injustices done to theirancestors.

Dominant culture loves to have its cake and eat it too, and often that means going with it's own flow and staying within its comfortable, self-appreciating, and infallible echo chambers. This fragile egocentric reality relies heavily upon the habit of ignoring, invalidating, and even challenging other points of view - especially others who tell them they are being more harmful than helpful. They are told "your actions are hurting us", and they can't help but defend their good intentions; mistakenly assuming that anyone standing up against against their behavior to be directly attacking their character.

( P.s. I feel the burning, seething need to mention that human trafficking and enslavement still exists today; Yes, even here in America. It never ended. It just took on new names and forms. Un/intentional ignorance and in/direct perpetuation of the status quo are the one constant aspect of these atrocities that help them to continue. To me, these two aspects are also the same reason why Dana Raphael's coined iteration of the word "doula" is still being used. )

4. Dominant Culture, and further Marginalization of "Minorities".

(or, " The nice privileged people are trying to enjoy their dinner, can you please stop bleeding all over their carpet - it's gross, and it's distracting. Thank you. ")

There have been countless requests across the last few decades for the term "doula" to be relinquished, abandoned, and replaced due to its negative associations, but its wide-spread usage and popularity among western dominant culture has consistently undermined and inhibited these attempts. In my own solidarity with ESL people, and in the name of Language Justice, this is another major reason why I reject the term.

If something is harmful to any specific group of people, it is harmful. Period. It's not my place to debate that fact, nor am I required to fully understand it, but I do have an ethical duty to acknowledge and respect it. Especially as someone who describes themself as one who provides radically holistic, intentional, and trauma-informed support and care during my clients most precious and sensitive moments in life. Especially as someone who works with clients of traditionally-marginalized identities. Especially as someone who lives at various traditionally-marginalized identities, myself. I would be wholly remiss in my professional duties and go against my personal ethical values to ignore such a blatant fact that the term "doula" is harmful.

If dominant culture is being told by traditionally-marginalized people that they are being harmed, and that harm is coming from dominant culture itself, and if dominant culture doesn't take it seriously, then that compounds the harm by making it both complacent and overt. It's no longer covert and insidious. The emperor absolutely is naked. And now we all know it.
Unfortunately, though, it's never that simple.

The sad fact is that most white people I come across in the "doula" world have no clue about any of the issues mentioned above; that the term was unethically appropriated by white people, does currently and has always meant "slave", directly harms Black and Indigenous people, actively excludes trans and intersex people, and perpetuates white-supremacy, privilege-centering, and Indigenous genocide. They have no idea at all. This is one of the many forms of harm that people don't automatically think about when we talk about perpetuating white-supremacy. The ignorant, misguided, or skewed cultural appropriation of terms, practices, and sacred symbols by members of dominant culture has always been a painful, frustrating, and toxic aspect of intersectional life in western society. The only thing worse is when it's done complacently.

Words have power, and must be given a standard of respect and understanding. The words we think we choose for one intention or connotation, are purely subjective, and because language is so alive, it is irresponsible to pick and choose definitions and connotations. It is wildly inappropriate and egotistical to think that our personal intentions and our own definitions could ever be more important or more valid than all else. Just because you have good intentions and consider yourself to be a good person, doesn't mean you are infallible and incapable of doing harm.

Risky opinion: Claiming to be an expert in your field - especially a field that exists in service to and care of others - but not being aware of or giving proper attention and respect to the harmful connotations of the very word that you call yourself and insist that others call you, is morally and ethically irresponsible and harmful.

We have a moral and ethical obligation to do right by our traditionally-marginalized and oppressed clients, peers, coworkers, neighbors, friends, partners, and so on. A word adopted by dominant culture, which should not have been, has been found to be harmful and toxic. What are we going to do about it?

What we do about it?
Well, as it happens, a lot actually...

Less Toxic Alternatives and Our Duty as Care-giving and Support Persons
-~-

I have settled most definitively on the term " Support Specialist" for my own practice. Depending on the context, I use Postpartum Support Specialist, Parentbirthing and Reparenting Support Specialist, Family and Individual Transition Support Specialist, and so on. I believe the term " Support Specialist " yields an appropriate amount of professionalism and gravitas, without being exclusionary to those who intentionally choose not to pursue "doula certification", without interfering with any terms in the medical profession, and without feeling inaccessible to ESL and other non-dominant-culture identities. I am passionate about this term as being an effective, ethical, and future-proof replacement as the official name for this particular field of specialized caregiving professions currently know as "doula" work.

-~-

I am still exploring other possible terms that have no notable historically or current negative definitions or connotations, such as Caregiver, Childbirthing Steward, Transitions Companion, Birthkeeper, Support Person, Postpartum Companion, Caregivers Companion, Parenting & Caregiving Guide or Consultant ( I personally avoid the term "coach" here because I do not "train or instruct" my clients; rather, I support and collaborate with them), and more.

I have even considered the task of finding others to help in founding new terminology, with the explicit consultation and permission of that culture, of course. There are some beautiful word from North Sámi (one of the languages that is spoken by the Indigenous people of Northern Scandinavia, and is where my first name comes from), such as "Váhnen" which means "parent", or "Fuolki" which means "relative; kin". I am so inspired by the idea of replacing "doula" with something utterly devoid of a problematic past, that can be claimed and reclaimed for all future generations as a word that has only positive meanings and associations.

I have yet to come across something that fully encompasses the tone of all that my own practice has to offer our myriad intersectional clients and community, or any word from another culture whose definitions and connotations strike significant cords with me. I am not quite sure how to go forward in my support practice with such ambiguity and uncertainty in what, of all things, to call myself professionally. However, I do hope that in my lifetime, a radical shift is made from one of ignorance and complacency, to one of unconditional radical respect and authentic, effective allyship. My hope is that maybe we can find a term, that is devoid of even the slightest twinge of toxic connotation -one that inspires connotations even more powerful and beautiful than the current options - and that we can step forward into the future with our hearts and minds in a more healthy direction.

Until then, though, it our humble duty and ineffable privilege to continue to unearth and explore and challenge the status quo, both in society at large as well as deep within ourselves.
Until then, that's where I'll be.
I hope to see you there.

Thank you for your time and energy, and your consideration of my words here. I hope this has been a learning and inspiring experience for you. It has been very cathartic and healing for me to get out.

Live long and prosper,
and Party on, Wayne.

Post Publish Edit:
While the birthworker-related definition of "doula" was originally only coined in the US in the 1970's by Dana Raphael, it was heavily urge to be popularized and normalized through government and medical lobbying by various members of dominant culture. These efforts were made by people who - both knowingly and ignorantly - appropriated both open and closed practices from Indigenous cultures.

The entire aspect of mainstream certification of professional support persons and birthworkers under this title, as defined by and gatekept by predominantly white, non-Indigenous, non-Black, cisgender, heterosexual, middle+class, able-bodied individuals, is highly problematic in and of itself. "Doula" certification has only existed since the 1990's at earliest, and began in the United States of America, a country which was founded on genocide and slavery, the criminalization of Indigenous practices and culture, and perpetuates and enforced settler-colonist-centered consumer-capitalist ideals.

"Doula Certification" has only existed for less years than I have been alive on this earth, for a profession which has existed since human beings have existed in any forms of society. For as long as there have been birthing people in communities, there have been dedicated community members who provide care and support with passion, love, trust, and wisdom. This profession existed and thrived long before the inventions of the capitalism or credentialism. It wasn't until well after WEIRD societies rose and the health care industry became unhealthily obsessed with pristine, clean, white, sterile birthing approaches, that all ancestral birthing practices were made illegal, and smear campaigns against them were injected into society at an alarming rate.

Many birthing and postpartum [doulas] today intentionally choose not to "certify" through any organization, even with ones they do choose to train through. As someone who holds traditional* birthing and postpartum care and support to be a sacred calling and responsibility, I abhor the entire act of credentialist gatekeeping, as well as other highly capitalistic aspects that the greedy, paranoid, capitalist mentality has seeped into this profession; such as trademarking certain universal birthing and postpartum terms, copyrighting of private practice names which contain key terms of the profession, operating ones practice primarily in terms of marketing and branding instead of the sacred privilege of providing care for parents and future ancestors, and more.

And so this last segment is an "homage" if you will to exactly why I refuse to "certify" as a member of this profession, especially while "doula" is still being used as the official professional title. And especially while most forms of credentialism in WEIRD societies are systematically anti-Black, anti-Indigenous, anti-Trans, and anti-immigrant. No thanks.

For more information on the problems of Credentialism:
https://www.theatlantic.com/magazine/archive/1985/12/the-case-against-credentialism/308286/
The Credential Society: A 1979 book by Randall Collins which argues that public schools are social institutions that teach and reward middle class values of competition and achievement.

-~-
* (The original meaning of the word "traditional", as in pre-colonized, authentic, Indigenous, traditional. Not the post-colonial "the way things are done now" version of the word "traditional" which regards Indigenous ways to be antiquated, ridiculous, uncivilized, and other reasons for not being worthy of respect in any form.)

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Four (and a half) major issues concerning the etymology, connotations, & appropriation of the word "Doula", as well as the gatekeeping of the "Doula" profession through capitalist-colonizer credentialism. Disclaimer: For the sake of anti-ableism and Language Justice, I want to be clear that I am open to making this essay more accessible, and available for clarification on things which I have failed to express in a clear and accessible manner.

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Learn about perinatal mood and anxiety disorders

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Learn about perinatal mood and anxiety disorders

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Learn More | Postpartum Support International (PSI)

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Learn about the symptoms of perinatal mood or anxiety disorder, such as postpartum depression.

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Breastfeeding and parenting from a transgender perspective

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Breastfeeding and parenting from a transgender perspective

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Diclaimer

This blog is not intended to provide medical advice. It is meant to be fun and maybe informative. It's based on my personal experience. I'm not a doctor or health care provider of any kind. For medical advice, please go see your health care provider. Furthermore, just because what I describe here worked for me and my family does NOT mean it will necessarily work for you and yours. Again, this is my personal experience.

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This blog is not intended to provide medical advice. It is meant to be fun and maybe informative. It's based on my personal experience. I'm not a doctor or health care provider of any kind. For medical advice, please go see your health care provider.

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This breaks it down nicely.

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Here's a whole bunch of data to wade through about giving birth in BC.

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The annual indicators report is no longer produced. The indicators have been incorporated into the Perinatal Health Reports above.

Please review the Technical Notes for Indicators by Place of Residence.

Please review the Technical Notes for Indicators by Place of Delivery.

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The annual indicators report is no longer produced. The indicators have been incorporated into the Perinatal Health Reports above. Please review the Technical Notes for Indicators by Place of Residence. Please review the Technical Notes for Indicators by Place of Delivery.

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Canadian health care isn’t immune to racism, experts say. Here’s why | Globalnews.ca

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‘Your risk of illness and chance of getting better are very linked to who you are, how you live, what your income is.’

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about birthing while Black

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Postpartum support for Queer and Trans families

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Postpartum support for Queer and Trans families

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No family is immune to mental health challenges, including queer & trans families. In fact, queer & trans families are at higher risk for perinatal mood struggles for a variety of reasons including discrimination, stigma, personal mental health history, possible issues with their family of origin, conception or adoption complications, denial of parental rights, and more.

PSI offers specialized support for queer families. We have a weekly Queer & Trans Families Support Group and a specialized Support Coordinator for members of the LGBTQIA+ community. Please see more below.

Queer & Trans Parent Support Group

Every Wednesday at 2:30pm Eastern/ 1:30pm Central / 12:30pm Mountain / 11:30am Pacific / 10:30am Alaska/ 9:30am Hawaii...and all other time zones are totally welcome!

PSI's Queer & Trans Parent Support Group is FREE and open to all members of the queer & trans community who are expecting, adopting, and/or parenting babies up to 2 years. This group is intended for gestational, non-gestational and adoptive parents.

Our online groups are here to help you connect with other parents, talk about your experience, and learn about helpful tools and resources. Whether you are going through stress, adjustment to parenting, baby blues, or pregnancy/postpartum depression/anxiety, our groups are here for you.

Please note this group is intended for those who are expecting, postpartum, adopting and/or post-adoption not those looking for information on trying to conceive or adoption. Please contact Megan Roberts for more information on those topics.

LGBTQIA+ Coordinator

Queer and Trans families face many unique challenges that can put them at greater risk for mental health complications. PSI's Specialized Coordinator for LGBTQIA+ parents, is here to help!
Connect with this Specialized Coordinator
Pregnancy & Infant Loss Resources

Find a Provider

There are many different treatment options available for treating perinatal mood disorders including peer support, therapy, and medication. Finding a provider can be daunting. The provider directory link directs you to providers who identify as knowledgeable and competent in treating queer folx.

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Help for Queer & Trans Parents | Postpartum Support International (PSI)

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No family is immune to mental health challenges, including queer & trans families. In fact, queer & trans families are at higher risk for perinatal mood struggles for a variety of reasons including discrimination, stigma, personal mental health history, possible issues with their family of origin, conception or adoption complications, denial of parental rights, and [...]

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Resources for Pregnancy and Infant Loss online and in Victoria.

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Resource Pages on the Mothering Touch Website

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Resource Pages on the Mothering Touch Website

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Parenting resources: https://www.motheringtouch.ca/pnb-class-resources/
Childbirth Resources: https://www.motheringtouch.ca/childbirth-class-resources/

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Decolonizing Indigenous birth work and reproductive health

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Decolonizing Indigenous birth work and reproductive health

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Decolonizing Indigenous birth work and reproductive health | CGSHE Spotlight Series

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Parking Lot Questions - this is where you can park questions that can't be answered right now

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Parking Lot Questions - this is where you can park questions that can't be answered right now

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In Plain Sight - Addressing Indigenous-specific Racism and Discrimination in B.C. Health Care 

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In Plain Sight - Addressing Indigenous-specific Racism and Discrimination in B.C. Health Care 

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Pacific Postpartum Support Society - Vancouver

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Pacific Postpartum Support Society - Vancouver

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Pacific Post Partum Support Society - Vancouver, BC Canada

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Pacific Post Partum Support Society is located on the traditional, ancestral, unceded, and occupied territories of the xʷməθkʷiy̓əm (Musqueam), Sḵwx̱wú7mesh (Squamish), səlilwətaʔɬ (Tsleil-Waututh), and Stó:lō First Nations.

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https://www.healthyfamiliesbc.ca/home/articles/how-choose-prepare-and-store-infant-formula

https://www.inspq.qc.ca/en/tiny-tot/feeding-your-child/bottle-feeding-your-baby

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Beautiful story from a mom whose baby has Down's Syndrome

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Beautiful story from a mom whose baby has Down's Syndrome

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https://www.popsugar.com/family/Bethany-Van-Delft-Video-About-Down-Syndrome-43609970

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Five Countries, Six Births, Seven Babies

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Five Countries, Six Births, Seven Babies

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Around the world (well, not quite) in birth!

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Get access to files anywhere through secure cloud storage and file backup for your photos, videos, files and more with Google Drive.

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Video about DONA International

https://www.youtube.com/watch?v=u792CxDT7cE&ab_channel=DONAIntl

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An Honest Exploration of the Work of a Death Doula by: Tanis

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Perinatal mental Health - Online - ASK Therapy

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Perinatal mental Health - Online - ASK Therapy

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www.therapyformoms.ca
Listen to the Healing After Birth Podcast
www.anchor.fm/healingafterbirth

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This is my blog post about feeding a baby with a bottle.

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Whether we are exclusively bottle-feeding, breast/chestfeeding-with-occasional-bottles, or doing-half-and-half, it makes sense to feed the baby in the most physiologic, relaxing, pleasant way possible, which helps parent and baby develop a comfortable attachment. This process is sometimes called Paced Bottle Feeding. It involves mimicking the flow that the baby might get at the breast, and allowing the baby to have control of their experience, the way they would at the breast.

This information is intended for babies from birth to six months or so. After that, the baby will be better able to communicate their needs.
General guidelines:
Feed your baby based on the baby's cues, not on a schedule. Hunger cues are:

a. Lip-smacking
b. Tongue darting
c. Squirming
d. Rooting - looking for something to suck on with their mouth
e. Hands to mouth
f. "Barking"
g. Crying is a very late cue - really more a sign of distress than hunger.

In the first three months or so, a formula-fed baby will need small amounts of milk, 2-3 ounces, about 8-10 times per day (24 hours). Gradually they will start to take more milk at a time and feed less often.

Hold and cuddle the baby a lot. Even when you are not feeding them. We often over-interpret baby's crying as meaning hunger when really the baby is asking for physical contact, movement, stimulation.

Don't change the baby before the feed (unless absolutely necessary.) It just makes a hungry baby angry to be changed when they want to eat. It's better to take a little break in the middle of a feed to change a diaper. And babies often poop when eating anyway!

Have your baby skin-to-skin when feeding, if you like, and if it's convenient. Do not swaddle the baby when feeding them. Let the baby's hands be free to explore and participate.

Use a slow-flow nipple - this is a nipple which, when held upside-down with milk in it, will release one drop of milk per second. This makes sure the baby does not eat too much, too fast.

Plan to take 10-20 minutes to complete the feed. Every feed does not need to be the same length. We all have some long meals and some short ones. Taking a longer time to feed allows the baby to recognize the feeling of being full before they become over-full. This reduces "colicky" crying.
Step-by-step Feeding:
Make sure you, the parent, are comfortable. Make sure you are not hungry yourself, and can sit and focus on the baby for the next 20 minutes or so without interruption. Find a cosy place to sit, with good support for your back and arms. Make sure you have the bottle and a burp cloth and maybe a box of tissues nearby, as well as a water-bottle for yourself, and perhaps your phone, so you don't have to jump up if it rings.

1. Make the baby comfortable in the crook of your arm. Your elbow should be supported, and the baby's head is resting against your forearm. The baby's head should be higher than their stomach. The baby does not have to sit absolutely upright, but being on an incline is better than flat on the back. (Babies fed while lying flat are at more risk for dental caries and ear infections.) Being upright means the baby is able to release air they might swallow.

2. Touch the baby's upper lip with the nipple and draw the nipple downwards over the bottom lip. When the baby opens their mouth, put the nipple in slowly, letting the baby draw it in. Do not force the nipple into the baby's mouth.

3. Keep the bottle tilted so most the nipple is full of milk. But don't worry if the baby sucks in a little air - this is quite normal.

4. Count the baby's sucks and swallows. If the baby does not take a breath by the fourth or fifth suck, remove the nipple and allow the baby to have a break in the flow to swallow and breathe. Keep the nipple right there, by the mouth, so the baby can latch on again when ready.

5. The baby may be upset when you remove the nipple. Talk to them and tell them it's coming back. They just need a little break. After you have done this a few times, and they know it always comes back, they will be calmer.

6. Other signs a baby needs a break are:
a. Opening eyes wide
b. Pulling the head back, or turning it to the side
c. Arching the back
d. Pursing the lips
e. Letting go of the nipple

7. Take the nipple out right away and sit baby upright or put baby up on your shoulder if you see these signs of mild distress:
a. Milk spilling from the mouth
b. Opening eyes widely
c. Stiffening of arms and legs
d. Flaring nostrils
e. Grimacing
f. Lips turning blue

8. Talk to your baby. Tell them a story. Talk about your plans for the rest of the day, or about what you did this morning. Make it clear that you are focussing your attention on them in a loving and relaxed way, and that you enjoy their company. Develop a habit of pleasant meal-time conversation that will last a life-time!

9. Switch sides halfway through the feed. If you were holding the bottle in your right hand to start with, switch so you are now holding it in your left hand, and the baby is resting on your right arm. This provides for symmetrical eye stimulation and development.

10. Let the baby decide when the feed is done. Signs of being finished are:
a. Falling a sleep
b. Turning head aside or back from the nipple
c. No longer sucking
d. Letting go of the nipple

11. Resist the urge to encourage the baby to finish the last bit of milk in the bottle. The baby is in charge of their body and their stomach. Letting the baby feel satiation cues and responding to them is a good way to set up good eating habits for later life.

12. Put the baby up on your shoulder to burp. Pat their back gently.

13. A baby will often fall asleep for a few minutes, and then decide they could use a little more milk. Take advantage of that little break to change the diaper. Then be prepared to give the baby a little more milk. That's okay.

14. If the baby still seems to root around even when they have had a large amount of milk, consider that they might just need to do a little more sucking. Offer a pacifier and a cuddle and see if baby falls asleep.

Resources
HealthyFamiliesBC.ca is a good website on family health - lots of information there on formula feeding and bottle preparation.

HealthLinkBC.ca is another source of British Columbian health information.

https://www.inspq.qc.ca/en/tiny-tot/feeding-your-child/bottle-feeding-your-baby is a Quebec resource with good, detailed information - in English.

Much of the ideas I have shared here are influenced by:
https://www.peelregion.ca/health/family-health/breastfeeding/pdf/paced-bottle-feeding.pdf
https://kellymom.com/bf/pumpingmoms/feeding-tools/bottle-feeding/

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How to bottlefeed a baby – Paced Bottlefeeding – Eva Bild – Supporting New Parents

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This is a great podcast overall, but this episode - on the Question: "How are you?" is all about grief - and has a beautiful story from a dad whose baby died, as well as a contribution from a death doula. Useful listening!
https://www.cbc.ca/listen/cbc-podcasts/414-inappropriate-questions/episode/15782325-how-are-you

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Eva Bild
evarbild@gmail.com
250-588-4905

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Breath: The New Science of a Lost Art

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"The trauma caused by childhood neglect, sexual or domestic abuse and war wreaks havoc in our bodies, says Bessel van der Kolk in The Body Keeps the Score . . . . Van der Kolk draws on thirty years of experience to argue powerfully that trauma is one of the West's most urgent public health issues. . . . Packed with science and human stories, the book is an intense read. . . . [T]he struggle and resilience of his patients is very moving."-Shaoni Bhattacharya, helps us understand how life experiences play out in the function and the malfunction of our bodies, years later." is a seminal work by one of the preeminent pioneers in trauma research and treatment. This essential book unites the evolving neuroscience of trauma research with an emergent wave of body-oriented therapies and traditional mind/body practices that go beyond symptom relief and connect us with our vital energy and here-and-now presence." we share the author's courageous journey into the parallel dissociative worlds of trauma victims and the medical and psychological disciplines that are meant to provide relief. In this compelling book we learn that as our minds desperately try to leave trauma behind, our bodies keep us trapped in the past with wordless emotions and feelings. These inner disconnections cascade into ruptures in social relationships with disastrous effects on marriages, families, and friendships. Van der Kolk offers hope by describing treatments and strategies that have successfully helped his patients reconnect their thoughts with their bodies. We leave this shared journey understanding that only through fostering self-awareness and gaining an inner sense of safety will we, as a species, fully experience the richness of life. body, and learn about the exciting new approaches that allow people with the severest forms of trauma to put all the parts back together again." is, simply put, brilliant." articulates new and better therapies for toxic stress based on a deep understanding of the effects of trauma on brain development and attachment systems. This volume provides a moving summary of what is currently known about the effects of trauma on individuals and societies, and introduces the healing potential of both age old and novel approaches to help traumatized children and adults to fully engage in the present." eloquently articulates how overwhelming experiences affect the development of brain, mind, and body awareness, all of which are closely intertwined. The resulting derailments have a profound impact on the capacity for love and work. This rich integration of clinical case examples with ground breaking scientific studies provides us with a new understanding of trauma, which inevitably leads to the exploration of novel therapeutic approaches that 'rewire' the brain, and help traumatized people to (re)-engage in the present. This book will provide traumatized individuals with a guide to healing and permanently change how psychologists and psychiatrists think about trauma and recovery." is a cutting-edge offering for the general reader to comprehend the complex effects of trauma, and a guide to a wide array of scientifically informed approaches to not only reduce suffering, but to move beyond mere survival-and to thrive." leaves us with both a profound appreciation for and a felt sense of, the debilitating effects of trauma, along with hope for the future through fascinating descriptions of novel approaches to treatment. This outstanding volume is absolutely essential reading not only for therapists but for all who seek to understand, prevent, or treat the immense suffering caused by trauma." is masterful in bringing together science and humanism to clearly explain how trauma affects the whole person. Bessel van der Kolk brings deep understanding to the pain and chaos of the trauma experience. The treatment approaches he recommends heal the body and the mind, restoring hope and the possibility of joy. One reads this book with profound gratitude for its wisdom."
New Scientist Nature -European Journal of Psychotraumatology -Medical Library Association, Consumer Connections - Henry Strick van Linschoten, European Society For Trauma And Dissociation Newsletter Booklist Library Journal (Starred Review) -Judith Herman, M.D., clinical professor of psychiatry, Harvard Medical School; author of Trauma and Recovery The Body Keeps the Score -Vincent J. Felitti, M.D., chief of preventative medicine, emeritus, Kaiser Permanente San Diego; co-principal investigator, ACE study -Rachel Yehuda, Ph.D., professor of psychiatry and neuroscience; director of the Traumatic Stress Studies Division at the Mount Sinai School of Medicine, New York, NY The Body Keeps the Score -Peter A. Levine, Ph.D., author of In an Unspoken Voice: How the Body Releases Trauma and Restores Goodness The Body Keeps the Score -Stephen W. Porges, Ph.D., professor of psychiatry, University of North Carolina at Chapel Hill; author of The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-Regulation

"This is an absolutely fascinating and clearly written book by one of the nation's most experienced physicians in the field of emotional trauma. -Alexander McFarlane AO, MB BS (Hons) MD FRANZCP, director of the Centre for Traumatic Stress Studies, The University of Adelaide, South Australia. -Jon Kabat-Zinn, professor of medicine emeritus, UMass Medical School; author of
Full Catastrophe Living. -Richard Schwartz, originator, Internal Family Systems Therapy The Body Keeps the Score is clear, fascinating, hard to put down, and filled with powerful case histories. Van der Kolk, the eminent impresario of trauma treatment, who has spent a career bringing together diverse trauma scientists and clinicians and their ideas, while making his own pivotal contributions, describes what is arguably the most important series of breakthroughs in mental health in the last thirty years. We've known that psychological trauma fragments the mind. Here we see not only how psychological trauma also breaks connections within the brain, but also between mind and

"Breathtaking in its scope and breadth, -Norman Doidge, author of
The Brain That Changes Itself -Stephen Cope, founder and director, Kripalu Institute for Extraordinary Living; author of Yoga and the Quest for the True Self The Body Keeps the Score -Onno van der Hart, Ph.D., Utrecht University, The Netherlands; senior author,
The Haunted Self: Structural Dissociation and the Treatment of Chronic Traumatization "The Body Keeps the Score -Jessica Stern, policy consultant on terrorism; author of Denial: A Memoir of Terror -Glenn N. Saxe, M.D., Arnold Simon Professor and chairman, Department of Child and Adolescent Psychiatry; director, NYU Child Study Center, New York University School of Medicine -Francine Shapiro, Ph.D., originator of EMDR therapy, senior research fellow, Emeritus Mental Research Institute, author of Getting Past Your Past -Ed Tronick, distinguished professor, University of Massachusetts, Boston, author of Neurobehavior and Social Emotional Development of Infants and Young Children The Body Keeps the Score -Ruth A. Lanius, M.D., Ph.D., Harris-Woodman chair in Psyche and Soma, professor of psychiatry, and director PTSD research at the University of Western Ontario; author of The Impact of Early Life Trauma on Health and Disease The Body Keeps the Score -Daniel J. Siegel, M.D., clinical professor, UCLA School of Medicine, author of Brainstorm: The Power and Purpose of the Teenage Brain
; Mindsight: The New Science of Personal Transformation; and The Developing Mind: How Relationships and the Brain Interact to Shape Who We Are The Body Keeps the Score -Pat Ogden Ph.D., Founder/Educational Director of the Sensorimotor Psychotherapy Institute; author of Sensorimotor Psychotherapy: Interventions for Trauma and Attachment

"Bessel van der Kolk is unequaled in his ability to synthesize the stunning developments in the field of psychological trauma over the past few decades. Thanks in part to his work, psychological trauma-ranging from chronic child abuse and neglect, to war trauma and natural disasters-is now generally recognized as a major cause of individual, social and cultural breakdown. In this masterfully lucid and engaging tour de force, van der Kolk takes us -both specialists and the general public- on his personal journey and shows what he has learned from his research, from his colleagues and students, and, most importantly, from his patients. -Jack Kornfied, author of A Path with Heart
The Body Keeps the Score -Alicia Lieberman, Ph.D., Professor of Medical Psychology UCSF, Director of the Child Trauma Research Project, San Francisco General Hospital; author of The Emotional Life of the Toddler

"When it comes to understanding the impact of trauma and being able to continue to grow despite overwhelming life experiences, Bessel van der Kolk leads the way in his comprehensive knowledge, clinical courage, and creative strategies to help us heal.

"In this magnificent book, Bessel van der Kolk takes the reader on a captivating journey that is chock full of riveting stories of patients and their struggles interpreted through history, research, and neuroscience made accessible in the words of a gifted storyteller. We are privy to the author's own courageous efforts to understand and treat trauma over the past 40 years, the results of which have broken new ground and challenged the status quo of psychiatry and psychotherapy.

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The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

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The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma [van der Kolk M.D., Bessel] on Amazon.com. *FREE* shipping on qualifying offers. The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma

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From Amy Gilliland : Five Ways White Doulas Can Heal Racial Inequities

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From Amy Gilliland : Five Ways White Doulas Can Heal Racial Inequities

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https://amygilliland.com/blog/we-can-all-do-five-ways-white-doulas-can-heal-racial-inequities?fbclid=IwAR3wMnlsDaLpaha6ZtOkudgP1rVm4xBTtsi-tC1FUEkciHLygceHr5oLQkM

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Funny

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A good, FREE basic guide to breast/chestfeeding: 

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A good, FREE basic guide to breast/chestfeeding: 

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This is about holding space during loss/death. But the "Eight Ways" are totally applicable to doula work.

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When my mom was dying, my siblings and I gathered to be with her in her final days. None of us knew anything about supporting someone in her transition out of this life into the next, but we were pretty sure we wanted to keep her at home, so we did.

While we supported mom, we were, in turn, supported by a gifted palliative care nurse, Ann, who came every few days to care for mom and to talk to us about what we could expect in the coming days. She taught us how to inject Mom with morphine when she became restless, she offered to do the difficult tasks (like giving Mom a bath), and she gave us only as much information as we needed about what to do with Mom's body after her spirit had passed.

"Take your time," she said. "You don't need to call the funeral home until you're ready. Gather the people who will want to say their final farewells. Sit with your mom as long as you need to. When you're ready, call and they will come to pick her up."

Ann gave us an incredible gift in those final days. Though it was an excruciating week, we knew that we were being held by someone who was only a phone call away.

In the two years since then, I've often thought about Ann and the important role she played in our lives. She was much more than what can fit in the title of "palliative care nurse". She was facilitator, coach, and guide. By offering gentle, nonjudgmental support and guidance, she helped us walk one of the most difficult journeys of our lives.

The work that Ann did can be defined by a term that's become common in some of the circles in which I work. She was holding space for us.

What does it mean to hold space for someone else? It means that we are willing to walk alongside another person in whatever journey they're on without judging them, making them feel inadequate, trying to fix them, or trying to impact the outcome. When we hold space for other people, we open our hearts, offer unconditional support, and let go of judgement and control.

Sometimes we find ourselves holding space for people while they hold space for others. In our situation, for example, Ann was holding space for us while we held space for Mom. Though I know nothing about her support system, I suspect that there are others holding space for Ann as she does this challenging and meaningful work. It's virtually impossible to be a strong space holder unless we have others who will hold space for us. Even the strongest leaders, coaches, nurses, etc., need to know that there are some people with whom they can be vulnerable and weak without fear of being judged.

In my own roles as teacher, facilitator, coach, mother, wife, and friend, etc., I do my best to hold space for other people in the same way that Ann modeled it for me and my siblings. It's not always easy, because I have a very human tendency to want to fix people, give them advice, or judge them for not being further along the path than they are, but I keep trying because I know that it's important. At the same time, there are people in my life that I trust to hold space for me.

To truly support people in their own growth, transformation, grief, etc., we can't do it by taking their power away (ie. trying to fix their problems), shaming them (ie. implying that they should know more than they do), or overwhelming them (ie. giving them more information than they're ready for). We have to be prepared to step to the side so that they can make their own choices, offer them unconditional love and support, give gentle guidance when it's needed, and make them feel safe even when they make mistakes.

Holding space is not something that's exclusive to facilitators, coaches, or palliative care nurses. It is something that ALL of us can do for each other - for our partners, children, friends, neighbours, and even strangers who strike up conversations as we're riding the bus to work.

Here are the lessons I've learned from Ann and others who have held space for me.

1. Give people permission to trust their own intuition and wisdom. When we were supporting Mom in her final days, we had no experience to rely on, and yet, intuitively, we knew what was needed. We knew how to carry her shrinking body to the washroom, we knew how to sit and sing hymns to her, and we knew how to love her. We even knew when it was time to inject the medication that would help ease her pain. In a very gentle way, Ann let us know that we didn't need to do things according to some arbitrary health care protocol - we simply needed to trust our intuition and accumulated wisdom from the many years we'd loved Mom.

2. Give people only as much information as they can handle. Ann gave us some simple instructions and left us with a few handouts, but did not overwhelm us with far more than we could process in our tender time of grief. Too much information would have left us feeling incompetent and unworthy.

3. Don't take their power away. When we take decision-making power out of people's hands, we leave them feeling useless and incompetent. There may be some times when we need to step in and make hard decisions for other people (ie. when they're dealing with an addiction and an intervention feels like the only thing that will save them), but in almost every other case, people need the autonomy to make their own choices (even our children). Ann knew that we needed to feel empowered in making decisions on our Mom's behalf, and so she offered support but never tried to direct or control us.

4. Keep your own ego out of it. This is a big one. We all get caught in that trap now and then - when we begin to believe that someone else's success is dependent on our intervention, or when we think that their failure reflects poorly on us, or when we're convinced that whatever emotions they choose to unload on us are about us instead of them. It's a trap I've occasionally found myself slipping into when I teach. I can become more concerned about my own success (Do the students like me? Do their marks reflect on my ability to teach? Etc.) than about the success of my students. But that doesn't serve anyone - not even me. To truly support their growth, I need to keep my ego out of it and create the space where they have the opportunity to grow and learn.

5. Help them feel safe enough to fail. When people are learning, growing, or going through grief or transition, they are bound to make some mistakes along the way. When we, as their space holders, withhold judgement and shame, we offer them the opportunity to reach inside themselves to find the courage to take risks and the resilience to keep going even when they fail. When we let them know that failure is simply a part of the journey and not the end of the world, they'll spend less time beating themselves up for it and more time learning from their mistakes.

6. Give guidance and help with humility and thoughtfulness. wise space holder knows when to withhold guidance (ie. when it makes a person feel foolish and inadequate) and when to offer it gently (ie. when a person asks for it or is too lost to know what to ask for). Though Ann did not take our power or autonomy away, she did offer to come and give Mom baths and do some of the more challenging parts of caregiving. This was a relief to us, as we had no practice at it and didn't want to place Mom in a position that might make her feel shame (ie. having her children see her naked). This is a careful dance that we all must do when we hold space for other people. Recognizing the areas in which they feel most vulnerable and incapable and offering the right kind of help without shaming them takes practice and humility.

7. Create a container for complex emotions, fear, trauma, etc. When people feel that they are held in a deeper way than they are used to, they feel safe enough to allow complex emotions to surface that might normally remain hidden. Someone who is practiced at holding space knows that this can happen and will be prepared to hold it in a gentle, supportive, and nonjudgmental way. In The Circle Way, we talk about "holding the rim" for people. The circle becomes the space where people feel safe enough to fall apart without fearing that this will leave them permanently broken or that they will be shamed by others in the room. Someone is always there to offer strength and courage. This is not easy work, and it is work that I continue to learn about as I host increasingly more challenging conversations. We cannot do it if we are overly emotional ourselves, if we haven't done the hard work of looking into our own shadow, or if we don't trust the people we are holding space for. In Ann's case, she did this by showing up with tenderness, compassion, and confidence. If she had shown up in a way that didn't offer us assurance that she could handle difficult situations or that she was afraid of death, we wouldn't have been able to trust her as we did.

8. Allow them to make different decisions and have different experiences than you would. Holding space is about respecting each person's differences and recognizing that those differences may lead to them making choices that we would not make. Sometimes, for example, they make choices based on cultural norms that we can't understand from within our own experience. When we hold space, we release control and we honour differences. This showed up, for example, in the way that Ann supported us in making decisions about what to do with Mom's body after her spirit was no longer housed there. If there had been some ritual that we felt we needed to conduct before releasing her body, we were free to do that in the privacy of Mom's home.

Holding space is not something that we can master overnight, or that can be adequately addressed in a list of tips like the ones I've just given. It's a complex practice that evolves as we practice it, and it is unique to each person and each situation.

It is my intention to be a life-long learning in what it means to hold space for other people, so if you have experience that's different than mine and want to add anything to this post, please add that in the comments or send me a message.

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If you've found yourself to this post, a few years after it went viral, you might want to check out my book, The Art of Holding Space: A Practice of Love, Liberation and Leadership. I've also co-founded the Centre for Holding Space where we've got lots of new programs and resources to help you learn how to hold space for yourself and others, including a Path to Certification. Since this post was published, I have trained hundreds of people all over the world in how to hold space, and the work continues to grow.
Follow-up pieces about holding space:
How to hold space for yourself first
What's the opposite of holding space?
Sometimes holding space feels like doing nothing
Sometimes you have to write on the walls: Some thoughts on holding space for other people's personal growth
On holding space when there is an imbalance of power and privilege
Leave space for others to fill your needs
What the circle holds
An unresolved story that I don't know how to tell
Holding liminal space (moving beyond the cliché into deeper space)
If you're looking for a pdf version for printing and/or passing around to others, you can download it here. You're welcome to share it, but if you want to re-publish any part of it, please contact me.

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What it means to "hold space" for people, plus eight tips on how to do it well - Heather Plett

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When my mom was dying, my siblings and I gathered to be with her in her final days. None of us knew anything about supporting someone in her transition out of this life into the next, but we were pretty sure we wanted to keep her at home, so we did.

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Feel free to add your contact information here if you’d like to share it with the class!  I encourage you folks to take the initiative to form a group text chat or Facebook group or whatever works well to stay connected to each other! ~E

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The Essence of Coping in Labour - with Penny Simkin

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The Essence of Coping in Labour - with Penny Simkin