Your Birth Business – Connecting Head, Heart and Body for a Sustainable Practice

In the 19 years I have been a doula, I have seen hundreds of doulas come enthusiastically into this business and then quietly leave it, often in less than 3 years. There is a multitude of reasons for this – many doulas are of childbearing age and are still having babies so their own births move many of them from “mothering the mother” to mothering their children for one or, more likely, several years. Some doulas move on to nursing or midwifery either because their sights were always set on those professions (and doula training was a prerequisite) or because they realized the scope of practice of a doula wasn’t enough for them. I heard a colleague – another birth doula trainer – often asks the doulas she trains, “Where do you see yourself in relation to the birthing woman? Are you wiping her brow? Massaging her shoulders? Or positioned to catch a baby?” That is a good question to ask because a doula’s role is completely non-clinical and some doulas find they are itching to catch that baby.

And then there are the most common, less satisfying (read frustrating) reasons doulas leave this work – burn-out and inability to create sustainable living through the practice. At first glance these appear to be opposites of each other. I believe they are connected. I invite you to consider this view of what happens and how it affects not only your ability to practice as a doula in the birthing room, but your ability to run your practice as a business.
Stay with me for a while. I promise I will knit this together for you and the shape will reveal itself.

First, let’s start with the less common reason doulas leave this work – burn-out. I am calling this a less common reason because, in the context of this post, I am looking at doulas who don’t remain long in this career very long and the concept of burn-out in someone newer to the work suggests the doula was, in the first three years, very busy – or had no boundaries – which is a part of burn-out so I will include it here. Full disclosure, this doula could have been me. I jumped into this work because I saw how important birth was and I became a busy doula relatively fast. What I noticed quickly was how much and how long I felt I was swimming upstream. The truth is all normal birth advocates are constantly swimming upstream. We share evidence-based information and help our clients find their voices (if we understand our doula role is to help them advocate for themselves) and still they may experience unnecessary interventions, preventable cesarean births, or simply – profoundly – a somehow unsatisfying birth experience because of something/someone they couldn’t foresee or control. With regard to a challenging (some say broken) maternity care system, this is deeply frustrating to the doula who excels at helping her clients determine what they value and take self-determining action.

Lamaze Childbirth Educator and DONA Certified Doula, Stephanie Antunes, describes what happens in her article for DONA’s International Doula called Overcoming the Three Year Itch: “Over the years, perhaps some negative experiences occur — the ones where women’s choices fall on deaf ears or a mother or baby may have been harmed, even though there were options to avoid it. We may find ourselves supporting a mother whose birth experience went very wrong and who is feeling like her life is falling apart. For many, what begins to happen is the formation of a gloomy cloud overhead, which may bring about a feeling of unease, a feeling that something just isn’t right, speaking in an “us versus them” tone, a feeling that there is no need for these things to happen and believing it’s not fair.”

Over time, this gloomy cloud wears on the psyche/spirit and the body keeps the score. Doulas begin to feel the weight and resistance of their body against the current. Caught in the rip-tide, they often respond in one of two ways. They begin to flail-possibly bringing their activism into the birth room and/or advocating for their clients or they do the what we have learned the drowning victim actually does and slowly, quietly disappear beneath the surface.

Let’s look at the first choice…flailing/fighting the current. This option can feel active, but in actuality there is little forward motion. What may be happening is that the doula is exhibiting several of the warning signs of what author, Laura van Dernoot Lipsky calls “trauma exposure response”. She identifies 16 responses in her book Trauma Stewardship but in the case of the flailing against the rip-tide example, I would like to look at three of them: hyper-vigilence, diminished creativity and inability to embrace complexity.

The hyper-vigilent doula might see nearly every care-provider as someone to protect her client against. This is common when the doula doesn’t see that the client must take responsibility for their own choices and care. This doula may believe or particularly enjoy when a client tells her, “we couldn’t have done it without you” not understanding that the skills we seek to help parents develop are those that give them confidence to do just that…find their own voices, and based on what they value, advocate for themselves.

Diminished creativity leads to a mindset where possibility is overlooked. Her world-view is altered – and we might hear things like “If you want a low-interventive birth, you don’t want to go to that hospital/doctor.” As van Dernoot Lipsky writes, “the deeper we sink into a culture of trauma, the less flexible and original our thinking becomes.” So, the doula may begin to take on the very perspective of the system she found dangerous to her client – one where normal exists only retrospectively. And this perspective can move into her opinion about her colleagues as well – seeing only the negative in both organizations and people. Like the care providers she hopes to protect her client from, it no longer matters what the doula looks at, she sees only what she sees.

And finally, the last trauma exposure response I feel so often comes into play is the one I find most dangerous: inability to embrace complexity. Here, a person “craves clear signs of good and bad, right and wrong and you feel an urgent need to take sides.” van Dernoot Lipsky goes on to say that the inability to embrace complexity as a trauma exposure response shows itself personally in fractured thinking and a culturally in fractured segments through the forms of gossip, divisions, and rigid expectations. “You may feel like you’re in high school, or worse, junior high.” At this point, the “us versus them” expands to our colleagues; other doulas struggling with the same challenges. Where once we worked together, highlighting diversity and leveraging skills and talents, we can no longer see how the threads work well together. van Dernoot Lipsky explains that this behavior is common among those who have experienced primary trauma. “Making room for all the complexities and gray area is too painful and seems cognitively impossible. When we are rested, in a good place emotionally, we know that the world is a complex place and we know that seeing things through a flattened and reductionist lens does not serve us. Yet we live in a polarized civic universe. You can only vote for or against.” You are either with us or against us.

And there you’ll stay, divided. With no safe place to be vulnerable, and, amongst the waves created by doulas still fighting the current head-on with broad, full-force strokes, the quiet doula, feels guilty for not being angry enough. Determined not to become a target herself, she’ll attempt selective numbing (which is impossible of course) and when asked how she is doing will answer “fine” like the drowning victim who seems fine one minute and gone the next.

Antunes writes, “It can also be described as “compassion fatigue.” Whatever the term, when we are in it, it feels awful. It can change the way we look at the world, the way we sleep and the way we interact in our community …”
I think it is clear how this comes into play in your doula practice – working with clients in their births, however, it may be less obvious how this impacts a doula’s ability to create a sustainable birth business. And again, the two are inseparable. After all, as doulas we ARE our birth business. We provide the services, and for many of us, WE are our brand. With that in mind…let’s look for a moment at what happens when we let our bodymind hang out in inability to embrace complexity.

In her research on the attachment needs of laboring women and how the doula can be seen as the “secure base” or attachment figure to the mother in labor, Amy Gilliland states that one of the five properties that had to be present for the mother to experience the doula as a secure base was that the doula “needs to perceive the mother’s emotional needs accurately.” When present (along with the other 4 properties) attunement happens between the mother and doula. Attunement, as it is defined by Daniel Stern is: “the acts and processes that let other people know you are feeling something very like they are feeling.” In other words, the outward expression of empathy.

To me, the inability to embrace complexity is, perhaps, the inability to empathize and I firmly believe it plays a role in both burn-out and the inability to create an emotionally rewarding and financially sustainable business.

In the book, Empathic Accuracy, contributors Sara D. Hodges and Daniel M Wegner describe empathy, as a “state of mind” which requires us to not just change our mind, but to change our perception of others, our judgment of their situation, their traits and goals and possibly even change our perception of ourselves. It is a complex emotional and mental structural transformation that is unlike most changes in mental processing. “A social perspective is an organized mental entity not unlike a mood, a belief system, or a spatial perspective and can be most clearly understood as a state of mind. With this idea, we can glimpse the remarkably numerous repercussions produced in human thought and emotion by simple variations in empathy.”

 

 

In my advanced doula workshop, Bereaved: Supporting the Family and Ourselves through Loss and Trauma, we spend time looking at the losses that birth professionals experience (such as loss of time with family – birthdays, anniversaries, loss of spontaneity, loss of income/financial security, loss of idealism/trust, loss of respect/understanding) which, once spoken out loud, can bring a flood of emotion…often grief and mourning…to the forefront. This is ultimately a good thing, because as a friend of mine says, “what the mind will not speak, the body will leak.”