It’s 11 a.m. on a Monday morning and Ariel Swift is late. Five minutes to be exact.
The lobby of the Feinberg Pavilion in Chicago hums with movement, as doctors exit the large double doors leading to the attached hospital. They are dressed head to toe in blue scrubs, the only exposed skin is their hands typing methodically away on their phones.
The coffee kiosk I sit next to is the only source of noise as baristas yell out orders for pick up. Iced coffee. Caramel macchiato. Double shot Americano. A gaggle of preteens flood the entrance and laugh as they get caught in the revolving door.
I look up from jotting down questions in my top-spiral notebook and someone is walking toward me with an outstretched hand. It’s Ariel Swift. She apologizes profusely, shaking my hand and introducing herself.
“I’m so sorry I’m late! I’ve been running around all morning.”
She is short, with dirty-blonde hair and nose ring. T-shirt, sweater, jeans. She has a warm laugh and as she pulls her chair out, I realize she is very pregnant. She reminds me of someone who always gets the compliment “you look like a friend of mine,” or a person who evokes life stories out of strangers. The moment before I dive into the interview and start simultaneously scribbling notes and quotes, I feel a wave of serenity wash over me. The professional reporter exterior I’ve crafted melts away, and I feel like we are catching up on old times. I realize Ariel Swift must be very good at her job.
Ariel Swift is a doula. Turn to any television show or movie for the definition of a doula and this is what you’ll likely get: A woman in handmade clothes with scarves and beaded jewelry dripping from every limb. Hair piled on top of her head, possibly barefoot, shaking incense around the room. She will walk in with a knapsack filled with herbs and oils, with techniques that have been passed down for generations “in her culture.” She will probably be racially ambiguous – this is the writers hoping you connect her work with the work of a bayou witch. She’ll asks you to “roar” your baby out and possibly suggests labor is the most pleasure one can have in their life.
Honestly? I equated doula to this stereotype too, before I embarked on this story. Unfortunately for Hollywood, that’s not what most doulas look like today. Many of them look like Ariel Swift.
Swift is the owner and creator of Doulas of Chicago, which services women for pre-, during, and postpartum maternal care. Doula businesses focus on all three aspects of giving birth in an intimate setting, which most health care providers can’t do because of the patient-to-doctor ratios. Prenatal care usually involves checking in with clients about fears or concerns, and how to talk to their doctor. During-care is the big day, where doulas provide phone support during early labor and their presence for active labor and delivery. Postpartum care can involve lactation consulting and visits with the family to see if everything is okay. New mothers can experience postpartum depression, and doulas can recognize those initial stages and facilitate a match with professional help.
What inspired Swift to become a doula was the birth of her first child.
“I didn’t think my doula was very good,” says Swift. “My only criteria was that she look like my mom.”
After that experience, she decided to train with ProDoula and start practicing as a doula. To become certified with ProDoula, you must attend a two-day seminar, which focuses on hands-on work and emotional support. Doula training programs vary and can cover several aspects of work as a doula. After certification, one is able to start taking clients. Since her first client in January of 2012, Swift’s attended 112 births. “Having a doula is like having a person to help you weigh the pros and cons,” says Swift.
Doula vs midwife
Before weighing pros and cons, we should clear something up first. There is the common misconception between doula and midwife. A doula is there to help you emotionally process these life changes and be there during birth to act as a guide. A midwife is medically trained to facilitate a birth, usually in a home birth. Doulas do not perform births, nor should they be advertising that they do so.
Midwife training is split into two categories: CNM (certified nurse-midwife) and CM (certified midwife). Both go through an accreditation process, but a CNM is a certified nurse, whereas a CM is someone in a medical field. Though midwives are trained in some medical aspect, there are still states that outlaw midwives to practice. Recently, Alabama changed its law to allow midwives to start seeing patients and attending home births.
Some question why modern medicine needs doulas and midwives. The United States boasts that we are at the forefront of medical advancements, but sit in a waiting room for two hours and you might think otherwise.
Birth in the US, then and now
The history of the midwife in the US goes back to at least 1660. Before modern medical advancements, home birth was all a woman had. Formal midwife training wasn’t created until 100 years later, and it was still a developing trade for women. Mind you, during this development midwifery was still being practiced in rural areas and low-income communities where it was a necessity to seek a midwife instead of a doctor. Modern medicine thought they were re-inventing the wheel when it came to midwives when in reality it was a practice as old as time. Hospitals weren’t even a thought until around 1751 when voluntary and public hospitals were being built.
Flash forward to the 1930s, when the boom of women going to the hospital for birth was started. At the beginning of the 20th century, most women knew someone who died from childbirth. Now women wanted to feel safe and comfortable, and sterile metal and baby nurseries gave them that. “The perception was that it was the modern way to give birth,” says Sarah Rodriguez, a medical historian at Northwestern University who focuses on women’s health.
Ironically, going to the hospital was a luxury, and not as commonplace as today. But still, this luxury was only for middle-class white women, because America was still in a period of segregation. Many women didn’t speak English or couldn’t afford the new way of birthing, which can even be seen today when it comes to insurance premiums and how costly it can be to have a baby in today’s world. And despite the sterility and perceived safety a hospital birth provides, the numbers paint a troubling picture.
Rising maternal mortality
A recent study by NPR and ProPublica reminded us that the United States has the highest rate of maternal mortality in any developed country, and it hasn’t been just this year. Since 1998, the graphs have been working their way to the top with no end in sight. “It’s embarrassing, horrifying, and sad,” says Maura Winkler, the owner of Chicago Birth and Baby, who is trained as both a doula and a midwife.
Google this issue, and there will be countless articles declaring it doesn’t exist, or or explaining it away because of X, Y, or Z. Putting criticisms aside – such as how the US defines maternal mortality different than other developed countries – there’s still a birth problem within our current healthcare system. Rising rates of maternal mortality currently claim 26.4 deaths per 1,000 live births. For a place like Presence Medical Center in the heart of downtown Chicago, commonly referred to as the “baby factory,” this covers a busy month.
“We have a quilt with lots of holes in it, we don’t have a system,” says Rodriguez. She refers to the various programs and sections of American health care, in place of a baseline care that can help everyone. There are veteran affairs hospitals, children’s cancer hospitals, and even labs where organs are being grown. But when it comes to general care, our system can’t provide safety for something as common and natural as childbirth.
When I tell her about our growing problem, she isn’t fazed.
“I’m not surprised about this,” she says, “If you compare the UK to the US, our maternal mortality stats are quite poor.”
Which many studies do. To grasp how strange it is that America would have such high mortality rates, studies compared our stats to those of other first-world countries. In the UK, maternal mortality rates are falling so drastically one journal claimed your husband is more likely to die during your pregnancy than you are.
Doctors and medical professionals speculate many reasons why women are dying during birth. Today there are more women with pre-existing conditions and high-risk pregnancies. Women are having children later in life and the farther you get away from your 20s, which is physically your most fertile years, the harder it can be to have a smooth pregnancy. That’s why most doulas agencies focus on women who are in their early 30s.
Doctors may label women over 35 as high-risk simply because of age, which can cause problems down the road. When women are labeled high-risk, it can justify a doctor’s desire to medically intervene, even though the woman may be as healthy as ever. These interventions can include C-section, episiotomy, or hooking up a fetal monitor during labor, which limits the mother’s freedom to move around. If active labor lasts longer than around six to seven hours, a C-section is usually the next step. Pushing C-sections on women isn’t putting health first, especially when perfectly healthy natural birth can last up to 16 hours.
“I think doctors don’t want to risk waiting and they go for the extreme quicker,” says Helen Stevenson, a registered nurse who is pregnant with her second child. “I think this scare has led to a rise in C-sections here in the US.” She’s right. C-sections in the United States have risen, from five percent in the 70s to 20 percent by 1996. Pitocin, a drug commonly used in the hospital to induce labor, creates contractions and speeds up the opening of the cervix. For some mothers, this is necessary. But often these drugs are used to start active labor, even though letting nature run its course is a viable option. A Pitocin-induced labor is often painful, forcing your body to start active labor when it’s not prepared for it. Other times it can affect a baby’s breathing during birth.
“Some of them [nurses] slam it into women,” says Kate Ritter, a doula with Chicago Birth and Baby. Ritter experiences birth rooms where women receive procedures like episiotomies and Pitocin. An episiotomy, where a cut is made to further dilate the cervix, was considered efficient when first invented in 1742. Now, it can cause painful healing and is used as a last result.
Ritter recalled an instance where an episiotomy was performed on a client without discussion and against her strict instruction. Ritter wanted to say something to the doctor but held her tongue because ultimately, she acts as an emotional support for the client, not to tell the doctor what to do. Doctors must make quick decisions when a baby is in distress, but for a doula these situations it can put them in a moral dilemma. “A lot of women just need to understand what’s happening,” says Ritter.
The role of the doula
There are ways a doula can facilitate those conversations between provider and client, like playing “dumb doula.” If the doula is the curious one, asking doctors what’s happening step-by-step, it takes the pressure off the mother to ask. Doulas can offer more than just emotional support and can help new mothers have control over what happens to them in childbirth. When speaking to women, that seemed to be the number one priority in their birth plan: having control over what happens to them in the birth room.
“Overall I wanted freedom in my birth plan,” says Reagan Weaver, who recently gave birth to her first child. “To let my body do what it was built to do and for me to find what worked best for me. This being my first child, I wasn’t completely sure what to expect; no one can really prepare you.” Weaver lives in Alabama, so she couldn’t use a midwife because she knew the state didn’t allow these practices yet.
Here’s the thing: There is a glaring discrepancy between the horror stories of childbirth gone wrong and the stories of these doulas. With a doula, the mothers-to-be understand what’s going on and they have someone in their corner during one of the most stressful event in their life.
These doulas can teach women how to speak to their provider and discuss with them all options for their pregnancy. The women who I spoke to whodidn’t use doulas lamented that “if they knew more” or “had enough money” they would have absolutely used a doula.
“I can definitely understand some women wanting more of an intimate/personal experience with their deliveries and the people involved with it,” says Claire Dansereau Auerbach, who recently gave birth to her first child Addie. This makes me wonder why these practices are falling by the wayside and shot down by women choosing birthing plans? Surprisingly, 95 percent of women in low-risk pregnancies can give birth without medical intervention, yet only two percent do.
It’s surprising to think doulas are what started it all, and yet today they are a luxury.
“Right now the expenses of just having a child are already overwhelming, so I don’t see how we could afford to add anything else,” says Valerie Tull, who works at The University of Alabama in the Center for Public Safety and is expecting her first child in a couple of months. “If doulas ever became an option covered by health insurance I’d definitely consider using one.”
Doula services are an out of pocket expense, not covered under major health insurance companies. Now that these holistic practices are legitimized, they are charging and acting like a business. The average doula service can range from $4,000 to $6,500. On top of the medical fees to give birth in a hospital, which can cost $3,500 or more, it’s easy to understand the financial reasons why women aren’t keen on hiring a doula.
Owners like Swift think doula companies aren’t charging enough. Being a doula is an involved profession that requires you to be on call for a pool of expecting mothers. But accounting for licenses and overhead, this business can cost the doulas quite a bit too. “Because it’s work that involves the heart, not everyone is open to know that it’s a job,” says Swift.
Doulas usually start off as independent workers, which can allow for some wiggle room in price if they let the connection to their client come before money. Which, on one hand, is a bit heart breaking. It’s hard to remember there is a business side to something so pure as helping a woman give birth. On the other hand, these services can’t go unpaid, and if doulas are undercharging their clients because of a soft heart, eventually that doula will go out of business.
Swift sees being a doula as an “altruistic” profession and a passion that is sometimes hard to put a price tag on. Money, passion, and compassion aside, there still is one major thing to consider when discussing holistic childbirth: insurance. Under the current Affordable Care Act, maternity care and child birth are an essential health care. With our disparaging political climate and the notorious health care bill trying to seep its way into congress, things could change. If the proposed healthcare bill were to somehow pass, a number of regulations would make it harder for many to handle pregnancy.
First off, it would gut Planned Parenthood. Regardless of what you think about them, they offer prenatal care for women who don’t have insurance. Not as many of their offices offer the care, but you can’t deny the help they are giving to people in need.
Secondly, it would allow states to regulate what is considered “essential care.” Like previously stated, the ACA considers maternity care and childbirth as an essential care, but in more conservative states that have already proven their lack of understanding of the female body (looking at you, Texas), those legislators could completely change the game for women, and not for the better.
Doing it right
On the flip side, you have facilities like the Presence Saints Mary and Elizabeth Medical Center, located in Chicago, which has in-house midwives. Which means it’s covered under insurance. You can have your child in one of their swanky birth rooms with a midwife, with a team of doctors on-call if anything should go awry.
“It’s a very collaborative relationship,” says Mary Bauer, director of Midwifery Services at Presence and a nurse-midwife. “It’s very respectful, understanding that the two disciplines of midwifery and obstetrics have different philosophies.” Bauer started the midwifery program at Presence after nine years of practice as a midwife. The program has only been established for a year, but so far has proven to be a model that works with patients and providers. The midwives work eight-hour work days, with a lot of time spent with patients individually. It’s like having the backing of a hospital with the intimacy of a private practice.
These programs are popping up around the country, but they are few and far in between. On top of the shaky ground that is our healthcare and the overwhelming statistics, it can seem like right now (and the near future) is a terrible time to start procreating.
It seems to me the problem is a lack of education and understanding. These doula practices are doing the good work, but if people don’t know about them or can’t afford to use them, then more and more women will have difficult or deadly births. As a healthy child of a high-risk pregnancy, I have to believe hospitals want what’s best for you. But as a 23-year-old woman with hopes of children in the future, I am setting up a kiddie pool in my living room and calling nine midwives. When the holistic option seems to be the safer way, my trust in modern medicine fades. The facts speak for themselves: Medical intervention can irreparably damage or kill a mother. It seems hospital lawyers are more in charge of a birth room than mothers, and that’s something no legislation or regulation will stop.
As I dove into my interview with Ariel Swift, past the pleasantries and apologies, I felt a twinge of guilt. I was talking to an expectant mother about how often women die in childbirth. I watched her grab her stomach when I recited my findings on maternal mortality. Even she, a birth professional, isn’t safe.
This is fear. The fear that no matter what we do, things can still go wrong in a split second. It plagues us all, this fear of the unknown. Yet succumbing to fear is the easiest way to complete a self-fulfilling prophecy and put yourself in an early grave. It is the doula, the champion in our corner, who can provide courage, shine a light on the unknown, and lessen our fear as we women perform an act as natural and beautiful as the setting sun.