Childbirth Education and Doula Care During Times of Stress, Trauma, and Grieving

Abstract

A collaborative, interspecialty volunteer program extending for nine months after September 11, 2001, provided free support and service to pregnant women widowed by the attacks on the World Trade Center. Participating providers studied the physiological and psychological effects of stress. Group sharing, discussions about the effects of emotions on labor progress, and other techniques were incorporated into sessions. The program's success suggests that childbirth educators should prepare all pregnant women to cope with stress. Subsequent national and international events have reinforced the importance of such training. The childbirth educator can also help by maintaining a referral list of local trauma counselors and other resources.

Immediately after the events of September 11, 2001, I was privileged to play a unique role: coordinating a volunteer program to provide support and service to pregnant women in the greater New York/New Jersey area, where I live, who had been widowed by the terrorist attack. The result was an unprecedented collaborative effort supported by numerous related agencies and individual providers. I subsequently wrote about this experience in detail for BIRTH: Issues in Perinatal Care (Pascali-Bonaro, 2002).

Despite the group's impressively amassed knowledge and resources, we identified many gaps in our understanding of how to address the needs of the widows of 9/11 and, in addition, how to generalize such understanding for the needs of other pregnant women in our area who were experiencing stress, trauma, and grief for any reason.

As we discussed our role in the days immediately after the World Trade Center attacks, we identified a unique opportunity—in fact, an obligation—to determine how the pervasive, elevated level of fear and concern (including questions about bringing a child into a frightening world) might affect women's feelings about pregnancy, birth, and parenting. We agreed that many of the techniques that educators use regularly would be especially appropriate and provide a source of healing in order to help women cope during an emotional time such as those harrowing weeks.

The following year and a half demonstrated this was true. As I write this paper in August 2003, I realize that with the ongoing war in Iraq and a heightened stress level in our region, I continue to address these concerns in my childbirth classes. Women express surprise and relief that I am willing to introduce such topics as I encourage them to share their concerns with the group. Their feedback has been overwhelmingly positive. They tell me later that these discussions have been helpful and necessary.

With the ongoing war in Iraq and a heightened stress level in our region, I continue to address these concerns in my childbirth classes.

I now believe that including at least an element of this sort of information and discussion is valuable at all childbirth education classes, not only during a time of terrorism or war. Feelings of dread and fear can overwhelm any pregnant woman at some time. These feelings may occur for purely personal reasons or because of an emergency such as the electrical blackout that struck a large portion of the country and parts of Canada on August 14, 2003. In such situations, being prepared to cope with stress may be particularly useful.

In an effort to promote birth as a positive experience, childbirth educators may unwittingly ignore the need to discuss doubts and fears that may overpower a pregnant woman. Recognizing the reality of such feelings, just as educators recognize the realities of birth, can be of benefit to expectant couples as they face birth and parenthood.

Techniques to Reduce Stress

Stress-reduction techniques can ease pregnancy and birth. One way to introduce stress reduction in the childbirth-education setting is to create a class environment that supports group sharing. Arranging chairs, birthing balls, or beanbag chairs in a circle or “U” shape encourages everyone to participate. Breaking a large class into smaller groups may also foster helpful discussion among participants.

As many educators have traditionally done, the childbirth educator may begin or end each session with a few minutes devoted to sharing. She may use the following phrases to invite participants to speak: “We will go around the circle. If you would like to share a short statement about how you are feeling this week, such as about your upcoming labor and birth or how your week has gone, we would like to hear it. If you would rather not talk today, just say, ‘I pass.’ ”

The skill of the childbirth educator becomes evident as common themes arise, and she is then able to weave them into subsequent group discussions. Participants often appreciate the support they receive in hearing others echo their sentiments and in having the opportunity to express and address their own concerns, fears, and hopes. One way to facilitate this discussion is to identify three feelings shared by the members of the group that day. The group may be given free rein to take these topics as far as they wish and the lesson plan may be adjusted as needed.

Understanding Physical Aspects of Stress

Childbirth educators have long aspired to provide a clear understanding of the physical, emotional, and spiritual aspects of pregnancy, labor, birth, and parenting in order to help women and their families create a sense of wholeness encompassing the entire continuum. This sense of wholeness becomes even more important when stress, trauma, and grief enter the picture. A group-sharing exercise such as the one described above—once it has played out—can then lead directly to a presentation and discussion about the effects of emotions on labor progress. Thus, the initial discussion is integrated into the class rather than seen as an addition.

One way to facilitate the participants' discussion of their concerns, fears, and hopes is to identify three feelings shared by the members of the group that day.

One excellent resource on this topic is the Maternity Center Association's (2001a) “Hormones Driving Labor and Birth.” Another fine reference is The Labor Progress Handbook: Early Interventions to Prevent and Treat Dystocia (Simkin & Ancheta, 2000). Authors Penny Simkin and Ruth S. Ancheta describe techniques for preventing what they call “emotional dystocia” in labor, defined as “dysfunctional labor caused by emotional distress and the resulting excessive production of catecholamines” (p. 70).

Most of what is known about the human stress response, popularly called the “fight-or-flight” response, has been studied only in men. The first study on the effects of stress on women was published only a few years ago in a psychological journal by researchers at the University of California, Los Angeles (Taylor et al., 2000). The authors concluded that women's stress response differs biologically from men's response to stress. Instead of a fight-or-flight response, women respond to stress with a pattern called “tend and befriend.” According to Taylor and colleagues, the mechanism underlying this pattern seems “to draw on the attachment-caregiving system” (p. 411). The researchers stated that studies of the neuroendocrine system in humans and in animals suggest that the core of this mechanism may be oxytocin, in conjunction with female reproductive hormones and other body chemicals.

Instead of a fight-or-flight response, women respond to stress with a pattern called “tend and befriend.”

Physiological stress affects the fetus as well as the birthing and new mother. Martin Maldonado, MD, President of the Kansas Association for Infant Mental Health, wrote in the organization's newsletter:

It is now well known that the baby in utero is very sensitive to what is happening with the mother, in terms of her physiology. [Certain] situations … trigger also a state of distress and alarm in the baby. The fetus reacts with higher blood levels of cortisol and adrenaline (substances associated with stress) when the mother suffers the distress, for example in cases like domestic violence or when she has to deal with multiple stressors. It is suspected that these experiences have a negative impact on the developing baby's brain and his/her behavioral organization and self-regulation abilities after birth. Also, those problematic situations may make things difficult for the mother or couple to be able to meet the multiple demands of parenthood or to enjoy the relationship with the baby (Maldonado, 2000, August).

Thus, providing a support system to reduce stress during the perinatal year is a worthy goal of prenatal care.

Stress Reduction Through Communicating with Other Women

Female friends and relatives play a highly significant role in reducing women's stress levels. Opportunities to talk with other pregnant and parenting women can be extremely helpful in this regard, as focus-group participants observed in a study by Hartstone and Van Patten (2003). Many women know this intuitively. When women feel stressed, they look to their female friends and relatives to listen and ease their minds. The tend-and-befriend stress response might be one reason that female companionship (doulas and other supporting women) during labor and birth has had such a profound effect throughout history on labor as well as on women's perceptions of the birth experience. This is one reason leaders of childbirth classes are advised to include labor support options, including family participation and doulas. Ample information is available through the Maternity Center Association, especially in the organization's articles “How Do I Get the Labor Support I Need? Labor Support Options” (2001b) and “How Do I Get the Labor Support I Need? Resources for Finding and Choosing Support for Labor and Birth” (2001c).

Dr. Maldonado's article in the Kansas Association for Infant Mental Health newsletter continues:

If something could be done to reduce stressors, detect anxiety and depression in the mother (or parents) to be, if the future mother could feel more supported and assisted in this delicate period of life, it is possible this would help the baby directly and indirectly. There is clearly a need for research in this area and more interest on its impact on the child and the parents during and after pregnancy (Maldonado, 2000, August).

Tools for Reducing Stress During Labor and Beyond

Childbirth educators traditionally instruct women in learning how to reduce stress during labor as well as in other life events. It is well documented that visualization, relaxation, affirmations, and structured breathing can moderate the stress response. Other activities, such as meditation, prenatal yoga, prenatal exercise, and other forms of physical activity, also prepare the body and mind for the physical challenges of labor and birth while, at the same time, reducing stress (Nichols & Humenick, 2000).

When a woman's level of stress, grief, or loss is severe, the childbirth educator may need to refer her to a professional counselor, organization, or both. Every childbirth educator should develop and regularly update a referral list of local resources and counselors who are skilled in assisting pregnant and parenting women and their partners who are deeply distressed.

Guiding Women to Informed Choices

Since the inception of childbirth education, a primary purpose of the profession has been to enhance the childbirth experience by guiding women and their partners in making informed choices regarding the upcoming birth, including care for the baby and new mother. Creating a document of the woman or couple's birth preferences has typically been part of this process. Because the document describes their choices (e.g., the place where the birth will occur, comfort techniques, and options for pain management and support), it has become a vehicle for helping expectant parents contemplate their options. Resources that can assist parents in this process include “Making Informed Decisions” (Maternity Center Association, 2001d), The Thinking Woman's Guide to a Better Birth (Goer, 1999), and “Having a Baby? Ten Questions to Ask” (Coalition for Improving Maternity Services, 2000).

While providing access to good information and choice options is important, it is not enough. The childbirth educator may also facilitate positive communication and the sharing of birth preferences with the woman's health care provider, although this is not easy for some women. However, learning to expressing her fears and issues ahead of time to the provider can contribute to the woman's desired goal of receiving the respect, care, and involvement in decision-making—aspects needed to make birth a positive experience. This is especially important during a time of stress, loss, and grief. Achieving such openness with her health care provider may also help the woman create an opportunity for healing. In contrast, for women whose concerns are not openly expressed or treated with respect, whose fears are not addressed, and who are not encouraged to participate in decisionmaking, birth can become a negative experience, compounding feelings of loss and grief instead of relieving them. Thus, birth plans and discussions about preferences are an especially important part of childbirth education for women experiencing stress, loss, and grief during pregnancy.

Doula Care in Times of Trauma, Loss, and Communal Grieving

Doulas help women create safe environments during labor and birth in many ways, large and small. They dim the lights, play soft music of the woman's choosing, and encourage the woman to bring familiar items and use her labor space in ways that will enhance her feelings of security and comfort. The significance of a “safe environment” assumes a new meaning and importance during difficult times. Like childbirth educators, doulas encourage women to plan—long before their due date—what they will need to feel secure during the birth.

Emotions play a strong role in driving the hormones of labor. In recognizing that emotions can sometimes block or slow labor, doulas encourage mothers to consider the question, “What was going through your mind with the last contraction?” The woman does not need to resolve issues during labor; rather, she can acknowledge and express her feelings and release the negative ones. She allows her emotions to calm, her mind to let go, and her body to open and allow her baby to be born.

Doulas encourage mothers to consider the question, “What was going through your mind with the last contraction?”

Doulas take on the role of advocate for the laboring mother. In this role, doulas facilitate positive communication between provider and client, helping both partners and providers address and consider the woman's fears. Positive communication is key to assuring that the woman is honored and respected. With good, supported communication, women can participate in decision-making, a process that has been shown to contribute to a positive experience and a positive memory of the birth. While the care provider may be heavily focused on the biological safety of mother and child, doulas complement this care by providing sustained recognition that labor and birth constitute a significant life event that the woman will remember in detail for the rest of her life. The words spoken to her and the way she is treated overall will shape and mold her memory and feelings. Penny Simkin, a founder of Doulas of North America (DONA) and author of numerous books and articles, urges doulas and all providers to consider, “How will the woman remember her labor and birth experience?”

When doulas have an opportunity to meet with their clients prior to the birth, they seek to understand the words, images, beliefs, touch, massage, and comfort techniques that will create the most positive environment and experience for each birthing woman. When thus prepared, doulas help others who will be involved in the birth—including the woman's support system and health care providers—to offer the most supportive and encouraging environment possible. Many childbirth educators are also doulas. Those educators who do not participate in the doula role can assist expectant mothers to comprehend the benefits of engaging a doula.

In some settings, doula availability is based on a sliding fee scale. Childbirth educators should be familiar with the type and cost of doula support in their community. Tables 1 and 2 list some of the major contributions of doulas to women's physical and mental health and to the baby's health during and after birth.

Table 1.

Role of the Doula During Labor, Birth, and the Baby's First Hour of Life

Doulas are taught to:

• recognize birth as a key life experience;

• nurture and protect a woman's memory of birth;

• maintain an uninterrupted presence during labor and birth;

• recognize the effects of emotions on the physiology of labor;

• provide comfort techniques and encourage positions that promote progress during labor;

• facilitate positive communication; and

• promote early breastfeeding and bonding.

Table 2.

How Continuous Labor Support Improves Labor and Delivery

An analysis of 12 clinical studies* on the effects of uninterrupted labor support, such as a doula provides, identified the following improvements over births that lacked continuous support:

• 51% reduction in cesarean births;

• 25% reduction in labor length (average of 98 minutes);

• 35% reduction in analgesia;

• 71% reduction in oxytocin augmentation; and

• 57% reduction in use of forceps/vacuum.

Continuous labor support benefits both mother and baby. Mothers who have labored in the presence of a doula report:

• greater satisfaction with childbirth;

• more positive assessments of their babies;

• less postpartum depression; and

• increased self-esteem.

Their babies:

• have shorter hospital stays;

• are less likely to be admitted to special-care nurseries;

• breastfeed more easily; and

• receive more affection from their mothers postpartum.

^*Scott, K. D., Klaus, P. H., & Klaus, M. H. (1999). The obstetrical and postpartum benefits of continuous support during childbirth. Journal of Women's Health and Gender-Based Medicine, 8(10), 1257–1264.

The value of doula support has been increasingly documented in the medical literature. In July 2003, the Cochrane Review, a database that provides the gold standard of systematic evidence-based reviews in medicine, published an updated review of continuous (called “caregiver” in the previous version) support for women during childbirth (Hodnett, Gates, Hofmeyr, & Sakala, 2003). Fifteen trials involving 12,791 women met the stringent criteria for inclusion in the database. The reviewers concluded:

Continuous labour support reduces a woman's likelihood of having pain medication, increases her satisfaction and chances for “spontaneous” birth [without cesarean, vacuum, or forceps delivery], and has no known risks…. In general labour support was more effective when it was provided by women who were not part of the hospital staff (p. 4).

Working with the Widows of 9/11

As we worked with pregnant women whose partners were killed on September 11, 2001, we encouraged them to reserve a mental space during labor and birth in which to include the memory of their partners. We found that calling on the partner's remembered strength or imagined presence comforted many of the women.

In gathering information for the Maternity Center Association's November 2002 Forum on Trauma, Loss and Communal Grieving (Pascali-Bonaro, 2003), I queried other childbirth educators in and near New York City as to how they had responded to their clients' needs at that terrible time. Many responded, sharing their insights.

Billee Wolff, RN, CD(DONA), a registered nurse and a doula at the Childbirth Center in Englewood, NJ, described what many others reported they had observed and felt:

After 9/11, we had a period where [it appeared] we had an extraordinarily high number of breech babies. I had the sense that it was somehow related to fear about the future and what might happen. I also witnessed an increase in postpartum depression.

I think 9/11 has caused some emotional fragility for all of us. Pregnant women and new moms, who are so often emotionally fragile, have been even more fragile. Being a new mom and responsible for a new life coming into this world is awesome and often overwhelming; 9/11 added even more uncertainty and fear. I found myself being more sensitive to women's fears. I have become more liberal with encouragement and just listening (B. Wolff, personal communication, October 2002).

Cathy Daub, president of Birth Works®, Inc., an organization that offers training and certification to childbirth educators and doulas, sent the following thoughts:

When tragedies occur in life, they bring us closer to our own mortality and immortality. Those who survive will experience the stages of grieving, which include shock, anger, and guilt. Since energy is vibration, such emotions will have an effect on the body.

In pregnant women, the emotions will be felt by the fetus in some way. It is an important time for such women to allow full expression of their emotions, and stay centered in their hearts so that love can pour into their growing babies. There is nothing that love can't heal and, ultimately, we must all heal from such tragic events (C. Daub, personal communication, September 2002).

In summary, when we experience tragedy of this magnitude, we have the opportunity to stop, think about what is important, become more sensitive to others, and face our own fragility. Ideally, childbirth educators may extend this new level of sensitivity to others, even when the level of tragedy is less severe or less widespread.

Caring for Ourselves, Too

The heightened homeland security in the United States and the war with Iraq have triggered renewed stress, grief, and fear. Even as they attend to the expectant women they serve, childbirth educators and doulas are reminded to care for themselves. They benefit from strengthening their own support networks and practicing stress-reduction techniques. As doulas and childbirth educators feel and remain centered, they may effectively continue the journey to educate, support, and nurture pregnant women and their partners. They can help expectant parents to connect with and care for their unborn child, to feel safe, confident, and supported during labor and birth, and to welcome a new life into the world in peace, love, and light.

If we hope to create
a non-violent world
where respect and kindness
replace fear and hatred

We must begin
with how we treat each other
at the beginning of life.

For that is where
our deepest patterns are set.

From these roots
grow fear and alienation
—or love and trust.

—©Suzanne Arms

Resources Mentioned in This Article

Birth Works®, Inc.

P.O. Box 2045

Medford, NJ 08055

1-888-TO-BIRTH (1-888-862-4784)

www.birthworks.org

email: mailroom@birthworks.org

Coalition for Improving Maternity Services (CIMS)

P.O. Box 2346

Ponte Vedra Beach, FL 32004

1-888-282-2467

www.motherfriendly.org

email: info@motherfriendly.org

Doulas of North America (DONA)

P.O. Box 626

Jasper, IN 47547

1-888-788-DONA

www.dona.org

email: doula@DONA.org

Maternity Center Association

281 Park Avenue South, 5th Floor

New York, NY 10010

212-777-5000

www.maternitywise.org

email: info@maternitywise.org